Correlation of Portal Vein Diameter as a Reflection of Portal Hypertension With Clinical and Laboratory Parameters in Chronic Liver Disease.

Chronic liver disease (CLD) patients develop portal hypertension which lead to complications like splenomegaly, ascites and esophageal varices. Portal hypertension is defined as hepatic venous pressure gradient more than 5mmHg, being invasive it is difficult to measure. Some studies show that increased portal vein diameter (PVD) on ultrasonography correlate with oesophageal varices and can indicate portal hypertension. Studies correlating PVD with other complications of portal hypertension like ascites and spleen size are lacking. Aim of this study was to correlate portal vein diameter with ascites, spleen size, thrombocytopenia and prognostic markers like Child-Turcotte Pugh (CTP) score and Model for End stage Liver Disease (MELD) score in Chronic liver disease patients. MATERIAL: This was a cross-sectional observational study of patients with Chronic liver disease conducted at tertiary care teaching hospital. All patient underwent clinical history, examination, blood testing and ultrasonography. Data collected was analysed by using statistical tests. OBSERVATION: Out of 97 CLD patients taken in study, the mean age of patients was 47.39 ± 12.64 year and majority were male (75.3%). Most common etiological factor was alcohol (in 53.7%). On clinical examination, 55.7% patients had pallor, 54.6% had icterus. Chest radiograph shows pleural effusion in 14.4% patients. Mean portal vein diameter was found to be 12.31 ± 2.71mm. Correlation coefficient of portal vein diameter with spleen size was 0.3 with p value of 0.004 suggesting a positive correlation. Parameters like thrombocytopenia, CTP score and MELD score correlation coefficient was -0.2(p-value: 0.066), 0.1(p value: 0.463) and 0.0(p-value: 0.725) respectively. The mean of PVD(mm) in ascites group was 12.43 and non ascites group was 11.92. Strength of association was 0.08 (Point Biserial correlation) indicating no association. CONCLUSION: Portal vein diameter had positive correlation with spleen size which is statistically significant in our study. No significant correlation was observed between PVD with ascites, thrombocytopenia, CTP score and MELD score.

Crosstalk between T Helper Cell Subsets and Their Roles in Immunopathogenesis and Outcome of Polytrauma Patients.

PURPOSE: One of the leading causes of morbidity and early-age mortality across the globe is trauma. It disrupts immune system homeostasis and intensely affects the innate and adaptive immune responses, predisposing patients to posttrauma complications and poor outcomes. Most of the studies on posttrauma cellular immune response have been centered on the T helper-1-T helper-2 imbalances after trauma. This study was conducted to understand the role of circulating novel T helper cells in the acute posttraumatic period and clinical outcome of trauma patients. MATERIALS AND METHODS: Signature cytokines and transcription factors of circulating Th (T helper)-9, Th-17, Th-22, and regulatory T helper cells were studied using flowcytometry along with serum biomarkers in 49 patients with polytraumatic injuries admitted to a tertiary care hospital. The patients were followed up until their outcome. The results were correlated with their clinical outcomes. RESULTS: In patients who died, higher nTreg, iTreg, Tr1 (early-phase), and higher IRF4+Th-9, IL17+ Th-17, and RORγT+ Th-17 (mid-phase) were seen. However, by the late phase, only RORγT+ Th-17 remained higher. Serum IL-6 and PCT were found to be consistently higher. In survivors, higher Th-3 (early phase), Th-22 (mid-phase), and IRF4+Th-9, IL17+ Th-17, nTreg, Th-3 (late phase) were observed to have played a protective role. Serum IL-2, IL-4, IL-17A and IL-22 were significantly higher in survivors. CONCLUSION: Different T helper subsets were observed to be playing pathogenic and protective roles in different phases of trauma and could be used for early prognostication and make way for noninvasive management of critically injured trauma patients by immunomodulation. HOW TO CITE THIS ARTICLE: Khurana S, Bhardwaj N, Kumar S, Sagar S, Pal R, Soni KD, et al. Crosstalk between T Helper Cell Subsets and Their Roles in Immunopathogenesis and Outcome of Polytrauma Patients. Indian J Crit Care Med 2020;24(11):1037-1044.

Pathogen burden & associated antibiogram of Pseudomonas spp. in a tertiary care hospital of India.

Antimicrobial resistance particularly in Gram-negative bacilli is an increasing problem worldwide. Pseudomonas spp. is one the most common Gram-negative bacteria associated with nosocomial infections and therefore, its trend of antimicrobial resistance needs to be studied. The aim of this study was to evaluate the rate of antimicrobial resistance and changes in resistance pattern over a period of five years (2012-2016) in Pseudomonas spp. isolated from trauma patients attending a tertiary care hospital in north India. During the study, a total of 2444 Pseudomonas spp. were isolated from the various clinical sample. The most common species isolated was P. aeruginosa (2331, 95%). The highest level of resistance was observed against levofloxacin (1678, 69%) and the lowest level of resistance was observed against tobramycin (1254, 51%). Irrational and inappropriate use of antibiotics was found to be responsible for multidrug resistance in Pseudomonas spp. Hence, there is an urgent need to emphasize strict antibiotic policy to minimize the misuse of antimicrobials.

Antimicrobial resistance in beta-haemolytic streptococci in India: A four-year study.

BACKGROUND & OBJECTIVES: The incidence and severity of invasive and non-invasive infections demonstrate variability over time. The emerging resistance of Group A streptococci (GAS) to commonly used antibiotics is of grave concern. This study was conducted to assess the antimicrobial resistance of beta-haemolytic streptococci (ßHS) in India and to ascertain the molecular mechanisms of resistance. METHODS: All isolates of ßHS from the Trauma Centre of All India Institute of Medical Sciences (AIIMS) (north India), and heavily populated area of old Delhi from 2010 to 2014 and Yashoda Hospital, Secunderabad (in south India, 2010-2012) and preserved isolates of ßHS at AIIMS (2005-2009) were included. Phenotypic confirmation was done using conventional methods and the Vitek 2. Antibiotic sensitivity testing was done by disc diffusion and E-test. Detection of resistance genes, erm(A), erm(B), mef(A), tet(M) and tet(O), was done by polymerase chain reaction (PCR). RESULTS: A total of 296 isolates of ßHS (240 from north and 21 from south India) were included in the study. Of the 296 ßHS, 220 (74%) were GAS, 52 (17.5%) were Group G streptococci and 11 (3.7%), 10 (3.3%) and three (1%) were Group B streptococci, Group C streptococci and Group F streptococci, respectively. A total of 102 (46%) and 174 (79%) isolates were resistant to tetracycline and erythromycin, respectively; a lower resistance to ciprofloxacin (21, 9.5%) was observed. A total of 42 (14%) and 30 (10%) isolates, respectively, were positive for tet(M) and erm(B) genes. Only 13 (5%) isolates were positive for mef(A). None of the isolates were positive for erm(A) and tet(O). There was discordance between the results of E-test and PCR for erythromycin and tetracycline. INTERPRETATION & CONCLUSIONS: A high level of resistance to erythromycin and tetracycline was seen in ßHS in India. Discordance between genotypic and phenotypic results was reported. Absence of erm(A) and tet(O) with high prevalence of tet(M) and erm(B) was observed.

CD14+ Monocytic Cytokines: Impact on Outcome in Severely Injured Patients.

INTRODUCTION: Trauma is one of the leading causes of mortality worldwide. Trauma patients, who presented to the hospital casualty department within 24 h of injury, further admitted to the Surgical Intensive Care Unit were enrolled in this study. MATERIALS AND METHODS: The aim was to study the peripheral blood monocyte activity to produce tumor necrosis factor (TNF-α), interleukin-1 (IL-1) ß, IL-6, and IL-8 in severely injured patients after trauma. RESULT: A total of 28 polytrauma patients were enrolled and observed that the levels of TNF-α, IL-1 ß, IL-6, and IL-8 were significantly decreased and levels of IL-8 were increased in the fatal patients compared to the healthy controls. CONCLUSION: After trauma, an immediate hyperactivation of circulating monocytes is rapidly followed by a substantial paralysis of cell function. Decreased activity of monocytes can be used to identify potential fatal immunological disruption. Since immunological disruption occurs before clinical symptoms; our study proposes an immunological prognostication score for trauma victims.

Bronchoalveolar lavage fluid cytokine bead array profile for prognostication of ventilated trauma patients.

AIM OF STUDY: Ventilator-associated pneumonia (VAP) is a common cause of mortality in trauma patients admitted to Intensive Care Units. The outcome of such patients may be dependent on local host immune response, which may be best reflected in studies using bronchoalveolar lavage (BAL) fluid. The present study was conducted to ascertain the cytokine profile of BAL using the cytometric bead array (CBA) in a flow cytometer and to correlate the levels of Th-1/Th-2 cytokines in BAL with the clinical outcome of ventilated trauma patients. PATIENTS AND METHODS: BAL was collected from the patients with suspected VAP. CBA was performed to assess the levels of interleukin-4 (IL-4), IL-6, IL-8, IL-1 ß, interferon gamma (IFN-γ), and tumor necrosis factor-alpha in the BAL samples. After acquiring the BAL samples on the flow cytometer, the results were generated using FCAP Array™ software. The cytokine profile was correlated to clinical outcomes. RESULTS: A total of forty patients were enrolled during the study period. Of these, 12 patients (30%) had confirmed VAP and 8 (20%) patients had a fatal outcome. The levels of IL-8 and IFN-γ correlated significantly with the development of VAP and elevated IL-6 in BAL was associated with a poor outcome. CONCLUSION: A proinflammatory response in the form of elevated IL-6 and IL-8 correlated poorly with the clinical outcome. Th-1 response was significantly reduced in patients with VAP. A proinflammatory response in the form of elevated IL-6 and IL-8 correlated poorly with the clinical outcome.

Antibiotic susceptibilities, streptococcal pyrogenic exotoxin gene profiles among clinical isolates of group C or G Streptococcus dysgalactiae subsp. equisimilis & of group G S. anginosus group at a tertiary care centre.

BACKGROUND & OBJECTIVES: Group C and group G streptococci (together GCGS) are often regarded as commensal bacteria and their role in streptococcal disease burden is under-recognized. While reports of recovery of GCGS from normally sterile body sites are increasing, their resistance to macrolides, fluoroquinolone further warrants all invasive ß haemolytic streptococci to be identified to the species level and accurately tested for antimicrobial susceptibility. This study was aimed to determine the prevalence, clinical profile, antimicrobial susceptibility and streptococcal pyrogenic exotoxin gene profile (speA, speB, speC, speF, smeZ, speI, speM, speG, speH and ssa) of GCGS obtained over a period of two years at a tertiary care centre from north India. METHODS: The clinical samples were processed as per standard microbiological techniques. ß-haemolytic streptococci (BHS) were characterized and grouped. Antimicrobial susceptibility of GCGS was performed using disk diffusion method. All GCGS were characterized for the presence of streptococcal pyrogenic exotoxins (spe) and spe genes were amplified by PCR method. RESULTS: GCGS (23 GGS, 2GCS) comprised 16 per cent of ß haemolytic streptococci (25/142 ßHS, 16%) isolated over the study period. Of the 25 GCGS, 22 (88%) were recovered from pus, two (8%) from respiratory tract, whereas one isolate was recovered from blood of a fatal case of septicaemia. Of the total 23 GGS isolates, 18 (78%) were identified as Streptococcus dysgalactiae subsp equisimilis (SDSE, large-colony phenotype), five (21%) were Streptococcus anginosus group (SAG, small-colony phenotype). The two GCS were identified as SDSE. All GCGS isolates were susceptible to penicillin, vancomycin, and linezolid. Tetracycline resistance was noted in 50 per cent of SDSE isolates. The rates of macrolide and fluoroquinolone resistance in SDSE were low. Twelve of the 20 SDSE isolates were positive for one or more spe genes, with five of the SDSE isolates simultaneously carrying speA+ speB+ smeZ+ speF or speB+ smeZ+speF, speI+speM+speG+speH or, speI+spe M+speH or speA+ speB+ speC+ smeZ+ speF. One notable finding was the presence of spe B in four of the five isolates of the Streptococcus anginosus group. No isolate was positive for ssa. INTERPRETATION & CONCLUSIONS: Our study showed no association between GCGS isolates harbouring streptococcal pyrogenic exotoxins and disease severity. This might be attributed to the small sample size of spe-positive isolates.

Outbreak of Streptococcus pyogenes emm type 58 in a high dependency unit of a level-1 trauma center of India.

BACKGROUND AND AIMS: Group A Streptococcus (GAS) can cause illnesses ranging from self-limited to severe, life-threatening, invasive infections. The objective of the following study was to investigate a suspected Streptococcus pyogenes outbreak in a high dependency unit (HDU) of our trauma center. MATERIALS AND METHODS: All the isolates of beta hemolytic Streptococci were identified by standard microbiological methods, Vitek 2 system and latex agglutination tests. Antimicrobial susceptibility testing was performed as recommended by Clinical Laboratory Standards Institute. Exotoxin genes, including speA, speB, speC, speF, smeZ, ssa, speG, speH, speJ, speL, speM and speI were detected by polymerase chain reaction (PCR). The emm types of isolates of S. pyogenes were determined by sequencing the variable 5' end of emm gene after amplification by PCR. RESULTS: In a 28 bedded poly-trauma ward with a four bedded HDU three out of four patients developed S. pyogenes emm type 58 infection. The strain was macrolide and tetracycline resistant and produced the Streptococcal pyrogenic exotoxins speB, speC, speG, speF and smeZ. Surveillance sampling was done for investigation from patients, health-care workers and environmental samples. CONCLUSION: An outbreak of GAS infections was established caused by the uncommonly reported emm type 58. The outbreak was controlled by prompt treatment, intensive surveillance, feedback and training.

Implementation of a short course of prophylactic antibiotic treatment for prevention of postoperative infections in clean orthopaedic surgeries.

BACKGROUND & OBJECTIVES: Perioperative antimicrobial prophylaxis constitutes the bulk of antimicrobial consumption in any hospital. This study was conducted at a level 1 Trauma Centre of a tertiary care hospital of India to assess the efficacy of a short (24 h) course of perioperative antibiotic prophylactic regimen in preventing surgical site infections (SSI) in open reduction and internal fixation (ORIF) of closed fractures of limbs and to assess if the same can be implemented as a general policy. METHODS: Patients of either sex, aged 18 yr or more, who were scheduled for ORIF and were willing and able to give informed consent, were included in the study. Patients were randomly allocated into two groups. Group 1 (n=100) received 3 doses of 1 g i.v. cefuroxime perioperatively spaced 12 h apart and group 2 (n=97) received the conventional existing regimen [5 days of i.v. antibiotics (cefuroxime 1 g twice daily along with amikacin 15 mg/kg in 2 divided doses), followed by oral cefuroxime, 500 mg twice daily till suture removal]. RESULTS: Of the 197 patients, four patients developed a surgical site infection (three with methicillin resistant Staphylococcus aureus and one Acinetobacter baumanii). Of these, two patients were in group 1 and the remaining two in group 2. These patients were treated with i.v. antibiotics based on the culture and antimicrobial sensitivity reports. The cost of the short course treatment was ` 150 per patient as compared to ` 1,900 per patient for conventional regimen. INTERPRETATION & CONCLUSIONS: There was no significant difference in rates of SSI among the two groups in our study. Cost evaluation revealed that shorter course was less expensive than conventional long course regimen. Implementation of a short course perioperative regimen will go a long way in reducing antimicrobial resistance, cost and adverse reactions to antimicrobials.

Acute Kidney Injury in Acute Myocardial Infarction and Its Outcome at 3 and 6 Months.

Epidemiological data on the prevalence of acute kidney injury (AKI) in acute coronary syndrome are sparse, with most studies having been conducted retrospectively. This study prospectively analyzed the incidence of AKI in patients with acute myocardial infarction (AMI) and to identify the risk factors for AKI and their renal outcome at 3 and 6 months. This was a prospective and observational study, which enrolled 120 patients presenting with their first episode of AMI to our hospital and consented to the study. Renal function tests were performed at admission, at 48 h, and at follow-up at 3 and 6 months. The majority of the patients underwent a percutaneous coronary intervention (59.2%), 21.7% received thrombolytic therapy, and 19.2% were managed conservatively. At 48 h, 11 patients had AKI. At 3 months, 8 patients had died, and renal dysfunctions were seen in 9 out of 112 patients. At 6 months, 12 patients out of 112 had renal dysfunction. There was no difference in the incidence of AKI in patients with an estimated glomerular filtration rate above and below 60 mL/min/1.73 m2. Killip Class 4 and diabetes mellitus were associated with an increased incidence of renal dysfunction in AMI patients. The type of treatment and the use of a contrast agent in the coronary intervention did not affect the development of AKI. According to this study, if indicated, a percutaneous coronary intervention should not be denied to patients for fear of developing AKI. This needs to be examined in larger randomized trials.

Common microRNAs in Epilepsy and Migraine: Their Possibility as Candidates for Biomarkers and Therapeutic Targets during Comorbid Onset of Both Conditions.

Epilepsy and migraine are chronic neurological disorders with shared clinical as well as pathophysiological mechanisms. Epileptic patients are at a higher risk of developing migraine compared to normal individuals and vice versa. Several genetic and environmental risk factors have been reported to be associated with the development of both diseases. Previous studies have already established standard genetic markers involved in various pathways implicated in the pathogenesis of both these comorbid conditions. In addition to genetic markers, epigenetic markers have also been found to be involved in the pathogenesis of epilepsy and migraine. Among the epigenetic markers, miRNAs have been explored at length and have emerged as significant players in regulating the expression of their target genes. miRNAs like miR-22, miR-34a, miR-155, miR-211, and Let-7b play a significant role in neuronal differentiation and seem to be associated with epilepsy and migraine as comorbid conditions. However, the exact shared mechanisms underlying the role of these miRNAs in these comorbid conditions are still unclear. The current review has been compiled with an aim to explore common microRNAs targeting the genes involved in shared molecular pathways leading to epilepsy and migraine as comorbid conditions. The new class of ncRNAs, i.e., tRNA transfer fragments, are also discussed. In addition, their role as potential biomarkers and therapeutic targets has also been evaluated. However, limitations exist, and based on the current literature available, only a few microRNAs seem to be involved in the pathogenesis of both these disorders.

Facial Nerve Palsy with Total Ophthalmoplegia; a Novel Presentation of Fungal Invasion.

Mucormycosis is an expeditious invasion of a fungus of angioinvasive nature, predominant in immunocompromised individuals, often leading to organ malfunction and loss. Facial nerve involvement and total ophthalmoplegia are its rare presentations. Early detection and treatment can alter natural disease course and prevent potential catastrophic outcomes in diabetic patients. Facial nerve palsy is mostly attributed to peripheral neuropathy in patients with advanced diabetes mellitus. It rarely raises alarm about an invasive fungal infection. Here, we report the case of a 38-year-old male with type 2 diabetes mellitus, who presented to us with left lower motor neuron type facial palsy and left-sided total ophthalmoplegia due to invasive rhino-orbito-cerebral mucormycosis (ROCM). Despite aggressive measures, including antifungal therapy and repeated endoscopic debridement, he subsequently developed central retinal artery occlusion (CRAO) and underwent left eye exenteration.

Epilepsy and Migraine Shared Genetic and Molecular Mechanisms: Focus on Therapeutic Strategies.

Epilepsy and migraine are both episodic disorders and share clinical as well as pathophysiological mechanisms. The prevalence of epilepsy in migraine patients is generally higher than normal as compared to general population and vice versa. Various environmental risk factors and genetic factors have been reported to be associated with susceptibility of these comorbid diseases. Specific genes have been implicated in the pathogenesis of the two diseases. However, the shared genetic susceptibility has not been explored extensively. Previous studies have reported that the alterations in the genes encoding ion channel proteins are common risk factors for both the diseases. The alterations in ion channel-encoding genes CACNAIA (T666M) and SCNIA (Q1489K and L1649Q) have been found to be involved in the development of familial hemiplegic migraine (FHM) as well as generalized epilepsy and some cases of focal epilepsy as well. The fact that both these disorders are treated with anti-epileptic drugs (AEDs) strongly supports common underlying mechanisms. This review has been compiled with an aim to explore the alterations in common genes involved in various pathways regulating neuronal hyperexcitability, a common risk factor for both these conditions. The avenue for future treatment strategies targeting common genes and molecular mechanisms has also been discussed.

Bilateral Renal Replacement Lipomatosis: A Case Report on Rare Complication of Obstructive Uropathy.

Renal replacement lipomatosis (RRL) is an uncommon complication, leading to the fatty replacement of the renal parenchyma. Various etiologies have been described for this long-term infirmity, but obstructive uropathy is one paramount cause. Previously described reports have documented unilateral disease in the majority, but we are narrating a case of bilateral RRL, which is very scarce in the literature. A 57-year-old man, who was a known case of obstructive uropathy, presented to us with the symptoms of urinary tract infection. In imaging evaluation, the patient was found to have bilateral RRL.

Brain MRI in Epstein-Barr Virus Meningoencephalitis in Children.

BACKGROUND AND PURPOSE: Epstein-Barr virus (EBV) meningoencephalitis can have variable and nonspecific brain magnetic resonance imaging (MRI) findings in children. This study was done with the purpose of describing brain MRI findings in children with EBV meningoencephalitis. MATERIALS AND METHODS: The study included 45 pediatric patients that presented with variable neurological symptoms and were found to have EBV meningoencephalitis based on positive EBV deoxyribonucleic acid (DNA) in the cerebrospinal fluid. All these patients had undergone brain MRI. Clinical and radiological features were evaluated. RESULTS: Fever was a presenting feature in all cases. Signs of meningitis and raised intracranial pressure (ICP) were seen in 24 (53.3%) cases, encephalopathy in 15 (33.3%), and seizures were present in 33 (73.3%). MRI was abnormal in 29 (64.4%) patients. The cortical/subcortical pattern was diagnosed in 9 (20%) cases, white matter involvement in 7 (15.5%), basal ganglia in 5 (11.1%), thalamic involvement in 4 (8.8%), brain stem involvement in 2 (6.2%), substantia nigra involvement in 2 (4.4%), and cerebellar involvement in 2 (4.4%). Diffusion restriction was present in 11 (24.4%) cases and susceptibility changes in 7 (15.5%). Meningeal enhancement was present in 10 (22.2%) cases. In addition, brain abscess and subdural effusion/empyema were present in 1 (2.2%) case each. CONCLUSION: Pediatric EBV meningoencephalitis has varied clinicoradiological spectrum and there is no specific MRI pattern to characterize the meningoencephalitis on imaging. Common MRI findings include cortical-subcortical involvement, white matter changes, basal ganglia, and thalamic involvement.

MRI Spectrum of Haemophilus influenzae Meningoencephalitis in Children.

BACKGROUND AND PURPOSE: Haemophilus influenzae type b (Hib) infection occurs mostly in children and is transmitted from person to person through the respiratory pathway. Hib strain is associated with meningitis or encephalitis. It is not an uncommon infection, particularly, in the developing world. This prospective cohort study was done with the aim of describing imaging findings in patients with Hib meningoencephalitis. MATERIALS AND METHODS: In a prospective cohort study, consecutive children admitted in the pediatric emergency unit with acute febrile encephalopathy were enrolled. The clinical details, CSF analysis, and microbiological and serological investigations were recorded on a case record proforma. Children with confirmed Hib meningoencephalitis were included in this study. Clinicoradiological features were assessed. RESULTS: A total of 16 patients with acute febrile encephalopathy, in whom CSF latex agglutination, CSF culture, or CSF multiplex PCR were positive for H. influenzae were included in this study. All these children were investigated with magnetic resonance imaging (MRI) brain. Important imaging findings were meningitis, predominantly around frontoparietal lobes (43%), cerebritis (28%), ventriculitis (14%), and subdural collections (21.5%). One patient had features consistent with acute disseminated encephalomyelitis (ADEM) while four patients had normal MRI scan. CONCLUSIONS: H. influenzae is still a common cause of meningitis in infants and children in the developing world. We have tried to study the most common MRI features associated with Hib infection to help radiologists alert the treating clinicians to further investigate these patients for appropriate prognostication.

Impact of monocytic cytokines in polytrauma patients with orthopedics injures.

OBJECTIVE: Orthopedic injuries are a growing epidemic affecting predominantly, the young population, after trauma. Polytrauma patients with a femoral fracture and with Injury Severity Score of >15 are of special concern because of complications like Systemic inflammatory response syndrome (SIRS), Multi-organ dysfunction syndrome (MODS) and sepsis. Against this background. We aimed to assess the role of monocytic cytokines in the development of complications in patients, having isolated diapheseal fracture of femur as compared to those having diapheseal fracture of femur along with ISS score >15. METHODOLOGY: Patients were divided into to two groups: in first group, only those patients who had isolated femur fracture were included (named as 'Group A'). In the second groups patients having femur fracture along with ISS >15 at the time of admission (named as 'Group B'), were included. The study used flowcytometry based intracellular cytokine assay to circumvent the problem associated with extracellular cytokine assay. RESULTS AND CONCLUSION: A total of 20 patients aged between 20 and 55 years, presenting to the emergency department within 24 h of injury were enrolled in Group 'A' and 'B' as per criteria mentioned above. Intracellular expression of cytokines in isolated femur fracture tends to normalize towards healthy control in the late phase of trauma. Elevated levels of IL-8 and IL-6 levels in late phase (Day 10) of trauma. IL-8 and IL-6 may increases to compensate the higher levels of IL-1ß. The effect of cytokines on the severity of injury was observed. This complex action of immune cells and proinflammatory cytokines were seen in initial and later stage of trauma.

Protocol for developing a surveillance system for surgical site infections.

Purpose: Healthcare-associated infections (HCAIs/ HAIs) are the most common adverse occurrences during health care delivery. Across the globe, millions of patients are affected by HAIs annually, with a higher burden and impact in developing nations. a major lacuna in planning preventing protocols is the absence of National Surveillance Systems in most low-middle income countries, which also prevents allocation of resources to the high-priority areas. Among all the HAIs, there is a huge global burden of SSIs, in terms of morbidity, prolonged hospital stays, increased antimicrobial treatment as well as attributable mortality. Method: This manuscript details the process of establishment of an SSI surveillance protocol at a level-1 trauma centre in North India. Result and Conclusion: Surveillance is an essential tool to reduce this burden. It is also an important primary step in recognizing problems and priorities, and it plays a crucial role in identifying risk factors for SSI and to be able to target modifiable risk factors. Therefore, it is imperative to establish reliable systems for surveillance of HAIs, to regularly estimate the actual burden of HAIs, and to use these data for developing indigenous preventive measures, tailored to the country's priorities.