Invasive aspergillosis in liver transplant recipients in the current era.

Invasive aspergillosis (IA) is a rare but fatal disease among liver transplant recipients (LiTRs). We performed a multicenter 1:2 case-control study comparing LiTRs diagnosed with proven/probable IA and controls with no invasive fungal infection. We included 62 IA cases and 124 matched controls. Disseminated infection occurred only in 8 cases (13%). Twelve-week all-cause mortality of IA was 37%. In multivariate analyses, systemic antibiotic usage (adjusted odds ratio [aOR], 4.74; P = .03) and history of pneumonia (aOR, 48.7; P = .01) were identified as independent risk factors associated with the occurrence of IA. Moreover, reoperation (aOR, 5.99; P = .01), systemic antibiotic usage (aOR, 5.03; P = .04), and antimold prophylaxis (aOR, 11.9; P = .02) were identified as independent risk factors associated with the occurrence of early IA. Among IA cases, Aspergillus colonization (adjusted hazard ratio [aHR], 86.9; P < .001), intensive care unit stay (aHR, 3.67; P = .02), disseminated IA (aHR, 8.98; P < .001), and dialysis (aHR, 2.93; P = .001) were identified as independent risk factors associated with 12-week all-cause mortality, while recent receipt of tacrolimus (aHR, 0.11; P = .001) was protective. Mortality among LiTRs with IA remains high in the current era. The identified risk factors and protective factors may be useful for establishing robust targeted antimold prophylactic and appropriate treatment strategies against IA.

A sinister itch: prurigo nodularis in Hodgkin lymphoma.

A 24 year old lady presented with pruritis and lichenified nodular skin lesions for 1 year. She also had clinical features to suggest a superior venacaval syndrome (SVC) with large rubbery cervical lymph nodes. She was subsequently diagnosed to have Hodgkin lymphoma on lymph node biopsy. Skin changes in lymphoma can precede other clinical symptoms by months. High clinical suspicion and thorough systemic examination would help in excluding a sinister problem in patients with chronic dermatosis.

Toxicology of the newer neonicotinoid insecticides: imidacloprid poisoning in a human.

Imidacloprid, a potent neonicotinoid insecticide, is currently one of the best selling insecticides. We report a patient with clinical toxicity due to the ingestion of imidacloprid in a deliberate suicide attempt. The structure and mode of action of imidacloprid are discussed.

Enterococcal Bacteremia is Associated with Prolonged Stay in the Medical Intensive Care Unit.

BACKGROUND: Although enterococci are relatively common nosocomial pathogens in surgical intensive care units (ICUs), their significance in blood cultures from patients in the medical ICU is unclear. MATERIALS AND METHODS: In this retrospective study spanning 2 years, the clinical and microbiological characteristics of enterococcal bacteremia among medical ICU patients were evaluated. RESULTS: Of 1325 admissions, 35 with enterococcal bacteremia accounted for 14.8% of positive blood cultures. They were significantly older (P=0.03) and had various co-morbidities. Most had vascular (96.9%) and urinary (85.3%) catheters, and 67.7% were mechanically ventilated. In addition to blood, enterococci were isolated from vascular catheters (8.6%) and other sites (20%), while no focus was identified in 77% of patients. Prior use of broad-spectrum antimicrobials was nearly universal. All isolates tested were sensitive to vancomycin and linezolid. Resistance to ampicillin and gentamicin were 44.7% and 52.6%, respectively. Compared with other medical ICU patients, patients with enterococcal bacteremia had a longer ICU stay (P<0.0001) and a trend toward higher ICU mortality (P=0.08). CONCLUSIONS: Enterococcal bacteremia is an important nosocomial infection in the medical ICU, with a predilection for older patients with multiple comorbidities. Its occurrence is associated with a significantly longer ICU stay and a trend to a higher mortality. The choice of antibiotics should be dictated by local susceptibility data.

Risk factors for MDR and XDR-TB in a tertiary referral hospital in India.

BACKGROUND: India has a high burden of drug resistant TB, although there are few data on XDR-TB. Although XDR-TB has existed previously in India, the definition has not been widely applied, and surveillance using second line drug susceptibility testing has not been performed. Our objective was to analyze clinical and demographic risk factors associated with isolation of MDR and XDR TB as compared to susceptible controls, at a tertiary center. METHODOLOGY/FINDINGS: Retrospective chart review based on positive cultures isolated in a high volume mycobacteriology laboratory between 2002 and 2007. 47 XDR, 30 MDR and 117 susceptible controls were examined. Drug resistant cases were less likely to be extrapulmonary, and had received more previous treatment regimens. Significant risk factors for XDR-TB included residence outside the local state (OR 7.43, 3.07-18.0) and care costs subsidized (OR 0.23, 0.097-0.54) in bivariate analysis and previous use of a fluoroquinolone and injectable agent (other than streptomycin) (OR 7.00, 95% C.I. 1.14-43.03) and an initial treatment regimen which did not follow national guidelines (OR 5.68, 1.24-25.96) in multivariate analysis. Cavitation and HIV did not influence drug resistance. CONCLUSIONS/SIGNIFICANCE: There is significant selection bias in the sample available. Selection pressure from previous treatment and an inadequate initial regimen increases risk of drug resistance. Local patients and those requiring financial subsidies may be at lower risk of XDR-TB.

Corticosteroids in the prevention and treatment of acute respiratory distress syndrome (ARDS) in adults: meta-analysis.

OBJECTIVE: To systematically review the efficacy of steroids in the prevention of acute respiratory distress syndrome (ARDS) in critically ill adults, and treatment for established ARDS. DATA SOURCES: Search of randomised controlled trials (1966-April 2007) of PubMed, Cochrane central register of controlled trials, Cochrane database of systematic reviews, American College of Physicians Journal Club, health technology assessment database, and database of abstracts of reviews of effects. DATA EXTRACTION: Two investigators independently assessed trials for inclusion and extracted data into standardised forms; differences were resolved by consensus. DATA SYNTHESIS: Steroid efficacy was assessed through a Bayesian hierarchical model for comparing the odds of developing ARDS and mortality (both expressed as odds ratio with 95% credible interval) and duration of ventilator free days, assessed as mean difference. Bayesian outcome probabilities were calculated as the probability that the odds ratio would be > or =1 or the probability that the mean difference would be > or =0. Nine randomised trials using variable dose and duration of steroids were identified. Preventive steroids (four studies) were associated with a trend to increase both the odds of patients developing ARDS (odds ratio 1.55, 95% credible interval 0.58 to 4.05; P(odds ratio > or =1)=86.6%), and the risk of mortality in those who subsequently developed ARDS (three studies, odds ratio 1.52, 95% credible interval 0.30 to 5.94; P(odds ratio > or =1)=72.8%). Steroid administration after onset of ARDS (five studies) was associated with a trend towards reduction in mortality (odds ratio 0.62, 95% credible interval 0.23 to 1.26; P(odds ratio > or =1)=6.8%). Steroid therapy increased the number of ventilator free days compared with controls (three studies, mean difference 4.05 days, 95% credible interval 0.22 to 8.71; P(mean difference > or =0)=97.9%). Steroids were not associated with increase in risk of infection. CONCLUSIONS: A definitive role of corticosteroids in the treatment of ARDS in adults is not established. A possibility of reduced mortality and increased ventilator free days with steroids started after the onset of ARDS was suggested. Preventive steroids possibly increase the incidence of ARDS in critically ill adults.

An evaluation of the role of noninvasive positive pressure ventilation in the management of acute respiratory failure in a developing country.

OBJECTIVE: Noninvasive positive pressure ventilation (NIPPV) has been shown to decrease the need for invasive mechanical ventilation (MV) in patients presenting with acute respiratory failure (ARF). We conducted a prospective study to assess if NIPPV use, in a developing country, was associated with clinical and physiological improvements. DESIGN: Prospective observational study. MATERIALS AND METHODS: Forty patients admitted to a medical intensive care unit during a 2-year period who fulfilled criteria for inclusion formed the study cohort to receive NIPPV. FINDINGS: Baseline (mean +/- SD) pH, PaCO 2 and PaO 2 were 7.25 +/- 0.08, 76.6 +/- 20.9 and 79.18 +/- 40.56 mmHg respectively. The primary indication for NIPPV was hypercapnic respiratory failure (n = 36, 90%). The success rate with NIPPV was 85%, with 34 of 40 patients weaned successfully. Significant improvements were observed at 1 hour following institution of NIPPV in pH (7.31 +/- 0.09, P 2 (65 +/- 17.9, P 2 54.7 +/- 20) and maintained (within 12 h) postweaning from the ventilator (pH 7.39 +/- 0.08, PaCO 2 51.9 +/- 12.4). No significant change in the PaO 2 was observed during NIPPV; PaO 2 after 1 h, prior to weaning and after weaning was 90.53 +/- 42.85, 84.80 +/- 33.76, 78.71 +/- 43.81 respectively. CONCLUSION: This study has demonstrated benefits of NIPPV in avoiding the need for invasive MV in patients presenting with ARF of diverse etiology, with results comparable to developed nations. Increased use of NIPPV in ARF is likely to impact favorably in nations with limited resources.