Clinical Manifestations, Antimicrobial Drug Susceptibility Patterns, and Outcomes in Melioidosis Cases, India.

We studied the clinical manifestations and outcomes of 114 patients with culture-confirmed melioidosis treated at a tertiary hospital in southern India. Diabetes mellitus is the main risk factor, and chronic melioidosis mimicking tuberculosis was more common than acute disease. Septicemia and respiratory involvement were associated with poor outcomes.

Molecular epidemiology and genetic diversity of Orientia tsutsugamushi from patients with scrub typhus in 3 regions of India.

Scrub typhus, an acute febrile illness that is widespread in the Asia-Pacific region, is caused by the bacterium Orientia tsutsugamushi, which displays high levels of antigenic variation. We conducted an investigation to identify the circulating genotypes of O. tsutsugamushi in 3 scrub typhus-endemic geographic regions of India: South India, Northern India, and Northeast India. Eschar samples collected during September 2010-August 2012 from patients with scrub typhus were subjected to 56-kDa type-specific PCR and sequencing to identify their genotypes. Kato-like strains predominated (61.5%), especially in the South and Northeast, followed by Karp-like strains (27.7%) and Gilliam and Ikeda strains (2.3% each). Neimeng-65 genotype strains were also observed in the Northeast. Clarifying the genotypic diversity of O. tsutsugamushi in India enhances knowledge of the regional diversity among circulating strains and provides potential resources for future region-specific diagnostic studies and vaccine development.

Hypopituitarism and AutoimmuneThyroiditis Following Snake Bite: An Unusual Clinical Scenario.

Snake venom can cause local tissue damage and lead to coagulopathy, shock, neurotoxicity and acute kidney injury. Hypopituitarism is a rare complication following snake bite. It has been described following Russell's viper bite from Burma and South India. Herein we describe a patient who presented with severe thyrotoxicosis and partial hypopituitarism following snake bite.

Risk score for malignancy in patients with suspicious gallbladder lesions: Retrospective analysis of 175 cases.

BACKGROUND: Among cancers, carcinoma gallbladder has one of the most dismal prognosis. Early lesions are difficult to biopsy because of proximity to luminal structures and risk of biliary peritonitis. However, early surgery offers the only chance of a complete cure. Utilizing a risk score would allow characterization of the risk of malignancy and early referral to an oncology centre thereby resulting in better outcomes for patients with carcinoma gallbladder. METHODS: The aim of this study was to develop a risk score for carcinoma in patients with suspicious gallbladder lesions based on clinical presentation and imaging. All patients with suspicious gallbladder lesions on radiological imaging who underwent surgery were analyzed. Patients were considered for scoring if the ultrasound showed the gallbladder wall thickening (more than 4 mm) and computed tomography scan showed operable disease. Statistical analysis was done to derive a score for malignancy. RESULTS: Total 175 patients underwent an operation for suspicious gallbladder lesions from January 2005 to December 2014. The factors analyzed were clinical biochemical and imaging findings. Of these, 71 were benign on the final histopathology and 104 were malignant. The score was constructed with the following variables: female sex, high total bilirubin (≥ 1 mg/dL), presence of a mass, focal location of the lesion, presence of gallbladder stones and nodal involvement in the hepatoduodenal region on imaging. A model score and modified score were obtained. In this modified score, score of more than 8 out of 20 predicted malignancy with a sensitivity of 78% and specificity of 70.4%. Receiver operating characteristic (ROC) curve constructed with these variables had an area under curve of 0.828. There was no statistically significant difference between the model score and the modified score. CONCLUSIONS: A pre-operative risk score was obtained for carcinoma gallbladder, which needs to be validated prospectively in future.

Evaluation of Molecular Assays for Diagnosis of Amoebic Liver Abscess in India with Bayesian Latent Class Analysis.

Amoebic liver abscess (ALA) is the most common extra-intestinal complication of Entamoeba histolytica, accounting for 50,000 deaths annually, and is endemic in South Asia. Diagnosis based on microscopic examination is insensitive, and serological assays are not discerning of current infections in endemic settings with high exposure. For a rapid and confirmatory laboratory diagnosis of ALA, the performance of a polymerase chain reaction (PCR), quantitative real time PCR (qPCR), digital droplet PCR (ddPCR), and a loop-mediated isothermal amplification (LAMP) assay that detects E. histolytica DNA in liver abscess pus, and a lectin antigen detection ELISA were evaluated against clinical diagnosis (based on predefined criteria) as the gold standard. Owing to the lack of a laboratory gold standard, a Bayesian latent class analysis approach was also used to determine sensitivity and specificity of these assays. In the latent class analysis, qPCR and ddPCR showed the highest sensitivity (98% and 98.1%) and specificity (both 96.6%), and although clinical diagnosis had a comparable sensitivity to qPCR and ddPCR (95.2%), poorer specificity (64.3%) was seen. Kappa agreement analysis showed that qPCR and ddPCR had a perfect agreement of 1 followed by an agreement of 0.76 (95% CI: 0.64-0.88) with PCR. Considering the performance characteristics and relative ease of setting up qPCR as well as the wide availability of qPCR equipment needed, this would be the most optimal assay for rapid, confirmatory, molecular diagnosis of ALA in the tertiary care laboratory setting in India, whereas further optimization of LAMP or antibody-based detection is required for use at smaller or secondary hospitals.

Elastic stable intramedullary nailing versus submuscular plating in pediatric diaphyseal femur fractures: a randomized controlled trial among children in South India.

Elastic stable intramedullary nailing (ESIN) is the current preferred method for treating diaphyseal femur fractures in children. Introduction of the submuscular locked plate (SMP) fixation construct has opened the debate on treatment options for pediatric diaphyseal femur fractures in the older children and adolescents. A randomized controlled trial (RCT) protocol was designed to compare ESIN and SMP for diaphyseal femur fractures in children. An open-labelled RCT comparing SMP with ESIN was conducted from January 2013 to June 2016, for children aged 6-15 years with closed, acute femoral diaphyseal fractures. Randomization was done through computer-generated randomization sequence and opaque-sealed envelopes. Rate of adverse surgical events including unplanned re-operations was assessed as the primary outcome and secondary analysis was done for time to union, degree of malunion, limb length discrepancy, functional outcome at 2 years, surgical duration and blood loss, radiation exposure, hospital stay, cost incurred and secondary implant removal procedure. Forty children were randomized with allocation concealment. There were three adverse events in the SMP arm and five in the ESIN arm. Fifteen children with SMP underwent routine implant removal compared to only three children with ESIN (P < 0.001). Both ESIN and SMP are equally safe, viable and effective options for treating pediatric diaphyseal femoral fractures. However, the additional cost of secondary surgery for implant removal in the SMP group proved to be a deterrent factor, which led to ESIN being the preferred option in our resource-limited setting.

Acute myocardial injury and rhabdomyolysis caused by multiple bee stings.

Massive envenomation by honey bees is capable of causing multiorgan dysfunction as a result of direct toxic effect of massive envenomation and secondary to systemic anaphylactic reactions. Acute myocardial ischemia due to bee envenomation is a rare event. We report the case of a 65 year old lady who presented with acute myocardial ischemia, severe rhabdomyolysis and angioedema following massive bee envenomation.

Burden of diabetes among patients with tuberculosis: 10-year experience from a tertiary care referral teaching hospital in South India.

CONTEXT: Tuberculosis (TB) and diabetes mellitus (DM) are converging epidemics, each worsening the morbidity of the other. A study of the prevalence of DM in TB patients assumes great importance. AIMS: The study aims to evaluate the association between DM and TB over a 10-year period in a tertiary care hospital. SETTINGS AND DESIGN: A retrospective observational study in a southern Indian tertiary care teaching hospital was conducted. MATERIALS AND METHODS: All patients with TB diagnosed and treated during the 10-year study period were identified from the hospital database. All relevant clinical, microbiological, and laboratory results pertaining to diagnosis of DM were collected. The diagnosis of TB and DM was made as per the standard criteria. STATISTICAL ANALYSIS: Categorical variables were analyzed using Chi-square test while continuous variables using independent sample t-test. RESULTS: From 2001 to 2012, we studied 1979 TB patients among whom data on DM were available. The prevalence of DM was 29%, 21%, and 14%, in smear positive, smear negative and extrapulmonary TB respectively (overall 24%). Diabetics were more likely to be men (77.3% vs. 61%;P = 0.001); >40 years of age (81.7% vs. 38.9%;P < 0.001); heavier (59.96 vs. 50.37;P = 0.004); tobacco smokers (16.1% vs. 8.1%;P < 0.001); and alcohol consumers (6.8% vs. 4%;P = 0.02). They were less likely to be HIV coinfected (1.8% vs. 6.1%;P < 0.001). HIV coinfection was seen in 5% of patients and was substantially higher in extrapulmonary TB group (19.4%). Multidrug-resistant TB was lower in DM (11.7%) compared to non-DM (15.9%) (P = 0.02). Overall, 48% of the DM patients were diagnosed at the time of TB diagnosis. Over 10 years, no obvious changes in the trend were evident. CONCLUSIONS: Over a 10-year study period, 24% of the TB patients were diabetic, nearly half were detected at the time of TB diagnosis. There may be a good case for screening all TB patients for DM.

Suicidal Nonorganophosphate Poisoning in a Tertiary Hospital in South India: Nature, Prevalence, Risk Factors.

BACKGROUND: People who deliberately ingest poisons commonly present to emergency departments of hospitals in India. However, there is a dearth of information on poisoning using nonorganophosphorus pesticides. METHODS: This prospective, hospital-based study attempted to examine the nonorganophosphorus poisons used to attempt suicide. Data on sociodemographic characteristics of patients, site and source of poisons, co-ingested substances, premeditation, and reason for poisoning were collected. A multinomial logistic regression was performed to determine association between poison class and these exposure characteristics. RESULTS: Three hundred and forty-one cases of attempted suicide presented during the 6-month period (1.7% of all emergency room admissions). The majority was predominantly male and was young adults. Poisoning was the most common mode (91.7%), followed by hanging (7.3%) and self-injury (3, 0.9%). Pesticides (44.3%) including organophosphates (25.5%) were the predominant poisons, followed by pharmaceuticals (27.9%), caustics/chemicals (12.0%), and plant poisons (7.0%). One hundred and nine were available for prospective interview as the others who presented were not detained for prolonged observation the emergency department. Most patients who ingested such poisons were women, from rural backgrounds and were educated. The majority sourced the poisons from home, consumed poison at home, and mixed the poison with water; these attempts were impulsive and seemed to be in response to relationship conflicts. In the multivariate analysis, education (P = 0.08) and poison source (outside the home) were significant predictors of pesticide ingestion. CONCLUSIONS: Suicidal poisoning results from a complex synthesis of socioeconomic and psychological factors; certain patterns of poisoning are likely to be more prevalent in demographic niche groups.

Attributable cost of a nosocomial infection in the intensive care unit: A prospective cohort study.

AIM: To study the impact of hospital-acquired infections (HAIs) on cost and outcome from intensive care units (ICU) in India. METHODS: Adult patients (> 18 years) admitted over 1-year, to a 24-bed medical critical care unit in India, were enrolled prospectively. Treatment cost and outcome data were collected. This cost data was merged with HAI data collected prospectively by the Hospital Infection Control Committee. Only infections occurring during ICU stay were included. The impact of HAI on treatment cost and mortality was assessed. RESULTS: The mean (± SD) age of the cohort (n = 499) was 42.3 ± 16.5 years. Acute physiology and chronic health evaluation-II score was 13.9 (95%CI: 13.3-14.5); 86% were ventilated. ICU and hospital length of stay were 7.8 ± 5.5 and 13.9 ± 10 d respectively. Hospital mortality was 27.9%. During ICU stay, 76 (15.3%) patients developed an infection (ventilator-associated pneumonia 50; bloodstream infection 35; urinary tract infections 3), translating to 19.7 infections/1000 ICU days. When compared with those who did not develop an infection, an infection occurring during ICU stay was associated with significantly higher treatment cost [median (inter-quartile range, IQR) INR 92893 (USD 1523) (IQR 57168-140286) vs INR 180469 (USD 2958) (IQR 140030-237525); P < 0.001 and longer duration of ICU (6.7 ± 4.5 d vs 13.4 ± 7.0 d; P < 0.01) and hospital stay (12.4 ± 8.2 d vs 21.8 ± 13.9 d; P < 0.001)]. However ICU acquired infections did not impact hospital mortality (31.6% vs 27.2%; P = 0.49). CONCLUSION: An infection acquired during ICU stay was associated with doubling of treatment cost and prolonged hospitalization but did not significantly increase mortality.

Draft genome sequence of reduced teicoplanin-susceptible and vancomycin-heteroresistant methicillin-resistant Staphylococcus aureus from sepsis cases.

Here we report the whole-genome shotgun sequence of six methicillin-resistant Staphylococcus aureus (MRSA) showing reduced susceptibility to both vancomycin and teicoplanin. The typical Indian community-acquired MRSA (CA-MRSA) clone ST772-MRSA-V-t657 was the most common genotype (3/6; 50%), followed by ST672-MRSA-IV (2/6; 33%) and ST22-MRSA-IV (1/6; 17%). All strains harboured a mutation in the tcaRAB operon, vraSR, graSR and/or rpoB genes, which are frequently mutated determinants in a heteroresistant vancomycin-intermediate S. aureus (hVISA) phenotype.

Kikuchi-fujimoto disease: clinical and laboratory characteristics and outcome.

INTRODUCTION: Kikuchi-Fujimoto disease is an uncommon disorder with worldwide distribution, characterized by fever and benign enlargement of the lymph nodes, primarily affecting young adults. Awareness about this disorder may help prevent misdiagnosis and inappropriate investigations and treatment. The objective of the study was to evaluate the clinical and laboratory characteristics of histopathologically confirmed cases of Kikuchi's disease from a tertiary care center in southern India. MATERIALS AND METHODS: Retrospective analysis of all adult patients with histopathologically confirmed Kikuchi's disease from January 2007 to December 2011 in a 2700-bed teaching hospital in South India was done. The clinical and laboratory characteristics and outcome were analyzed. RESULTS: There were 22 histopathologically confirmed cases of Kikuchi's disease over the 5-year period of this study. The mean age of the subjects' was 29.7 years (SD 8.11) and majority were women (Male: female- 1:3.4). Apart from enlarged cervical lymph nodes, prolonged fever was the most common presenting complaint (77.3%). The major laboratory features included anemia (54.5%), increased erythrocyte sedimentation rate (31.8%), elevated alanine aminotransferase (27.2%) and elevated lactate dehydrogenase (LDH) (31.8%). CONCLUSION: Even though rare, Kikuchi's disease should be considered in the differential diagnosis of young individuals, especially women, presenting with lymphadenopathy and prolonged fever. Establishing the diagnosis histopathologically is essential to avoid inappropriate investigations and therapy.

Nasopharyngeal swabs of school children, useful in rapid assessment of community antimicrobial resistance patterns in Streptococcus pneumoniae and Haemophilus influenzae.

OBJECTIVES: The present study evaluates the feasibility of rapid surveillance of community antimicrobial resistance (AMR) patterns of Streptococcus pneumoniae and Haemophilus influenzae in India using nasopharyngeal swabs (NPSs) of school children. It compares the AMR data obtained with that of invasive and nasopharyngeal (NP) isolates studied previously. No one has done such surveillance since our study so we decided to publish and more clearly demonstrate the feasibility of the methodology we did. STUDY DESIGN AND SETTING: This community-based, cross-sectional, cluster sample study had seven centers; each had two sites distant to them. Two hundred sixty school children per center were enrolled. NP swabbing was performed and isolates identified as S. pneumoniae and H. influenzae at each center were sent to reference laboratories. RESULTS: From January to December 2004, 1,988 NP swabs were processed; 776 S. pneumoniae and 64 H. influenzae were isolated. The AMR patterns for S. pneumoniae to co-trimoxazole varied, with sensitivity as low as 6% in Mumbai, 29% in Chennai and Vellore, and 100% in Delhi and Lucknow. For H. influenzae, sensitivity rates to co-trimoxazole ranged from 22% to 62%. The AMR patterns for both bacteria in the present study with data from invasive and NP isolates studied earlier were similar. CONCLUSION: The study demonstrates that it is practical and feasible to rapidly assess the AMR patterns of both S. pneumoniae and H. influenzae in NPSs of school children in different geographic locations all over India.

Risk factors for tuberculosis among health care workers in South India: a nested case-control study.

OBJECTIVE: The epidemiology of tuberculosis (TB) among health care workers (HCWs) in India remains under-researched. This study is a nested case-control design assessing the risk factors for acquiring TB among HCWs in India. STUDY DESIGN AND SETTINGS: It is a nested case-control study conducted at a tertiary teaching hospital in India. Cases (n = 101) were HCWs with active TB. Controls (n = 101) were HCWs who did not have TB, randomly selected from the 6,003 subjects employed at the facility. Cases and controls were compared with respect to clinical and demographic variables. RESULTS: The cases and controls were of similar age. Logistic regression analysis showed that body mass index (BMI) <19 kg/m(2) (odds ratio [OR]: 2.96, 95% confidence interval [CI]: 1.49-5.87), having frequent contact with patients (OR: 2.83, 95% CI: 1.47-5.45) and being employed in medical wards (OR: 12.37, 95% CI: 1.38-110.17) or microbiology laboratories (OR: 5.65, 95% CI: 1.74-18.36) were independently associated with increased risk of acquiring TB. CONCLUSION: HCWs with frequent patient contact and those with BMI <19 kg/m(2) were at high risk of acquiring active TB. Nosocomial transmission of TB was pronounced in locations, such as medical wards and microbiology laboratories. Surveillance of high-risk HCWs and appropriate infrastructure modifications may be important to prevent interpersonal TB transmission in health care facilities.

Scrub typhus in South India: clinical and laboratory manifestations, genetic variability, and outcome.

OBJECTIVES: This study sought to document the clinical and laboratory manifestations, genetic variability, and outcomes of scrub typhus, an often severe infection caused by Orientia tsutsugamushi, in South India. METHODS: Patients admitted to a large teaching hospital with IgM ELISA-confirmed scrub typhus were evaluated. Clinical examination with a thorough search for an eschar, laboratory testing, chest X-ray, and outcome were documented and analyzed. Additionally, a 410-bp region of the 56-kDa type-specific antigen gene of O. tsutsugamushi was sequenced and compared with isolates from other regions of Asia. RESULTS: Most of the 154 patients evaluated presented with fever and non-specific symptoms. An eschar was found in 86 (55%) patients. Mild hepatic involvement was seen in most, with other organ involvement including respiratory, cardiovascular, and renal. Multi-organ dysfunction was noted in 59 (38.3%), and the fatality rate was 7.8%. Hypotension requiring vasoactive agents was found to be an independent predictor of mortality (p<0.001). The phylogeny of 26 samples showed 17 (65%) clustering with the Kato-like group and eight (31%) with the Karp-like group. CONCLUSIONS: The presentation of scrub typhus can be variable, often non-specific, but with potentially severe multi-organ dysfunction. Prompt recognition is key to specific treatment and good outcomes. Further study of the circulating strains is essential for the development of a successful vaccine and sensitive point-of-care testing.

Informed consent among nursing students participating in biomedical research.

For consent in biomedical research, it is essential that research participants understand the need for research, the study protocol, the risk and benefits of participation, the freedom to participate or decline and the right to leave the study at any time. A structured questionnaire was used to assess understanding and knowledge among nursing trainees participating in a cohort study investigating exposure and latent tuberculosis at a tertiary care hospital. Data were collected for 138 participants. While 97% were aware of their enrollment into a research protocol, only 78% could state that it was a study on tuberculosis. Approximately two-thirds were aware of plans for blood collection, but not all of them knew the timings or number of samples. The majority (59%) participants had consulted others before making the decision to participate, and only 73% felt that their participation was completely voluntary. Even among healthcare trainees, emphasis needs to be placed on testing both the knowledge and understanding of participants to ensure the principle and practice of truly informed consent.

An open-labelled randomized controlled trial comparing costs and clinical outcomes of open endotracheal suctioning with closed endotracheal suctioning in mechanically ventilated medical intensive care patients.

PURPOSE: Closed endotracheal suctioning (CES) may impact ventilator-associated pneumonia (VAP) risk by reducing environmental contamination. In developing countries where resource limitations constrain the provision of optimal bed space for critically ill patients, CES assumes greater importance. MATERIALS AND METHODS: In this prospective, open-labeled, randomized controlled trial spanning 10 months, we compared CES with open endotracheal suctioning (OES) in mechanically ventilated patients admitted to the medical intensive care unit (ICU) of a university-affiliated teaching hospital. Patients were followed up from ICU admission to death or discharge from hospital. Primary outcome was incidence of VAP. Secondary outcomes included mortality, cost, and length of stay. RESULTS: Two hundred patients were recruited, 100 in each arm. The incidence of VAP was 23.5%. Closed endotracheal suctioning was associated with a trend to a reduced incidence of VAP (odds ratio, 1.86; 95% confidence interval, 0.91-3.83; P = .067). A significant benefit was, however, observed with CES for late-onset VAP (P = .03). Mortality and duration of ICU and hospital stay were similar in the 2 groups. The cost of suction catheters and gloves was significantly higher with CES (Rs 272 [US $5.81] vs Rs 138 [US $2.94], P < .0001). Nine patients need to be treated with CES to prevent 1 VAP (95% confidence interval, -0.7 to 22). CONCLUSIONS: In the ICU setting in a developing country, CES may be advantageous in reducing the incidence of VAP, particularly late-onset VAP. These results mandate further studies in this setting before specific guidelines regarding the routine use of CES are proposed.