Risk-based fluconazole prophylaxis of <Emphasis Type="Italic">Candida</Emphasis> bloodstream infection in a medical intensive care unit

Candida bloodstream infection (CBSI) accounted for 50% of bloodstream infections in our medical intensive care unit (MICU) in 2004. Our objective was to evaluate a risk-based fluconazole prophylaxis program. CBSI incidence, patient demographics, and unit metrics were retrospectively reviewed for 2004. Starting on January 2005, patients meeting pre-specified criteria were placed on risk-based fluconazole prophylaxis and their outcomes, adverse events, and unit metrics were prospectively collected. The inclusion criteria were based on a clinical prediction rule and included an MICU stay greater than 72 h, broad-spectrum antibiotics, and central venous catheter, along with at least two of the following: mechanical ventilation for at least 48 h, any type of dialysis, parenteral nutrition, pancreatitis, systemic steroids, or other systemic immunosuppressive agents. For 2004, the unit had nine CBSI, corresponding to a rate of 3.4 CBSI/1,000 line-days. Four cases were caused by C. albicans, four by C. glabrata, and one by C. tropicalis. The mean ± standard deviation (SD) APACHE II score for these patients was 25 ± 9. In 2005, a total of 36 patients (2.6% of all unit admissions) received prophylaxis and the unit had two CBSI, corresponding to a rate of 0.79 CBSI/1,000 line-days. One patient had C. albicans and the other had C. tropicalis. The mean ± SD APACHE II score for these patients was 21 ± 8. The mean ± SD duration of fluconazole prophylaxis was 8 ± 6 days. Fluconazole was discontinued in two patients due to non-severe adverse events (acute eosinophilia, elevated transaminases). The attributable cost of CBSI in the unit in 2004 was $63,000 per episode. The total cost for the 36 courses of fluconazole was $6,000. When comparing the 2004 CBSI patients and the 2005 prophylaxis patients, we found similar acuity, demographics, and risk factors, with no differences in MICU or hospital mortality or length of stay. Risk-based fluconazole prophylaxis in an MICU with a high incidence of CBSI was safe and cost-effective when applied to a limited number of patients and produced a significant decrease in the incidence of this disease.     

Galactosemia with chorea — an unusual presentation

Galactosemia, an inborn neurometabolic disorder, results from an aberrant galactose metabolism due to the deficiency of serum galactose-1-phosphate uridyltransferase activity. It manifests in the central nervous system in the form of hypotonia, seizures, mental retardation, tremor, ataxia, and progressive cerebellar as well as extrapyramidal features. To the best of our knowledge, chorea due to galactosemia has not been reported in infancy.     

Hyperhomocysteinemia,and low intakes of folic acid and vitamin B12 in urban North India

Summary Background and Aim An adverse coronary risk profile has been reported amongst rural-to-urban migrant population living in urban slums undergoing stressful socio-economic transition. These individuals are likely to have low intakes of folic acid and vitamin B12, which may have an adverse impact on serum levels of homocysteine (Hcy). To test this hypothesis, we studied serum levels of Hcy in subjects living in an urban slum of North India and healthy subjects from urban non-slum area. Methods Group I consisted of 46 subjects (22 males and 24 females) living in an urban slum, while group II consisted of healthy subjects (n = 26, 13 males and 13 females) living in the adjacent non-slum area. Anthropometric measurements, biochemical profile (fasting blood glucose, total cholesterol, serum triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol) and fasting serum levels of Hcy were measured. Dietary intakes of folic acid, vitamin B12, vitamin B1, and iron were calculated by the 24-hour dietary recall method. Serum levels of Hcy were correlated with dietary intakes of nutrients, anthropometry, and metabolic variables. Results Sex-adjusted serum levels of Hcy in mmol/L (Mean ± SD) were high, though statistically comparable, in both the groups (group I: 20.8 ± 5.9 and group II: 23.2 ± 5.9). Overall, higher than normal serum levels of Hcy (> 15 μmol/L) were recorded in 84 % of the subjects. A substantial proportion of subjects in both groups had daily nutrient intakes below that recommended for the Asian Indian population (folic acid: 93.4 % in group I and 96.7 % in group II, vitamin B12: 76.1 % in group I and 88.4 % in group II). However, between the two groups, average daily dietary intakes of both the nutrients were statistically comparable. As compared to non-vegetarians, vegetarians showed lower intakes of folic acid (p < 0.01) and vitamin B12 (p < 0.01) in both groups. On multivariate linear regression analysis with serum Hcy as the response variable and vegetarian/non-vegetarian status and sex (male/female) as predictor variables, higher serum levels of Hcy were observed in vegetarians vs non-vegetarians (β = 4.6, p < 0.05) and males vs females (β = 5.3, p < 0.01). Conclusions Low intakes of folic acid and vitamin B12, and hyperhomocysteinemia, in both the healthy population living in urban slums and adjacent urban non-slum areas, are important observations for the prevention of nutritional and cardiovascular diseases in the Indian subcontinent. Received: 30 October 2001, Accepted: 14 January 2002     

Intraventricular rhabdoid tumor

Malignant rhabdoid tumor (MRT) most commonly occurs in kidney. In the central nervous system, cerebellum is the most common site of occurrence. CNS rhabdoid tumors typically occur in small children, do not respond favorably to treatment and are usually fatal within 1-year. Here is reported a 4-year-old child who presented with features of raised intracranial pressure. Apart from papillodema, there were no neurological signs. Imaging revealed a left lateral ventricular heterogeneous mass abutting the foramen of monro, with mild irregular contrast enhancement and hydrocephalus. the child underwent right ventriculo-peritoneal shunt followed by craniotomy and gross total tumor resection. He was discharged 10-days after surgery without any neurological deficits. Histopathology revealed features compatible with rhabdoid tumor. Despite radiotherapy and chemotherapy, the child died of progressive disease 10-months after surgery. the highly malignant nature of this tumor makes early diagnosis essential for aggressive management and prognostication.     

A primary care perspective of posttraumatic stress disorder for the Department of Veterans Affairs

Posttraumatic stress disorder (PTSD) is a major mental disorder associated with significant morbidity, psychosocial impairment, and disability. The diagnosis of PTSD can be missed in a primary care setting, as patients frequently present with somatic complaints or depression and are often reluctant to discuss their traumatic experiences. As recent studies of veterans returning from the Gulf War and the Iraqi War suggest high rates of PTSD, the U.S. Department of Veterans Affairs (VA) Hospitals are gearing up to face this challenge. It is important to screen these veterans for symptoms of PTSD and make an appropriate referral if required. In this article, we attempt to review PTSD with a special focus on the VA population. In addition to discussing the epidemiology, diagnosis, and treatment options for PTSD, we also suggest screening questions for both combat-related and military sexual trauma-related PTSD.     

Significance of primary hyperparathyroidism in the management of osteoporosis

Primary hyperparathyroidism (HPT) has catabolic effects on cortical bone and anabolic effects on cancellous bone with overall deleterious effects on skeleton. Primary HPT is associated with increased fracture risk both at the cancellous bone-enriched spine and the cortical bone-enriched distal one third of the radius. This risk is reversed by parathyroidectomy.     

Test characteristics of the respiratory syncytial virus enzyme-linked immunoabsorbent assay in febrile infants < or = 60 days of age

The test characteristics of rapid tests for respiratory syncytial virus (RSV) in infants may differ from older children secondary to a lower likelihood of previous illness with RSV. Our main goal was to establish the test characteristics of the RSV Abbott Testpack (TP) enzyme-linked immunoabsorbent assay (EIA) in febrile infants < or = 60 days of age. Our secondary goal was to determine the likelihood of RSV given a particular clinical syndrome and a negative or positive EIA. A prospective sample of infants with a temperature > or = 38.0 degrees C was evaluated during 2 successive RSV seasons. Conventional tissue and shell vial viral cultures were utilized as the reference standard. The RSV Abbott Testpack EIA had a sensitivity of 75% (95% CI 60-90%), a specificity of 98% (95% CI 96-100%), a positive predictive value of 89% (95% CI 77-100%), a negative predictive value of 95% (95% CI 91-98%), a likelihood ratio for a positive test of 35.5 (95% CI 11.4-110.7), and a likelihood ratio for a negative test of 0.26 (95% CI 0.14-0.47). Even with a negative EIA, patients with lower and upper respiratory tract illness still had a 22.3% and 5.5% chance of harboring RSV, respectively. The RSV Abbott Testpack is a useful diagnostic tool in the detection of RSV in febrile infants but has limitations. During months typically associated with RSV disease, a positive RSV TP indicates a high likelihood of illness, but clinicians should be wary of false negatives.