Pattern recognition receptor and autophagy gene variants are associated with development of antimicrobial antibodies in Crohn's disease

BACKGROUND

We sought to investigate whether variants in genes involved in bacterial sensing and autophagy (NOD2, TLR5, IRGM, ATG16L1) and the interleukin-23 signaling pathway (IL12B, IL23R, STAT3) were associated with development of antimicrobial antibodies in patients with Crohn's disease (CD).

METHODS

A cohort of 616 CD patients from a tertiary referral hospital (Mount Sinai Hospital, Toronto) was evaluated. DNA was tested for three CD-associated NOD2 variants (3020insC, G908R, R702W), variants in IRGM, ATG16L1, IL12B, IL23R, STAT3, and a TLR5-stop mutation. Serum was analyzed by enzyme-linked immunosorbent assay (ELISA) for anti-Saccharomyces cerevisiae (ASCA) IgG and IgA, anti-outer membrane porin C (anti-ompC), anti-Cbir1 flagellin, and anti-Pseudomonas fluorescens (anti-I2).

RESULTS

NOD2 3020insC was associated with cumulative seroreactivity by quartile sum (P = 0.003) and number of positive antibodies (P = 0.02). NOD2 G908R was also associated with quartile sum (P = 0.05). Increased ASCA seropositivity was associated with NOD2 3020insC (odds ratio [OR] = 1.9, P = 0.02) and G908R (OR = 1.8, P = 0.05), and ATG16L1 T300A (OR = 1.4, P = 0.01) variants; ASCA-positive patients had an increased cumulative number of NOD2 3020insC and ATG16L1 T300A variants (P = 0.007). TLR5-stop mutation abrogated development of anti-flagellin in a dominant-negative fashion (OR = 0.5, P = 0.009). The IRGM CD risk variant was associated with increased anti-flagellin seropositivity (OR = 1.5, P = 0.03). IL12B, IL23R, and STAT3 variants did not contribute to development of antimicrobial antibodies.

CONCLUSIONS

Variants in innate immune genes involved in pattern recognition and autophagy but not the interleukin-23 signaling pathway influence antimicrobial seroreactivity in CD. In particular, the additive effect of NOD2 3020insC and ATG16L1 T300A suggests a role for autophagy in development of ASCA.

Identification and weighting of the most critical "real-life" drug-drug interactions with acenocoumarol in a tertiary care hospital

PURPOSE

The objective of this study was to identify the most clinically relevant drug-drug interactions (DDIs) at risk of affecting acenocoumarol safety in our tertiary care university hospital, a 2,000 bed institution.

METHODS

We identified DDIs occurring with acenocoumarol by combining two different sources of information: a 1-year retrospective analysis of acenocoumarol prescriptions and comedications from our Computerized Physician Order Entry (CPOE) system (n = 2,439 hospitalizations) and a retrospective study of clinical pharmacology consultations involving acenocoumarol over the past 14 years (1994-2007) (n = 407). We classified these DDIs using an original risk-analysis method. A criticality index was calculated for each associated drug by multiplying three scores based on mechanism of interaction, involvement in a supratherapeutic international normalized ratio (INR) (≥ 6) and involvement in a severe bleeding.

RESULTS

One hundred and twenty-six DDIs were identified and weighted. Twenty-eight drugs had a criticality index ≥ 20 and were therefore considered at high risk for interacting with acenocoumarol by increasing its effect: 75% of these drugs involved a pharmacokinetic mechanism and 14 % a pharmacodynamic mechanism. An unknown mechanism of interaction was involved in 11 % of drugs.

CONCLUSION

Twenty-eight specific drugs were identified as being at high risk for interacting with acenocoumarol in our hospital using an original risk-analysis method. Most analyzed drugs interact with acenocoumarol via a pharmacokinetic mechanism. Actions such as the implementation of alerts in our CPOE system should be specifically developed for these drugs.

Open-lung biopsy in patients with undiagnosed lung lesions referred at a tertiary cancer center is safe and reveals noncancerous, noninfectious entities as the most common diagnoses

We evaluated the diagnostic yield of open-lung biopsies (OLBs) in a large tertiary cancer center to determine the role of infectious diseases as causes of undiagnosed pulmonary lesions. All consecutive adult patients with either single or multiple pulmonary nodules or masses who underwent a diagnostic OLB over a period of 10 years (1998-2007) were retrospectively identified. Their risk factors for malignancy and clinical and radiological characteristics were reviewed, and their postoperative complications were assessed. We evaluated 155 patients with a median age of 57 years (range, 19-83 years). We identified infectious etiologies in 29 patients (19 %). The most common diagnosis in this group was histoplasmosis (12 [41 %]), followed by nontuberculous mycobacterial infection (7 [24 %]) and aspergillosis (4 [14 %]). The majority of the 126 remaining patients had nonmalignant diagnoses, the most prevalent being nonspecific granuloma (26 %), whereas only 17 % had malignant diagnoses. We observed no significant differences among the patients with infectious, malignant, or both noninfectious and nonmalignant final diagnoses regarding their demographic, laboratory, and clinical characteristics. Six percent of the patients had at least one post-OLB complication, and the post-OLB mortality rate was 1 %. OLB is a safe diagnostic procedure which frequently identifies a wide variety of infectious and inflammatory diseases.

Impact of health policy based on the self-management program on Cesarean section rate at a tertiary hospital in Taiwan

BACKGROUND/PURPOSE

In 2005, a self-management program, based on the global budget system that met the criteria for reducing Cesarean delivery rates, was introduced to obstetric practices in Taiwan. The purpose of this study was to examine the impact of different national health policies on the Cesarean delivery rate at a tertiary hospital.

METHODS

We constructed a Poisson regression model and conducted an interrupted time series analysis to detect the effects of the implementation of each health policy on Cesarean deliveries. We used data collected at two points before the implementation of the global budget system (GBS) policy (in 2001 and 2002), and at two points after the implementation of the hospital-based self-management (HBSM) policy (in 2005 and 2010). All monthly data were collected at these time points.

RESULTS

Between June 2001 and August 2010, the rate of improvement of vaginal birth after Cesarean section (VBAC) during Period 1 revealed that VBAC may have long-term effects (p < 0.001). While there may have been a remarkable immediate improvement in the VBAC rate (p = 0.0276) in Period 3, the long-term effect of VBAC seemed to have decreased during the same period (p = 0.0003). Following the synergistic impacts of health policy implementation during Period 3, the immediate improved total Cesarean section (C/S) rate seemed to be maintained at an average value (p = 0.0183).

CONCLUSION

Over the long term, the C/S rate seemed to reach a plateau; the immediate effect on the VBAC rate was a significant increase consistent with that of the initial health policy implementation.

Hand fractures in children: epidemiology and misdiagnosis in a tertiary referral hospital

PURPOSE

To determine the local epidemiology of pediatric hand fractures and the rate of misdiagnosis.

METHODS

A retrospective study was performed on children aged 17 years and younger who were referred for actual or suspected metacarpal and phalangeal fractures. Medical records were reviewed for age at the time of injury, sex, fracture pattern, venue where the injury was sustained, injury mechanism, and diagnoses made by the referring doctor and hand surgeon. Differing diagnoses were considered misdiagnoses. The misdiagnosis rate was calculated as the percentage of misdiagnoses over the number of referrals.

RESULTS

Of 204 cases reviewed, emergency physicians referred 146 cases (72%), and primary health care physicians referred the rest. There were 193 cases of actual fractures in 181 patients and 16 cases of misdiagnosis. The fracture incidence peaked at 14 and 15 years. The median ages of children sustaining fractures of the distal phalanges, proximal phalanges, and metacarpals were 9, 12, and 15 years, respectively. The proximal phalanx was most commonly fractured (95 cases, 49%), as was the fifth ray (78 cases, 40%). Most fractures occurred at school (79 cases, 44%). Sports-related injury was the leading cause of fractures (70 cases, 39%). The misdiagnosis rate was 8% (16 of 204). The leading cause of misdiagnosis was misinterpretation of epiphyses (6 of 16), followed by missing multiple fractures (3 of 16).

CONCLUSIONS

The higher fracture incidence in teenagers is likely related to sports participation. Sports accounted for proximal fractures in older children, whereas young children sustained distal fractures through crushing injuries. Although the misdiagnosis rate seemed low, it might reflect that emergency physicians, who referred most of the cases, were adept at diagnosing fractures. To improve diagnostic accuracy, doctors should familiarize themselves with the location of epiphyses and look carefully for multiple fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analysis IV.

Screening for delirium within the interRAI acute care assessment system

OBJECTIVES

To develop and validate a screening strategy for delirium within the inter RAI acute care comprehensive assessment system.

DESIGN

Prospective validation cohort study.

SETTING

Acute general medical wards in two acute care metropolitan hospitals in Brisbane, Australia.

PARTICIPANTS

Two hundreds thirty-nine subjects with and without delirium, aged 70 and older.

MEASUREMENTS

Trained research nurses assessed subjects within 36 hours of hospital admission using the inter-RAI acute care (AC) system which includes four observational delirium items: Acute change mental status from baseline (ACMS), mental function varies over the course of the day (MFV), episode of disorganised speech (EDS), and easily distracted (ED). Geriatricians assessed subjects face to face within 4 hours of nurses' assessment using the Diagnostic and statistical manual of mental disorders (DSM IV) criteria and clinical judgement to determine delirium presence. Based on the performance of each delirium feature and to achieve highest predictive accuracy, a combination algorithm of either ACMS or MFV was developed and compared with the reference standard diagnosis determined by geriatricians.

RESULTS

Geriatricians diagnosed delirium in 52 of 239 (21.7%) subjects aged 70-102 years. The area under the receiver operator characteristics (AUC) for interRAI-AC delirium screener algorithm was 0.87 (95% CI; 0.80, 0.93), sensitivity 82%, specificity 91%, positive and negative predictive value of 0.72% and 95%, and likelihood ratio of 9.6 achieving the highest predictive accuracy of all possible combination of 4 delirium features. Underlying pre-morbid cognitive impairment did not undermine validity of the screening strategy, AUC 0.85 (95% CI; 0.74, 0.95), sensitivity 90% and specificity 69%.

CONCLUSION

The interRAI AC delirium screening strategy is a valid measure of delirium in older subjects in acute medical wards.

Ectopic pregnancy. Prevalence and risk factors in women attending a tertiary care hospital in Saudi Arabia

OBJECTIVES

To find the prevalence, risk factors, and pattern of management of ectopic pregnancy (EP).

METHODS

This retrospective study was conducted between January 2000 and December 2010 in all patients admitted to King Fahd Hospital of University, Al-Khobar, Kingdom of Saudi Arabia. Patients with suspected history of EP were collected. We collected the following data: age, parity, history of present pregnancy, any infertility treatment, diagnostic methods, and findings.

RESULTS

The prevalence of EP was 1.13%. The average age was 30.42±6.9 years. One hundred and eight (41.7%) women had previous pregnancies compared to 151 (58.3%) (p=0.0002, 95% CI of difference: greater than or equal to -0.0811 compared to primigravida. Eighty-four women had spontaneous pregnancy post EP. Thirty-one were 28.9±6.9 and 53 women were of 39.592±5.9 years (p<0.001; 95% CI of difference greater than or equal to -11.8735). Abdominal pain (n=251) and vaginal bleeding (n=240) was the most common presenting symptom.

CONCLUSION

This 10-year analysis showed that incidence of EP in our region is within the range as reported in the literature. Those who are undergoing in vitro fertilization (IVF), ovulation induction (OI), previous EPs are significantly more prone to acquire EP second time around. Age was an important risk factor for developing EP in women who had borne children.

Hyoid suspension surgery with UPPP for the treatment of hypopharyngeal airway obstruction in obstructive sleep apnea

We report our experience with hyoid suspension surgery in patients with obstructive sleep apnea (OSA) diagnosed on the basis of polysomnographic criteria. We conducted a prospective, observational study of 20 patients--18 males and 2 females, aged 15 to 52 years (mean: 42.1)--who were treated at our tertiary care center. All patients underwent hyoid suspension surgery and uvulopalatopharyngoplasty (UPPP) in a single session. Postoperative success was defined as either (1) a reduction in the apnea-hypopnea index (AHI) from 20 or higher to less than 20 or (2) a reduction in AHI of at least 50%. Postoperative follow-up polysomnography indicated that surgery was successful in 18 of 20 patients (90%). No important complications were observed. We conclude that hyoid suspension surgery is an effective procedure with low morbidity for the treatment of OSA in selected patients with hypopharyngeal obstruction. We believe it is a good option for those patients who will not or cannot tolerate therapy with continuous positive airway pressure.

Prevalence of high-level mupirocin resistance among meticillin-resistant Staphylococcus aureus isolates in a tertiary care hospital in Singapore

High-level resistance to mupirocin in meticillin-resistant Staphylococcus aureus (MRSA) jeopardizes its role in nasal decolonization protocols. We carried out a study in 2010 to determine the prevalence of high-level mupirocin resistance in our tertiary-care hospital. The prevalence of high-level resistance to mupirocin in MRSA in this hospital was 11%. There was also complete agreement between the genotypic and phenotypic methods of detection of high-level mupirocin resistance in 24 of the screening isolates.

Transmission dynamics of carbapenemase-producing Klebsiella pneumoniae and anticipated impact of infection control strategies in a surgical unit

Background

Carbapenemase-producing Klebsiella pneumoniae (CPKP) has been established as important nosocomial pathogen in many geographic regions. Transmission from patient to patient via the hands of healthcare workers is the main route of spread in the acute-care setting.

Methodology/Principal Findings

Epidemiological and infection control data were recorded during a prospective observational study conducted in a surgical unit of a tertiary-care hospital in Greece. Surveillance culture for CPKP were obtained from all patients upon admission and weekly thereafter. The Ross-Macdonald model for vector-borne diseases was applied to obtain estimates for the basic reproduction number R₀ (average number of secondary cases per primary case in the absence of infection control) and assess the impact of infection control measures on CPKP containment in endemic and hyperendemic settings. Eighteen of 850 patients were colonized with CPKP on admission and 51 acquired CPKP during hospilazation. R₀ reached 2 and exceeded unity for long periods of time under the observed hand hygiene compliance (21%). The minimum hand hygiene compliance level necessary to control transmission was 50%. Reduction of 60% to 90% in colonized patients on admission, through active surveillance culture, contact precautions and isolation/cohorting, in combination with 60% compliance in hand hygiene would result in rapid decline in CPKP prevalence within 8–12 weeks. Antibiotics restrictions did not have a substantial benefit when an aggressive control strategy was implemented.

Conclusions/Significance

Surveillance culture on admission and isolation/cohorting of colonized patients coupled with moderate hand hygiene compliance and contact precautions may lead to rapid control of CPKP in endemic and hyperendemic healthcare settings.

Evaluation of the burden of unsuspected pulmonary tuberculosis and co-morbidity with non-communicable diseases in sputum producing adult inpatients

BACKGROUND

A high burden of tuberculosis (TB) occurs in sub-Saharan African countries and many cases of active TB and drug-resistant TB remain undiagnosed. Tertiary care hospitals provide an opportunity to study TB co-morbidity with non-communicable and other communicable diseases (NCDs/CDs). We evaluated the burden of undiagnosed pulmonary TB and multi-drug resistant TB in adult inpatients, regardless of their primary admission diagnosis, in a tertiary referral centre.

METHODOLOGY/PRINCIPAL FINDINGS

In this prospective study, newly admitted adult inpatients able to produce sputum at the University Teaching Hospital, Lusaka, Zambia, were screened for pulmonary TB using fluorescent smear microscopy and automated liquid culture. The burden of pulmonary TB, unsuspected TB, TB co-morbidity with NCDs and CDs was determined. Sputum was analysed from 900 inpatients (70.6% HIV infected) 277 (30.8%) non-TB suspects, 286 (31.8%) TB suspects and 337 (37.4%) were already receiving TB treatment. 202/900 (22.4%) of patients had culture confirmed TB. TB co-morbidity was detected in 20/275 (7.3%) NCD patients, significantly associated with diabetes (P = 0.006, OR 6.571, 95%CI: 1.706-25.3). 27/202 (13.4%) TB cases were unsuspected. There were 18 confirmed cases of MDR-TB, 5 of which were unsuspected.

CONCLUSIONS/SIGNIFICANCE

A large burden of unsuspected pulmonary TB co-morbidity exists in inpatients with NCDs and other CDs. Pro-active sputum screening of all inpatients in tertiary referral centres in high TB endemic countries is recommended. The scale of the problem of undiagnosed MDR-TB in inpatients requires further study.

Comparison between innominate osteotomy and arthrodistraction as a primary treatment for Legg-Calvé-Perthes disease: a prospective controlled trial

PURPOSE

Legg-Calvé-Perthes (LCP) disease is currently managed by mechanical containment of the femoral head in the hip socket. As evidence suggests that hip distraction may offer a new treatment strategy, we used arthrodistraction as a primary treatment for active forms of LCP disease and prospectively compared the results with the Salter innominate osteotomy.

METHODS

A total of 54 children, six years or older of both genders with severe forms of LCP disease in the stages of necrosis or revascularisation, were enrolled. Patients were submitted to either Salter innominate osteotomy (n = 28) or hip arthrodistraction (n = 26). Final radiographs were used to evaluate the Mose index, Wiberg angle, extrusion index and the Stulberg et al. classification.

RESULTS

There were no significant differences in gender, age, lateral pillar classification and average follow-up time between the two groups. The osteotomy group progressed without major complications, but children in the joint distraction group experienced episodes of pin tract pain and infection, leading to the early removal of the external device in one case. Two patients developed joint stiffness, treated by physiotherapy or manipulation, and one child developed subluxation of the femoral head. The average time in distraction was 4.44 months (2.53-7.23 months). In the final evaluation the osteotomy group showed better containment of the femoral head. The Mose index and the Stulberg et al. classification were statistically similar between the two groups.

CONCLUSIONS

Despite similar final radiological results, arthrodistraction was associated with a higher morbidity. Consequently, we do not recommend hip distraction as a primary treatment for the early stages of LCP disease.

Significant differences in the expected versus observed longevity of implantable cardioverter defibrillators (ICDs)

BACKGROUND

Implantable cardioverter defibrillator (ICD) is a life-saving therapy for patients at risk of ventricular arrhythmias. Due to its high cost, its cost-effectiveness is highly dependent on its longevity, which is currently only based upon the manufacturer's predicted device life span.

AIM

We sought to assess the ICDs' longevity and the factors influencing it, and to compare the observed (real life) to the expected (manufacturer's prediction) life span at a device level.

METHODS

We retrospectively identified all patients who underwent an ICD implantation in a tertiary care medical center. For each device, an expected longevity was assigned based on the manufacturer/model, pacing percentage, and number of shocks per year. We defined device failure if the observed survival was shorter than 80 % of the expected. Only devices with follow-up time that exceeded the expected longevity were included.

RESULTS

Of the 275 devices in the cohort, 79 (29 %) failed. Median device longevity was 5 years and varied markedly between manufacturers (4.3, 4.8, 5.1, and 6.3 years for Biotronik, St. Jude Medical, Boston Scientific, and Medtronic, respectively). There were significant differences among the manufacturers in device failure rates: 48, 17, 22, and 14 % for Biotronik, St. Jude Medical, Boston Scientific, and Medtronic, respectively). In multivariate analysis, manufacturer, earlier year of implantation, congestive heart failure and chronic renal failure significantly predicted device failure.

CONCLUSIONS

In conclusion, there is a significant device failure rate among ICDs, with variability among manufacturers, impacting both patients and the medical economic systems.

Temporal changes in the genotypes of methicillin-resistant Staphylococcus aureus strains isolated from a tertiary Malaysian hospital based on MLST, spa, and mec-associated dru typing

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the main bacterial pathogens responsible for nosocomial infections leading to pneumonia, bloodstream, skin, and soft tissue infections. The objective of this study was to investigate the genomic changes of MRSA in a tertiary hospital between the years 2003, 2004, 2007, and 2008. One hundred fifty-four MRSA strains were characterized by multilocus sequence typing (MLST), spa, and mec-associated dru typing. Among the 154 strains, 29 different dru, 15 spa, and 8 MLST types were identified. Seven sequence types (STs) (ST239, ST22, ST5, ST6, ST80, ST573, and ST241) were identified among 2007-08 strains, although only 2 STs (ST239 and ST20) were observed among 2003 strains. Clones ST239-t037-dt13g, ST22-t032-(dt10a and dt10aw), and 28 other MRSA clones being introduced in 2007-2008 have replaced the ST239-t037 (dt13d, 14h, 13i, 13l, 13m, 15m, 15l, and 11al) clones present in 2003. The predominant MLST clone, ST239 (90.3%), was further distinguished into 7 different spa types and 26 different dru types, including 17 novel dru types. Maximum parsimony tree based on dru repeats revealed that 10 dru types (dt11am, dt13j, dt15n, dt13q, dt13n, dt13p, dt13f, dt13ao, dt12j, dt7v) shared the same MLST-spa types with dt13d, suggesting that these MRSA clones might have evolved from ST239-t037-dt13d. In conclusion, our data showed that the ST239-t037-dt13d clone and other MRSA clones in 2003 were replaced by ST239-t037-dt13g and other new emerging spa and dru types.

"Can we just stop and talk?" patients value verbal communication about discharge care plans

BACKGROUND

Studies show that hospitalized patients often do not understand their postdischarge care plan. There are few studies about patients' preferences regarding the content of discharge care plans.

OBJECTIVE

To identify what patients view as essential elements of a post-hospitalization plan.

DESIGN

Anonymous written survey distributed on the second day of admission to internal medicine wards.

SETTING

An academic tertiary care hospital and an academic county hospital in Seattle, Washington.

PATIENTS

Two hundred English-speaking adult inpatients ≥ 18 years or their proxies.

RESULTS

The majority of patients (64.5%) surveyed wanted verbal discharge instructions, with only 10.5% requesting written instructions (P < 0.0001). One hundred percent of patients valued the following discharge instructions as essential: "when you need to follow-up with [primary care provider] PCP," "warning signs to call PCP," and "medicines to continue post-hospitalization." One hundred percent of patients wanted "a lot of information about my condition" and "test results," but only 39% wanted "a lot of information about my medications" (P < 0.0001). When asked to choose the most important piece of discharge instruction related to their disease, 67.5% of patients chose "lifestyle changes." One hundred percent of patients thought that personal communication between the inpatient provider and the outpatient primary care provider was "extremely important" or "essential."

CONCLUSION

Patients uniformly placed high value on: 1) verbal communication about discharge care plans; 2) information about lifestyle changes for improved health; and 3) personal communication between inpatient and outpatient providers.

Sleep rounds: a multidisciplinary approach to optimize sleep quality and satisfaction in hospitalized patients

BACKGROUND

Poor sleep has adverse affects on heath, yet few studies have addressed the goal of improving sleep among hospitalized patients. We evaluated the effectiveness of a sleep-promoting intervention on the quality and quantity of sleep among inpatients.

METHODS

This study was conducted on a neurological ward in a large, tertiary care hospital. Sleep quality, quantity, and disruptors were assessed using questionnaires completed by patients during their hospital stay and Press Ganey surveys completed retrospectively. Room noise was also measured using noise meters. Data from each of 4 chronological phases of the study (baseline, basic intervention, "washout," and deluxe intervention) were analyzed. In the intervention phases, nurses conducted "Sleep Rounds" at bedtime, during which sleep-promoting practices were implemented, including lights out, television off, temperature adjustment, and a final restroom usage.

RESULTS

Patients reported 5 (interquartile range [IQR] 3) hours of sleep per night, awoke 3 (IQR 3) times nightly, and reported a median sleep latency of 11 to 15 minutes. Pain, staff interruptions, and roommates were the most significant barriers to good sleep. Noise levels were adequately low (35-40 dB) at night but were not positively impacted by our sleep-promoting interventions. Patients perceived noise on the unit to be worse during phases of the study in which there was no intervention.

CONCLUSIONS

Patient perception of sleep experience improved during the phases in which Sleep Rounds were implemented, despite the fact that there was no measurable improvement in sleep or sleep-disrupting factors.

The trend in maternal mortality in an upgraded tertiary facility in North Central Nigeria

BACKGROUND

The Millennium Development Goal 5(MDG-5) aims at reducing Maternal Mortality Ratio MMR) by 75% by the year 2015 as compared with the 1990 estimates. There is paucity of recent information on the pattern of maternal mortality in the north central Nigeria.

OBJECTIVE

This study aims to document the trend and causes of maternal deaths at the Federal Medical Centre, (FMC), Lokoja and to suggest ways of improving safe motherhood services at the centre and in Nigeria.

METHOD

This is a review of case records of 44 aternal deaths that occurred between 1st January 2005 and 31 December 2009 at FMC, Lokoja, north central Nigeria.

RESULTS

Forty four maternal deaths occurred and 9496 live births were recorded, giving a Maternal Mortality Ratio (MMR) of 463 per 100,000 live births. The annual MMR decreased from 779/100,000 live births in 2005 to 392/100,000 live births in 2009. The unbooked patients constituted about 68.2% of maternal deaths and about half (56.9%) of women that died were within the age range of 25-29 years. Hypertensive disorders (31.8%), abortion complications (18.2%), obstructed labour/uterine rupture (9.1%) and hemorrhage (9.1%)were the leading causes of death.

CONCLUSION

We observed a decreasing trend in annual maternal mortality at the hospital but more commitment is needed to achieve the MDG-5.

Donor human milk versus mother's own milk in preterm VLBWIs: a case control study

As for term infants, over the past decades there has been increasing evidence of the benefits of human milk in the feeding of Very Low Birth Weight Infants (VLBWI), influencing not only short-term health outcomes but also long-term neurodevelopmental, metabolic outcomes, and growth. Mother's own milk is the first choice for all neonates including preterm infants, when it is unavailable or in short supply, pasteurized donor breast milk offers a safe alternative and is considered the next best choice. The main aim of this case-control retrospective analysis was to evaluate short term advantages of mother's own milk as a sole diet compared to donor milk as a sole diet, in terms of growth, antiinfectious properties, feeding tolerance, NEC and ROP prevention in a population of VLBWI born in a tertiary center. We did not find significant differences in clinical outcome from mother's own milk compared with pasteurized donor milk. Only a slight and statistically not significant difference in growth could be observed, in favour of maternal milk. We conclude that the maximum effort should always be put in supporting and promoting breastfeeding and donor milk used not only as an alternative to mother's milk but also as a breastfeeding promotion and support strategy.

Treatment of chronic hepatitis C in end stage renal disease: experience at a tertiary care centre

INTRODUCTION

Treatment of patients with chronic hepatitis C (CHC) is difficult in the setting of end stage renal disease (ESRD). The present study aimed to analyze the treatment outcome in patients with CHC and ESRD, being evaluated for kidney transplantation.

METHODS

Data of 65 patients of ESRD with CHC (males: 53, mean age: 39.2 +/- 14.4 years) was analysed retrospectively. Patients were treated with either pegylated or conventional interferon (IFN) without ribavirin. Treatment response was assessed for rapid virological response (RVR), early virological response (EVR), end of treatment response (ETR) and sustained virological response (SVR).

RESULTS

All patients were receiving hemodialysis (duration 1-60 months). Sixteen patients (25%) (genotype 1: 11, genotype 3: 4, genotype 2: 1) agreed for treatment (13 pegylated IFN and 3 conventional IFN). RVR was achieved in 7 patients (44%) and out of 11 patients (69%) who achieved EVR, ETR was achieved in 7 (44%) patients. Seven patients (44%) dropped out during treatment (2 because of side effects). SVR could be demonstrated in one of 7 patients who achieved ETR (6 patients were lost to follow up after ETR).

CONCLUSIONS

In our experience, dropouts before, during and after treatment are a major problem in patients with CHC and ESRD. Of those who complete treatment, around half of them are able to achieve the end of treatment response.

Safety and efficacy of drug-eluting balloons in the treatment of drug-eluting in-stent restenosis: experience of a tertiary care hospital

BACKGROUND

The advent of drug-eluting balloons (DEBs) is a promising development for coronary revascularization procedures, especially for in-stent restenosis (ISR). This study aims to highlight our experience with DEBs in the treatment of drug-eluting ISR at a tertiary care hospital in Pakistan.

METHODS

All patients presenting to our institution from August 2008 to February 2011 with significant drug-eluting in-stent restenosis (DES-ISR) who were eligible to receive treatment via DEB were included in the analysis. Patient baseline characteristics and angiographic data about the lesion characteristics were obtained. Postprocedural and follow-up endpoints, including cardiac death, myocardial infarction, and repeat revascularization, ie, major adverse cardiovascular events (MACE), were included in the analysis.

RESULTS

A total of 26 patients received treatment with DEB in the study period, with a significant number having major predisposing factors for the development of ischemic heart disease (IHD; 46% diabetics; 92% hypertensives). The culprit lesion was most commonly identified in the left anterior descending (31%), with presence of American College of Cardiology/American Heart Association lesion type C in 68% of patients. The SeQuent Please paclitaxel-eluting balloon (B. Braun) was used for revascularization. Patients were followed for a median of 16 months. Only 5 patients (19%) developed MACE during this period.

CONCLUSION

Our experience demonstrates the effectiveness of DEBs in the treatment of drug-eluting ISR, especially in complex lesions with patients having significant risk factors for development of IHD. However, further studies are needed to define their indications in this role.

Utilization of bacteriological culture for increased diagnostic performance at a tuberculosis reference center hospital

The purpose of this study was to assess the increase in positive results of bacteriological diagnostic tests for tuberculosis with the utilization of culture at a referral hospital for tuberculosis (TB). A retrospective analysis was conducted based on the positive bacteriological results obtained at the Júlia Kubistchek Hospital. The number of bacteriological diagnoses was increased by 24.6 % with the utilization of culture of sputum samples and by 56.1% of bronchoalveolar lavage samples. With regard to pleural fluid, all six positive cultures were negative for bacilloscopy. Mycobacterium tuberculosis was isolated in 59.6 % of positive cultures. Since mycobacterial culture was not undertaken for all clinical samples, this procedure is an important laboratory routine at the Júlia Kubistchek Hospital in order to learn the real TB prevalence.

The efficacy of intramuscular loading dose of MgSO4 in severe pre-eclampsia/ eclampsia at a tertiary referral centre in Northwest Nigeria

AIMS AND OBJECTIVES

The efficacy of 10g intramuscular loading dose of magnesium sulphate in women with severe preeclampsia/eclampsia was assessed at a tertiary health centre for potential use at primary health level.

SUBJECTS AND METHODS

Intramuscular 10g loading dose and 14g loading dose of Pritchard were compared in women with severe preeclampsia/eclampsia. Primary outcome measures were the occurrence of fits in women with severe preeclampsia, further fits in those with eclampsia and maternal death. Other outcome measures were mode of delivery and severe birth asphyxia at 5 minutes of life.

RESULTS

One hundred and three women were enrolled; 54 and 49 women had 10g and 14g loading dose respectively. No significant convulsions (p= 0.1424) occurred in women with severe preeclampsia who had 10g intramuscular loading dose and repeat convulsion was averted in 93% of women with eclampsia. 10g loading dose did not increase the likelihood of caesarean section in women with preeclampsia (p=0.2832) or eclampsia (p=0.9112). The mean Apgar score at 5 minutes of life of neonates whose mothers had 10g and 14g loading dose for preeclampsia was 8 and 8.46 respectively, and 8.9 and 8.8 respectively for eclampsia. There was no statistically significant difference in maternal death between the two groups for severe preeclampsia (p= 0.2020) and eclampsia (p=0.3496).

CONCLUSION

This study suggests a potential use of intramuscular 10 gram loading dose of MgSO4 at the primary health care level in Nigeria.

Clinical manifestations of nontyphoid salmonellosis in children younger than 2 years old--experiences of a tertiary hospital in southern Taiwan

BACKGROUND

Few published studies have explored the clinical manifestations of nontyphoid salmonellosis in children <2 years of age. The aim of this study was to investigate the clinical manifestations, microbiological features, complications, fecal excretion time, and responses to treatment in children <2 years of age with nontyphoid salmonellosis.

METHODS

Between January 2005 and December 2009, pediatric patients who were admitted to Kaohsiung Veterans General Hospital with positive cultures for nontyphoid Salmonella were enrolled. The following data were recorded: demographic, clinical, and microbiological features, underlying diseases, treatment regimen, complications, responses to treatment, and fecal excretion time. The clinical manifestations were compared between patients <2 years of age and patients >2 years of age.

RESULTS

Of a total 279 enrolled patients, 179 were >2 years of age. Compared with the patients who were ≥2 years of age, patients <2 years of age demonstrated a significantly higher incidence of bloody stool, mixed infection, extraintestinal infection, longer course of antibiotics, longer course of diarrhea after admission, and more days spent in the hospital. The rates of insusceptibility of nontyphoid Salmonella to ampicillin, chloramphenicol, trimethoprim/sulfamethoxazole, ceftriaxone, and ciprofloxacin in patients <2 years of age were 37.87%, 29.09%, 23.73%, 3.26%, and 2.25%, respectively. Younger patients were generally more susceptible to antibiotics than patients ≥2 years of age, although this result was not statistically significant.

CONCLUSION

The clinical manifestations of nontyphoid salmonellosis are more severe in younger children <2 years of age than older children. Local susceptibility patterns could serve as a guide for the prescription of antibiotics by clinicians.

[Total laparoscopic hysterectomy (TLH): results at a tertiary referral hospital]

BACKGROUND

The laparoscopic total hysterectomy is an increasingly applied alternative in the surgical management of uterine pathology.

OBJECTIVE

To describe the results obtained in patients that underwent total laparoscopic hysterectomy for the management of benign uterine pathology.

MATERIAL AND METHOD

We performed a descriptive, longitudinal and retrospective study in which results on 151 patients who underwent total laparoscopic hysterectomy between October 2008 and July 2011 are reported.

RESULTS

The average age of the population was 42.5 years (30-56 years); body mass index averaged 25.8 kg/m2 (18-37 kg/m2). The most common surgical indication was uterine fibroids in 121 cases (80.1%). Among the surgical outcomes, the average operative time was 140.3 minutes (70-275 minutes); average total bleeding, 131 mL (50-400 mL); 3 cases (1.98%) of bladder injury were reported. The immediate postoperative evolution was hospitalization of 1.4 days (1-7 days). Late postoperative complications were fistulas of the urinary tract in 7 cases (4.63%), and in 1 case (0.66%) infection of the vaginal vault. The average weight of surgical specimens was 210 g (50-650 g).

CONCLUSIONS

Total laparoscopic hysterectomy is an appropriate therapeutic option We believe that careful selection of patients is critical to providing the best results.

[Survey about responsiveness of third-level hospitals to a medical disaster: after the pandemic influenza in Mexico]

BACKGROUND

The recent pandemic influenza AH1N1 virus made it clear that planning for medical disaster response is critical.

OBJECTIVE

To know the responsiveness of a sample of highly specialized hospitals in Mexico to a medical disaster, with the previous pandemic influenza AH1N1 as reference.

METHODS

A survey was conducted among the Medical Directors of a sample of highly specialized hospitals, covering: previous experience with the pandemic influenza, space considerations, material resources, staff, logistics, and current general perspectives. Descriptive statistics were used for analysis.

RESULTS

A 95% response was obtained from the institutions (19 hospitals). Of these, 47.4% considered that the medical institution was not ready to respond to pandemic influenza. The median surge capacity for the Intensive Care Unit beds was 30% (range 0 to 32 beds). The least reserve in medication was found in the antivirals (26.3%). Only 47.4% considered having enough intensive care nurses and 57.9% enough respiratory technicians; 42.1% would not have an easy access to resources in an emergency.

CONCLUSIONS

Prevention is key in responsiveness to medical disasters, and therefore the basic steps for planning strategies must be considered.

Epidemiology of Acinetobacter spp.-associated healthcare infections and colonization among children at a tertiary-care hospital in Saudi Arabia: a 6-year retrospective cohort study

A retrospective cohort study was conducted among hospitalized children less than 12 years of age who had Acinetobacter spp. isolated from ≥1 cultures between October 2001 and December 2007 at King Abdulaziz Medical City in Riyadh, Saudi Arabia. Children with multidrug-resistant (MDR) Acinetobacter spp. healthcare-associated infections (HAIs) were compared to children with antimicrobial-susceptible Acinetobacter spp. HAIs and to children colonized with Acinetobacter. Children with MDR Acinetobacter spp. HAIs were older (p = 0.01), more likely to be admitted to an intensive care unit (ICU) (p = 0.06), and had a higher mortality rate (p = 0.02) than colonized children. Children with MDR Acinetobacter spp. HAIs were older than children with antimicrobial-susceptible Acinetobacter spp. HAIs (p = 0.0004), but their mortality rates were similar. Among children with MDR Acinetobacter spp. HAIs, burn injuries were the most common underlying illness. HAIs caused by MDR or susceptible Acinetobacter spp. occurred after prolonged hospitalization, suggesting nosocomial acquisition. Patients infected with MDR Acinetobacter spp. frequently received inappropriate empiric therapy (73.9 %). Further studies are needed in order to identify effective strategies to prevent nosocomial transmission and effective ways of improving patient outcomes.

Epidemiology and risk factors of intensive care unit-acquired infections: a prospective multicentre cohort study in a middle-income country

INTRODUCTION

This study aimed to determine the incidence and risk factors of infections among patients admitted to intensive care units (ICUs) in tertiary care hospitals in Turkey.

METHODS

Adult patients who were admitted to the ICUs of five tertiary care hospitals for over 48 hours between June and December 2007 were monitored daily. Potential risk factors such as age, gender, comorbidities, diagnosis at admission, severity of disease (Acute Physiology and Chronic Health Evaluation II scores), exposure to antibiotics, history of invasive procedures and significant medical interventions were evaluated. A multivariate analysis of these risk factors was carried out using Cox regression.

RESULTS

A total of 313 patients with a median ICU stay of 12 days were selected for the study. 236 infectious episodes (33.8/1,000 ICU-days) were diagnosed among 134 patients (42.8/100 patients) in this group. Multivariate analysis revealed that exposure to a cephalosporin antibiotic (hazard ratio [95% confidence interval] 1.55 [1.10-2.19]) was an independent risk factor, whereas having a tracheostomy cannula (0.53 [0.36-0.81]) or nasogastric tube (0.48 [0.33-0.70]) was protective. Patients admitted to the ICUs from surgical wards were significantly more exposed to cephalosporins.

CONCLUSION

ICU-associated infections, which are quite high in Turkey, are largely due to inadequate infrastructure and facilities and understaffing. Abuse of antibiotics, particularly in patients who have undergone surgery, and prolonged ICU stays are significant risk factors for such infections.

[Management of pancreatic cystic tumors in the Alberto Sabogal Sologuren hospital]

INTRODUCTION

Cystic tumors of the pancreas comprise 1% of all neoplasms of the pancreas and 10 to 15% of pancreatic cysts. There are a variety of cystic lesions, of which 90% is made up of serous cystadenomas, mucinous cystic neoplasms, intraductal mucinous neoplasms and solid pseudopapillary neoplasms.

MATERIALS AND METHODS

This study describes and analyzes retrospectively the clinical, radiological, surgical, pathological and follow up of 12 patients operated on for cystic tumors of the pancreas in the hospital IV Alberto Sabogal Sologuren, in the period 2005 to 2010.

RESULTS

we found 5 (41%) serous cystadenomas with a mean age of 66 years, localized 80% in the head and 20% body; 2 (17%) mucinous cystic neoplasms with a mean age of 54, all located in body, 2 (17%) intraductal mucinous neoplasms with a mean age of 63, all located in the head, and 3 (25%) solid pseudopapillary neoplasms with a mean age of 33 years, located in body 33% and 66% in tail with a predominance of females in a ratio of 3:1. Had abdominal pain (75%), weight loss (17%) and palpable mass (17%). Of the 2 cystic mucinous neoplasms, only one have a low-grade dysplasia, of the two mucinous intraductal neoplasms, one have grade moderate dysplasia and the other with a high degree, the rest of cystic neoplasms were benign. We realize 6 Pancreaticoduodenectomy, 4 corporocaudales pancreatectomies, 2 distal pancreatectomies; of them splenectomy realize in 4 patients (2 in corporocaudal pancreatectomies and 2 distal pancreatectomies). In all cases the preoperative diagnosis was based on abdominal TEM. in 4 patients was expanded with RMN for suspicion of mucinous tumor and in 2 patients was performed CPRE for suspected intraductal tumors. Two patients coursed with atelectasis, and one patient had pancreatic fistula grade A and other mild pancreatitis post-operative. No patient was reoperated. There was no mortality post operative. Postoperative was more for the pancreaticoduodenectomy group. In a 2 year follow up, no observed recurrence and all patients are alive.

CONCLUSION

Preoperative diagnosis is crucial given the differences in natural history of the spectrum of lesions. Despite improved radiographic imaging, techniques, definitive diagnosis is only made after studying the resection sample.

Risk of mortality and predisposing factors after osteoporotic hip fracture: a one-year follow-up study

BACKGROUND AND AIMS

To determine mortality and predisposing factors in patients with fracture of the proximal femur, one year after the initial fracture, in a tertiary hospital in Castile and Leon (Spain).

METHODS

Observational case-control study. Patients aged ≥65 years admitted to the orthopedic surgery department of the Rio Hortega Hospital, a tertiary care hospital with approximately 560 beds, due to non-traumatic hip fracture between September 2005 and November 2006, were included. An age-matched control group of 81 institutionalized patients with similar characteristics was recruited. A protocolized telephone interview and a review of hospital medical records was made at 12 months followup.

RESULTS

Of the 170 patients recruited, the final analysis was made in 139: 121 (87.1%) women and 18 (12.9%) men. The control group was formed of 81 patients: 64 (79%) women and 17 (21%) men. Mortality was 41.7% in the study group and 2.5% in controls (p; 0.001). Mortality was 31% in month 1, 24.1% between months 2 and 6 and 29.3% between months 6 and 12 (in 15.6% the date of death was unknown). Factors associated with mortality were: age >86 years (p; 0.024); prior cognitive deterioration (p; 0.011); prior locomotor disorder (p; 0.047); male gender (p; 0.017); heart disease (p; 0.042).

CONCLUSIONS

Patients with hip fracture, had substantially higher mortality than comparable healthy people, and mortality was highest in the first six months after fracture. Age and prior comorbidities were associated with excess mortality.

A study on workplace violence against health workers in a Nigerian tertiary hospital

BACKGROUND

Workplace violence is a common phenomenon which cuts across all work settings. Its prevalence is particularly high in the health sector and adversely affected service delivery. However, in Nigeria there are limited data on the magnitude of the problem. In this study, we aim to describe the prevalence of workplace violence against health workers in a tertiary hospital located in Abia state, Nigeria.

METHODOLOGY

In this descriptive cross-sectional study, data was collected using self-administered questionnaires distributed to 395 health workers of the clinical services division of the hospital to assess their experience of workplace violence in the preceding year. The response of 303 was returned and analyzed.

RESULTS

Most (88.1%) of the respondents had experienced workplace violence with more than half (54.4%) of all violent incidents occurring in the wards. Psychological violence was more prevalent than physical violence. Verbal abuse (85.4%) was the most prevalent while sexual harassment (4.5%) was the least. Approximately one quarter (25.1%) of all the respondents had been physically assaulted in the preceding year. Patients and their relations were the main perpetrators of physical assault and threats. Senior colle agues were the main workplace bullies.

CONCLUSION

The prevalence of workplace violence was high in this hospital.

Evaluation of awareness about pharmacovigilance and adverse drug reaction monitoring in resident doctors of a tertiary care teaching hospital

OBJECTIVE

Adverse drug reactions (ADRs) are associated with significant morbidity and mortality and have a major impact on public health. Pharmacovigilance helps in early detection of ADRs and identification of risk factors. Underreporting of ADRs can be improved by imparting knowledge regarding pharmacovigilance to healthcare professionals. This study was aimed at investigating the knowledge and attitude of resident doctors about ADR reporting and suggesting possible ways of improving ADR reporting.

MATERIALS AND METHODS

This study was a cross-sectional, questionnaire-based survey conducted in a tertiary care teaching hospital. The respondents were resident doctors. Study instrument was a self-developed, pre-validated, semi-structured questionnaire consisting of open- and close-ended items.

RESULTS

A total of 84 questionnaires were considered for analysis, giving a response rate of 93.33%. In all, 64.28% of the respondents were aware about pharmacovigilance, 52.38% were aware of ADR reporting system in India, 83.33% opined that only serious ADR with any medicine should be reported, and 35.72% believed that ADRs should be reported only for newly marketed agents. Although 67.85% of respondents observed an ADR, only 25% reported it; 44.04% were aware about the complete procedure of ADR reporting. General attitude of the respondents about ADR reporting was as follows: ADR reporting should be compulsory (15.19%), voluntary (41.66%), remunerated (3.57%), identity of prescriber should be concealed (21.42%), and identity of reporter should be concealed (29.7%).

CONCLUSION

Increasing awareness about pharmacovigilance will be helpful in improving the status of ADR reporting. Other measures such as making ADR reporting guidelines available in the form of booklets and displaying posters can also play a useful role.

The proportion of asthma and patterns of asthma medications prescriptions among adult patients in the chest, accident and emergency units of a tertiary health care facility in Uganda

BACKGROUND

Asthma is a common chronic disease with high morbidity. In Uganda, the proportion of asthma in health care facilities and the extent to which asthma management guidelines are followed is unknown.

OBJECTIVES

To determine the proportion of adult patients diagnosed with asthma and the proportion of asthma patients that receives recommended asthma therapy prescriptions according to Global Initiative for Asthma with GINA management and prevention guidelines, in the chest clinic and accident and emergency (A&E) departments in Mulago Hospital.

METHODS

A retrospective chart review at Mulago Hospital chest clinic and A&E department from January 1(st) 2009 to December 31(st) 2009 was performed. Patients diagnosed with asthma were identified and medications prescribed were recorded. Patients were categorized as having received recommended asthma therapy prescriptions (if therapy was compatible GINA guidelines) or not. Proportions of asthmatics in the two departments and those who received recommended asthma therapy were calculated.

RESULTS

One hundred thirty four (134) of 792 patients in the chest clinic (16.9%) were diagnosed with asthma. At the A&E four hundred and sixteen (416) patients out of 16 800 (2.5%) were diagnosed with asthma. Sixty nine point seven (69.7%) were female. The median age was 29 years (IQR, 19-42). Wheezing was the commonest presenting symptom (55%). Recommended asthma therapy prescriptions were 47.4% for the chest clinic, and 32.2% of the patients at A&E department received asthma therapy prescriptions as recommended for asthma exacerbations management during hospitalization.

CONCLUSION

Asthma accounts for a significant proportion of outpatients in the chest clinic. The majority of the patients do not receive recommended asthma therapy prescriptions.

Anaesthetic and obstetric challenges of morbid obesity in caesarean deliveries--a study in South-eastern Nigeria

BACKGROUND

Morbid obesity of parturient has become very important in perinatal medicine because of a worldwide obesity epidemic. Morbid obesity of parturient is reportedly associated with severely increased anaesthetic and obstetric risk.

OBJECTIVE

To determine the prevalence rate, anaesthetic and obstetric complications in morbidly obese parturient that had caesarean delivery in a Nigerian tertiary care centre.

METHODS

The obstetric theatre records and case files were reviewed for caesarean deliveries in the University of Nigeria Teaching Hospital, Enugu, Nigeria from May 2008 to December 2010. A sample size of 250 patients, calculated based on a prevalence rate of 19%, confidence interval of 95% , a power of 80% and a finite population of zero was used to determine the prevalence rate of morbid obesity (Body Mass Index of greater than or equal to 35 kg/m(2)).

RESULTS

There were thirty-one patients with morbid obesity (12.4%). The average Body Mass Index (BMI) was 38.3 kg/m(2)(SD ± 2.99). Other findings included macrosomia (7 or 25.8%), gestational diabetes (13%) and pregnancy induced hypertension (7 or 22.5%).There were two neonatal deaths but no maternal deaths.

CONCLUSION

The prevalence rate of morbid obesity is about 10% in Nigerian women of child bearing age. This mirrors a World Health Organisation report published in the World Health Organisation Global Information Base.

Coordination Group for the Survey of Present Status of Oxygen Use in Premature Infants in NICUs and Prevention and Treatment of ROP. [Present situation of oxygen therapy and retinopathy of prematurity management in premature infants in NICUs: a survey based on 16 tertiary class-one hospitals in the mainland of China]

OBJECTIVE

To investigate the present status of oxygen therapy and retinopathy of prematurity (ROP) management in premature infants in tertiary class-one hospitals of the mainland of China.

METHODS

A non-informed inspection on oxygen therapy and ROP management in premature infants was carried out by experts in neonatal intensive care units (NICU) of 16 tertiary class-one hospitals in different areas of the mainland of China in Oct. 2010, and data were collected and analyzed.

RESULT

In 16 tertiary first-class hospitals, NICU had (113.0 ± 67.0) beds for newborn per unit, with hospital admission of (3596.6 ± 1609.8) newborns in 2009, among them (1030.5 ± 580.2) cases were premature infants, and (397.8 ± 237.1) cases had gestational age less than 34 weeks. Most hospitals obtained written informed consents before using oxygen for premature infants and 11 of them informed parents of all patients, while the lowest inform rate was only 22.06%. Indication for oxygen administration was abided strictly in all patients in 9 hospitals, but the lowest accordance rate to the indication was only 20%. All of the hospitals were equipped with central oxygen supply system, but only 8 hospitals were equipped with air-oxygen mixers, and 14 hospitals were equipped with oxygen concentration detectors. Incomplete records of oxygen therapy were found in 9 hospitals, and high oxygen saturation (> 95%) was found in more than 10% of infants who received oxygen therapy in 6 hospitals. High PaO2 (> 80 mm Hg, 1 mm Hg = 0.133 kPa) was found in more than 10% infants who received oxygen therapy in additional 3 hospitals. All of the NICUs had carried out ROP screening, but only 13 of them conducted it by themselves, and one still conducted it by direct ophthalmoscope. Of the 1023 medical records inspected randomly in 16 hospital, 612 (59.8%) had retinal examination records, and 69 were found to suffer from ROP, with the incidence rate of 11.27%, of them 7 threshold ROP cases were found with the incidence rate of 1.14%.Only 4 hospitals had carried out ROP treatment, of them 3 used laser therapy, and one used cryotherapy. The follow-up rates of ROP in premature infants after discharge were less than 50% in 8 hospitals.

CONCLUSION

Since the first guidance on oxygen therapy and ROP management was promulgated by the Ministry of Health in 2004, the situation of oxygen therapy and ROP management in tertiary first-class hospitals of China had made considerable improvement, most of hospitals could abide the guidance well without blindness were found during the inspection, but some hospitals still have problems to be solved, including oxygen therapy without informing, loose implementation of oxygen indication, insufficient oxygen therapy facilities, inadequate oxygen concentration monitoring, incomplete records, low screening rate and follow-up rate, as well as under-treatment.

Profile of women admitted at an obstetric ICU due to non-obstetric causes

OBJECTIVE

To characterize patients admitted during the pregnancy-puerperal cycle for non-obstetric causes in the obstetric intensive care unit (ICU) of a tertiary hospital in northeastern Brazil.

METHODS

A descriptive study, analyzing the participants from a bidirectional cohort study was conducted between January 2005 and October 2010. A total of 500 patients admitted during the pregnancy-puerperal cycle due to non-obstetric causes in an obstetric ICU in northeastern Brazil were included; cases of gestational trophoblastic disease (GTD), ectopic pregnancy, death or ICU stay lasting < 24 hours, and lack of signed informed consent form (ICF) were excluded. The biological, sociodemographic, obstetric, and clinical variables were analyzed. Statistical analysis was performed using Epi-Info 3.5.3.

RESULTS

Of 5,078 obstetric admissions in the service, 500 patients (9.8%) were due to non-obstetric causes. The mean age was 25.9 years, the predominant ethnicity was mixed-race (68.9%), and mean BMI was 27.5. In 79.9% of cases, women had a partner, and schooling over eight years was observed in 49.2%. The main clinical diagnoses seen at ICU admission were heart disease, deep vein thrombosis (DVT), urinary tract infection (UTI), asthma, acute pulmonary edema (APE), and community-acquired pneumonia (CAP). Central access was used in 10.2% of patients, 11% were on mechanical ventilation, 20.4% received blood transfusions, and 4.0% of the patients died.

CONCLUSION

Women admitted at the obstetric ICU due to non-obstetric causes represent a significant number of patients in this sector. They are mostly young women, and the main admission diagnoses were cardiovascular, respiratory, and infectious diseases, with a fatality rate of 4%.

Influence of replacing tuberculin skin test with ex vivo interferon γ release assays on decision to administer prophylactic antituberculosis antibiotics before anti-TNF therapy

Background

The recommendations for detecting latent tuberculosis infection (LTBI) before antitumour necrosis factor (anti-TNF) therapy are based on the tuberculin skin test (TST), which lacks both specificity and sensitivity and can lead to unnecessary treatment with antibiotics. A study was undertaken to investigate the effect of replacing TST with interferon γ (IFNγ) release assays (IGRA) in screening for LTBI and deciding to begin prophylactic antituberculosis (TB) antibiotics before anti-TNF therapy in immune-mediated inflammatory diseases.

Methods

In 15 tertiary care hospitals, consecutive patients with rheumatoid arthritis, spondylarthropathies or Crohn's disease were screened for LTBI before anti-TNF therapy with TST, QuantiFERON TB Gold in tube (QTF-Gold IT) and T-SPOT.TB at the same time. The potential diagnosis of LTBI and the effect on the decision to begin antibiotic prophylaxis were assessed.

Results

Among 429 patients, 392 had results for the three tests. The results for TST, T-SPOT.TB and QTF Gold IT were positive for 35.2%, 15.1% and 9.9% of patients, respectively (p<0.0001). Antibiotics were required for 177 patients (45.2%) if positive TST results were included in the LTBI definition, 107 patients (27.3%) if TST results were replaced with results from one of the IGRA tests and 84 patients (21.4%) if TST results were replaced with QTF-Gold IT results (p<0.0001). The decision on the use of antibiotic prophylaxis was changed for 113 patients (28.8%, 95% CI 24.4% to 33.6%) if TST results were replaced with QTF-Gold IT results.

Conclusions

Replacing TST with IGRA for determining LTBI allowed the proportion of patients with immune-mediated inflammatory diseases needing prophylactic anti-TB antibiotics before beginning anti-TNF agents to be reduced by half.

TrialRegNo: NCT00811343.

Ceftriaxone resistance and genes encoding extended-spectrum β-lactamase among non-typhoidal Salmonella species from a tertiary care hospital in Kuala Lumpur, Malaysia

The prevalence of ceftriaxone resistance and the associated genes encoding extended-spectrum β-lactamase (ESBL) was determined in 149 non-duplicate non-typhoidal Salmonella isolated in 2008-2009 from patients in a tertiary care hospital in Kuala Lumpur, Malaysia. The resistance rate to ceftriaxone was 2.7% (2/74) in 2008, 4.0% (3/75) in 2009, and 3.4% (5/149) overall. CTX-M ESBL genes were detected in 2 of the 5 ceftriaxone-resistant isolates. The prevalence of ceftriaxone resistance, although low, is a concern because it limits therapeutic options. Continued surveillance of ceftriaxone resistance is important to monitor its trends.

A ten year review of emergency peripartum hysterectomy in a tertiary care hospital

BACKGROUND

Emergency peripartum hysterectomy (EPH) is a life saving procedure considered in cases of severe haemorrhage unresponsive to medical and conservative surgical procedures. The aim of present study was to review the frequency, indications, maternal morbidity and mortality associated with emergency peripartum hysterectomy in a tertiary care hospital in a developing country.

METHODS

This was a cross sectional study in which data was retrospectively collected from January 2000 to December 2010. Main outcome measures were maternal morbidity and mortality associated with EPH.

RESULTS

The incidence of EPH was 10.52/1000 deliveries. The main causes of EPH were rupture uterus 76 (34.86%), atonic uterus 65 (29.81%), placenta accreta 19 (8.71%), placenta previa 17 (7.7%), and placental abruption 36 (16.5%). Mostly subtotal hysterectomy was the preferred method done in 196 (89.9%) of cases, while total abdominal hysterectomy was done only in 22 (10.09%) of cases. The over all complication rate was 81.2% which included both minor and major complications like hypovolemic shock 180 (82.5%), febrile morbidity 108 (49.5%), wound infection 40 (18.3%), bladder injury 6 (2.75%), and thrombophlebitis 22 (10.09%). The maternal mortality in present review was (10.5%).

CONCLUSION

Frequency of EPH was found to be high in this study. Obstetricians must be skilled in it particularly in developing countries where the main indication of hysterectomy is rupture uterus.

Visual disability in newly diagnosed primary open angle glaucoma (POAG) patients in a tertiary hospital in Nigeria

BACKGROUND

Glaucoma remains the second leading cause of blindness worldwide and the highes cause of irreversible blindness worldwide. In N Glaucoma accounts for 16% of blindness and primary open angle glaucoma is the most prevalent clinical type.

AIM

The aim of this study is to assess the visual disability resulting from glaucoma in newly diagnosed POAG patients in University of Port Harcourt Teaching Hospital.

MATERIALS/METHOD

This is a retrospective study of newly diagnosed glaucoma patients referred from the general ophthalmology clinic to the glaucoma clinic over a 12 month period (January-December 2010). All patients had a glaucoma workup includin Snellen distant visual acuity, slit lamp examination, Goldman applanation tonometry, gonioscopy, dilated fundoscopy with +78 diopter lens as well as perimetry. All examinations were carried out by both authors. Patients with other co-morbidities such as cataract and retinal/macular pathologies were excluded from the study.

RESULTS

A total of 98 patients were reviewed. The were 34 males and 27 females, giving a male to female ratio of 1.3:1. The average age was 54.2 years and most patients (>80%) were in the 40-59 year age group. Of the 98 patients reviewed, 62.2% had POAG. 30 patients were-blind by distant visual acuity criteria while 45 patients were blind by central visual field criteria.

CONCLUSION

POAG is the most prevalent clinical subtype of glaucoma in Nigeria and sub-Saharan Africa Paucity of symptoms in early stages of the disease at late presentation is a characteristic finding in our clinic environment. Our study showed that POAG in our environment is associated with marked visual disability at the time of presentation.

Medical management of retroperitoneal fibrosis

BACKGROUND

Small series and case reports suggest that a combination of mycophenolate mofetil and prednisone is an efficatious and safe treatment for patients with retroperitoneal fibrosis.

OBJECTIVE

To describe the outcomes of patients with retroperitoneal fibrosis treated with a combination of prednisone and mycophenolate mofetil.

DESIGN

Prospective, case series.

PATIENTS

31 patients with retroperitoneal fibrosis.

SETTING

Single-center tertiary care facility.

INTERVENTION

Prednisone 40 mg administered daily and tapered over 6 months and mycophenolate mofetil 1,000 mg given twice daily.

MEASUREMENT

Clinical course, laboratory assessment, measurement of periaortic mass.

RESULTS

Systemic symptoms resolved in all patients. Eighty-nine percent of patients had a 25% or greater reduction in periaortic mass. Eighteen patients had 32 obstructed ureters. Thirty of these ureters were free of obstruction after an average of 513 days of therapy. Laboratory abnormalities of elevated erythrocyte sedimentation rate and serum creatinine and decreased hemoglobin levels normalized in all patients. Recurrent disease occurred in 2 of 28 patients.

CONCLUSION

Combined prednisone and mycophenolate mofetil appears to be an effective therapeutic option for patients with retroperitoneal fibrosis.

Profile of cancer patients treated at the emergency room of a tertiary cancer care centre in southern Brazil

The number of cancer care visits in the emergency department for evaluation and treatment has been steadily increasing. Cancer patients represent a challenge for the emergency team because they may have acute symptoms of still undiagnosed malignancy, vague symptoms related to the disease or complications of cancer treatment, all of which can be either mild or potentially life-threatening. The Santo Antonio Hospital is a public institution located in the city of Blumenau (SC, southern Brazil), which serves as a reference centre for cancer care patients for a population of over a million and a half. The objective of this research was to describe the epidemiological profile of the oncologic population who were treated at the emergency department of this hospital, during a period of over six months, starting on April 1st , 2011 to October 31st of the same year. There were 1,051 oncologic visits during this period, with the age ranging from 19 to 89 years. The greater demand for care was sought by patients with urological, breast, upper and lower gastrointestinal tract and lung cancer. The three major complaints of the consultations were pain, respiratory and gastrointestinal symptoms. The visits occurred mainly during daytime mostly on Mondays and Tuesdays. The improvement of primary care services and efficiency of oncology clinics in meeting the high demand for appointments is extremely important, in order to prevent unnecessary visits to the emergency department.

Epidemiology of breast cancer patients at a tertiary care center in the Eastern Province of Saudi Arabia

BACKGROUND

Breast cancer is the most common cancer in Saudi Arabia. However, detailed published epidemiologic data are scarce. In this study, breast cancer patients at a tertiary care hospital were characterized and compared with data from the United States.

METHODS

Medical records were retrospectively reviewed of female patients with confirmed diagnosis of invasive breast cancer who consulted with Saad Specialist Hospital between 2004 and 2011. Descriptive statistics were calculated and compared with published data.

RESULTS

Two-hundred and sixty-two female patients with cytologically or histologically confirmed diagnosis of invasive breast cancer were identified and analyzed. Compared to published American data derived from the SEER database, patients were diagnosed at a markedly younger age (<50 years: 57.5% versus 12.5%) and more advanced disease (localized disease: 28.6% versus 61.2%). The difference of the age at diagnosis could not be fully explained by the different age structures of the Saudi Arabian and American population in our analysis. Although the overall mastectomy rate was higher (58.2% versus 38.5%), no relevant difference in the mastectomy rates was found if analyzed by stage.

CONCLUSION

Our data suggest that breast cancer in this part of Saudi Arabia is diagnosed at a much higher stage compared to the United States. More effort in awareness campaigns, easier access to screening and treatment are needed to improve the prognosis and to reduce the currently relatively high mastectomy rate.

Maternal morbidity in emergency versus elective caesarean section at a tertiary care hospital

BACKGROUND

In the past 30 years the rate of caesarean section (C/S) has steadily increased from 5% to more than 20% for many avoidable and unavoidable indications. The objective of this study was to compare maternal morbidity and determine its cause in elective and emergency caesarean section.

METHOD

It was a cross-sectional comparative study conducted in Civil Hospital Karachi at Obs/Gyn Unit III. All mothers admitted through OPD or emergency during the study period, of any age or parity undergoing C/S were recruited in the study. Patients having previous myomectomy, hysterotomy or classical C/S were excluded from the study. Patients undergoing emergency C/S were placed in group A, and those delivered by elective C/S were included in group B. Study variables were general and obstetric parameters and complications observed intra-operatively. Any postoperative complications were recorded from recovery room till patient was discharged from the ward.

RESULTS

There were 50 patients in each group. In group A, 11 (22%) were booked and 33 (66%) were referred cases. In group B, 48 (96%) were booked. The mean age in both groups was 28 years. In both groups, multigravida compared to primigravida were 78% vs 22% in group A, and 92% vs 8% in group B. Indication for C/S was previous C/S in 10 (20%) patients in group A, and 39 (78%) patients in group B, placenta previa, chorioamionitis, obstructed labour (6, 12% each); pregnancy induced hypertension and eclampsia in 5 (10%) cases in group A only. Intra-operative complications in group A were 48 (96%) vs 15 (30%) in group B (p = 0.000). Postoperative morbidity in group A was 50 (100%) and 26 (52%) in group B (p = 0.000). Intra-operative complication was haemorrhage in 46 (92%) cases in group A and 11 (22%) in group B. Anaesthetic complications were 40 (80%); prolonged intubation 25 (50%), aspiration of gastric contents 8 (16%), and difficult intubation 7 (14%) in group A. Ten (20%) cases had anaesthetic complications in group B. Commonest postoperative complication in both groups was anaemia in 41 (82%) and 11 (22%) cases respectively.

CONCLUSION

Maternal morbidity is significantly higher in emergency C/S. Haemorrhage is a frequent complication in C/S, emergency or elective.

Perception of leadership among health managers working in tertiary level hospitals

BACKGROUND

Rapid growth of medical knowledge has created major changes in technology which in turn has created greater demand of the client for better health services, and health sector is constantly under pressure of great internal and external demands. Quality of services, largely depend on to what extent managers are well versed with the concept of evidence based management, team and group approach in achieving organizational objectives. Making an effective health system, addressing the double burden of diseases coupled with resource crunch in developing countries is a big challenge for policy makers and health managers. Comprehensive concepts and application knowledge of leadership is very important for health managers in the present day in order to get best output that satisfies all the stake holders. Present anthropological study was done to assess the perception and knowledge of leadership among the health managers working in tertiary level hospitals.

METHODS

This qualitative study was conducted in two public sector tertiary level hospitals of Lahore chosen randomly out of a total of seven such hospitals in the same city. Convenient sampling technique was used. Observation and in- depth interviews were conducted for data collection. Open ended questionnaire on the lines of MLQ was used. One main domain of leadership was developed and categorisation of the themes was done in the two evolved categories of transformational and transactional leadership.

RESULTS

In the domain of leadership 10 of the health managers showed positive themes for transactional leadership, 6 showed positive themes for transformational leadership, and still 1 health manager showed overall negative response for the concept of leadership; he was totally in favour of dictatorship.

CONCLUSION

Health managers with degrees in management/administration had better concept about the key idea of leadership and its variables. Female health managers were more inclined towards transformational leadership behaviour.

Determination of methicillin resistant Staphylococcus aureus (MRSA) using several phenotypic methods--a report from a tertiary care center at New Delhi, India

Staphylococcus aureus is a serious current health care concern. Rapid, precise identification of MRSA is a prerequisite tool for control of hospital infection. The present study aimed at studying the antibiotic susceptibility and demographic profile of MRSA isolated from clinical specimens and also to assess the reliability of five methods of identifying methicillin resistance. A total of 112 isolates of Staphylococcus aureus isolated from critical areas of the hospital were randomly selected and subjected to various phenotypic methods for determining methicillin resistance. Determination of minimum inhibitory concentration (MIC) for oxacillin by microbroth dilution method was the 'gold standard'. The present study also focuses on the comparison of oxacillin disc diffusion and cefoxitin disc diffusion screening for determination of MRSA. The sensitivity and specificity values for latex agglutination, oxacillin salt agar screening, E-Strip, cefoxitin disc diffusion and oxacillin disc diffusion method are 98.7% and 72.5%, 94.4% and 92.5%, 93.1% and 65.0%, 86.1% and 65%, 83.3% and 90.0% respectively. No single phenotypic test is completely reliable for the detection of oxacillin resistance in S. aureus. Oxacillin salt agar screening at 6 microg/ml and PBP2' detection by latex agglutination method were the most sensitive and specific method for detecting MRSA. Amidst the disc screening methods which are most often used in the smaller laboratory set-up where agar screen may not be functionally feasible for various reasons (economic and performance) cefoxitin disc screening has good sensitivity and specificity overall and perhaps is closest to being the cheap and reliable alternative in these settings.

Management of early onset severe preeclampsia in a tertiary hospital in India: does expectant management alter perinatal outcome?

OBJECTIVE

The aims of the study were to find out the maternal and perinatal outcome of early onset severe preeclampsia (PE) in a tertiary care center in a developing country like India and to determine whether expectant management in such a setup improves the perinatal outcome.

MATERIALS AND METHODS

It was a retrospective study. All women with early PE were admitted stabilized and evaluated. Expectant management was given whenever there was no indication for eminent delivery. The perinatal outcome of the expectant group was compared with that of the aggressive group, and appropriate statistical analysis was carried out.

RESULTS

A total of 106 women were admitted with severe PE, 61 were treated aggressively, and 45 were stable enough to receive expectant management. The total days gained on expectant management was 7 days. Perinatal mortality was 31.13%. Perinatal outcome of the expectant and aggressive management groups did not differ (P = 0.141); there was no increase in maternal complications on expectant management. There were 2 cases of maternal mortality in the aggressively managed group.

CONCLUSION

Perinatal mortality in severe PE is high. There was no increase in maternal morbidity on expectant management; however, there was no difference in perinatal mortality on expectant management.

[Compliance on hand-hygiene among healthcare providers working at secondary and tertiary general hospitals in Chengdu]

OBJECTIVE

To evaluate the compliance on hand-hygiene and related factors among healthcare providers working at secondary and tertiary hospitals in Chengdu.

METHODS

On-site observations regarding hand-hygiene compliance and facilities were conducted in 6 hospitals in Chengdu. Doctors and nurses were asked and recorded about their knowledge regarding hand-hygiene.

RESULTS

Of 1535 activities where hand-hygiene was deemed necessary, under observating healthcare providers would perform hand-hygiene procedures 17.8% of the time (12.8% of the time before touching a patient, 21.0% of the time before touching objects around a patient, 27.3% of the time after touching a patient, and 31.5% of the time after removing gloves). Only 2.2% of the treating rooms were equipped with foot-operated or automatic faucets;of these only 24.5% had soap or alcohol-based hand-sanitizer, and 6.3% had paper towel or other hand-drying equipment. 92.8% of the healthcare providers knew of the six-step method on hand-washing. More than 90.0% of the healthcare providers knew that both palm and back of the hands as well as the front and back of the fingers should be washed. However, only 22.8% knew that the hand-washing procedure should last ≥ 15 seconds. Rates on hand hygiene among chief or more senior physicians (14.6%), attending physicians (9.2%) and junior doctors (15.6%), nurses in chief (25.0%), senior nurses (26.3%) and junior nurses (20.5%) showed no significant differences (P > 0.05). Similarly, scores on related knowledge between chief or senior physicians (12.4 ± 3.2), attending physicians (13.6 ± 3.3) and junior doctors (13.4 ± 2.9), nurses in charge (15.2 ± 2.0), senior nurses (14.8 ± 2.1) and junior nurses (14.3 ± 2.6) also showed no significant differences (P > 0.05). Rate on hand hygiene among nurses (22.7%) was significantly higher than that of the doctors (13.6%). Rate of hand hygiene among 50 - 59 years old healthcare providers (7.4%) was significantly lower than those of all the other age groups (17.1% - 25.0%); rate of female health care providers (19.5%) was significantly higher than that of males (13.8%). Similarly, the nurse's knowledge score (14.7 ± 2.3) was significantly higher than that of the doctors (13.2 ± 3.1). Among 50 - 59 years old healthcare providers, the rate was (12.2 ± 3.8) significantly lower than that of 20 - 29 (14.0 ± 2.6), 30 - 39 (14.3 ± 2.9) and 40 - 49 year olds (13.8 ± 2.7). Again, the knowledge score of females (14.5 ± 2.5) was significantly higher than that of males (12.7 ± 3.2) (P < 0.05).

CONCLUSION

The high-level knowledge on hand-hygiene among healthcare providers in this area did not translate into good practices. Also, most of the hospitals had poor hand-hygiene equipment. We recommend that training and periodic monitoring be conducted, and hand-hygiene equipment be improved to facilitate hand-hygiene practices among healthcare providers.

HIV-1 drug resistance among newly HIV-1 infected individuals attending tertiary referral center in Chennai, India

CONTEXT

In the era of free HAART, accessibility and availability of ARV has been dramatically increased in India. However, rates of treatment literacy and adherence appear to be sub-optimal. Therefore, it is essential to monitor the extent of primary drug resistance in such settings.

MATERIALS AND METHODS

Between July and October 2006, 18 anti-retroviral-naοve individuals were identified as recent infected by the BED-Capture enzyme immunoassay in a VCTC clinic in Chennai. Specimens from these individuals were subjected to genotypic drug resistance testing. Phylogenetic trees were generated using MEGA for Windows version 4.0 using neighbor-joining method. The significant differences in polymorphic mutation frequencies between the study specimens and established subtype C-specific polymorphisms were examined using the Chi-square test.

RESULTS

Amino acid substitution (K103N and V106MV) at drug resistance positions occurred in two (11%) isolates, conferring high-level resistance to the non-nucleoside reverse-transcriptase inhibitors nevirapine (NVP), efavirenz (EFV), delavirdine (DLV) and notably extensive genetic variations were observed. K122E (94.4%) and K49R/KR (11.1%) polymorphisms identified in this study have not been previously described in established subtype-C specific polymorphisms. The rate of polymorphisms showed marked difference at the locations V60, D121, V35, and D123 (P < 0.0001). All the sequences showed maximum homology with Indian HIV-1 subtype C reference strain C.IN.95IN21068.

CONCLUSIONS

The finding of resistance to NNRTIs is of public health importance. There is an urgent need to establish surveillance for primary drug resistance in large scale. Further studies are required to determine the phenotype impact of newer polymorphic mutations in relation to drug resistance and viral fitness.

Anti-microbial resistance profile of Citrobacter species in a tertiary care hospital of Southern India

BACKGROUND

Recently, the isolation of this pathogen in hospital settings is increasing and multidrug-resistant strains are emerging; these strains present a challenge for clinician and the clinical microbiologist because of their increased occurrence in nosocomial infection. The current study was done to find out the antibiotic sensitivity pattern of Citrobacter species from various clinical specimens.

MATERIALS AND METHODS

Samples were collected from patients in accordance with standard protocols. Citrobacter species were identified by conventional biochemical tests. Antibiotic susceptibility of the isolates was done by disc diffusion method according to National Committee for Clinical Laboratory Standards (NCCLS) recommendations.

RESULTS

Out of 563 isolates of Citrobacter, majority were from pus (48.1%), followed by urine (24.3%), sputum (20.3%), body fluids (05.2%), blood (02.1%). C. koseri was the predominant species [391 (70%)] isolated. Infection was nosocomialy acquired in 493 (87.4%) patients. The mean age was 39.5 years. Anti-biograms of Citrobacter isolates revealed that effective agent against Citrobacter isolates was imipenem (91.8% sensitive), followed by piperacillin/tazobactam (58.3%) and amikacin (53.4%).

CONCLUSION

Citrobacter isolates resistant to multiple anti-microbial agents have emerged, including strains resistant to imipenem, making it an emerging nosocomial pathogen. Therefore, the results of this study suggest that surveillance of anti-microbial resistance in Citrobacter is necessary. Antibiotic policy should be formulated in the hospital. Depending on the antibiotic sensitivity pattern of the Citrobacter isolates, antibiotics should be used, and proper infection control measures should be strictly followed to prevent spread of this pathogen.