Risk factors for clinical infection in patients colonized with methicillin resistant Staphylococcus aureus (MRSA)

OBJECTIVE

To identify the risk factors involved in development of infection in individuals colonized with Methicillin-resistant Staphylococcus aureus (MRSA) among intensive care unit (ICU) patients.

METHODS

A total of 1431 patients were admitted in ICU of which 63 grew MRSA during January 1998 to December 1999. Patients who developed infection with MRSA in less than 48 hours of their admission to ICU were excluded. Medical records of all patients who grew MRSA were reviewed and 57 patients were identified for inclusion in the study. Thirty-seven of these had features of infection with MRSA and were selected as cases and 20 were identified as asymptomatic colonizers and labeled as controls. Risk factors like age of the patient, duration of ICU stay, gender, co-morbidity, presence and duration of central lines, number of arterial-punctures and number and duration of intubations were compared between cases and controls.

RESULTS

Cases were found to be significantly older (52.8 +/- 15.1) than controls (34.9 +/- 21.2). Other identified risk factors were diabetes mellitus (p = 0.001) and the first 15 days of central line placement (p = 0.025). Although chronic liver disease and hypertension could not be identified as significant risk factors, they clearly showed association. Other risk factors were not significantly different from controls.

CONCLUSION

It is suggested that greater care is required for the elderly, diabetic patients with a central venous line in place especially during the first fifteen days of its introduction.

Morphological study of liver biopsy in Thalassaemia major

OBJECTIVE

To see the morphological changes in liver in transfusion dependent Thalassaemia major children undergoing bone marrow transplantation.

METHODS

This retrospective cross-sectional survey was conducted at Pathology department of Army Medical College and Paediatric department of Military Hospital, Rawalpindi from Jul 2000 to Aug 2003. Liver biopsies were done in 40 thalassaemic major children and histological changes including Knodell Histological activity index (HAI); grade, stage and score along with degree of haemosiderosis were noted. Serum ALT levels, ferritin assays and screening for HBsAg and Anti- HCV antibody were also carried out in these cases.

RESULTS

Forty children 1.5-10.5 years of age (mean 6.1 years) with a male to female ratio of 1.2:1 were included in the study. According to Knodell HAI scoring, 24 (60%) cases had Knodell HAI score between 13/22 to 18/22 and 18 patients (45%) in grade 9-12/18. Six children had fully developed cirrhotic changes whereas 22 and 12 patients showed stage 3 and 1 respectively. Twenty eight (70%) patients had grade 3-4 haemosiderosis. HBsAg was positive in 6 and anti- HCV antibody in 14 patients. Serum ferritin and ALT levels were markedly raised in most of the patients.

CONCLUSION

Seventy percent patients had moderate to severe haemosiderosis and high Knodell HAI score was found in children with severe haemosiderosis, raised ALT and Ferritin levels and with positive serology for HBsAg and anti- HCV antibody. Liver biopsy is useful in thalassaemic children to assess the stage of liver disease and selection of suitable cases for bone marrow transplantation (BMT).

Comparison of optimal malarial test with light microscopy for the diagnosis of malaria

OBJECTIVE

To evaluate the efficacy of a parasite lactate dehydrogenase-based immunochromatographic antigen detection assay (optimal) against conventional light microscopy in the diagnosis of malaria at Military Hospital, Rawalpindi and Department of Pathology Army Medical College Rawalpindi from August to October 2002 in patients reporting sick with history suggestive of malaria.

METHODS

The blood samples were collected from 215 patients reporting with symptoms suggestive of malaria. Thick and thin blood films were prepared, stained with Leishman's stain and examined by light microscopy for the presence of malarial parasites. Parasitaemia was estimated on all positive slides. All samples were tested for presence of malarial parasite by optimal dipstick method according to the manufacturer's instructions.

RESULTS

A total of 215 cases were studied. Malarial parasites were visualized in 98 (45.5%) cases with light microscopy. Optimal test revealed 93 (43.2%) of these samples as positive. Microscopy showed 61 out of 98 positive cases to be P. vivax and 37 P. falciparum. The Optimal dipstick method revealed that 58 out of 93 were positive for P. vivax and 35 positive for P. falciparum. These results demonstrated that Optimal had sensitivities of 95% and 94.5% for P. vivax and P. falciparum respectively. It has 100% specificity for both malarial species, when compared to conventional microscopy.

CONCLUSION

Optimal test showed excellent correlation with microscopy in the diagnosis of P. vivax and P. falciparum. It is expensive but it has an advantage of being simple, rapid and effective test in the diagnosis of malaria especially where well trained microscopists are not available or work load is too high.

Dehydroepiandrosterone sulfate increases hepatic ubiquinone-9 in male F-344 rats

Administration of dehydroepiandrosterone sulfate (DHEAS) for 14 days caused a significant increase in the total ubiquinone-9 level in the hepatic tissue of male F-344 rats (p < 0.05). Hepatic ubiquinone-10 level of DHEAS-treated rats however, was found not to be statistically different from control animals. These findings suggest that peroxisome proliferator DHEAS displays typical hepatic response in increasing ubiquinone concentration in the rat.

Factors affecting rates of infection and nonunion in intramedullary nailing

We report a retrospective study over five years to determine the incidence of infection and nonunion after intramedullary nailing in fractures of 214 long bones; 122 femoral, 75 tibial and 17 humeral. The indications for nailing were trauma (n = 161), pathological fracture (n = 30) and nonunion (n = 23). There were 30 open fractures. The overall rates of deep infection and nonunion were 3.8% and 14.2%, respectively. Using multiple logistic regression analysis, we determined the relationships between deep infection and nonunion and the pre- and peri-operative factors of age, ASA score, indication for nailing, the use of reaming, the use of antibiotics, whether the fracture was open and the operating time. Open fractures were found to be significantly associated with deep infection. The length of the operation may also affect the outcome. Opening of the fracture at the time of surgery and the ASA score were found to be significantly associated with the development of nonunion after intramedullary nailing. We have compared our findings with previously published data from large teaching hospital units.

Entomological observations on dengue vector mosquitoes following a suspected outbreak of dengue in certain parts of Nagaland with a note on their susceptibility to insecticides

Three species of Aedes viz., Aedes albopictus, Aedes aegypti and Aedes annandalei were detected from different breeding sources in and around human habitats during entomological study conducted following an outbreak suspected to be of dengue (which occurred during, 1994) in parts of Medziphema PHC area of Nagaland in two different points of time ie., in the year, 1994 and, 2000. The potential dengue vector, Aedes albopictus showed high preponderance by breeding in all types of containers searched with high Breteau Index (BI) value of 85.0 and 72.72 recorded in, 1994 and, 2000 respectively whereas the BI value for other potential vector, Aedes aegypti was recorded low (4.9) in the year, 1994 with a substantial increase (31.81) in, 2000. The change in ecosystem along with the process of urbanization has facilitated the growth of these dengue vector mosquitoes in the area of investigation. Adults of both Aedes aegypti and Aedes albopictus were found to be susceptible to DDT, dieldrin and malathion in insecticide bioassay carried out using WHO test kit.

Efficacy of bronchial wash cytology and its correlation with biopsy in lung tumours

OBJECTIVE

To evaluate bronchial wash cytology with histology in our set up.

METHODS

Seventy three specimens were obtained by flexible fiberoptic bronchoscope at pulmonology department of Military Hospital Rawalpindi. All the preserved samples were processed under standard conditions. The slides were stained with Papanicolaou and Haematoxylin and Eosin stains.

RESULTS

A total of 73 patients were studied. The age range was 21 to 80 years. Male to female ratio was 8:1. Complete cytological and biopsy consensus was found in 55 (77.4%) cases. Cytology revealed 24 cases as malignant and nine as atypical/suspicious. Benign and inadequate were 29 and 2 respectively. Histopathology of these cases confirmed 24 (32.9%) as malignant and 29 (39.8%) as benign. True positive alongwith suspicious/atypical were 33 and true negative cases were 29. False positive was one case only whereas false negative cases were eight. The bronchial wash cytology showed sensitivity (80.5%), specificity (96.6%) and accuracy (87.3%). Positive predictive value and negative predictive value were 97% and 78.4% respectively. The commonest types of tumours were squamous cell carcinoma and small cell carcinoma.

CONCLUSION

It is concluded that bronchial wash cytology is a valuable tool and yields almost same information as biopsy. It is useful in patients with evidence of obstruction or risk of haemorrhage.

Soil properties and crop productivity as influenced by flyash incorporation in soil

Field experiments were carried out during 1996-97 at Gulawathi, Muthiani and Salarpur Villages, IARI Farm, New Delhi and NCPP Campus, Dadri to evaluate changes in soil characteristics and growth of wheat (Triticum aestivum L.), mustard (Brassica juncea L.), lentil (Lence esculenta Moench.), rice (Oryza sativa L.) and maize (Zea mays L.) by varying amounts of flyash addition (up to 50t ha(-1)) in soils at sowing/transplanting time of crops. Flyash addition in areas adjoining NCPP Thermal Power Plant, Dadri, Ghaziabad, U.P. ranged from 5-12 t ha(-1)] yr(-1) in 1995-96. Shoot and root growth and yield of test crops at different locations after flyash incorporation resulted in beneficial effects of flyash addition in most cases. The silt dominant texture of flyash improved loamy sand to sandy loam textures of the surface soils at the farmers' fields. The increased growth in yield of crops with flyash incorporation was possibly due to modifications in soil moisture retention and transmission characteristics, bulk density, physico-chemical characters such as pH and EC and organic carbon content. The response of flyash addition in the soil on soil health and crop productivity needs to be evaluated on long-term sustainable aspects.

Correlation of early lymphocyte recovery and progression-free survival after autologous stem-cell transplant in patients with Hodgkin's and non-Hodgkin's Lymphoma

The importance of the association between early lymphocyte recovery and outcome has not been well studied in autologous stem cell transplantation (ASCT). In this retrospective study, we analyzed 90 consecutive patients with non-Hodgkin's and Hodgkin's lymphoma who underwent ASCT. Patients were divided into two groups: group 1 with absolute lymphocyte count (ALC) on day +15 below the median of 667/mm(3), and group 2 with ALC >or=667/mm(3). The median progression-free survival (PFS), but not overall survival (OS), was significantly longer in group 2 when compared to group 1 (16 months vs not reached P=0.02). Group 2 patients also had significantly shorter hospital stay, received higher CD34(+) cell dose, and had shorter time to neutrophil recovery. Multivariate analysis demonstrated day +15 ALC to be an independent prognostic indicator for PFS, but not OS, while CD34(+) cell dose and the number of pretransplant treatments were better predictors for both PFS and OS. We conclude that higher day +15 ALC may independently predict better PFS after ASCT for lymphoma patients; however, whether this merely reflects faster overall recovery caused by higher infused CD34(+) cell dose and less pretransplant therapy needs further investigation.

Poor mobilization of peripheral blood stem cells is a risk factor for worse outcome in lymphoma patients undergoing autologous stem cell transplantation

The effect of poor blood stem cells mobilization on the outcome of autologous stem cell transplantation (ASCT) has not been well studied. Our aim is to evaluate poor mobilization as a prognostic factor in lymphoma patients undergoing ASCT. We analyzed 90 consecutive patients with Hodgkin's (HD) and non-Hodgkin's lymphoma (NHL) who underwent ASCT. Poor mobilization was defined as the inability to obtain > or = 1 x 10(6) CD34+ cells/kg ideal body weight with two large volume aphereses. Patients were divided into 2 groups: group 1 = poor mobilizers, and group 2 = good mobilizers. The poor mobilizers received lower median transplant CD34+ cell dose (2 x 10(6) vs. 4.5 x 10(6)/kg for good mobilizers, P = 0.001), were more heavily pretreated (P = 0.01), and required higher number of aphereses for PBSC collection (P = 0.0006). The median progression-free survival (PFS) in groups 1 and 2 was 10 and 41 months (P = 0.04), while the median overall survival (OS) was 38 months and not reached (P = 0.02), respectively. Univariate analysis showed that > or = 3 pre-transplant treatments, CD34+ cell dose < or = 2 x 10(6), elevated LDH before transplant, and poor mobilization were significant prognostic factors for poor PFS, while only the first three were significant for worse OS. Multivariate analysis using these same four factors revealed that number of pre-transplant treatments (HR = 6.03, P = 0.001), CD34+ cell dose (HR = 0.1, P = 0.0007) were the only independent predictive factors for worse overall outcome. In conclusion, our data show that poor mobilization could indicate poor outcome in lymphoma patients undergoing ASCT, however, it is more likely to be a reflection of the heavy pre-transplant therapy and lower CD34+ cell dose re-infused in this group of patients.

DNA adducts, detected by 32P postlabelling, in human cholangiocarcinoma

BACKGROUND

Reported mortality from intrahepatic cholangiocarcinoma (CCa) has risen steeply in the UK and other industrialised countries over the past 30 years, the cause of which has not been explained. DNA adduct formation is promutagenic and demonstrates exposure to a DNA damaging agent. It is a key step in chemically induced carcinogenesis. We hypothesise that the increase in CCa mortality is caused by a rise in a genotoxic environmental agent(s), causing cholangiocyte DNA damage.

AIMS

To investigate and compare tumour and tumour adjacent CCa tissue, and non-cancer control bile duct tissue, for DNA adducts as a biomarker of genotoxin exposure.

METHODS

DNA from 32 intrahepatic CCa patients (and in 28 cases DNA from adjacent non-tumour tissue) and from biliary ducts of seven non-cancer patients were investigated for the presence of DNA adducts using the nuclease P1 method of (32)P postlabelling. DNA adduct levels (number of adducts/10(8) nucleotides) were quantified.

RESULTS

There was no significant difference in relative adduct labellings (RALs) between tumour adjacent DNA (median 8.6, range 1.2-51.6) and CCa DNA (7.2, 1.8-48.4). However, RALs were significantly higher in DNA from cancer patients (tumour adjacent and CCa DNA) compared with non-cancer patient DNA (2.9, 0.6-11.5; p=0.032, two tailed Mann-Whitney U test). Different adduct patterns were also seen in CCa compared with non-cancer patients.

CONCLUSION

Quantitative and qualitative differences in adducts between cancer and non-cancer patients support the hypothesis that genotoxins may play a role in the development of intrahepatic CCa.

A new on-line method for predicting aortic root dilatation during two-dimensional echocardiography in pediatric patients with Marfan syndrome using the sinus of valsalva to annulus ratio

The objective of this study was to determine if calculation of the sinus of Valsalva to annulus ratio (SOV/Ann) effectively screens for root dilatation (ARD) during two-dimensional (2D) echocardiography in young patients (1 month-15 years) with suspected or confirmed Marfan syndrome. The aortic root was imaged using 2D echocardiography (parasternal long-axis view) and the SOV/Ann ratio calculated/analyzed in 27 Marfan patients and 45 age-matched controls. All controls had a SOV/Ann ratio <1.45, and 82% of Marfan's with ARD had a SOV/Ann ratio 1.45. Five of the Marfan patients with ARD had a SOV/Ann ratio < 1.45 due to normalization of the SOV/Ann ratio because of pathologic annular enlargement. Determination of the SOV/Ann ratio allows rapid on-line screening for aortic root dilatation during 2D echocardiography. A SOV/Ann ratio 1.45 predicted ARD in young Marfan patients with a high degree of accuracy (sensitivity = 0.82, specificity = 1.00). Screening for ARD using the SOV/Ann ratio fails when annular dilatation has progressed to the degree that the SOV/Ann ratio normalizes (SOV/Ann < 1.45). In this subgroup of patients, determination of aortic root dilatation will have to be evaluated by standard methods.

Synthesis and antihepatotoxic activity of some heterocyclic compounds containing the 1,4-dioxane ring system

Silymarin isolated from Silybum marianum is a mixture of three isomers, silybin (1), silydianin (2) and silychristin (3). Silybin is the most active antihepatotoxic agent, and contains a 1,4-dioxane ring in addition to a flavonoid moiety. Based on the skeleton of silybin, we prepared some flavones and coumarins containing the 1,4-dioxane ring system and evaluated them for antihepatotoxic activity against carbon tetrachloride induced hepatotoxicity in albino rats. The degree of protection was determined by measuring biochemical parameters such as serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), alkaline phosphatase (ALKP), total protein (TP) and total albumin (TA). The compounds namely 3',4'(1",4"-dioxino) flavone (4f), and 3',4'(2-hydroxy methyl, 1",4"-dioxino) flavone (4g) were found to exhibit a significant activity comparable to standard drug silymarin (silybon-70). Other compounds also exhibited good activity. The structure activity relationship (SAR) was also studied, and where the flavonoid analogues containing a hydroxy methyl group at position-2" in the dioxane ring exhibited superior antihepatotoxic activity in comparison to coumarin derivatives.

Sonographic prevalence of acquired cystic renal disease in patients receiving haemodialysis

OBJECTIVE

To determine the sonographic prevalence of Acquired Cystic Renal Disease (ACRD) in patients on maintenance haemodialysis and its relationship to the duration on dialysis.

METHODS

All patients with end stage renal disease (ESRD) who were receiving maintenance haemodialysis in Urology Department of Mayo Hospital Lahore between November 1997 to February 1998 were screened by ultrasound for the prevalence of ACRD.

RESULTS

Forty patients with ESRD on maintenance haemodialysis were evaluated. The mean age of patients was 39.9 years. The male to female ratio was 2.3:1. Four patients (10%) had documented ACRD. The proportion of patients with ACRD increased with increasing duration of dialysis; ACRD was found in 60% of patients who had dialysis for more than 3 years, 20% in those who had been dialyzed for 1-3 years, and no patient developed ACRD who was on dialysis for less than one year. All patients remained asymptomatic except one, who had intermittent macroscopic haematuria. There was no evidence of neoplasm in any of these patients on clinical grounds or on ultrasound.

CONCLUSION

We found a low prevalence of ACRD in the population studied compared to previously published series. This can be explained by the fact that most of our patients were on dialysis for less than one year. A further study is suggested with greater numbers in a center where patient stay on dialysis for longer period and patient turnover is low.

Molecular characterization of fluoroquinolone-resistant Campylobacter spp. isolated from poultry

Campylobacteriosis, an infectious disease caused by Campylobacter jejuni and Campylobacter coli, is treated by fluoroquinolone antibiotics in clinical practices. However, use of these drugs in animal husbandry may select for fluoroquinolone-resistant campylobacters and, thereby, compromise the clinical treatment of infection. In this study, 21 fluoroquinolone-resistant campylobacters were isolated from poultry samples. Morphological and biochemical characteristics indicated that 19 isolates were C. jejuni and two were C. coli. All isolates were resistant to multiple antibiotics but sensitive to chloramphenicol and gentamicin. These isolates were characterized at the molecular level by amplifying the flagellin gene (flaA) by PCR. The PCR protocol amplified a 1.7-kb flaA gene from all isolates. RFLP analysis of the 1.7-kb amplicons after digestion with DdeI yielded four distinct patterns. The 21 fluoroquinolone-resistant campylobacter isolates were further characterized by pulsed-field gel electrophoresis (PFGE) and compared with the PFGE patterns of nine fluoroquinolone-sensitive campylobacter strains. Four of the 21 fluoroquinolone-resistant isolates were untypable by the PFGE protocol. The PFGE analysis with SalI or SmaI indicated that seven or five, respectively, of the 17 resistant isolates had identical macrorestriction profiles (mrps). However, PFGE analysis with a combination of SalI and SmaI indicated that four of the 17 isolates had similar macrorestriction profiles. The PFGE patterns of the 17 fluoroquinolone-resistant isolates were different from the nine sensitive campylobacter strains.

Management of atrial fibrillation in older patients

INTRODUCTION

There has been a rapid growth in the elderly population and atrial fibrillation (AF) is the most common sustained cardiac arrhythmia among older patients. There is considerable diversity in the management of AF and different treatment regimens have been proposed. These treatments are influenced by multiple factors. However there is no information available on the management of AF in very elderly patients. Most evidence is based upon research in younger people which cannot be extrapolated to older patients.

METHOD

The study was a prospective assessment of patients over 77 years admitted to a district general hospital. New onset AF was defined as AF of less than 3 months duration and chronic AF was defined as AF for more than 3 months. The electrocardiograms of all patients were reviewed following admission and patients were included provided they had AF on admission or during their hospital stay.

RESULTS

Over the six months 783 patients were admitted and of those 153 patients had AF (20%). The mean age was 85.2 years and in 33% of patients AF was the primary cause for admission. New onset AF was noted in 35% of patients and 65% had chronic AF. Intermittent AF was noted in 10% and no patient met the criteria for lone AF. Most patients presented with multiple medical problems averaging nearly five pathologies per patient. Though 41% of patient received thromboprophylaxis, most had inappropriate dosage thus highlighting the problems surrounding less rigid patient selection or inadequate monitoring. Twentysix percent of patients died during their hospital stay but no deaths were recorded in patients who reverted to sinus rhythm.

CONCLUSION

Elderly patients with AF are a diverse group with limited treatment options due to delayed hospital admission and multiple pathology. Chemical cardioversion is safe in the short term and those who cardiovert have better prognosis. Awareness is required for adequate dosage and monitoring of antithrombotic medications.