Effect of Training and Checklist Based Use of Ventilator Associated Pneumonia (VAP) Prevention Bundle Protocol on Patient Outcome: A Tertiary Care Centre Study.

OBJECTIVE: VAP prevention bundle includes daily sedation free interval, DVT prophylaxis, raising head end of bed, use of orogastric rather than nasogastric tube. This study aims to study the practices regarding VAP prevention bundle and its compliance, educating about the practices and effects on patients outcome. DESIGN: Quasi-experimental study, conducted in 3 phases. SETTING: Hospital based. PARTICIPANTS: Invasive Mechanically ventilated patients in the Department of Medicine of a tertiary care hospital. 50 patients included in phase 1 and 3. INTERVENTION: Phase 1 and Phase 3 were pre and post intervention phases respectively when compliance to VAP prevention bundle was assessed with intermediate Phase 2, the intervention phase where the residents and nurses were educated about VAP bundle through various means. A checklist was attached to patient records. OUTCOME MEASURES: Incidence of VAP, total hospital and ICU stay, duration of mechanical ventilation and mortality. RESULTS: On comparing the 2 phases, it was found that there was increase in the compliance to VAP bundle(p<0.001), use of orogastric tube (p<0.001) and use of daily sedation free interval (p<0.001). Statistically insignificant increase in the use of DVT prophylaxis (p= 0.996) and raising the head end of the bed (p=0.513), and decline in the number of days of ICU(p=0.804) and hospital stay(p=0.907), the duration of mechanical ventilation(p=0.909), mortality(p=0.315) and incidence of VAP(p=0.715) was noted. Among those who developed VAP, there was lower compliance to bundle. CONCLUSIONS: Practices like use of VAP prevention bundle improve on teaching efforts and use of checklist which improves patient care.

Mortality due to scrub typhus - report of five cases.

Scrub typhus is largely ignored in India particularly during outbreaks of viral fever. The disease course is often complicated leading to fatalities in the absence of treatment. However, if diagnosed early and a specific treatment is initiated, the cure rate is high. We report here five cases of scrub typhus to highlight the fact that high clinical suspicion for such a deadly disease is an absolute necessity.

Antibiotic stewardship initiative in a Medicine unit of a tertiary care teaching hospital in India: A pilot study.

Background & objectives: The models for implementation of antibiotic stewardship programme (ASP) in the acute care settings of developing countries are lacking. In most of the hospitals, patient turnover is high and a proper system for recording antibiotic-related information and tracking hospital-acquired infections is not in place. This pilot study was conducted in a tertiary care teaching hospital in north India to assess the feasibility of implementation of an ASP in a Medicine unit and to evaluate the effect of implementation as per the criteria applicable in this set up. Methods: A pre-post-quasi-experimental non-randomized study was conducted in two phases. In the first phase, current practices in the Medicine wards were observed. In the second phase, the ASP was implemented in a single Medicine unit, along with prospective audit and feedback, tracking of the process, as well as outcome measures. Patient risk stratification, blood culture on day one, day 3 bundle, dose optimization, de-escalation and intravenous to oral conversion of antibiotics were the key elements focused upon. Results: There was a significant improvement in the appropriateness of antibiotic prescription (66 vs. 86%, P<0.001) and reduction in the mean number of antibiotics used per person (4.41 vs. 3.86, P<0.05) along with decrease in the duration of hospital stay (17 vs. 14 days, P<0.05). There was a significant improvement in sending of blood cultures on day one during the stewardship phase (P<0.001). Interpretation & conclusions: The ASP approach used in our pilot study may be feasible and beneficial. However, it needs further confirmation in other settings and on a large scale.

Spectrum of cytomorphological features of extranodal NK/T-cell lymphoma, nasal type.

OBJECTIVE: Extranodal natural killer/T-cell lymphoma, nasal type (ENKTL) is an aggressive extranodal lymphoma of NK-cell or T-cell lineage. Its clinical features overlap with those of several sinonasal mass lesions. While the histopathological features are well described, diagnosis is often difficult, owing to presence of extensive coagulative necrosis, so that repeated biopsies may sometimes be necessary for correct diagnosis. Literature on cytological findings of ENKTL is limited. METHODS: Cytomorphological features of cases of histologically confirmed ENKTL having corresponding cytology samples were reviewed retrospectively, to identify distinctive features that could possibly suggest this entity. RESULTS: Aspirates from five patients were studied: four from cervical nodes, one from cheek swelling and one from pleural fluid. Two aspirates were reported as positive for malignancy, two as atypical lymphoid proliferation and one was non-diagnostic. Pleural fluid was reported as malignant, favouring a diagnosis of carcinoma. On cytology, aspirates showed medium to large cells with folded, indented nuclei and abundant pale cytoplasm, some with tongue-like cytoplasmic protrusions. A distinctive feature was presence of large loose clusters of tumour cells with arborising capillaries running through them. Interestingly, necrosis was consistently absent. Subsequent biopsies from palate (three cases) and nasal masses (two cases) confirmed the diagnosis of ENKTL. CONCLUSIONS: Suspicion of ENKTL on cytology is crucial for timely diagnosis to avoid diagnostic delay, especially when only highly necrotic biopsy samples are available. Awareness of distinctive cytomorphological features is required to make fine needle aspiration an effective diagnostic tool for initial diagnosis and for evaluation of possible recurrences.

Treatment of Pulmonary Embolism with Chemotherapy in a Case of Newly Diagnosed Osteosarcoma.

A 21-year old female, recently diagnosed with osteosarcoma of right humerus, presented to the emergency with history of fever, productive cough, chest pain and progressive respiratory distress for six days. Initial investigations suggested pneumonia but she did not respond to parenteral antibiotics. CT pulmonary angiogram revealed bilateral pulmonary artery embolism. Thrombolysis was performed using alteplase, which failed to improve the clinical condition. In view of underlying malignancy, a possibility of tumour-embolism was considered and she was started on chemotherapy for osteosarcoma. There was dramatic improvement in her respiratory symptoms after the first chemotherapy cycle, along with radiological resolution of the embolism. This case highlights the importance of suspecting tumour embolism in a known case of malignancy with respiratory distress.

An Unusual Case of Intractable Vomiting: Unravelling the Present, Through the Past!

A 54 year old lady presented to our institute with a history of low grade fever for one week associated with occasional loose stools, vomiting and severe malaise. Initial evaluation revealed low serum sodium. An initial diagnosis of acute gastroenteritis with secondary hyponatremia was made. Work up for infective causes of gastroenteritis was however negative. ENT evaluation and review of drug history did not contribute towards a diagnosis. The patient's symptoms persisted and did not respond to symptomatic treatment. Ultrasound of abdomen revealed cholelithiasis with no evidence of cholecystitis. Further evaluation revealed hypotonic hyponatremia with normal levels of urinary sodium excretion. With other causes of hyponatremia ruled out, an endocrinopathy was suspected as the likely culprit. Follow up hormonal studies revealed hypopituitarism and MRI of brain revealed a partially empty sella. On reviewing the case, a past history of amenorrhea immediately after the birth of her third child (almost 20 years ago!) was elicited. Intractable vomiting is quite an unusual presentation for Sheehan's syndrome, but a thorough case history coupled with a high index of suspicion can contribute towards identifying the cause among a series of confounding clinical and radiological findings, as in our case.

CRAB Manifestations in a Middle-Aged Female: A Diagnostic Dilemma.

A 56 year old lady, presented to our institute with six months history of low grade fever, generalized weakness, decreased food intake and fluctuating sensorium. Initial investigations revealed hypercalcemia, renal dysfunction and anemia. Initial working diagnosis of likely underlying hematological malignancy such as lymphoma or multiple myeloma (MM) was kept after hyperparathyroidism was ruled out. Her skeletal survey revealed lytic lesions in the skull, bone marrow aspirate showed 12% plasma cells and beta-two microglobulin level was markedly elevated. However, the criterion for MM was not fully satisfied. In view of persistent altered sensorium, MRI brain was done which suggested the diagnosis of disseminated tuberculosis and was further confirmed through MR spectroscopy, bone marrow biopsy (showing granulomas) and whole body PET. She was started on anti-tubercular therapy along with steroids with marked response within a week. We describe the details of this interesting case through a systematic approach to the various features.

Dyskeratosis Congenita with Acute Myeloid Leukemia, Cryptogenic Liver Fibrosis and Portal Hypertension.

Dyskeratosis Congenita (DC), a 100-year-old known rare hereditary entity, has recently changed its definition as per the pathogenetic model in the last decade. Now it is well known as one of the telomeropathies, pathognomonically characterized by a triad of reticulate pigmentation of the skin, nail dystrophy, and mucosal leukoplakia. It is a progressive systemic disorder which usually presents with involvement of several family members. Malignancies are increasingly reported. Clinical diagnosis is simple once there is a suspicion, but nowadays genetic diagnosis is advocated. Treatment is symptomatic and organ-oriented. We hereby report an adolescent male who presented with the classical mucocutaneous triad of DC with pancytopenia for four months. Bone marrow examination later revealed evolution of acute myeloid leukemia (AML). Liver function tests, imaging, and liver biopsy showed cryptogenic fibrosis with portal hypertension. Chemotherapy was started since hematopoietic stem cell transplantation was not feasible; however, he died very early due to repeated infections before completion of the treatment. AML and liver disease are increasingly reported independently in DC; however, coexistence of both complications in a single patient at first presentation has never been reported earlier. Early age onset of AML is noticeable too.

Workplace-based assessment: measuring and shaping clinical learning.

Assessment of clinical competence is a challenge. It should not only help us in measuring performance but also in improving performance. Traditional assessment has many flaws, mainly related to snapshot observations, artificial settings and lack of opportunity to improve performance. Workplace-based assessment (WPBA) refers to direct observation of performance at the workplace. It builds on the ways people learn at the workplace. The key feature of all tools used for WPBA is direct observation of trainee performance at the workplace followed by provision of feedback based on that observation. This makes such an assessment valid. Though most of the tools use subjective observations, the assessment is reliable due to use of multiple encounters being assessed by multiple assessors in multiple settings. In addition, WPBA has high utility in terms of its educational impact. WPBA involves sampling of the clinical work using logbooks or encounter cards and direct observation of performance of clinical competence and procedural skills. These are supplemented by assessment by various people who can provide authentic information about a trainee's work habits. The encounters and ratings are documented in a portfolio, which allows a longitudinal record of trainees' progress. Experience suggests that WPBA has the potential to shape clinical learning and steer it towards desirable learning outcomes. Most of the tools used for WPBA can be applied in the Indian context.

Management of F/P+/- hypereosinophilic syndromes: case report and treatment review.

Eosinophilia in clinical practice can occur due to various pathologic processes. Causes of eosinophilia include idiopathic eosinophilia, reactive eosinophilia, idiopathic hypereosinophilic syndrome (HES), chronic eosinophilic leukemia, and other hematopoietic neoplasms (myeloid, lymphatic, or mast cell). We present a case of a 22-year-old man with HES with remarkable clinical manifestations and treatment challenges.

Assessment in medical education: evolving perspectives and contemporary trends.

Assessment is an important part of the educational process. It influences students' learning. Traditionally, assessment has been used to measure the achievement of students for certification or selection. However, increasing attention is being paid to using formative assessment to improve learning. Miller's pyramid provides a good conceptual model to assess clinical competence by providing tiered levels of assessment. All levels of the pyramid need to be included in the assessment process. To be useful, assessment should be valid (measuring what it is supposed to measure), reliable (confidence in the results), acceptable (to various stakeholders), feasible and have a positive educational impact. The major attributes (validity and reliability) refer to judgements that we make from the assessment data and are not the inherent property of any test or tool. All validity is construct validity. There is often a trade-off between validity and reliability but an assessment which is low on one can still be useful by virtue of its being high on the other. No one tool is enough for assessing students and a combination of tools is preferred to get a composite picture of students' attainment Assessment of knowledge is largely made by written assessment. The tests and questions should be contextual and look for application of knowledge rather than mere recall of facts. Assessment of clinical skills is done by traditional methods such as long and short cases and newer methods such as mini-clinical evaluation exercises, objective-structured clinical examinations, case-based discussions and portfolios. An adequate and representative sample of clinical tasks and direct observation of performance are the key to the validity and reliability of the assessment process. Faculty training is important for improving the quality of assessments.

Actinomycosis and nocardiosis co-infection in chronic granulomatous disease.

Chronic granulomatous disease (CGD) is an inherited disease of the phagocyte NADPH oxidase system that causes defective production of toxic oxygen metabolites, leading to impaired bacterial and fungal killing, and recurrent life threatening infections; mostly by catalase producing organisms. Nocardiosis in CGD is well described, however actinomycosis is rare. We describe a patient of CGD with actinomycosis and nocardiosis coinfection. A 43-year-old male with history of recurrent discharging sinuses presented with fever, dyspnea and cough. He had multiple discharging sinuses over neck and anterior chest wall. There was only partial response to intravenous penicillin. Needle aspirate from chest wall showed co-infection with actinomyces and nocardia. His nitroblue tetrazolium (NBT) reduction test was negative. He was treated with penicillin, amikacin and trimethoprim-sulfamethoxazole and had good clinical and radiological response.

N-terminal pro-brain natriuretic peptide is an independent predictor of mortality in patients with sepsis.

This study aims to evaluate the role of cardiac enzymes N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponin-I (CTnI) as predictors of outcomes in patients with sepsis.78 cases with a diagnosis of sepsis were enrolled over a 2-year period. Baseline demographic, Acute Physiology and Chronic Health Evaluation-II (APACHE-II), Simplified Acute Physiology Score-II (SAPS-II), hematologic and biochemical parameters were noted. Serum NT-proBNP and CTnI were evaluated at 24 and 72 hours of admission along with echocardiography. Patients were prospectively followed up until death or discharge.Mean APACHE-II score was 19.8±9.6 and SAPS-II was 44.8±17.2. Survival rate in the study was 47.5% (36 of 78 patients). NT-proBNP was significantly higher in non-survivors with values over 4300 pg/mL at 24 hours and 5229 pg/mL at 72 hours associated with poor outcomes (p<0.05). CTnI was higher among non-survivors than in survivors, but the difference was not significant. APACHE-II score combined with NT-proBNP predicted a poor outcome in 51.2% cases compared with 14.6% cases with APACHE-II alone (p<0.05), while SAPS-II combined with NT-proBNP predicted a poor outcome in 53.6% cases as compared with 9.6% cases with SAPS-II alone (p<0.05). SAPS-II greater than 45 and NT-proBNP values at 72 hours were independent predictors of mortality in patients with sepsis.NT-proBNP is an independent predictor of mortality in patients with sepsis and its combination with APACHE-II and SAPS-II improves the predictive values of the scoring systems.

Prognostic utility of biomarker levels and clinical severity scoring in sepsis: a comparative study.

Procalcitonin (PCT) is one of the best validated biomarkers in the management of sepsis. However, its prognostic utility remains poorly studied. The present study sought to assess the prognostic utility of serial PCT assessments in patients with sepsis, and to compare the prognostic predictive capability of serial measurements of PCT with conventional markers of inflammation and validated intensive care unit (ICU) severity scoring systems. We recruited consecutive patients admitted to the medical units of a tertiary care center with suspected or proven bacterial infection and sepsis. Measurement of serum PCT levels, inflammatory markers, and ICU severity scores were performed at admission and repeated every 48 hours subsequently for the duration of hospital stay. 99 patients with bacterial infection and sepsis were recruited and followed until death or discharge. Median serum PCT level was similar between survivors and non-survivors on day 1, but was significantly lower at days 3, 5 and 7 in the survivors. The analysis found Acute Physiology and Chronic Health Evaluation (APACHE IV) score on all days (1, 3, 5, and 7), PCT on days 5 and 7, and Sequential Organ Failure Assessment score at 24 hours to have good predictive accuracy for adverse patient outcome. PCT clearance on days 3 and 5 of admission was measured and demonstrated predictive accuracy comparable to day-matched APACHE IV scores. While serial levels of serum PCT in patients with sepsis are accurate in the prediction of adverse patient outcome, they do not offer any additional clinical benefit over existing severity of illness scores and may be cost prohibitive in resource-limited settings. While serial levels of serum PCT in patients with sepsis are accurate in the prediction of adverse patient outcome, they do not offer any additional clinical benefit over existing severity of illness scores and may be cost prohibitive in resource-limited settings.

Prevalence and evaluation of risk factors of anti-retroviral therapy failure among human immunodeficiency virus/acquired immune deficiency syndrome patients in North India.

BACKGROUND: The prevalence of anti-retroviral therapy (ART) failure is not uniform in India. In this study we attempted to determine the prevalence and risk factors of treatment failure among patients who were on ART for >1 y. METHODS: We conducted an ambispective study from 2017 to 2019 in the All India Institute of Medical Sciences, New Delhi, India. Patients and their past medical records were examined to determine clinical, immunological and virological failure. RESULTS: Among 301 enrolled patients, the majority was male (61.8%), with a mean age of 36.98±10.84 y. The prevalence of ART failure in our study was 10.63% (32/301). Clinical, immunological and virological failure rates were 1.66%, 10.63% and 5.65%, respectively. The maximum chance of failure was the tenofovir-lamivudine-nevirapine (33.3%) regimen followed by the stavudine-lamivudine-nevirapine (30.4%) regimen. Among the nucleoside reverse transcriptase inhibitors, a stavudine-based regimen had a significantly greater chance of failure (25.8%) compared with tenofovir (9.6%) and zidovudine (7.9%) regimens (p<0.005). Low baseline CD4 count and development of tuberculosis after ART initiation were significantly (p<0.05) associated with treatment failure in univariate analysis. Patients with a low peak CD4 count (adjusted odds ratio [AOR 4.26 {95% confidence interval 1.83 to 9.88}]) and who developed symptoms after ART initiation (AOR 3.77 [95% CI 1.47 to 9.69]) had significantly higher odds of treatment failure in the multivariate analysis (p<0.001). CONCLUSIONS: Early identification of risk factors by regular follow-up and selection of the proper ART regimen can reduce the rate of treatment failure.

Ambispective study of clinical picture, management practices and outcome of snake bite patients at tertiary care centre in Northern India.

BACKGROUND: Snakebite is a common but neglected public health problem of tropical & subtropical regions worldwide. This study was conducted to look into profile, first aid measures, management strategy and outcomes of snake bite patients. METHODS: This was an ambispective study conducted in the Department of Medicine & Emergency Medicine at AIIMS, New Delhi from June 2011 to May 2017 and enrolled 54 patients. In retrospective part 33 case records of snake bite patients were retrieved and in prospective part 21 patients were recruited. All relevant information including demographic parameters, first aid measures, clinical and laboratory profile and outcomes were recorded in pre made proformas. All data were analysed using IBM Stata version 13 and Microsoft Excel 2011. RESULTS: Majority of patients were male, and the mean age was 27.6 years. Maximum numbers of bites 34 (63%) happened in the rainy season and Krait was the most common culprit species. Neurological manifestations were most common (70.4%) followed by haematological. Most common complication was ventilatory failure (78.6%), and median dose of ASV was 20 vials. Forty-nine (90.7%) patients were discharged successfully. There was significant association of sepsis and shock with non survivors of snake bite with respective P values of 0.02 and 0.007. CONCLUSION: Neurotoxic snake bite (70.4%) was the most common type of envenomation. Most common complication was ventilatory failure and majority of patient (90.7%) successfully discharged. Sepsis and shock were significantly associated with non survivors of snake bite.

Structured internship orientation programme for undergraduate students: easy transition to clinical work.

BACKGROUND: Internship is a phase of training when a new graduate is expected to acquire skills under supervision, so that he/she may become capable of functioning independently. Often, new graduates go through this period without a clear aim. We conducted an orientation programme before fresh graduates started their 1-year internship to familiarize them with their clinical tasks and their role in the community. METHODS: Interns were invited to participate in a one-and-a-half day programme conducted by faculty members and administrators that included interactive lectures, structured panel discussions, group discussions and role plays. The participants provided feedback using a structured questionnaire and during informal group discussions. They were also evaluated by a pre-test and post-test questionnaire. RESULTS: Of the 41 interns who attended the programme on day 1 and the 28 who completed it on day 2, 19 completed the post-test questionnaire. The post-test score (median 14.5; range 10-18) represented a significant improvement over the pre-test score (median 13, range 3-16). All participants felt that the workshop was successful in achieving its objectives. CONCLUSION: A brief and structured orientation programme before internship offers a practical means of making the transition of new graduates from students to practising doctors smoother.

Rodenticide poisoning as a cause of quadriparesis: a rare entity.

Acute flaccid paralysis with its wide repertoire of causes presents a challenge to the clinician. We present a case of barium carbonate poisoning, a rare yet easily treatable cause of acute quadriparesis. Barium acts by redistribution of potassium from the extra- to intravascular compartment causing hypokalemia. Early recognition and prompt potassium supplementation under cardiac monitoring yield gratifying results.