Psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Nepal.

BACKGROUND: In recent years there has been a growing appreciation of the issues of quality of life and stresses involved medical training as this may affect their learning and academic performance. However, such studies are lacking in medical schools of Nepal. Therefore, we carried out this study to assess the prevalence of psychological morbidity, sources and severity of stress and coping strategies among medical students in our integrated problem-stimulated undergraduate medical curriculum. METHODS: A cross-sectional, questionnaire-based survey was carried out among the undergraduate medical students of Manipal College of Medical Sciences, Pokhara, Nepal during the time period August, 2005 to December, 2006. The psychological morbidity was assessed using General Health Questionnaire. A 24-item questionnaire was used to assess sources of stress and their severity. Coping strategies adopted was assessed using brief COPE inventory. RESULTS: The overall response rate was 75.8% (407 out of 525 students). The overall prevalence of psychological morbidity was 20.9% and was higher among students of basic sciences, Indian nationality and whose parents were medical doctors. By logistic regression analysis, GHQ-caseness was associated with occurrence of academic and health-related stressors. The most common sources of stress were related to academic and psychosocial concerns. The most important and severe sources of stress were staying in hostel, high parental expectations, vastness of syllabus, tests/exams, lack of time and facilities for entertainment. The students generally used active coping strategies and alcohol/drug was a least used coping strategy. The coping strategies commonly used by students in our institution were positive reframing, planning, acceptance, active coping, self-distraction and emotional support. The coping strategies showed variation by GHQ-caseness, year of study, gender and parents' occupation. CONCLUSION: The higher level of psychological morbidity warrants need for interventions like social and psychological support to improve the quality of life for these medical students. Student advisors and counselors may train students about stress management. There is also need to bring about academic changes in quality of teaching and evaluation system. A prospective study is necessary to study the association of psychological morbidity with demographic variables, sources of stress and coping strategies.

Atypical presentations of melioidosis as emerging threat: a case report.

We report two atypical presentations of melioidosis as mediastinal lymphadenitis and prostatic abscess with Burkholderia pseudomallei, the emerging category 2 organism which led to diagnostic and therapeutic dilemma and thereby, delay in appropriate management. Any similar presentation should always be supported by microbiological opinion without any delay, which can help in instituting proper antibiotics with successful outcome.

Isolation & antimicrobial susceptibility of Shigella from patients with acute gastroenteritis in Western Nepal.

BACKGROUND & OBJECTIVE: Shigellae play an important role as a causative organism of acute gastroenteritis, which is a global health problem with significant morbidity and mortality in especially in developing countries. This study was carried out to determine the isolation and pattern of antimicrobial resistance of Shigella in patients with acute gastroenteritis in western Nepal. METHODS: The study included all patients with acute gastroenteritis who visited a tertiary care hospital at Pokhara, Nepal during a 2-year period (2002-2004). The isolates was confirmed as Shigella by biochemical reaction and slide agglutination test using specific antisera. Antibiotic sensitivity test was determined by agar diffusion method and minimum inhibitory concentration (MIC) of the drugs was detected. RESULTS: Of the 770 stool samples, 83 (10.8%) yielded Shigella. Shigella flexneri caused 56 (67.4%) of the total cases of shigellosis followed by S. dysenteriae 12 (14.5%), S. sonnei 10 (12%) and S. boydii 5 (6%). Of the 83 isolates, 67 (80.7%) showed resistance to various drugs and 62 (74.7%) were resistant to two or more drugs. Resistance to cotrimoxazole was 80.7 per cent followed by tetracycline 74.7 per cent, ampicillin 53.0 per cent, nalidixic acid 31.3 per cent and ciprofloxacin 2.4 per cent. The MIC(50) and MIC(90) values of those drugs were also very high. All isolates were sensitive to cefotaxime and ceftriaxone. INTERPRETATION & CONCLUSION: The findings of our study suggested that Shigellae was an important etiological agent for acute gastroenteritis, with a high rate of drug resistance and requires constant monitoring in this region.

First documented cure of a suggestive exogenous reinfection in polymyositis with same but multidrug resistant M. tuberculosis.

BACKGROUND: MDR Mycobacterium tuberculosis is the major cause of treatment failure in tuberculosis patients, especially in immunosuppressed. We described a young polymyositis patient on immunosuppressive therapy who was started with antituberculosis therapy as a susceptible strain of M. tuberculosis was isolated from a single cutaneous abscess in his neck and from regional lymph nodes. CASE PRESENTATION: He had non-reactive miliary tuberculosis and multiple cutaneous abscesses 6 months later with the same strain, which was resistant this time to 9 antituberculosis drugs. We described clinical presentation, radiological and laboratory work-up, treatment and follow-up as the patient was cured after 1.5 years with 6 antituberculosis drugs. CONCLUSION: To our knowledge, this is the first reported case where an immunosuppressed patient with suggestive exogenous reinfection within 6 months with the same but MDR strain of M. tuberculosis was cured. Intense management and regular follow up were important since the patient was a potent source of MDR M. tuberculosis infection and there was limited choice for therapy.

Role of mechanical ventilation & development of multidrug resistant organisms in hospital acquired pneumonia.

BACKGROUND & OBJECTIVES: Among hospital-acquired infections, pneumonia is considered to be the leading cause of death mainly in patients with mechanical ventilation in intensive care units (ICUs). The present study was undertaken to estimate the occurrence of hospital-acquired pneumonia (HAP) as well as ventilator-associated pneumonia (VAP) along with the effect of different variables and to detect the presence of multi drug resistant (MDR) organisms in the intensive care unit (ICU). METHODS: Of the 328 patients admitted in the ICU during 2001, 241 stayed for > 72 h and 148 were ventilated. The respiratory specimens collected from the cases and controls were sent for cytology, bacterial culture and antimicrobial sensitivity. RESULTS: The overall rate of HAP was 53.9 per cent, mortality rate was 47.3 per cent and attributable risk of mortality with ventilator was 72.3 per cent. Occurrence of VAP was 81.7 per cent. The rate of acquisition of HAP increased along with the duration of stay in the ICU. Of the total bacterial isolates, 96.2 per cent were obtained from patients on ventilator, an overall preponderance of Gram-negative bacteria, commonest being Pseudomonas spp along with 16.3 per cent polymicrobial infection was found in ICU. A significant number of ICU isolates were MDR in comparison to those from the non-ICU settings. INTERPRETATION & CONCLUSION: Mechanical ventilation and duration of ICU stay emerged as important risk factors for the development of HAP and VAP. MDR Gram-negative bacilli were the commonest respiratory pathogens responsible for increased mortality in patients with VAP.

Aeromonas hydrophila and aspiration pneumonia: a diverse presentation.

Although there are ever increasing reports of extraintestinal human infections caused by Aeromonads, in both immunocompromised and immunocompetent patients, respiratory tract infections remain uncommon. We describe a case of aspiration pneumonia in an immunocompetent patient with multiple sclerosis, caused by a community acquired, multidrug resistant strain of Aeromonas hydrophila sensitive only to meropenem. The case highlights the clinical significance of Aeromonas hydrophila as a respiratory pathogen, as well as the community origin of multidrug resistance and the utility of newer carbapenems in such cases.

Neurocysticercosis in clinically suspected and MRI proven cases: evidence of sub-optimal antibody response.

Neurocysticercosis (NCC) has a worldwide distribution mainly in the developing countries like India. The study was done to find the seroprevalence of anti-cysticercus antibodies in clinically suspected and MRI proven cases and to corroborate the serological findings with radiological findings (MRI). A hospital based study among 204 suspected patients during January, 1996 to August, 2001 showed that 77 (32.2%, M:F = 2.2:1) had serological evidence of NCC. Of the total 189 sera, tested at 1:100 dilution 68 (35.9%) and of the total 50 CSF, tested at 1:5 dilution 9 (18%) were positive for anti-cysticercus IgG antibodies. In 35 cases where both were tested 13 sera (37.1%), 9 CSF (25.7%) and in 7 (20%) both sera and CSF were positive. In CSF from 62 patients with tubercular meningitis (disease control) 2 (3.2%) samples whereas in sera of 60 normal blood donors (normal control) 7 (11.7%) samples had anti-cysticercus IgG antibodies. In 33 MRI-positive cases, anti-cysticercus antibodies were seen in 15 (45.4%) patients. Antibodies were seen in 6 of 14 (42.8%) cases with single cortical cyst, 4 of 11 (36.3%) with 2-3 cysts and in 5 of 8 (62.5%) with multiple cysts. Alternatively, 18 of 33 (54.5%) MRI positive cases lacked anti-cysticercus antibodies. Six MRI negative cases were found to be seropositive and were treated successfully. Hence, immune response was sub-optimal even in MRI positive cases and conversely, few MRI negative cases were seropositive. Since positive response with MRI or serology depends on the stage of the disease, therefore both tests should be done together to confirm or to rule out NCC.

Multiple cutaneous swellings in an immunocompetent host--cryptococcosis overlooked.

Recently, there has been an increase in the incidence of cryptococcosis even among immunocompetent patients. We present a case of multiple subcutaneous swellings later developing into a non-healing ulcer caused by Cryptococcus in a 60 year-old immunocompetent male along with a brief review of clinical presentations of cutaneous cryptococcosis in immunocompetent and immunocompromised individuals. A high index of suspicion is desired in view of possible dissemination and variable non-specific clinical presentations.

Multiple cutaneous swellings in an immunocompetent host: cryptococcosis overlooked

Recently, there has been an increase in the incidence of cryptococcosis even among immunocompetent patients. We present a case of multiple subcutaneous swellings later developing into a non-healing ulcer caused by Cryptococcus in a 60 year-old immunocompetent male along with a brief review of clinical presentations of cutaneous cryptococcosis in immunocompetent and immunocompromised individuals. A high index of suspicion is desired in view of possible dissemination and variable non-specific clinical presentations.

Nocardial brain abscesses in a HIV positive patient misinterpreted as tubercular brain abscesses.

We present a case of nocardial (Nocarda transvalensis) brain abscesses in a HIV infected person with CD4 count of 53 cells/ml, who received antitubercular therapy for one year. A magnetic resonance imaging study showed multiple ring-enhancing lesions in right parieto-occipital parenchymal region along with perilesional edema and mass effect. Right posterior temporal burr hole aspiration of the abscesses and postoperative cotrimoxazole and ampicillin-sulbactum therapy cured the patient. It is a case of HIV infection with rare and sole manifestation of multiple cerebral abscesses due to N. transvalensis.

Emerging opportunistic protozoa and intestinal pathogenic protozoal infestation profile in children of western Nepal.

Intestinal parasitic infestation continues to be of public health importance in many tropical and subtropical countries for their high prevalence and effects on the morbidity in the population. This 5-year hospital-based retrospective analysis was aimed to find out the intestinal protozoal parasitic profile in 1790 pre-school and school-going children visiting the hospital with gastrointestinal illness. Giardia lamblia was the most prevalent pathogenic protozoan intestinal parasite (73.4%), followed by Entamoeba histolytica (24.4%). Interestingly, "newer" opportunistic pathogens like Cyclospora cayetanensis (1.0%) and Cryptosporidium sp. (1.0%) were detected from immunocompromised children below 2 years of age as a result of vertical transmission, which is alarming for a country like Nepal at the stage of 'concentrated epidemic' of HIV infection.

Two novel clinical presentations of Burkholderia cepacia infection.

We report two cases of multidrug-resistant Burkholderia cepacia (B. cepacia genomovar I) and Burkholderia multivorans causing multiple liver abscesses in a patient with bronchial asthma (case 1) and peritonitis in a patient with cirrhosis and hepatitis C virus disease (case 2), respectively. Both patients were treated successfully.

Multisystem involvement of microfilaria in a HIV positive patient.

A 35-year-old HIV positive male presented with dyspnoea and chest pain was diagnosed having acute pericardial and pleural effusion. Microfilaria was detected from blood as well as from the pericardial and pleural fluid and from urine. CD4 count was 123 cells microl. The patient was receiving treatment with antiretroviral therapy and Cotrimoxazole for last 4 months. The patient had no opportunistic infection and no symptoms suggestive of filarial infection in the past. This is for the first time we are reporting high microfilarial load (1000/ml) from blood in HIV positive patient, where microfilaria was also demonstrated from the pericardial and pleural fluid and from urine.

Novel nosocomial infections by Stenotrophomonas maltophilia: first reported case from Lucknow, North India.

We describe a case of empyema with infected ascites caused by Stenotrophomonas maltophilia, which has rarely been reported as pathogenic. The source was determined to a disinfectant solution. The isolate was sensitive to a newer carbapenem-meropenem, and the patient was treated successfully. This case represents a novel dual presentation of a nosocomial infection by the isolate in question.

Sero-molecular evaluation of human cytomegalovirus disease in renal transplant rejection.

Cytomegalovirus (CMV) is the most common viral pathogen in renal transplant recipients resulting in graft rejection. The prevalence of CMV disease and renal graft rejection is not well studied in India. Sequential specimens from 32 renal allograft recipients were examined by using CMV IgM specific mu capture ELISA and DNA by PCR. Twelve of the 32 patients were CMV IgM positive and out of 12 patients, 9 had rejection and 4 experienced CMV disease. CMV IgM specific mu capture ELISA helped in diagnosis of CMV disease, though it is less sensitive in detection of rejection. PCR itself was proved not sensitive enough in detecting either CMV disease or rejection. At present, optimal laboratory detection of CMV infection in these patients can be achieved only by multiple and more sensitive parameters.