Antimicrobial susceptibility pattern of extended spectrum beta-lactamase producing gram-negative bacteria isolated from wound and urine in a tertiary care hospital, Dhaka City, Bangladesh.

From a total of 320 bacterial samples from wound swab and urine 169 (53%) gram-negative bacteria were isolated, of which 42 (25%) extended-spectrum beta-lactamase (ESBL) producers were detected by double-disk synergy test. ESBL producers were significantly more resistant against amoxiclav, Co-trimoxazole, ciprofloxacin, amikacin and gentamicin than non-ESBL producers. Among the 42 ESBL producers, 76% were positive for blaCTX-M and 43% were positive for blaOXA, with blaCTX-M predominantly (97%) observed in E. coli and blaOXA predominantly (80%) in Pseudomonas spp. Class 1 integron was found in 75% of blaCTX-M positive and 56% of blaOXA positive strains. Combinations of ESBL genes and class 1 integron were observed in 29 (69%) of the ESBL producers. The findings of this study infer that CTX-M and OXA producers are emerging in Bangladesh and we report the presence of blaOXA for the first time in Bangladesh.

Dengue infection in Dhaka City, Bangladesh.

Dengue fever (DF) and dengue haemorrhagic fever (DHF) are now endemic in Bangladesh with outbreaks being reported quite frequently. This cross sectional study was done clinically suspected dengue patients were selected from different hospitals of Dhaka city, Bangladesh, from January 2008 to December 2008. The clinical features, risk factors and laboratory findings associated with dengue infection were investigated among 201 clinically suspected patients. Antibodies were detected in 137(68.2%) cases. Of these, 80(58.4%) were primary and 57(41.6%) as secondary dengue cases according to presence of dengue-specific IgM and/or IgG antibodies. Among primary cases, 70(87.5%) were DF and 10(12.5%) were DHF cases, in contrast to secondary cases, where 10(18.1%) were DF and 47(81.9%) were DHF cases. Majority (57.9%) of patients presented with Grade I and 42.1% had Grade II disease. Patients between 16-30 years were the most vulnerable age group (81.3% DF and 71.9% DHF patients). Males out-numbered females with 72.5% male vs. 27.5% female patients having DF and 68.4% male vs. 31.6% female patients having DHF. The monsoon period was the peak season for dengue infection. Headache and arthralgia were the most frequent symptoms in both DF and DHF, but vomiting was more common in DHF. The Tourniquet test was significantly positive among DHF than DF cases (p = 0.001). Platelet count was the only laboratory parameter that showed significantly higher values among DHF than DF cases (p = 0.001).

Heavy Metals Accumulation in Vegetables and Its Consequences on Human Health in the Areas Influenced by Industrial Activities.

The degradation of the environment due to numerous industrial practices has emerged as a major issue globally, particularly in a country like Bangladesh. The present study dispenses information about heavy metal (Cr, Mn, Fe, Co, Ni, Cu, Zn, Cd, and Pb) contamination in some frequently consumed vegetables, namely, ash pumpkin, potato, bitter gourd, buffalo spinach, snake gourd, and pointed gourd grown in an industrially prone location and their repercussion on consumers' health. Proton-induced X-ray emission (PIXE) technique was used as the major analytical tool to detect heavy metal concentrations. Mean concentration and the range of Cr, Mn, Fe, Co, Ni, Cu, Zn, Cd, and Pb in vegetables were detected (4.81 ± 2.79, 2.43-10.94), (497.57 ± 258.08, 181.24-886.67), (644.49 ± 298.40, 179.56-998.78), (38.88 ± 14.31, 18.88-60.12), (58.11 ± 12.58, 42.55-84.79), (137.24 ± 48.37, 71.99-208.98), (123.31 ± 63.62, 49.97-256.09), (8.09 ± 2.69, 4.29-14.94), and (4.16 ± 2.95, 1.22-9.98) mg/kg (dry weight basis), respectively. An extreme level of heavy metal contamination in vegetable samples was notified regarding the estimated metal pollution index (MPI) and Nemerow pollution index (P) value, which underpinned the health risk values. The estimated hazard index (HI) value stipulated high risk in all varieties of vegetables regardless of age group and cadmium (Cd) was found as the major contributor. Concerning the carcinogenic risk index (CR) for single elements, the value of Co, Ni, and Cr was approximated far above the USEPA threshold risk limit (CR>1E-04). Moreover, total carcinogenic risk (TCR) for all varieties of vegetables exceeded the safety threshold value for both the age group and children, in particular, were found most vulnerable. The outshot of the present study divulged associated health risks for the population group by the heavy metals via dietary intake of vegetables.

Elemental Analysis of Basella alba, Spinacia oleracea, Abelmoschus esculentus (L.), Ipomoea aquatica, Colocasia esculenta, Amaranthus dubius, and Raphanus sativus Vegetables Using the PIXE Technique in a Saline Region of Bangladesh, Rampal Area.

Particle-induced X-ray emission (PIXE) method was used in this present research to identify the elements present in selected vegetable samples to show the possible influence in the metal absorption by the vegetables grown in a saline region of Rampal area of Munshiganj District, Bangladesh. The data acquisition setup is calibrated using a 2.5-MeV proton beam in the current ranges of 5nA to 15nA. The detector was used to measure the X-rays emitted during the irradiation. Data acquisition system MAESTRO-32 was used to measure the spectrum picks, and concentration calculation has been done by GUPIX/DAN-32 software. The purpose of this study is to determine the concentration of heavy and trace elements in these samples and to give current information on their safety for consumption. The result shows that K, Ca, and Fe have the highest concentrations, while lead exhibits the lowest but alarming rates compared to reference materials. The findings were likened to IAEA-V-10, IAEA-359, SRM 1515 (apple leaf), and SRM 1573a (tomato leaf). The outcomes of the present investigation demonstrate that these samples are not devoid of health risks in intake.

Factors causing delay in discharge of elderly patients in an acute care hospital.

INTRODUCTION: Prolonged hospitalisation not only increases cost, it is also associated with other complications. Length of stay (LOS) is one of the indicators that reflect total cost of care during hospitalisation. So, it is of paramount importance to find out why elderly patients overstay in acute care hospitals and address these issues proactively. Since no local data is available, a study was planned to ascertain reasons why the discharging of elderly patients from hospital is delayed and whether these reasons are avoidable. MATERIALS AND METHODS: Long-stay patients were defined as those whose LOS had notably exceeded the average LOS for the Diagnosis Related Group (DRG), based on principal admitting diagnosis. A separate analysis showed that the specialty-specific long-stay marker for geriatric medicine was 28 days, so casenote review was done for all patients with LOS of more than 28 days who were discharged from geriatric medicine service of an acute care hospital during a 1-year study period. Information was collected on demographic profile, functional and cognitive status, past medical and social history, admitting medical diagnoses, discharge limiting and delaying factors. RESULTS: During the study period, 150 patients stayed over 28 days and 137 casenotes were available for review. The mean age of the patients was 84 years, 55.5% were female, 77.4% were Chinese, mean abbreviated mental test (AMT) score was 3 and mean modified Barthel's score was 11. The commonest primary diagnosis was sepsis followed by neurological problems, falls-related complication and cardiovascular diseases. The 2 most common discharge limiting factors (the final event which resulted in delay in discharge) were social issues (54, 39.4%) and sepsis (47, 34.3%). Of 47 patients with sepsis, 37 (78.7%) were nosocomial infection. Urinary tract infection and pneumonia were the 2 most common nosocomial infections. The 4 most common factors contributing to delayed discharge (various problems that surfaced throughout the hospital stay) were sepsis (94, 68.6%), deconditioning (65, 47.4%), social issues (52, 38.0%) and cardiovascular disorders (37, 27.0%). CONCLUSION: Elderly patients are more prone to hospitalisation-related complications like nosocomial infection and deconditioning leading to prolonged hospital stay. Early interventions can reduce these complications. Early identification of social issues and prompt discharge planning should be done to avoid delay in discharge.

A survey of antimicrobial prescribing and dispensing practices in rural Bangladesh.

This study was undertaken to determine the patterns of antimicrobial prescription by 64 Rural Medical Practitioners (RMPs) from Bangladesh. The antimicrobial dispensing procedures followed by the local retail drug sellers along with the purchasing capacities of the patients was also assessed. All antimicrobial agents were prescribed mainly on the patient's complaints, and all available antibiotics were prescribed in inappropriate doses and duration. In most cases, the RMPs initiated treatment with a parenteral form of antibiotic, and a different oral antibiotic usually followed. Parenteral streptomycin was used most frequently in short inadequate courses. Almost half of the antibiotics were sold without any prescriptions, and even ordinary people without any knowledge of medicine asked the drug seller for specific antibiotics. This unregulated prescribing and dispensing practice has the potential risk for the development and spread of antimicrobial resistance on a global scale.

Role of nasogastric tube in preventing aspiration pneumonia in patients with dysphagia.

INTRODUCTION: Every year, a large number of patients with dysphagia are placed on feeding tubes to prevent aspiration pneumonia. This prospective study was planned to compare the incidence of aspiration pneumonia and death in patients with dysphagia who were either fed orally or through a nasogastric tube. METHODS: All patients aged 65 years or older, at the point of discharge from the geriatric medicine ward of a hospital, were recruited over a six-month period with a two-month follow-up. Patients diagnosed with dysphagia by the speech therapist were recommended to have either oral feeding with modified diet or nasogastric tube feeding. The incidence of aspiration pneumonia and death among patients on oral feeding, nasogastric tube feeding and patients who refused nasogastric tube feeding were compared. RESULTS: A total of 122 patients completed the study. The rate of aspiration pneumonia and death were, respectively, 31.2 percent in nasogastric tube-fed patients and 10.3 percent in orally-fed patients (Fisher's exact test, p-value equals 0.007). Multivariate analysis showed that the mode of feeding predicted outcome (p-value equals 0.03). The rate of aspiration pneumonia and death were 31.2 percent in nasogastric tube-fed patients and 11.5 percent in those who refused nasogastric tube feeding (Fisher's exact test, p-value equals 0.064). Nasogastric tube-fed patients were more cognitively- and functionally-impaired compared to those on oral feeding. CONCLUSION: In our study, patients on nasogastric tube feeding did not have a better outcome against aspiration pneumonia and mortality when compared to those who were on oral feeding. The poorer outcome of nasogastric tube-fed patients could be attributed to their worse cognitive and functional statuses. Larger studies are needed to refute or confirm the usefulness of nasogastric tube in elderly patients with dysphagia.

Use of physical restraints in nursing homes: current practice in Singapore.

INTRODUCTION: One of the indicators of quality care in nursing homes is the proper use of physical restraints. Restraints have been associated with multiple complications, such as pressure ulcers, incontinence and immobility. The aim of our study was to assess the indication, use and complications related to physical restraints in Singapore nursing homes. MATERIALS AND METHODS: All residents aged >65 years old from 3 nursing homes were included in the study. A geriatrician reviewed the medical records of all elderly residents on restraints. Nursing staff interviews were also done to assess their knowledge regarding restraint use. A brief medical record review was also done for the elderly residents without restraints. RESULTS: Out of 390 elderly residents, 91 were on physical restraints. The mean age of these residents were 80.1 years; 67% were female, 90.1% were Chinese and 82.4% belonged to functional category IV. Both urinary and faecal incontinence were observed in 97.8% of residents. Forty-six (50.5%) residents had no documented indication for restraints. It was noted that 20 (22%) residents were restrained to prevent dislodgement of the feeding tube, 17 (18.7%) were restrained to prevent falls and 8 (8.8%) were restrained for agitation. There were documented trials of removal of restraints for only 21 (23.1%) residents. Alternative approaches, such as diversion technique, were used for 31 (34.1%) residents to avoid restraint use. CONCLUSION: Our study revealed a high rate of restraint use in the nursing homes. A restraint protocol should be available in every nursing home, requiring physician approval for the long-term application of physical restraints and intermittent reviews by physicians to assess the continued need for restraints.

Movement decoding using neural synchronization and inter-hemispheric connectivity from deep brain local field potentials.

OBJECTIVE: Correlating electrical activity within the human brain to movement is essential for developing and refining interventions (e.g. deep brain stimulation (DBS)) to treat central nervous system disorders. It also serves as a basis for next generation brain-machine interfaces (BMIs). This study highlights a new decoding strategy for capturing movement and its corresponding laterality from deep brain local field potentials (LFPs). APPROACH: LFPs were recorded with surgically implanted electrodes from the subthalamic nucleus or globus pallidus interna in twelve patients with Parkinson's disease or dystonia during a visually cued finger-clicking task. We introduce a method to extract frequency dependent neural synchronization and inter-hemispheric connectivity features based upon wavelet packet transform (WPT) and Granger causality approaches. A novel weighted sequential feature selection algorithm has been developed to select optimal feature subsets through a feature contribution measure. This is particularly useful when faced with limited trials of high dimensionality data as it enables estimation of feature importance during the decoding process. MAIN RESULTS: This novel approach was able to accurately and informatively decode movement related behaviours from the recorded LFP activity. An average accuracy of 99.8% was achieved for movement identification, whilst subsequent laterality classification was 81.5%. Feature contribution analysis highlighted stronger contralateral causal driving between the basal ganglia hemispheres compared to ipsilateral driving, with causality measures considerably improving laterality discrimination. SIGNIFICANCE: These findings demonstrate optimally selected neural synchronization alongside causality measures related to inter-hemispheric connectivity can provide an effective control signal for augmenting adaptive BMIs. In the case of DBS patients, acquiring such signals requires no additional surgery whilst providing a relatively stable and computationally inexpensive control signal. This has the potential to extend invasive BMI, based on recordings within the motor cortex, by providing additional information from subcortical regions.

Prescribing psychoactive medications in nursing homes: current practice in Singapore.

AIM: To assess the prescribing practice, use and potential adverse effects of psychoactive medications in Singapore nursing homes. METHOD: From a list of existing 24 voluntary welfare organisation (VWO) run nursing homes, four homes with the largest bed capacity were selected from the eastern zone of Singapore. When contacted, two homes agreed to participate in the study. Medical records of all residents aged 65 years and above were reviewed to obtain demographic information, clinical diagnoses and medication orders. Two geriatricians and one psychogeriatrician reviewed the psychoactive medications used in these nursing homes. RESULT: A Total of 384 residents were enrolled in the study. Mean age of the participants was 79.1 years (65-107); 60.7% were female and 92.4% were Chinese. Dementia was documented for 131 (34.1%) residents, depression for 50 (13%) residents. Residents were on an average of 5.2 (0-14) medications. A total of 309 psychoactive medications were prescribed for the residents. Fifty-nine (63%) antipsychotics, 42 (65%) Benzodiazepines, 65 (61%) antidepressants, 10 (77%) others sedatives and 31 (100%) anticonvulsants were deemed inappropriate. Lack of documented indication, potential adverse drug reaction, drug-drug interaction and therapeutic duplication were the most common medication related problems observed in this study. CONCLUSION: Majority of the nursing home residents were on psychoactive medications. Residents with dementia were more likely to be on psychoactive medications. Statistically significant association was observed between the use of inappropriate psychoactive medications and the diagnosis of dementia. Better documentation of clinical diagnoses and indications, and regular medication review for potential adverse drug reactions would improve the quality of care in Singapore nursing homes.

Polypharmacy and inappropriate medication use in Singapore nursing homes.

INTRODUCTION: At present, 7.2% of the population in Singapore is in the geriatric age group, which will increase to 18.4% in the year 2030. The frailest segment of the geriatric population live in nursing homes. They suffer from multiple co-morbidities requiring multiple medication use. Polypharmacy and inappropriate medication use have been considered as quality indicators for nursing home care. As no data of these indicators are available in Singapore, this study was planned to assess the prevalence of polypharmacy and inappropriate medication use in Singapore nursing homes. MATERIALS AND METHODS: A total of 454 residents in the geriatric age group residing in 3 randomly selected nursing homes were involved in the study. Case notes were reviewed for demographic information, clinical history and medication use. The data were analysed for polypharmacy (5 or more medication orders) and inappropriate medication use (based on established criteria). RESULTS: Residents were on an average of 5.32 medications. Polypharmacy and inappropriate medication use were seen in 266 (58.6%) and 318 (70.0%) residents, respectively. There was significant association between polypharmacy and inappropriate medication use [P < 0.001, chi2 = 82.56 at 95% confidence interval (CI)]. The most common medication-related problems were the use of medication without proper indication (n = 302), significant potential for adverse drug reactions (n = 281) and drug interactions (n = 141). CONCLUSION: The prevalence of polypharmacy and inappropriate medication use is high in Singapore nursing homes. Current practice of medication use in the nursing homes may lead to significant adverse drug reactions and drug interactions. A multidisciplinary approach involving geriatricians, nursing home physicians, nurses and pharmacists may potentially reduce polypharmacy and inappropriate medication use in Singapore nursing homes.

Emergence of methicilllin resistant Staphylococcus aureus (MRSA) associated with wound infections.

In a hospital setting antimicrobial resistant organisms especially Methicillin resistant Staphylococcus aureus (MRSA) has emerged as an important variable influencing patients' outcome and overall resource utilisation. The present study was undertaken to find out the proportion of MRSA and other organisms and their antimicrobial resistance pattern in admitted cases with postoperative wound infections. A total of 50 wound swabs were collected irrespective of age and sex of the patients from National Institute of Traumatology and Orthopaedics Rehabilitation (NITOR). The laboratory work was performed in the department of microbiology of National Institute of Cardiovascular Diseases (NICVD). Isolation, identification and susceptibility testing was done according to the guideline of the National Committee for Clinical Laboratory Standards (NCCLS, 1998). Out of the 50 samples 34 yielded growths of which 15 had growth of single organism and 19 had mixed growth of 2 to 3 organisms. Four different types of organisms were identified. Highest percentage was Escherichia coli 55.9%, followed by Pseudomonas sp. 52.9%, Proteus sp. 38.2%, and Staphylococcus aureus 17.6%. Of the 6 isolates of S aureus 5 (83.3%) were MRSA. Therefore it can be concluded that MRSA is existing in the hospital premises of NITOR, which can endanger the life of many. This study emphasises that susceptibility testing of all clinical isolates is essential to reduce the morbidity, mortality and longer duration of hospital stay. In addition proper management of the cases can decrease the spread of multiple drug resistant organisms in the community.

Molecular analysis of multi-drug resistant Salmonella typhi from urban paediatric population of Bangladesh.

The prevalence and genetic basis of resistance of multi-drug resistant (MDR) S typhi strains from an urban paediatric population was determined. Blood cultures performed on 109 cases of suspected typhoid fever yielded 30(27.5%) S typhi isolates. Of these, 20(67%) S typhi isolates were resistant to the common antimicrobials used in Bangladesh, eg, chloramphenicol, ampicillin, cotrimoxazole, streptomycin and tetracycline, while 6(20%) isolates were resistant only to streptomycin. However, all the isolates were sensitive to fluquinolones and cephalosporins. Molecular analysis demonstrated that all MDR strains possessed a single large transferable 98 MDal plasmid. On conjugation, chloramphenicol, ampicillin and cotrimoxazole resistance was transferred from MDR strains to E coli K-12. Restriction endonuclease analysis of plasmid DNA showed similar digest profiles of all 5 selected donors and their transconjugants. This trend of increasing resistant strains of S typhi, especially by the transferable plasmid is of major public health concern.

Immunofluorescent microscopic findings in glomerulonephritis.

Histopathology and direct immunofluorescence (DIF) microscopy were performed on renal biopsy specimens of 60 clinically suspected cases of glomerulonephritis (GN). Histopathological diagnosis was obtained in 44 (73.3%) cases and immune complex deposition were detected by DIF in 28 (46.7%) cases. Immune complex deposition were observed in all cases of membranous GN, systemic lupus erythematosus (SLE), and rapidly progressive GN (RPGN), most of the cases of diffuse proliferative GN (2 out of 3) mesangioproliferative GN (12 out of 15) and focal glomeruloscleros is (3 out of 5 cases). No immune deposits were observed in minimal change GN, chronic GN, and diabetic nephropathy. Histopathological diagnosis was not obtained in 16 (26.7%) cases, 3 (5%) of which showed immune complex deposition by DIF. Anti-GBM nephritis was demonstrated in one (3.6%) case, the rest were immune complex nephritis.

Evaluation of a typhoid/paratyphoid diagnostic assay (TPTest) detecting anti-Salmonella IgA in secretions of peripheral blood lymphocytes in patients in Dhaka, Bangladesh.

BACKGROUND: Rapid and reliable diagnostic assays for enteric (typhoid and paratyphoid) fever are urgently needed. We report the characterization of novel approach utilizing lymphocyte secretions, for diagnosing patients with enteric fever by the TPTest procedure. METHODOLOGY: TPTest detects Salmonella-specific IgA responses in lymphocyte culture supernatant. We utilized TPTest in patients with suspected enteric fever, patients with other illnesses, and healthy controls. We also evaluated simplified modifications of TPTest for adaptation in laboratories with limited facilities and equipment. PRINCIPAL FINDINGS: TPTest was positive in 39 (27 typhoid and 12 paratyphoid A) patients confirmed by blood culture and was negative in 74 healthy individuals. Among 32 individuals with other illnesses, 29 were negative by TPTest. Of 204 individuals with suspected enteric fever who were negative by blood culture, 44 were positive by TPTest and the patients were clinically indistinguishable from patients with confirmed bacteremia, except they were more likely to be under 5 years of age. We evaluated simplifications in TPTest, including showing that lymphocytes could be recovered using lysis buffer or buffy coat method as opposed to centrifugation, that incubation of cells at 37°C did not require supplemental CO2, and that results were available for majority of samples within 24 hours. Positive results by TPTest are transient and revert to negative during convalescence, supporting use of the test in endemic areas. The results can also be read using immunodot blot approach as opposed to ELISA. Since no true gold standard currently exists, we used a number of definitions of true positives and negatives. TPTest had sensitivity of 100% compared to blood culture, and specificity that ranged from 78-97% (73-100, 95% CI), depending on definition of true negative. CONCLUSION: The TPTest is useful for identification of patients with enteric fever in an endemic area, and additional development of simplified TPTest is warranted.

The prevalence and genetics of resistance to commonly used antimicrobial agents in faecal Enterobacteriaceae from children in Bangladesh.

The present study was undertaken to investigate the occurrence of antibiotic resistance in enteric flora in 64 children in rural Bangladesh over a 12-month period. The antibiotic resistance pattern of the isolates varied throughout the year and multiple resistance was highest during the post monsoon period. Seventy-three percent of children had isolates resistant to more than three antibiotics throughout the year. Resistance to streptomycin was highest (78%), followed closely by ampicillin (72%). Of 82 multiply resistant isolates, plasmid DNA was demonstrated in 75%. Plasmid sizes ranged between 3.7 and 110 MDa, the commonest plasmids were of 70, 98 and 110 MDa. Complete or partial resistance was transferred by conjugation from 52% of the isolates, most frequently by single plasmids. The commonest plasmid incompatibility group was F11-A (46%) followed by incompatibility group P (22%). Plasmids of molecular weight 98 MDa most often hybridized with F11-A probes and those of 110 MDa with H11 probes. Plasmids from 10 transconjugants were digested with restriction enzymes and digest patterns demonstrated the presence of common plasmids. The findings show that there is a diverse, and mobile, genetic pool of resistance genes in this rural community. This genetic reservoir is potentially transferable to enteric pathogens, with major implications for public health and diarrhoeal disease control.

Water sources and environmental transmission of multiply resistant enteric bacteria in rural Bangladesh.

The role of different water sources in the spread of multiply resistant enteric bacteria was investigated in rural Bangladesh. The prevalence of resistance to commonly used antimicrobial agents in the faecal flora of village children and the water quality and prevalence of resistance in village water sources were studied. Most of the children studied (81%) had multiply resistant faecal coliform bacteria, i.e. bacteria resistant to at least three antimicrobials. Although tubewells provided water with low faecal coliform counts, 62% of household storage pots contained water with moderate to high counts. Most of the storage pots (76%) and each of the river and pond sites tested contained multiply resistant isolates. Contamination of water within the household, and the widespread distribution of resistant coliforms in the environment, contribute to the high prevalence of multiply resistant enteric flora in the community. These findings are of importance in understanding the spread of multiply resistant enteric pathogens.