Comparison of clinical presentation and out-comes of Chikungunya and Dengue virus infections in patients with acute undifferentiated febrile illness from the Sindh region of Pakistan.

BACKGROUND: Arboviruses are a cause of acute febrile illness and outbreaks worldwide. Recent outbreaks of Chikungunya virus (CHIKV) in dengue endemic areas have alarmed clinicians as unique clinical features differentiating CHIKV from Dengue virus (DENV) are limited. This has complicated diagnostic efforts especially in resource limited countries where lab testing is not easily available. Therefore, it is essential to analyse and compare clinical features of laboratory confirmed cases to assist clinicians in suspecting possible CHIKV infection at time of clinical presentation. METHODOLOGY: A prospective point prevalence study was conducted, with the hypothesis that not all patients presenting with clinical suspicion of dengue infections at local hospitals are suffering from dengue and that other arboviruses such as Chikungunya, West Nile viruses, Japanese Encephalitis virus and Zika virus are co-circulating in the Sindh region of Pakistan. Out-patients and hospitalized (in-patients) of selected district hospitals in different parts of Sindh province of Pakistan were recruited. Patients with presumptive dengue like illness (Syndromic diagnosis) by the treating physicians were enrolled between 2015 and 2017. Current study is a subset of larger study mentioned above. Here-in we compared laboratory confirmed cases of CHIKV and DENV to assess clinical features and laboratory findings that may help differentiate CHIKV from DENV infection at the time of clinical presentation. RESULTS: Ninety-eight (n = 98) cases tested positive for CHIKV, by IgM and PCR and these were selected for comparative analysis with DENV confirmed cases (n = 171). On multivariable analysis, presence of musculoskeletal [OR = 2.5 (95% CI:1.6-4.0)] and neurological symptoms [OR = 4.4 (95% CI:1.9-10.2)], and thrombocytosis [OR = 2.2 (95% CI:1.1-4.0)] were associated with CHIKV infection, while atypical lymphocytes [OR = 8.3 (95% CI:4.2-16.7)] and thrombocytopenia [OR = 8.1 (95% CI:1.7-38.8)] were associated with DENV cases at time of presentation. These findings may help clinicians in differentiating CHIKV from DENV infection. CONCLUSION: CHIKV is an important cause of illness amongst patients presenting with acute febrile illness in Sindh region of Pakistan. Arthralgia and encephalitis at time of presentation among patients with dengue-like illness should prompt suspicion of CHIKV infection, and laboratory confirmation must be sought.

Microbiological and clinical profile of infective endocarditis patients: an observational study experience from tertiary care center Karachi Pakistan.

BACKGROUND: The study analyzed microbiological and antimicrobial susceptibility profile of organisms isolated from patients with infective endocarditis (2015-17) and compared disease outcomes in cohorts of endocarditis patient with history of prior invasive vascular intervention (high risk group) vs those without (native valve group). We hypothesized that high risk group would be more likely to have severe disease outcomes. METHODS: This was a prospective cohort study (2015-17). All blood and cardiac tissue samples of enrolled patients suspected of endocarditis according to modified Duke's criteria were followed for microbiological and antimicrobial susceptibility profile. The high risk group was compared with the native valve group with 90 day follow up to determine difference in clinical course and outcome in terms of disease severity (defined as any patient with endocarditis undergoing surgical management, readmission or dying). The data was analyzed using SPSS 21.0 software and chi-square test. 90 day mortality was calculated using Kaplan Meier survival curves. RESULTS: Total 104 patients with endocarditis were enrolled. Overall culture positivity rate was 71.2%. Streptococcus species were the most common isolate (36.7%), followed by S. aureus (17.3%) cases. In Streptococcus species, 14.2% showed intermediate susceptibility to penicillin. Thirty six patients were included in the cohort analysis. A poor outcome was seen in 85.7% high risk group as compared to 50% of native valve group. The overall mortality rate was 19.4%. CONCLUSIONS: We found Streptococcus species to be the predominant pathogen for endocarditis overall. However Staphylococcus aureus predominated native valve group. High risk group showed more complicated clinical course.

Irrational antibiotic prescribing practice among children in critical care of tertiary hospitals.

This study assessed the prescribing pattern of irrational use of antibiotic among children under age of 12 years in public and private sector hospitals in Pakistan. The prospective clinical evaluation of drug utilization pattern of antimicrobials from Patient Bedside File (PBF) of in-patients and Culture Sensitivity Test (CST) reports were evaluated to determine the antibiotic resistance. Two indicators recorded to assess antibiotic prescribing were; dose of prescribed antibiotic (low-dose, rational and high -dose) and Indication (valid or invalid). Antibiotics resistance for 25 selected antibiotics was determined by culture sensitivity test. This study showed that in Private Sector Hospital 77.7% neonates, 13.3% infants and 9% children admitted in ICU were receiving antibiotics, among them only 57.3% neonates, 62% infants and 59.9% children were found valid that is prescribed antibiotics for right indication. 27% neonates, 19% infants and 22.1% children were prescribed under dose of antibiotics, which may lead to antimicrobial resistance and increased cost of hospital stay. Only 29.1% neonates, 30% infants and 36.8% children were receiving rational dosing. In Public Sector Hospital, 65.6% neonates, 19.4% infants and 15% children were receiving antibiotics. Among them valid indication was found in 35.3% neonates, 35.6% infants and 39.8% in children. 33.3% neonates, 26.6% infants and 28.2% children were receiving under dose that may lead to resistance not only among those who were prescribed under dose but also such bacteria become resistant and spread to other population to increase antimicrobial resistance. The irrational prescribing of antibiotics was found very high (above 50%) in Public sector hospital (Hospital-B) for every age group whereas in Private sector hospital (Hospital-A) this practice was found near to 50%. In this study the prescribing frequency of Amikacin, Cefixime, Cefotaxime, Meropenem, Amoxicillin, Vancomycin, Azithromycin, Levofloxacin and Clarithromycin was found above 80% in both hospitals (A and B). Among these, Amoxicillin, Penicillin, Erythromycin and Cephalexin showed higher resistance i.e. 49.2%.

Patterns of sudanophilic lesions at ostia of descending thoracic and abdominal aorta in cholesterol-fed adult rabbits / Patrones de lesiones sudanofílicas en el ostio de las partes torácica y abdominal de la aorta en conejos adultos alimentados con colesterol

Sudan-positive atherosclerotic lesions preferentially occur at downstream and lateral margins of arterial branch ostia in human neonates and weanling rabbits but tend to develop at lateral and upstream margins in old subjects. We investigated (i) the pattern of sudanophilic lesions at aortic ostia of cholesterol-fed adult rabbits and (ii) determined any differences in lesion distribution between descending thoracic and abdominal aorta. Ten adult males, New Zealand white rabbits were fed 2 percent high cholesterol diet. After six weeks, aortas were excised, opened longitudinally and stained with Sudan-IV for gross examination of atherosclerotic lesions. A total of 156 descending thoracic and 90 abdominal ostia were examined. Mean lesion frequencies upstream, downstream and at lateral margins of the affected ostia were calculated and compared. Sudanophilic lesions were detected around 32 percent ostia of descending thoracic aorta and 25 percent those of abdominal aorta. At ostia of descending thoracic aorta, lesion frequencies were significantly higher (P<0.001) downstream (95 percent) and at lateral margins (92 percent) than upstream (2 percent). In abdominal aorta, lateral (100 percent) and upstream (43 percent) margins were significantly (P<0.05) more affected while minimal lesion frequencies were seen at downstream branch points (9 percent). Comparison between descending thoracic and abdominal aorta showed an insignificant difference of lesion frequencies at lateral margins (P>0.05) but a highly significant difference at upstream versus downstream of ostia (P<0.001). We concluded that in cholesterol-fed adult rabbits, juvenile pattern of downstream lipid deposition persists at ostia of descending thoracic aorta while a switch towards the upstream pattern of old subjects occurs at ostia of abdominal aorta.

Las lesiones ateroscleróticas Sudán-positivas se producen preferentemente en los márgenes posteriores y laterales del ostio de las ramas arteriales en neonatos humanos y en conejos destetados, pero tienden a desarrollarse en los márgenes laterales y superiores en sujetos de edad avanzada. Investigamos el patrón de lesiones sudanofílicas en el ostio aórtico de conejos adultos alimentados con colesterol y determinamos las diferencias en la distribución de lesiones entre la aorta torácica descendente y abdominal. Diez conejos machos blancos adultos New Zealand fueron alimentados con una dieta alta en colesterol al 2 por ciento. Después de seis semanas, fueron extraídas las aortas, se disecaron longitudinalmente y se tiñeron con Sudan-IV para el examen macroscópico y se observaron las lesiones ateroscleróticas. Fueron examinados 156 ostios de aortas torácicas descendentes y 90 de aortas abdominales. Fueron calculadas y comparadas las frecuencias medias de lesiones superiores, inferiores y de los márgenes laterales de los ostios afectados. Las lesiones sudanofílicas se detectaron en alrededor del 32 por ciento de ostios de la aorta torácica descendente y en el 25 por ciento de las aortas abdominales. En el ostio de la aorta torácica descendente, las frecuencias de lesiones fueron significativamente mayores (p <0,001) por superior (95 por ciento) y en los márgenes laterales (92 por ciento) que por inferior (2 por ciento). En la aorta abdominal, los márgenes laterales (100 por ciento) y superiores (43 por ciento) fueron significativamente más afectados (p <0,05), mientras que las frecuencias mínimas de lesiones se observaron en los puntos de la rama descendente (9 por ciento). La comparación entre la aorta torácica descendente y abdominal mostró una diferencia no significativa de las frecuencias de lesiones en los márgenes laterales (p> 0,05), pero muy significativa al comparar el margen superior con el inferior (p <0,001). Llegamos a la conclusión que en los conej...