Central venous catheter-related bloodstream infections (CVC-BSI) in patients of clinically suspected septicemia

Central venous catheter-related bloodstream infections (CVC-BSI) are associated with morbidity and mortality especially in critically ill patients. This study was performed to find out the rate of CVC-BSI and CVC colonization, causative organism and their antibiogram in patients of Intensive Care Unit (ICU) and Department of Nephrology of tertiary care hospitals. A total of 100 patients from Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH) who had-CVC and clinically suspected of septicemia were included in the study. Paired CVC blood and peripheral venous blood (PVB) samples were collected from each patient and were cultured by automated blood culture method. CVC-BSI was diagnosed in 11% and CVC colonization in 43% patients by Differential time to positivity (DTP) method. Rate of CVC-BSI was 8/1000 CVC days and 11/1000 CVC days in BSMMU and DMCH respectively whereas CVC colonization rate was 32/1000 CVC days and 47.5/1000 CVC days in BSMMU and DMCH. The most common bacteria causing CVC-BSI was Klebsiella spp. (36.4%) followed by Acinetobacter spp. (27.3%), Pseudomonas spp. (18.2%) and E. coli (18.2%). Among bacteria isolated from CVC colonization majority were Pseudomonas spp. (30.23%) and Staphylococcus epidermidis (30.23%) followed by Acinetobacter spp. (27.91%), Enterococcus spp. (6.98%). Most of the isolated bacteria causing CVC-BSI were resistant to commonly used antibiotics, but showed good sensitivity to imipenem and colistin. Information about CVC-BSI, -colonization and antibiogram of this study can help to guide the selection of suitable antibiotics for empirical therapy and to improve infection control measures of the hospital.

Serum Sclerostin Level Among Egyptian Rheumatoid Arthritis Patients: Relation to Disease Activity, Bone Mineral Density and Radiological Grading

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INTRODUCTION

Bone loss in rheumatoid arthritis is caused by increased bone resorption without increasing bone formation. The Wnt pathway is important in the control of bone formation through the regulation of osteoblast activity. Sclerostin is an important regulator of the Wnt pathway by blocking Wnt binding to its receptor and thereby inhibiting bone formation.

AIM

This study aimed to assess the serum sclerostin level in a group of Egyptian rheumatoid arthritis patients and to correlate its level with bone mineral density, disease activity and radiological grading.

METHODS

Forty rheumatoid arthritis patients (mean age 48.9 ± 11.6 years, disease duration 8 ± 6.4 years) and 40 age and sex matched apparently healthy subjects were included. Serum sclerostin level was measured using Enzyme linked Immunosorbent Assay. Plain radiographs of hands and feet and dual-energy x-ray absorptiometry test were done for all patients.

RESULTS

No significant difference was found between rheumatoid arthritis patients and healthy controls as regard mean value of sclerostin level. Postmenopausal healthy women had higher levels of sclerostin than premenopausal healthy women only. Serum sclerostin had significantly positive correlations with the age of onset and weight of rheumatoid arthritis patients and negative correlation with Erythrocyte Sedimentation Rate. No correlation was encountered between sclerostin level and bone mineral density, disease activity or radiographic grading.

CONCLUSION

For better clarification of the role of sclerostin on bone mass in rheumatoid arthritis, larger sample size is needed. More studies on serum sclerostin levels among different grades of RA activity are encouraged.</p>.

Spectacles in Stomach: A Case of Successful Endoscopic Removal

Ingestion of foreign bodies is a common reason for emergency visit. The ingested objects include batteries, needles, dentures, coins, sharps etc. Radiolucency and the length of the objects are important factors that affect their management. Long objects over 10 cm are less likely to pass through the duodenal curve. Sharp object that is not retrieved at the earliest may penetrate the wall and cause complications. We present here a challenging case of a middle aged psychiatric patient who swallowed long and sharp arms of her spectacles that were successfully retrieved endoscopically.

Antimicrobial resistance and in vitro biofilm-forming ability of Enterococci spp. isolated from urinary tract infection in a tertiary care hospital in Dhaka

The biofilm mode of life conveys a survival advantage to the microorganism associated with it. Biofilm on an indwelling urinary catheter consists of adherent microorganisms, their extra cellular products, and host components deposited on the catheter and thus biofilm on urinary catheters results in persistent infections that are resistant to antimicrobial therapy. This study was done during the period of January 2010 to December 2010. Fifty nine enterococci isolated from 1203 urine samples were speciated by conventional microbiological methods and examined for their ability to form biofilm by microtitre plate assay and antimicrobial susceptibility testing by disc diffusion method for 10 clinically relevant antibiotics respectively. Biofilm producing Enterococci were more frequently found in catheterized than in non catheterized patient (p<0.004). Enterococcus faecium showed increased resistantance to multiple antibiotic than Enterococcus faecalis. Significant relationship was found between biofilm production with antibiotic resistance to amoxicillin, co-trimoxazole, ciprofloxacin, gentamycin, cefotaxime, and cefuroxime. This study demonstrated a high propensity among the isolates of Enterococci to form biofilm and a significant association of biofilms with multiple drug resistance. DOI: http://dx.doi.org/10.3329/bmrcb.v40i1.20320 Bangladesh Med Res Counc Bull 2014; 40: 6-9

A cluster randomised controlled trial and economic evaluation of a structured training programme for caregivers of inpatients after stroke: the TRACS trial

BACKGROUND

The majority of stroke patients are discharged home dependent on informal caregivers, usually family members, to provide assistance with activities of daily living (ADL), including bathing, dressing and toileting. Many caregivers feel unprepared for this role and this may have a detrimental effect on both the patient and caregiver.

OBJECTIVE

To evaluate whether or not a structured, competency-based training programme for caregivers [the London Stroke Carer Training Course (LSCTC)] improved physical and psychological outcomes for patients and their caregivers after disabling stroke, and to determine if such a training programme is cost-effective.

DESIGN

A pragmatic, multicentre, cluster randomised controlled trial.

SETTING

Stratified randomisation of 36 stroke rehabilitation units (SRUs) to the intervention or control group by geographical region and quality of care.

PARTICIPANTS

A total of 930 stroke patient and caregiver dyads were recruited. Patients were eligible if they had a confirmed diagnosis of stroke, were medically stable, were likely to return home with residual disability at the time of discharge and had a caregiver available, willing and able to provide support after discharge. The caregiver was defined as the main person--other than health, social or voluntary care provider--helping with ADL and/or advocating on behalf of the patient.

INTERVENTION

The intervention (the LSCTC) comprised a number of caregiver training sessions and competency assessment delivered by SRU staff while the patient was in the SRU and one recommended follow-up session after discharge. The control group continued to provide usual care according to national guidelines. Recruitment was completed by independent researchers and participants were unaware of the SRUs' allocation.

MAIN OUTCOME MEASURES

The primary outcomes were self-reported extended ADL for the patient and caregiver burden measured at 6 months after recruitment. Secondary outcomes included quality of life, mood and cost-effectiveness, with final follow-up at 12 months.

RESULTS

No differences in primary outcomes were found between the groups at 6 months. Adjusted mean differences were -0.2 points [95% confidence interval (CI) -3.0 to 2.5 points; p = 0.866; intracluster correlation coefficient (ICC) = 0.027] for the patient Nottingham Extended Activities of Daily Living score and 0.5 points (95% CI -1.7 to 2.7 points; p = 0.660; ICC = 0.013) for the Caregiver Burden Scale. Furthermore, no differences were detected in any of the secondary outcomes. Intervention compliance varied across the units. Half of the participating centres had a compliance rating of > 60%. Analysis showed no evidence of higher levels of patient independence or lower levels of caregiver burden in the SRUs with better levels of intervention compliance. The economic evaluation suggests that from a patient and caregiver perspective, health and social care costs, societal costs and outcomes are similar for the intervention and control groups at 6 months, 12 months and over 1 year.

CONCLUSIONS

We have conducted a robust multicentre, cluster randomised trial, demonstrating for the first time that this methodology is feasible in stroke rehabilitation research. There was no difference between the LSCTC and usual care with respect to improving stroke patients' recovery, reducing caregivers' burden, or improving other physical and psychological outcomes, nor was it cost-effective compared with usual care. Compliance with the intervention varied, but analysis indicated that a dose effect was unlikely. It is possible that the immediate post-stroke period may not be the ideal time for the delivery of structured training. The intervention approach might be more relevant if delivered after discharge by community-based teams.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49208824.

FUNDING

This project was funded by the MRC and is managed by the NIHR (project number 09/800/10) on behalf of the MRC-NIHR partnership, and will be published in full in Health Technology Assessment; Vol. 17, No. 46. See the NIHR Journals Library website for further project information.

Immune responses to collagen-IV and fibronectin in renal transplant recipients with transplant glomerulopathy

Antibodies (Abs) to donor HLA (donor-specific antibodies [DSA]) have been associated with transplant glomerulopathy (TG) following kidney transplantation (KTx). Immune responses to tissue-restricted self-antigens (self-Ags) have been proposed to play a role in chronic rejection. We determined whether KTx with TG have immune responses to self-Ags, Collagen-IV (Col-IV) and fibronectin (FN). DSA were determined by solid phase assay, Abs against Col-IV and FN by enzyme-linked immunosorbent assay and CD4+ T cells secreting interferon gamma (IFN-γ), IL-17 or IL-10 by ELISPOT. Development of Abs to self-Ags following KTx increased the risk for TG with an odds ratio of 22 (p-value = 0.001). Abs to self-Ags were IgG and IgM isotypes. Pretransplant Abs to self-Ags increased the risk of TG (22% vs. 10%, p < 0.05). Abs to self-Ags were identified frequently in KTx with DSA. TG patients demonstrated increased Col-IV and FN specific CD4+ T cells secreting IFN-γ and IL-17 with reduction in IL-10. We conclude that development of Abs to self-Ags is a risk factor and having both DSA and Abs to self-Ags increases the risk for TG. The increased frequency of self-Ag-specific IFN-γ and IL-17 cells with reduction in IL-10 demonstrate tolerance breakdown to self-Ags which we propose play a role in the pathogenesis of TG.

Congenital Symptomatic Cytomegalovirus Infection

DOI: http://dx.doi.org/10.3329.bjms.v1i3.17913Bangladesh Journal of Medical Science Vol.1(3) 1994 pp.33-36

Adenocarcinoma of the anal canal - a systematic review

AIM

The prognosis of anal adenocarcinoma is poor and the management remains controversial. We carried out a literature review to identify current practice in the management of anal adenocarcinoma.

METHOD

A systematic review of the literature was performed for studies in the English language published between 1950 and 2011. All those that focused on the management of anal adenocarcinoma were considered for inclusion.

RESULTS

Sixteen retrospective observational studies were identified; no randomized trials were found. Most of the studies contained small numbers of patients due to the rarity of anal adenocarcinoma. Treatment included local excision), radiotherapy, chemotherapy, chemoradiotherapy and abdominoperineal excision. Most studies concluded that a multimodality approach, combining radical surgical resection with neoadjuvant/adjuvant chemoradiotherapy was the optimal management strategy.

CONCLUSION

The prognosis of anal adenocarcinoma is poor, and there is little information on the optimal management. The relevant studies indicate that a combination of radical surgical resection and pre- or postoperative chemoradiotherapy offers the best chance of survival.

Effect of tonsillectomy on humoral immunity

Tonsils are one of the important secondary lymphoid organ in immune system. It remains controversial whether tonsillectomy results in decreased serum immunoglobulin level. The purpose of this study was to observe the effect of tonsillectomy on humoral immunity parameters among the patients with tonsillar disease. Total group A 70 patients up to the age of 18 years, who were enrolled for tonsillectomy and 30 age matched children group B were included for comparative study. Serum IgG, IgM and IgA levels were measured in all 70 patients before tonsillectomy and in 56 patients who came for 1st follow-up after one month and 30 patients who came for 2nd follow up after three months of tonsillectomy. Serum IgG, IgM and IgA levels were also measured in group B children. Serum IgG, IgM and IgA levels in patients of group A did not show any significant difference in comparison to group B. One month after tonsillectomy the level of IgG was slightly decreased and IgM and IgA were increased compared to preoperative value but not statistically significant. All IgG, IgM and IgA were also not significantly altered in comparison to group B. Three months after tonsillectomy serum IgG, IgM and IgA level were found decreased in comparison to pre operative value and group B, among which difference of only IgG was significant. After tonsillectomy humoral parameters were found reduced but overall impact on humoral immune status was not significantly altered.

Occurrence and surgical repair of third degree perineal lacerations in adult female camels (Camelus dromedarius) by one-stage (Goetz) technique

Retrospective analysis of third degree perineal lacerations in 7 female camels (6-17 yrs of age) that were surgically corrected by one stage repair (Goetz technique) is presented. Majority (3/7) of the camels was primiparous and all parturitions had a history of calving assistance. Six (6/7) camels recovered by first intention of healing. Dehiscence of perineal structure occurred in only one camel due to infection and healed by second intention. Subsequent matings resulted in pregnancy in four camels and one camel died due to unrelated causes. We conclude that perineal lacerations can occur in primiparous camels with difficult assisted deliveries and that one stage repair of perineal lacerations in camels improves the perineal conformation and such camels may easily regain normal fertility.