Catheter associated mycobacteremia: Opening new fronts in infection control

Mycobacterium fortuitum is a rapidly growing Mycobacterium ubiquitous in nature, known to form biofilms. This property increases its propensity to colonize the in situ central line and makes it a prospective threat for nosocomial infection. We report a case of 48-year-old female with carcinoma cecum who reported to us with clinical illness and neutropenia while on chemotherapy via totally implanted central venous device, postlaparoscopic-assisted right hemicolectomy.     

Atrial Fibrillation in Patients Undergoing Liver Transplantation—A Single-Center Experience

Background

As the prevalence of atrial fibrillation rises with age and older patients increasingly receive transplants, the perioperative management of this common arrhythmia and its impact on outcomes in liver transplantation is of relevance.

Methods

Retrospective review of 757 recipients of liver transplantation from January 2002 through December 2011.

Results

Nineteen recipients (2.5%) had documented pre-transplantation atrial fibrillation. Sixteen patients underwent liver and 3 a combined liver-kidney transplantation. Three patients died within 30 days (84.2% 1-month survival) and another 3 within 1 year of transplantation (68.4% 1-year survival). Compared with patients without atrial fibrillation, the relative risk of death in the atrial fibrillation group was 5.29 at 1 month (P = .0034; 95% confidence interval [CI], 1.73–16.18) and 3.28 at 1 year (P = .0008; 95% CI, 1.63–6.59). Time to extubation and intensive care unit (ICU) and hospital readmissions were not different from the control cohort. Rapid ventricular response requiring treatment occurred in 4 patients during surgery and 7 after surgery, resulting in 3 ICU and 3 hospital readmissions.

Conclusions

The results suggest that patients with atrial fibrillation may be at increased risk of mortality after liver transplantation. Optimization of medical therapy may decrease ICU and hospital readmission due to rapid ventricular response.     

Spontaneous cryptococcal peritonitis with fungemia in patients with decompensated cirrhosis: Report of two cases

Cryptococcus neoformans is encapsulated yeast that predominately infects immunocompromised individuals. Liver disease is an under-recognized predisposition for cryptococcal disease. We report two nonalcoholic, nondiabetic, and human immunodeficiency virus - negative cirrhotic patients, with spontaneous cryptococcal peritonitis. Cryptococcus infection was diagnosed by culture of ascitic fluid and peripheral blood in both. We treated the first patient with amphotericin-B, but he expired. The second patient with earlier diagnosis, survived to discharge with fluconazole treatment. We suggest a high clinical suspicion for Cryptococcus as a possible etiology of spontaneous peritonitis in cirrhotic patients.     

Exploring the Burden of Mealtime Insulin Dosing in Adults and Children With Type 1 Diabetes

Timely and accurate mealtime insulin dosing can be an ongoing challenge for people with type 1 diabetes. This multinational, online study aimed to explore attitudes and behaviors around mealtime insulin dosing and the impact of mealtime dose timing, particularly with regard to premeal dosing (15–20 minutes before a meal). Although the majority of surveyed participants (96%) recognized the importance of accurate mealtime bolus insulin dosing, only a small proportion (35%) reported being “very confident” in accurate bolus insulin estimation. Given the choice, the majority of participants would prefer to administer insulin immediately before or after a meal, as this timing would improve their quality of life.

Key Points

• ≫ Although the majority of surveyed participants (96%) recognized the importance of accurate mealtime bolus insulin dosing, only a small proportion (35%) reported being “very confident” in accurate bolus insulin estimation.
• ≫ Most responding adults with type 1 diabetes (91%) and parents of children with type 1 diabetes (97%) experienced challenge(s) related to premeal insulin dosing.
• ≫ Most responding adults with type 1 diabetes (91%) and parents of children with type 1 diabetes (92%) reported worrying about postmeal glucose levels at least occasionally.
• ≫ A high proportion of responding adults with type 1 diabetes (67%) and parents of children with type 1 diabetes (72%) said that having the freedom to administer mealtime insulin immediately before or after the start of a meal rather than 15–20 minutes before the meal would have a positive impact on their lives.

A large proportion of people with type 1 diabetes, both adults and children, do not achieve guideline-recommended A1C targets (1,2). Contributing to overall glycemic burden is postprandial glucose (PPG), which, together with fasting plasma glucose, is a target measure that is incorporated into guideline recommendations (3). Elevated PPG levels have been shown to be associated with a significant increase in health care resource utilization, including clinic visits, calls, emails to health care providers, and hospitalizations among adults with diabetes who use a multiple daily injection insulin (MDI) regimen (4). However, managing PPG remains one of the most challenging aspects of diabetes care.PPG control is multifactorial; contributors include timing, quantity, and composition of the meal and asynchrony between postmeal glucose absorption and maximal exogenous insulin effect, which often lags behind glucose absorption by up to 2 hours. Patient-related causes greatly contribute to suboptimal PPG control and include reduced or skipped mealtime insulin doses and inaccurate estimation of carbohydrate intake (5).Optimal timing of mealtime insulin dosing is a key factor in controlling PPG levels (6,7). In this article, for clarity, we refer to the administration of insulin 15–20 minutes before a meal as a “premeal bolus.” When insulin is administered immediately before a meal (usually regarded as 0–2 minutes before the meal), we refer to this as a “mealtime bolus.” Administration of insulin after the start of a meal is referred to as a “postmeal bolus.”Multiple studies and clinical practice guidelines have suggested that the optimal time to administer a rapid-acting insulin analog is 15–20 minutes before the start of a meal (6,8). This recommendation follows observations in general practice and studies evaluating the effect on PPG excursions of dose timing of rapid-acting insulin relative to meals in people with type 1 diabetes (Supplementary Table S1) (7,9–13). Premeal bolusing of rapid-acting insulin analogs 15 minutes before mealtime resulted in lower PPG excursions and more time spent in the euglycemic range (3.5–10.0 mmol/L) without increased risk of hypoglycemia (7).Despite these results and clinical recommendations, real-world studies have demonstrated poor adherence to the recommended injection-to-meal interval, and postmeal bolus dosing is commonly observed (5,14,15). Synchronizing the administration of insulin with its anticipated effect on glucose absorption poses a significant challenge for many people with diabetes, especially children or anyone who struggles to adhere to lifestyle routines. Some of the challenges associated with mealtime insulin dosing include injection pain, embarrassment, and interference with daily activities (5,16).Quantitative data from studies investigating the challenges of mealtime insulin dosing are scarce. Here, we explore attitudes and behaviors around mealtime insulin dosing and the impact of mealtime dose timing, particularly with regard to premeal dosing, in both adults and children with type 1 diabetes, as well as physicians who treat people with type 1 diabetes.     

Nosocomial candiduria in chronic liver disease patients at a hepatobilliary center

Background:

Nosocomial urinary tract infections (UTIs) are common in catheterized patients. Fungal UTI has become an important nosocomial problem over the past decade. The microbiology of candiduria is rapidly evolving and new trends are being reported.

Aims:

To study the microbiological trends and antifungal resistance profile of Candida in urine of catheterized chronic liver disease (CLD) patients at a super specialty hepatobiliary tertiary-care center.

Materials and Methods:

urine samples were collected by sterile technique, processed by semi-quantitative method as per the standard protocols. Direct microscopic examination of urine sample was also done to look for the presence of pus cells, red blood cells, casts, crystals or any bacterial or fungal element.

Result:

A total of 337 yeast isolates were obtained from catheterized patients, non-albicans Candida spp. emerged as the predominant pathogen and was responsible for 67.06% of nosocomial fungal UTI. Candida tropicalis accounted for 34.71% of the cases, whereas Candida albicans grew in 32.93%, Candida glabrata 16.32%, rare Candida spp. Nearly 11.5% (Candida hemolunii to be confirmed by molecular methods). Antifungal sensitivity varied non-albicans species except C. tropicalis, Candida parapsilosis were more often resistant to antifungal drugs.

Conclusion:

Nosocomial Candida UTIs in CLD patients is common, due to the cumulative pressure of contributing factors such as urinary instrumentation and prolonged use of broad-spectrum antibiotics. Non-albicans Candida were found to outnumber C. albicans in catherized CLD patients. Risk of strain persistence is also higher with non-albicans Candida. Thus, species identification and susceptibility testing is a must for appropriate management of such patients.     

Melatonin attenuates cognitive dysfunction and reduces neural oxidative stress induced by phosphamidon

Melatonin is an important modulator of nervous system functioning and important neural antioxidant. Organophosphate pesticides like phosphamidon (PHOS) have been shown to adversely affect memory and induce oxidative stress on both acute and chronic exposure. This study was designed to explore the modulation of the effects of PHOS on cognitive function by melatonin (MEL). Cognitive function was assessed using step-down latency (SDL) on a passive avoidance apparatus and transfer latency (TL) on an elevated plus maze. Oxidative stress was assessed by examining the levels of malondialdehyde (MDA) and nonprotein thiols (NP-SH) in isolated homogenized whole brain samples. The results showed a significant reduction in SDL and prolongation of TL in the PHOS (1.74 mg/kg/day; p.o.)-treated group at weeks 6 and 8 as compared to the control group. Two-week treatment with MEL (5 mg/kg/day; i.p.) antagonized the effect of PHOS on SDL as well as TL. PHOS alone produced a significant increase in the brain MDA levels and decrease in the brain NP-SH levels. Treatment with MEL attenuated the effect of PHOS on oxidative stress. Together the results showed that MEL attenuated the cognitive dysfunction and decreased oxidative stress induced by PHOS in the brain.     

Acute Effect of Aloe vera Gel Extract on Experimental Models of Pain

The present study was performed to explore the effect of aqueous extract of Aloe vera on behavioural parameters of pain. Pain assessment was performed by the tail-flick and formalin tests. A. vera (100?mg/kg, per oral (p.o.)) produced an insignificant decrease in the pain response in the tail-flick and formalin tests. Moreover, A. vera (200 and 400?mg/kg, p.o.) did not have significant effect on the tail-flick test. However, A. vera (200 and 400?mg/kg, p.o.) significantly decreased the second phase of the formalin-induced pain. Thus, these findings suggest that A. vera exerts its effect by a peripheral mechanism of action rather than central.