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Introduction: Tuberculous meningitis remains the most severe and devastating form of tuberculosis with relatively severe morbidity and mortality. Risk factors for TB meningitis have not focused on the role of the BCG vaccine or social and food insecurity which are known to have a role in pulmonary TB. Methods: We prospectively conducted a Case-Control study among 65 patients with TB meningitis and 41 controls with other forms of meningitis. We evaluated the role of the BCG vaccine, the Household Food Insecurity Access Scale (HFIAS) and the Social Readjustment Rating Scale (SRRS) to look for food and social stress respectively. We also evaluated the known risk factors for TB meningitis including age, HIV co-infection, alcoholism, malignancies, use of immunosuppression, head injury among others. A bivariate followed by multivariate regression analysis was performed. Results: The presence of BCG scar was seen in 64.6 percent of patients with Tuberculous meningitis and 61.0 percent of control (P= 0.71). There was no difference in the size of the scars (P= 0.45) . Household food insecurity using the Household Food Insecurity Access Scale (HFIAS) ( a positive answer in any of the 9 items) was present in 16.9% of the patients in the TBM group and in 14.6% of the patients in the control group. (P= 0.75). Social stress assessed using the Social Readjustment Rating Score (< 150 suggest no social stress, 150 – 300 moderate social stress,> 300 high social stress) showed that a majority of the patients in both the groups reports no social stress. Only 9.8% of patients in the TBM group and 18.5% in the control group reports moderate presence of social stress whereas none of the patients had severe social stress. Logistic regression analysis suggested that only higher BMI was associated with lesser incidence of Tuberculous meningitis, odds ratio 0.83 (95% confidence interval of 0.73 – 0.930) and individuals performing clerical and unskilled and under-skilled jobs- odds ratio 0.13 (95% confidence interval of 0.02 – 0.93) had lower risk for TB Meningitis. Conclusions: In our sample of TB meningitis patients the BCG vaccine, food insecurity nor social stress appear to be risk factors. Bigger BMI and certain occupations appear to be possibly protective. [ABSTRACT FROM AUTHOR]

Introduction: Posterior circulation stroke (PCS) is often diagnosed late and long-term outcomes have not been described in South India. We wished to study clinical features, long-term outcomes, and independent predictors of the same. Materials and Methods: We conducted a prospective cohort study in PCS patients from January 2014 to May 2017. Morbidity and mortality at discharge, at 3 months and 6 months was studied. Univariate and multivariate analysis of predictors of poor outcome as well as the survival analysis was computed. Results: We recruited 291 PCS during the study period; prevalence of PCS among all strokes was 12.9% in 2014. The mean age was 53.34 years (standard deviation 13.34). Young strokes constituted 28.8%. The common comorbidities were hypertension 72%, diabetes mellitus 52.6%, smoking 38.5%, and dyslipidemia 32.6%. The common presenting symptoms were giddiness 79%, unsteadiness 75.35%, ataxia 56%, motor deficits 48.8% and nausea and vomiting 43%. Most were Ischemic strokes (86.5%); 10.3% gave a history of preceding TIAs. Common arteries involved were posterior cerebral 45%, posterior inferior cerebellar 38%, and basilar artery 19.2%. Among ischemic strokes, large artery atherosclerosis was 50.8%. Dysphagia was seen in 32.6% and sepsis in 19.2%; post stroke pain in 23%, followed by cognition decline in 10.3%. Bad outcome (modifies Rankins score 4-6) was 16.8% at discharge, 16.4% at 1 month, 14.4% at 3 months, and 13.8% at 6 months. Independent predictors of bad outcomes at 6 months were baseline National Institute of Health Stroke Scale (NIHSS) score (Odds ratio [OR] 1615.59 confidence interval [CI] 27.64-94447.7), invasive ventilation (OR 7.77 CI 1.57-38.43), sepsis (OR 17.22 CI 1.45-204.08), and basilar artery involvement (OR 19.98 CI 1.67-238.81). Baseline NIHSS scores between 0 and 5 suggest a good outcome while scores more than 13 suggest a bad outcome at 6 months. At 6 months, half are unemployed. Conclusions: The prevalence, clinical features, and comorbidities were also similar to previous studies. There was good survival at 6 months. NIHSS score is useful in predicting poor outcomes. [ABSTRACT FROM AUTHOR]

Background: Acute coronary syndrome (ACS) is associated with significant morbidity and mortality. There is an increase in the proportion of non-ST elevation myocardial infarction/unstable angina (NSTEMI/UA) but there is a sparsity of data about the long-term outcome of patients with NSTEMI managed by internists. The long-term outcome and predictors of mortality of individuals with NSTEMI, managed by internists were the subject of the present study. Methods: This is a prospective observational cohort study of patients admitted under the internal medicine units with ACS. One hundred forty participants were recruited from April 2016 to July 2017. The various clinical outcomes and all-cause mortality at discharge, 1 month and 6 months were recorded. Results: During the study, 132 patients had NTSEMI/UA while 8 had ST-elevation myocardial infarction; 53.2% were men. The mean age was 63.6 ± 11.8 years for NSTEMI/UA. The mean duration of onset of symptoms to primary care was 29.14 ± 34.6 h; 39 (27.9%) presented beyond 48 h. The most frequent comorbidities observed were diabetes mellitus 96 (68.6%), hypertension 94 (67.1%), and dyslipidemia 44 (31.4%). Fifty-two (37.1%) required respiratory support. All patients received Antiplatelet agents and statins. Mortality rates were 9.1%, 13.4%, and 16.1% at discharge, 1-month, and 6 month following admission. The median survival was 161 (147-175) days. Dyslipidemia (hazard ratio [HR]: 0.55, 95% confidence interval [CI]: 0.26, 1.15, P = 0.110) and smoking (HR: 2.16, 95% CI: 1.16-4.02, P = 0.015) were identified as risk factors which predicted mortality. Conclusions: Mortality rates following NSTEMI, managed by internists at our tertiary care hospital was similar to various national and international registries. Smoking and dyslipidemia were predictors of mortality. [ABSTRACT FROM AUTHOR]

Background: Although sepsis is a well-known cause of in-hospital mortality, data on long term outcomes are scarce. Aim: This study aims to estimate the cumulative 5-year mortality among patients with infection requiring admission. Methods: This was a cohort study done in tertiary care center in South India, with recruitment of those admitted with an infection between January 1st, 2009 and July 31st, 2014 in a medical unit. The patients were followed up by telephonic call or case record review. Kaplan-Meier survival curve was plotted and Cox-proportional hazard model was used as multivariable analysis to identify the independent risk factors of long-term mortality. Results: One thousand four hundred and fifty three patients were followed up in this cohort study. The mean survival by Kaplan-Meier survival analysis was 3.78 years (95% confidence interval [CI] 3.33, 4.22) in quick sepsis-related organ failure assessment (qSOFA) score positive patients and 6.07 years (95% CI 5.73, 6.41) in qSOFA negative patients which was statistically significant by the log-rank test. The cumulative 1-year mortality was 44.9% and 21.8% for qSOFA score of 2 or more and nonsepsis patients, respectively. The median survival of qSOFA score of 2 or more patients was 0.75 years (95% CI 0-2.1 years). The mortality among sepsis patients at discharge, 1 year, 5 and 8 years was 38.2%, 44.9%, 47.4%, and 47.8%, respectively. Cox regression analysis showed age hazard ratio (HR) 1.02 (1.01, 1.04), male gender 1.45 (1.03, 2.04), >qSOFA score HR 1.89 (1.32, 2.72), Charlson Comorbidity Index HR 1.29 (1.14, 1.46), respiratory tract infection HR 1.81 (1.10, 2.95), and inotrope requirement HR 3.24 (1.98, 5.29) were the independent predictors of long-term mortality. Conclusions: The median survival of patients with possible infection with qSOFA score of 2 or more patients was 0.75 years (95% CI 0-2.1 years). Older age, male gender, qSOFA score of 2 or more, Charlson Comorbidity Index, respiratory tract infection, and inotrope requirement HR 3.24 were the independent predictors of long-term mortality. [ABSTRACT FROM AUTHOR]

Objectives: Primary objective: The incidence of deep vein thrombosis in patients admitted to a medical ward. Methods: We conducted a prospective cohort to assess the incidence of deep vein thrombosis in patients admitted in a medical of our tertiary care center between October 2014 and May 2015. We excluded patients who had a preexisting deep vein thrombosis or a pulmonary embolism and patients on therapeutic anticoagulation. A bedside ultrasound machine was used for screening for deep vein thrombosis in the internal jugular, axillary, femoral, and popliteal veins. Noncompressibility of the vein compared to the artery was suggestive of thrombosis. Results: Among the 43 patients included in the study, 3 (6.98%) patients developed deep vein thrombosis. The incidence density is 7.48 per 1000 patient-days. One patient developed a central venous catheter-associated deep vein thrombosis. Multivariate analysis showed that the duration of hospital stay of more than 7 days was associated with a higher risk of development of deep vein thrombosis (odds ratio: 1.17 [confidence interval: 1.016-1.349]). Conclusions: The incidence of deep vein thrombosis among patients admitted in a medical ward of a tertiary care hospital in South India was 7.48 per 1000 patient-days. Hospital admission of more than 7 days was found to be a significant independent risk factor for development of deep vein thrombosis in our study. [ABSTRACT FROM AUTHOR]

Background and Objectives: The study was aimed to evaluate the role of stress, lifestyle as well as traditional risk factors in the development of hypertension among health-care workers (HCWs). Methods: This nested case--control study was done at a tertiary care university teaching hospital in South India. Cases were hospital employees diagnosed with hypertension and who were taking antihypertensive medications. Controls were age- and sex-matched HCWs who were not diagnosed with hypertension. They were identified preferably in the same department where its case was presently working. One hundred and twenty-eight cases and 128 controls were enrolled. We collected data on risk factors for hypertension, physical activity, diet, and stress. Those significant on the bivariate analysis were entered into a logistic regression analysis. Results and Interpretation: In the logistic regression, we found that living in a joint family (2 siblings and their families), family history of hypertension, family history of diabetes mellitus, and family history of ischemic heart disease were independently predictive of hypertension developing in the study HCWs. Occasional or regular walking/cycling to work and milk consumption were independent factors that protected against the development of hypertension. Extra added salt to food and stress more than normal in any domain tested were not associated with the development of hypertension in our cohort. Conclusions: HCWs have some novel and other similar risk factors to general population for developing hypertension. Simple preventive measures seem effective. Neither stress nor self-reported salt consumption seemed to play a role in the development of hypertension. [ABSTRACT FROM AUTHOR]

Introduction: Current diagnostic methods used in Central Nervous System Tuberculosis (CNS TB) are limited by the paucibacillary nature of this form of tuberculosis. Posterior pituitary bright spot (PPBS) refers to an area of T1 hyperintensity in the posterior pituitary in MR imaging of the brain. It is found in 80–90% of healthy children and adults. In children with CNS TB, nearly half have absence of PPBS. This finding has not been described in adults. Our study looked for absence of PPBS in MR imaging and its association with CNS tuberculosis. Objective: To study prevalence of the absence of PPBS in patients with CNS tuberculosis when compared to a control group of normal patients. Methods: This was a retrospective case-control study of 100 patients with CNS tuberculosis and 200 controls (matched in 1:2 ratio) of patients with normal MRI brain. The MRI images were presented to a blinded radiologist in a randomised sequence to report for absence of PPBS. The data was subsequently analysed to look for association of absence of PPBS with CNS tuberculosis. Results: Absence of PPBS (cases (47%), controls (8.5%)) was significantly associated with CNS tuberculosis in (Odds ratio-7.90, 95%CI 4.04–15.44, P-value<0.0001). The specificity, sensitivity, positive predictive value and positive likelihood ratio are 91.5%, 47%, 73.4% and 5.53 respectively. Adding of absence of PPBS as an additional radiological feature in diagnosis of CNS TB increased the sensitivity from 77% to 84%. Conclusion: Absence of PPBS is significantly associated with CNS tuberculosis and could be a relatively simple diagnostic aid in the diagnosis of CNS tuberculosis. [ABSTRACT FROM AUTHOR]

Background and Objectives: Upper urinary tract infections (UTIs) that require in-patient care can be expensive. Comorbid conditions such as diabetes as well as UTI due to extended-spectrum beta-lactamase (ESBL) producing bacteria may affect costs. The quality of life of patients with this condition has not been described. Methods: This was a cost of illness study that prospectively evaluated patients admitted with upper UTI to a medical ward in a tertiary care hospital. Direct medical and nonmedical costs, indirect costs were collected to make the total cost per admission. Quality of life was assessed using the World Health Organization Quality of Life-BREF score. We also compared costs between those with and without diabetes or ESBL infection. Results: Between March 2016 and July 2017, 92 eligible patients were included in the study. The average age was 55.8 years; two thirds were diabetics. The mean overall cost of a single admission for upper UTI was INR.88, 330.2 (1370.4 USD). This was INR.96, 193.0 (1492.6 USD) and INR.1, 03,154.9 (1600.4 USD) among those with diabetes mellitus and ESBL infection, respectively. The cost was higher among those with diabetes and ESBL than those without; this difference reached statistically significance for the ESBL group. The quality of life was affected in all domains; the psychological being most affected among diabetics and ESBL infected. Conclusions: The mean total cost of admission for an upper UTI in a tertiary care hospital in South India was INR 88,330 (1370.4 USD). This is higher if the patient has diabetes or ESBL organism causing the UTI. Quality of life is clearly reduced especially in the psychological domain. [ABSTRACT FROM AUTHOR]

Mixed connective tissue disease (MCTD) was initially described as a chronic immune-mediated disease with overlapping features of systemic lupus erythematosus, scleroderma, and polymyositis. We conducted a cross-sectional study to describe the clinical and immunological profile of patients with MCTD and to compare the four diagnostic criteria, namely, Sharp, Kasukawa, Alarcón-Segovia, and Khan criteria. A total of 291 patients who were admitted from June 2007 to June 2017 and fulfilled the inclusion criteria were included in the study. A clinical diagnosis of MCTD was made in 111 patients, of whom 103 (92.8%) were women. The mean age at presentation was 39.3 years (SD ± 11.6). The most common organ systems that were involved were musculoskeletal system (95.5%), skin and mucosa (78.4%), and the gastrointestinal and hepatobiliary systems (56%). The maximum sensitivity was for the Kasukawa criteria with a sensitivity of 77.5% (95% CI 68.4-84.6) and specificity of 92.2% (95% CI 87-95.5). The Kahn criteria and Alarcón-Segovia criteria had the maximum specificity; the Alarcón-Segovia criteria had a sensitivity of 69.4% (95% CI 59.8-77.6) and a specificity of 99.4% (95% CI 96.5-99.9), while the Kahn criteria had a sensitivity of 52.3% (95% CI 42.6-61.7) and a specificity of 99.4% (95% CI 96.5-99.9). The sensitivity and specificity of Sharp criteria were 57.7% (95% CI 47.9-66.87) and 90% (95% CI 84.4-93.8), respectively. [ABSTRACT FROM AUTHOR]

Introduction: Carbapenem resistance among Enterobacteriaceae continues to escalate. Carbapenemase encoding genes borne on plasmids leads to wide-spread transmission among Enterobacteriaceae. The accurate and rapid detection of Carbapenemase producing-Carbapenem resistant Enterobacteriaceae (CP-CRE) is imperative for patient management as well as for hospital infection control measures. We therefore evaluated the CHROMagar™mSuperCARBA™ (CMSCs) a phenotypic screening test for detection of CP-CRE. Aim: To evaluate the performance of CMSCs as a phenotypic test for detection of carbapenemase producing organisms. Materials and Methods: A total of 150 consecutive Carbapenem resistant Enterobacteriaceae (CRE) (E. coli n=81 and Klebsiella spp. n=69), isolated from consecutive hospitalised patients with significant bacteriuria, were subjected to CRE Multiplex PCR for the detection of blaKPC, blaNDM, blaVIM, blaOXA-48 like and blaIMP genes. Phenotypic detection of carbapenemase production was evaluated by the chromogenic medium CMSC, CarbaNP and Modified Hodge Test (MHT). results: The multiplex PCR detected carbapenemase encoding gene(s) in 108 isolates. The sensitivity of CMSC, CarbaNP test and MHT in detecting isolates carrying blaNDM and blaOXA48-like genes was 94.4%, 67.6%, 56.3% and 96%, 40.8%, 38.8% respectively. While overall sensitivity of CMSC, CarbaNP test and MHT for detection of CP-CRE was 85.3%, 46.6% and 40% respectively; with a negative likelihood ratio of 0.18, 0.55 and 0.64 respectively. conclusion: CMSC emerged as the most sensitive test for detection of isolates carrying blaNDM and blaOXA48-like genes, with an excellent negative likelihood ratio. In addition, it was found to be inexpensive and has the fastest turnaround time. It is a promising phenotypic test especially in geographic regions with wide spread resistance due to blaNDM and blaOXA48-like CP-CRE. [ABSTRACT FROM AUTHOR]

Background. Artemisinin-based combination therapy (ACT) is widely used in India and many generic preparations are available. Delayed response has been reported, suggesting inadequate response to artesunate (AS) or genotypic resistance. We designed a prospective observational study to assess the therapeutic response, elaborate pharmacokinetics of AS and identify Plasmodium falciparum kelch 13 (pfk13) propeller gene polymorphisms among hospitalized Indian patients with severe malaria. Methods. We collected blood samples from adult patients with severe P. falciparum or mixed (P. falciparum and P. vivax) malaria on ACT. We calculated the parasite clearance (CL) half-life using the Worldwide Antimalarial Resistance Network (WWARN) online parasite clearance estimator (PCE). We used the liquid chromatography tandem mass spectrophoto-metry method for simultaneous quantification of AS and dihydroartemisinin. We genotyped longitudinally archived DNA samples obtained pre-treatment (day 0) to study the point mutations in the pfk13 propeller domain. Results. A total of 54 patients with malaria were included, with a majority fulfilling the definitions of severe malaria. The median parasite CL slope half-life was estimated to be 6.44 hours (interquartile range 4.79-10.24). AS pharmacokinetics, assessed in 17 patients, were found to be similar in the groups with rapid (<48 hours) and slow CL (>48 hours) of parasites. No known mutations associated with artemisinin resistance in Southeast Asia were observed in our study participants. Conclusions. Slow parasite CL was seen with a high parasite burden without genotypic evidence of AS resistance. There is a need to standardize definitions of therapeutic efficacy of AS in cases of severe malaria. [ABSTRACT FROM AUTHOR]

Background. Admission of a patient to an intensive care unit (ICU) can result in tremendous stress to family caregivers not only because of the need to provide physical and emotional support to the sick relative, but also due to the burden of decision-making on behalf of the critically ill person. We enquired about family caregivers' perspectives on intensive care, the challenges they faced with decision-making and their perceptions on the nature of their interactions with healthcare providers. Methods. We used maximum variation sampling and enrolled 20 consenting caregivers for semi-structured interviews. Each interview, based on an interview guide, took 30-40 minutes and was conducted in a private place within the hospital premises. All interviews were recorded, transcribed verbatim and entered into a qualitative software (NVivo) for analysis. Results. The three emergent themes of analysis were (i) understanding about ICU, (ii) decision-making concerning ongoing treatment; and (iii) relationship with healthcareproviders. Some respondents saw the intensive care as an expensive facility for seriously ill patients while others were not so clear. The family's relationship with the patient and their financial status were seen as important deciding factors in continuing treatment. Decision-making was a complex and emotional issue and doctors were held in awe and seen as the main deciding authority. The importance of doctors being compassionate and communicative was stressed. Conclusion. Our study highlights the problems faced by family caregivers and of the need to improve their satisfaction through clear and simple communication strategies. [ABSTRACT FROM AUTHOR]

Introduction: Varicella zoster virus is an exclusively human neurotrophic virus. The primary infection with the virus causes varicella. The virus remains latent in nervous tissue and upon secondary activation causes a variety of syndromes involving the central nervous system (CNS) including meningoencephalitis and cerebellitis. Materials and Methods: In this study, we looked at the epidemiology, clinical and laboratory features, and outcomes of patients who were admitted with varicella zoster of the CNS from 2005 to 2014. Results: There were 17 patients. Fever was present in 13 patients, seizures in 9 patients and headache and vomiting in 4 patients each. A generalized varicella rash was present in 8 out of 17 patients. A single dermatomal herpes zoster was present in seven patients. Two patients had no rash. Varicella zoster polymerase chain reaction (PCR) in cerebrospinal fluid (CSF) was done in 5 patients of which 4 were positive and 1 was negative. Nine patients had diabetes with an average glycated hemoglobin of 8.6%. Total number of deaths was five. Conclusions: Patients with diabetes who develop varicella or herpes zoster may be at risk for CNS complications. The diagnosis of varicella encephalitis has to rest on a combination of clinical findings and CSF PCR, as neither the rash nor the PCR is sensitive enough to diagnose all the cases with varicella encephalitis. [ABSTRACT FROM AUTHOR]

Background: Acute undifferentiated febrile illness (AUFI) may have similar clinical presentation, and the etiology is varied and region specific. Materials and Methods: This prospective observational study was conducted in a tertiary hospital in South India. All adult patients presenting with AUFI of 3-14 days duration were evaluated for etiology, and the differences in presentation and outcome were analyzed. Results: The study cohort included 1258 patients. A microbiological cause was identified in 82.5% of our patients. Scrub typhus was the most common cause of AUFI (35.9%) followed by dengue (30.6%), malaria (10.4%), enteric fever (3.7%), and leptospirosis (0.6%). Both scrub typhus and dengue fever peaked during the monsoon season and the cooler months, whereas no seasonality was observed with enteric fever and malaria. The mean time to presentation was longer in enteric fever (9.9 [4.7] days) and scrub typhus (8.2 [3.2] days). Bleeding manifestations were seen in 7.7% of patients, mostly associated with dengue (14%), scrub typhus (4.2%), and malaria (4.6%). The requirement of supplemental oxygen, invasive ventilation, and inotropes was higher in scrub typhus, leptospirosis, and malaria. The overall mortality rate was 3.3% and was highest with scrub typhus (4.6%) followed by dengue fever (2.3%). Significant clinical predictors of scrub typhus were breathlessness (odds ratio [OR]: 4.96; 95% confidence interval [CI]: 3.38-7.3), total whole blood cell count >10,000 cells/mm3 (OR: 2.31; 95% CI: 1.64-3.24), serum albumin <3.5 g % (OR: 2.32; 95% CI: 1.68-3.2). Overt bleeding manifestations (OR: 2.98; 95% CI: 1.84-4.84), and a platelet count of <150,000 cells/mm3 (OR: 2.09; 95% CI: 1.47-2.98) were independent predictors of dengue fever. Conclusion: The similarity in clinical presentation and diversity of etiological agents demonstrates the complexity of diagnosis and treatment of AUFI in South India. The etiological profile will be of use in the development of rational guidelines for control and treatment of AUFI. [ABSTRACT FROM AUTHOR]

Objectives: The majority of patients in India access private sector providers for curative medical services. However, there is scanty information on the cost of treatment of critically ill patients in this setting. The study evaluates the cost and extent of financial subsidy required for patients admitted to an intensive care unit (ICU) in India.Methods: Data on direct medical, direct nonmedical, and indirect cost were prospectively collected from critically ill patients admitted to a tertiary teaching hospital in India. Willingness-to-pay (WTP) amount was obtained from the next-of-kin following admission and the actual cost paid by the family at discharge was recorded.Results: The main diagnoses (n = 499) were infection (26 percent) and poisoning (21 percent). The mean APACHE-II score was 13.9 (95 percent confidence interval [CI], 13.3–14.5); 86 percent were ventilated. ICU stay was 7.8 days (95 percent CI, 7.3–8.3). Hospital mortality was 27.9 percent. Direct medical cost accounted for 77 percent (US$ 2164) of the total treatment cost (US$ 2818). Indirect cost and direct nonmedical cost contributed to 19 percent (US$ 547.5) and 4 percent (US$ 106.5), respectively. Average total and daily ICU cost were US$ 1,897 and US$ 255, respectively. Although the family's WTP was 53 percent (US$ 1146; 95 percent CI, 1090–1204) of direct medical cost, their final contribution was 67.7 percent (US$ 1465; 95 percent CI, 1327–1604).Conclusions: The cost of an ICU admission in our setting is US$ 2818. Although the family's contribution to expenses exceeded their initial WTP, a substantial subsidy (33 percent) is still required. Alternate financing strategies for the poor and optimization of ICU resources are urgently required. [ABSTRACT FROM PUBLISHER]

Objectives: The majority of patients in India access private sector providers for curative medical services. However, there is scanty information on the cost of treatment of critically ill patients in this setting. The study evaluates the cost and extent of financial subsidy required for patients admitted to an intensive care unit (ICU) in India.Methods: Data on direct medical, direct nonmedical, and indirect cost were prospectively collected from critically ill patients admitted to a tertiary teaching hospital in India. Willingness-to-pay (WTP) amount was obtained from the next-of-kin following admission and the actual cost paid by the family at discharge was recorded.Results: The main diagnoses (n = 499) were infection (26 percent) and poisoning (21 percent). The mean APACHE-II score was 13.9 (95 percent confidence interval [CI], 13.3-14.5); 86 percent were ventilated. ICU stay was 7.8 days (95 percent CI, 7.3-8.3). Hospital mortality was 27.9 percent. Direct medical cost accounted for 77 percent (US$ 2164) of the total treatment cost (US$ 2818). Indirect cost and direct nonmedical cost contributed to 19 percent (US$ 547.5) and 4 percent (US$ 106.5), respectively. Average total and daily ICU cost were US$ 1,897 and US$ 255, respectively. Although the family's WTP was 53 percent (US$ 1146; 95 percent CI, 1090-1204) of direct medical cost, their final contribution was 67.7 percent (US$ 1465; 95 percent CI, 1327-1604).Conclusions: The cost of an ICU admission in our setting is US$ 2818. Although the family's contribution to expenses exceeded their initial WTP, a substantial subsidy (33 percent) is still required. Alternate financing strategies for the poor and optimization of ICU resources are urgently required. [ABSTRACT FROM AUTHOR]

AIDS associated Kaposi sarcoma (AIDS-KS) was first reported from India in 1993. Since then only 16 cases have been reported. Three of them had proven Human Herpesvirus 8 (HHV-8) infection. We report a case of disseminated KS in a heterosexual male from India with HIV, hepatitis B and HHV-8 infection. He was given six cycles of chemotherapy with liposomal doxorubicin over three months to which he showed a good response. The case highlights the clinical course and management of a HHV-8 positive disseminated KS in a patient co-infected with Hepatitis B and HIV. [ABSTRACT FROM AUTHOR]

A 26-year-old female presented with deliberate self-harm using chlorantraniliprole, an unknown substance in human toxicology. She developed symptomatic Mobitz Type I atrioventricular block during observation, for which a temporary pacemaker was inserted. She reverted to sinus rhythm after 48 h and was discharged. Although claimed to be nontoxic to humans, chlorantraniliprole, an insecticide, could cause conduction defects by activating ryanodine receptors. To the best of our knowledge, this is the first case of chlorantraniliprole poisoning reported in the medical literature. [ABSTRACT FROM AUTHOR]

Diagnosing encephalitis is often difficult with a definitive diagnosis being reached at best in only 40% of cases. This clinical condition is associated with a high morbidity and mortality. A brain biopsy is the gold standard for the diagnosis of this disease. However, this procedure is rarely done, resulting in the cause of death being largely speculative. We propose a simple procedure for postmortem brain biopsy through the transnasal transcribriform route that will possibly be more acceptable to clinicians and relatives alike due to lack of external disfigurement, relative ease of the procedure and economy of time and manpower. This could also prove to be of immense benefit in an epidemic of encephalitis, especially in remote areas. [ABSTRACT FROM AUTHOR]