Effectiveness of multimodal intervention to improve blood culture collection in the emergency department

Introduction:

The blood culture (BC) contamination was a significant problem in our hospital, especially in the emergency department (ED). The study, therefore, was undertaken to improve the BC collection in the ED.

Methods:

The study was conducted for 1 year divided into two phases of 6 months each: Preintervention phase and intervention phase (regular and phlebotomist groups). The interventions comprised implementing standard protocol for BC collection and conducting educational sessions. In preintervention and regular groups, the BCs were collected by interns and technicians, while dedicated phlebotomist did so in the phlebotomist group. Data were analyzed and interpreted for the contamination rate as well as compliance in adequate filling of the requisition form. Statistical Package for the Social Sciences (SPSS) version 22. A value of P < 0.005 was considered statistically significant, and P < 0.01 was considered statistically significant.

Results:

In the preintervention group, 13.7% of specimens were reported as contaminated which was reduced to 4.2% and 3.2% in the regular and phlebotomist group, respectively, after intervention. Compliance of health-care workers to various elements of BC collection protocol was also found to be significantly improved in the intervention phase compared to the preintervention phase (P < 0.001).

Conclusions:

Implementation of this multimodal intervention resulted in a drastic reduction in BC contamination and improvement in compliance to BC collection protocol and filling of various parameters in the BC requisition form, thus improving the overall effectiveness of BC testing. It was also noted that the contamination rate was further reduced by implementing dedicated phlebotomist.

Early/Subtle Electrocardiography Features of Acute Coronary Syndrome and ST-Segment Elevation Myocardial Infarction

Chest pain is one of the most common presenting complaints in the emergency department. Interpreting a 12-lead electrocardiography (ECG) for evidence of ischemia is always challenging. Frank ECG changes such as ST-segment elevation and ST-segment depression can be easily identified by emergency physicians. However, identifying subtle or early features of ACS in the 12-lead ECG is essential in preventing significant mortality and morbidity from ACS. In the following case series, we describe five of the subtle/early ECG changes of ACS, namely (1) T-wave inversion in lead aVL; (2) terminal QRS distortion; (3) hyperacute T-waves; (4) negative U-waves in precordial leads; and (5) loss of precordial T-wave balance. In all these cases, the initial 12-lead ECG showed only subtle/early ECG changes which were followed up with serial ECGs which progressed to STEMI.

An Unusual Cause of Bulbar Palsy in the Emergency Department

BACKGROUND

Osmotic demyelination syndrome commonly occurs after rapid correction of hyponatremia. But it has also been reported after graded correction of hyponatremia in the presence of other risk factors like chronic alcoholism, malnutrition, liver disease, and hypokalemia.

CASE REPORT

We report a case of a 67-year-old man who presented with dysphagia and nasal regurgitation and had features suggestive of bulbar palsy on neurological examination. He had spontaneous rapid correction of hyponatremia from a serum sodium level of 122 mEq/L to 132 mEq/L after discharge from our hospital. Neuroimaging was suggestive of extrapontine myelinolysis involving the basal ganglia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: An emergency physician should be aware of this because osmotic demyelination syndrome should also be considered in the differential diagnosis of patients presenting with bulbar palsy to the emergency department.

Memory T-Waves, a Rare Cause of T-Wave Inversion in the Emergency Department

One of the rare causes of diffuse T-wave inversion (TWI) in electrocardiogram (ECG) is memory T-waves. This should be considered among the differentials of diffuse TWI in ECG of patients presenting to the emergency department (ED), especially when they have previous episodes of ventricular tachycardia (VT) or pacemaker implantation or Wolff-Parkinson-White syndrome. These TWIs are benign and do not require any treatment. However, it is of paramount importance for the emergency physician to differentiate it from ischemia-related T-wave changes. In the following case series, we report three cases of memory T-waves. Two of the cases had TWI in leads II, III, aVF, and V3 to V6 following reversion of VT. The other patient, with a VVI (Left ventricle paced, Left ventricle sensed, Inhibition to sensing) pacemaker, had memory T-waves in the ECG taken during normal sinus rhythm. In all the three patients, we considered memory T-waves to be the possible cause of TWI. The electrocardiographic diagnostic criteria for memory T-waves are positive T in lead aVL and positive/isoelectric T in the lead I; and precordial TWI >inferior TWI. These criteria are 92% sensitive and 100% specific. In the following case series, we also provide an algorithmic approach for patients with suspected memory T-waves in their 12-lead ECG when they present to the ED.

The Hydrodynamics Studies on Loop Seal in CFBC Boiler Using CFD Analysis

In a circulating fluidized bed (CFB), the loop seal is an important component which recirculates the solids captured by the cyclone to the bottom of the riser and avoids the direct flow of gas from high-pressure riser to the low-pressure cyclone. Most of the CFBC systems employ a Non-Mechanical valve, and its function has been investigated by many researchers. In this work, the flow of solid particle within the loop seal has been studied elaborately, and various design and operating parameters of the loop seal were analyzed in detail using Computational Fluid Dynamics (CFD). The CFD study has handled a loop-seal of dimension 110 mm × 430 mm × 400 mm high. This analysis has been done with a 200 µm sand particle and it is checked for its flow ability through various sizes and by altering the L/H ratio for three solid mass fluxes and for three L/H ratios of loop seal. The rate of solid mass flux depends on the length of the horizontal passage connecting the recycle cycle compartment of the loop seal with the supply chamber and hence the solid flow rate and the pressure difference per unit length are directly proportional to the length of the chamber or passage. Hence, L/H ratio is taken as a driving variable for the optimum performance of loop seal. The CFD analysis results reveal that the aeration of the solid to be used within the loop-seal should be higher than the Minimum Fluidization velocity. Also, keeping the length of the horizontal passage constant and varying the height of the passage will reduce the pressure drop. The pressure drop across the horizontal passage decreases up to a certain L/H ratio after which it increases. By comparing the three L/H ratios, L/H ratio of 2.62 is having a lesser pressure drop for the three mass fluxes. L/H ratio of 2.62 is having a good fluidization phenomenon and also the flow from the recycle chamber is more in comparison to the other L/H ratios. Experimental data from the literature is in good agreement with the CFD results.

Assessment of insulin injection techniques among diabetes patients in a tertiary care centre

AIMS

The efficacy of insulin therapy in diabetes depends on proper storage and injection technique. The purpose of this study was to assess the practice of insulin administration among diabetes patients in a tertiary care center.

MATERIALS AND METHODS

This observational study was done in Endocrinology department of a tertiary care center during April-June 2015. The consecutive patients using insulin for at least three months by either syringe or pen were recruited. All of them underwent a survey by the questionnaire which focused on key insulin injection parameters.

RESULTS

One hundred and sixty eight (74.67%) patients were storing insulin vials properly. The thigh was the most common site of insulin injection and 209(92.89%) study participants were rotating at the injection sites. Only 48.57% (34/70) subjects were mixing insulin properly before injection. The practice of hand washing and the cleaning of the injection site was practiced by 158(70%) & 171(76.44%) subjects respectively. One hundred and fifty six (69%) patients were injecting with the proper skin fold and 123(55%) subjects were injecting insulin at 90° angle. The majority of patients (91%) were throwing the needle and syringes directly into the garbage and public drainage system.

CONCLUSIONS

There was a significant gap between the insulin administration guidelines and current insulin injection practice. The diabetic education and counseling about proper insulin injection techniques should be provided to all diabetic subjects.

The Serological and Biochemical Markers of Adrenal Cortex and Endocrine Pancreas Dysfunction in Patients with Hashimoto's Thyroiditis: A Hospital-based Pilot Study

BACKGROUND

The prevalence of both islet cell and adrenal autoimmunity among Asian Indian hypothyroidism patients with Hashimoto's thyroiditis (HT) is lacking in literature.

OBJECTIVES

The objective of this study was to assess the proportion of Addison's disease (AD) and type 1 diabetes mellitus (T1DM) in patients with HT.

MATERIALS AND METHODS

The patients with hypothyroidism due to HT were included in this study over 2 years. Primary hypothyroidism was defined as high serum thyroid-stimulating hormone (>5.5 mIU/L) with or without low thyroxine level. HT was defined by the presence of high thyroid peroxidase antibody (Ab) titer (>35 IU/ml). Autoimmune markers of AD and T1DM, i.e., adrenal (21-hydroxylase) Ab, glutamic acid decarboxylase (GAD) Ab, and insulinoma-associated antigen-2 (IA-2) Ab were measured among them. In addition, 250 μg adrenocorticotropic hormone (ACTH) stimulation test was done in patients with adrenal Ab. Similarly, beta cell function was assessed in patients with GAD and/or IA-2 Ab.

RESULTS

Out of 150 patients screened, 136 patients were included in this study. Seven patients had adrenal Ab while 15 had IA-2 Ab. The GAD Ab was not present in any of the patients in the study. ACTH stimulation test was done in four of seven patients with adrenal Ab and beta cell function was assessed in 8 of 15 patients with islet cell Ab. All patients with adrenal Ab had normal adrenal function and 1 out of 15 with IA-2 Ab developed diabetes mellitus during follow-up.

CONCLUSIONS

Either adrenal or islet cell Ab was found in 16% Asian Indian hypothyroidism patients with HT.

Sarcoidosis and adrenal angiomyolipoma - A rare tumor and a rarer coincidence

Angiomyolipoma is a benign mesenchymal tumor occurring in about 0.3 % of the general population. Angiomyolipoma of the adrenal gland is a rare entity, and only 5 cases have been reported so far in English literature. Sarcoidosis is a systemic illness of unknown etiology characterized histologically by non-caseating epithelioid granulomas in the affected tissues. Angiomyolipoma of the adrenal occurring in sarcoidosis is an unusual association with no prior published reports. We describe a case of adrenal angiomyolipoma in a 60 year old female with sarcoidosis. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 81-84).

Effect of steroid replacement on thyroid function and thyroid autoimmunity in Addison's disease with primary hypothyroidism

BACKGROUND

Steroid replacement without thyroxine supplementation normalizes thyroid function test (TFT) in some but not all Addison's disease patients with primary hypothyroidism. Both autoimmune and nonautoimmune mechanisms contribute to this improvement in TFT. However, the documentation of the change in thyroid autoimmunity after cortisol replacement is very limited in the literature. The aim of this study was to determine the effect of steroid replacement on TFT and anti-thyroid peroxidase antibody (anti-TPO-Ab) titer in Addison's disease with primary hypothyroidism.

MATERIALS AND METHODS

This observational study was conducted in a tertiary care center in South India. Six Addison's disease patients with primary hypothyroidism, who were only on steroid replacement, were included in the study. Low serum cortisol (<83 nmol/L) with high plasma adrenocorticotropic hormone (>22 pmol/L) and/or hyperpigmentation of skin/mucous membranes was considered as the diagnostic criteria for Addison's disease. Primary hypothyroidism (both overt and subclinical) was defined as high thyroid stimulating hormone (TSH) with/without low free thyroxine (fT4). TFT and anti-TPO-Ab were performed before and after steroid replacement in all of them.

RESULTS

Poststeroid replacement, there was a normalization of TSH in all but one subjects. In overt hypothyroidism patients, fT4 also normalized. The improvement in TFT was not associated with decreasing titer of the anti-TPO-Ab in all six patients. However, there was a significant difference in TSH after steroid replacement compared to the baseline status.

CONCLUSIONS

The concept of normalization of primary hypothyroidism with cortisol replacement in patients with Addison's disease should be recognized to avoid iatrogenic thyrotoxicosis caused by thyroxine replacement. Both autoimmune and nonautoimmune mechanisms contribute to these alterations.

Papillary thyroid microcarcinoma in Graves' disease presenting as a cystic neck mass

The presentation of papillary thyroid microcarcinoma (PTMC) as a solitary cystic neck mass is uncommon. Additionally, its association with Graves' disease is very rare. We report a case of occult PTMC, who presented with a cystic neck mass in the background of Graves' disease without any goiter. Imaging like ultrasound of neck, single photon emission computed tomography-CT (SPECT-CT), and technetium scan failed to detect any lesion in the thyroid, which was picked up only by the contrast-enhanced computed tomography (CECT) of neck. The patient underwent total thyroidectomy with right modified lymph node dissection. Our case highlights the presentation of metastatic PTMC as a differential diagnosis of a cystic neck mass even in a patient with Graves' disease without any thyroid enlargement.

Acalculous pyelonephritis and cholecystitis occurring simultaneously in a diabetic patient on sitagliptin therapy

Dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of anti-diabetic drugs. They control both fasting and postprandial hyperglycemia by inhibiting degradation of incretin hormones, such as, glucagon-like peptide-1(GLP-1) and glucose-dependent insulinotropic polypeptide (GIP). Sitagliptin is the first DPP-4 inhibitor to be marketed in India. In addition to its glucose lowering effect, it also suppresses immunity resulting in various infections in a diabetes patient. Here, we describe the simultaneous development of two infections (acalculous pyelonephritis and cholecystitis) in a postmenopausal female patient, well-controlled on sitagliptin-based anti-diabetic therapy.

Sclerosterosis (Truswell-Hansen disease)

Sclerosteosis or Truswell-Hansen disease is a rare autosomal recessive disorder characterized by dense bones, tall stature, and syndactyly. Most of the reports are from South Africa. Here we report the first such case from India.

Extension of molecular similarity analysis approach to classification of DNA sequences using DNA descriptors

Several alignment-free sequence comparison methods are available which use similarity, based on a particular numerical descriptor of biological sequences. Any loss of information incurred in the transformation of a sequence into a numerical descriptor affects the results. A pool of descriptors that use different algorithms in their computation is expected to suffer minimum loss of information and an attempt is made in this direction to study the similarity of DNA sequences. A number of descriptors based on information theory and connectivity were computed for DNA sequences. Principal component analysis (PCA) was used to extract minimum number (N) of orthogonal descriptors, principal components (PCs). Similarity/dissimilarity clustering of DNA sequences were carried out in the N-dimensional similarity space constructed using the PCs extracted from the DNA descriptors. The paper explains the extension of quantitative molecular similarity analysis (QMSA) from the prediction of physicochemical properties and toxicity of chemicals to bioinformatics for the classification of DNA sequences.

Outbreak of scrub typhus in Pondicherry

AIM

To describe the diverse clinical and laboratory manifestations of scrub typhus diagnosed in Pondicherry Institute of Medical Sciences, Pondicherry.

MATERIALS AND METHODS

All cases of febrile illness diagnosed as scrub typhus over a period of 2 years were analysed. Diagnosis was based on the presence of the eschar and/or positive Weil Felix test with a titre of > 1:80.

RESULTS

Fifty cases of scrub typhus were seen over a period of 2 years (April 2006 and April 2008). Common symptoms were high grade fever of 7-14 days duration, nausea, vomiting, headache, myalgia, cough and breathlessness. Eschar was seen in 23 cases (46%) and the common sites were axilla, breast and groin. Weil Felix test was positive in 39 cases (78%). Liver enzymes were elevated in nearly all cases (95.9%). Multiple Organ Dysfunction Syndrome (MODS) was present in one third of our patients (17 out of 50, 34%). Hypotension (8 patients, 16%), renal impairment (6 patients, 12%), ARDS (4 patients, 8%) and meningitis (7 patients, 14%) were some of the important complications. There was a dramatic response to doxycycline in nearly all the patients.

CONCLUSION

Scrub typhus has emerged as an important cause of febrile illness in Pondicherry. Empirical treatment with doxycycline is justified in endemic areas.

Reclamation of tannery polluted soil through phytoremediation

The huge volume of sludge emanating from the tannery effluent treatment plants poses a serious environmental problem. Phytoremediation is an emerging technology in which the plants are employed to reclamate the contaminated soil strewn with heavy metals (metalloids) and toxic compounds. This work focuses the impact of application of tannery sludge on biochemical properties of 6 months old tree saplings of Azadirachta indica A. Juss. (Neem), Melia azedarach Linn. (Wild Neem) and Leucaena leucocephala (Lam) de Wit (Subabool) raised over the tannery sludge in an attempt to use these plants for phytoremediation. The plants raised over the garden soil served as the control. The porosity and water holding capacity of the tannery sludge were higher. The plant growth supporting elements such as Ca, total N2, NO3 and Mg were higher in the sludge. The plants raised over the sludge were found to be dark green with increased morphometric parameters. Electrophoretic profile revealed amplification of a few polypeptides (100, 105, 49 and 55 KDa). The levels of biomolecules and the CO2 absorption increased in 6 months old plants. There was a significant uptake and transport of chromium in all the three tree species suggesting that these plants could be employed in phytoremediation of soils contaminated with heavy metals.

Photosynthetic Potential and Accumulation of Assimilates in the Developing Chloroembryos of Cyamopsis tetragonoloba (L.) Taub

The photosynthetic potential of leaves and chloroembryos of Cyamopsis tetragonoloba (L.) Taub as measured by (14)C-bicarbonate fixation, Hill activity, and in vivo fluorescence transients is compared. On a chlorophyll basis, dark fixation of NaH(14)CO(3) in chloroembryos was 1.5 times higher than that of the leaf, whereas carbon fixation under illumination was threefold higher in the leaf than in the embryos. Rates of O(2) evolution were four times more in embryo than in leaf chloroplasts. Shading of developing fruits on the day of anthesis for 10 days induced a 65% reduction in dry matter accumulation in the etiolated embryos, as compared to the normal green embryos of the same fruit half covered by a transparent Polythene sheet. The reduction in dry weight, size of the embryos, and levels of assimilates after shading the developing fruits may be ascribed to partial autotrophy of the chloroembryos.

Leaf development and the role of NADP-malate dehydrogenase in C3 plants

The activity of NADP-malate dehydrogenase (NADP-MDH) was determined in the developing first leaf of the C3 plants wheat, barley and pea. Light dependent activation of the enzyme was observed in all three species following rapid extraction and immediate assay. Maximum activity was obtained following extraction from preilluminated leaves and incubation on ice for 45 min in the presence of dithiothreitol. In all three species, maximum activity was obtained in the young leaf 4 days after emergence of the seedling (about 2.5 to 3 μmoles per milligram chlorophyll per min in wheat and barley, and 6 μmoles per milligram chlorophyll per min in pea). On a chlorophyll basis there was an approximate five-fold decrease in NADP-MDH activity as the leaf matured. A similar pattern was found for phospho-enolpyruvate carboxylase and NADP-malic enzyme which had maximum activity in younger leaf tissue. Similarly, the activity of nitrate reductase in wheat and barley was high in the young leaf and it rapidly declined as the leaf matured. In contrast, the capacity for photosynthesis was relatively low in the young leaf, reaching a maximum 6 to 8 days after seedling emergence. The pattern of change in activity of phosphoribulokinase, an enzyme of the reductive pentose phosphate pathway, was similar to that of photosynthesis. The results suggest NADP-MDH and phospho-enolpyruvate carboxylase have important function(s) in the young leaf, which are not directly linked to C3 photosynthesis, and which, in part, may be linked to nitrate assimilation and provision of malate to mitochondria.

Activation of NADP-malate dehydrogenase in C3 plants by reduced glutathione

NADP-malate dehydrogenase extracted from darkened leaves of the C3 plants pea, barley, wheat and spinach was activated by reduced glutathione, a monothiol, as well as by dithiothreitol (DTT). However, in the C4 plants maize and Flaveria trinervia, only dithiothreitol could effectively activate the enzyme. There was no activation of the maize enzyme and little or no activation of the F. trinervia enzyme by glutathione. The failure of glutathione to activate NADP-MDH in leaf extracts of maize and F. trinervia may indicate there is some difference in disulfide groups of the protein compared to the C3 plant enzyme. Both DTT and glutathione could activate NADP-malate dehydrogenase in a partially purified enzyme preparation from pea leaves with or without addition of partially purified thioredoxin. However, the required concentration of reductant was lower with addition of thioredoxin than in its absence. In extracts of C3 species and the partially purified pea enzyme the level of activation after 40 to 60 min under aerobic conditions was higher (up to twofold) with DTT than with glutathione. Under anaerobic conditions, the initial rate of activation was about twice as high with DTT as with glutathione, but the total activation after 40 to 60 min was similar. Ascorbate was totally ineffective as a reducing agent in activating NADP-MDH from C3 or C4 plants, possibly due to its more positive redox potential.

Studies on the mode of action of aminotriazole in the induction of chlorosis

The herbicide 3-amino-1, 2, 4-triazole induces complete chlorosis without any morphogenetic effect on Canna edulis leaves. Comparative analyses of the mineral and biochemical composition and also of the physiological properties of normal and bleached leaf cells establish a high specificity of this herbicide for inhibition of formation of chloroplast membranes. The synthesis of membrane lipids and chloroplastic terpenoid derivatives were specifically inhibited. This compound was found to inhibit photosynthetic O(2) evolution and (14)CO(2) fixation at the whole cell level and ferricyanide reduction in isolated chloroplasts immediately after its application. This inhibition was reversible with the addition of a number of unrelated compounds shown to nullify its herbicidal effect.The mechanism of action of this compound in specifically blocking the development of chloroplast membranes in discussed in terms of its primary action on photosynthetic carbon fixation.