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Introduction: Long-term quality of life, return to work, economic consequences following Acute Respiratory Distress Syndrome (ARDS) are not well described in India. This study was aimed to address the question., Methods: A prospective cohort study of 109 ARDS survivors were followed up for a minimum of 6 months following discharge. Quality of life was assessed using the SF-36 questionnaire. Respiratory quality was assessed using the St Georges Respiratory Questionnaire. Time to return to work was documented. Costs-direct medical, as well as indirect were documented up to 6 months., Results: At 6 months, 6/109 (5.5%) had expired. Low energy/vitality and general heath were noted in the SF-36 scores at 6 months; overall a moderate quality of life. Pulmonary function tests had mostly normalized. Six-min walk distance was 77% of predicted. Respiratory quality of life was good. It took at the median of 111 days to go back Interquartile range (55-193.5) to work with 88% of previously employed going back to work. There were no significant differences in the severity of ARDS and any of these outcomes at 6 months. The average total cost from the societal perspective was ₹ 231,450 (standard deviation 146,430-, 387,300). There was a significant difference between the 3-ARDS severity groups and costs (P < 0.01). There were no independent predictors of return to work., Conclusion: ARDS survivors have low 6-month mortality. Pulmonary physiology and exercise capacity was mostly normal. Overall, quality of life is average was moderate, while respiratory quality of life was good. Return to work was excellent, while cost of care falls under a catastrophic heath expense., Competing Interests: None

Respiratory infections like influenza infections have been found to increase the risk of coronary artery disease and precipitate cardiac failure. However, Indian data is lacking. A retrospective observational study was done to describe patients with influenza infection who had concomitant heart failure (HF) requiring admission over 5 years (January 2013-December 2017). A total of 93 influenza cases were hospitalised during this time, of which 14 (15%) also had features of HF. Among them, the types of influenza infection were AH1N1 (6,43%), BH1N1 (4,29%), AH3N2 (3,21%) with one patient having both strains. Two-thirds of the HF were new onset (10, 71%), whereas rest were due to acute worsening of pre-existing HF (4, 29%). Ten (64.3%) of the patients had HF with reduced ejection fraction (HFrEF). The average hospital stay was 10 days with 2 (14%) deaths. The peak of influenza in August and September preceded the peak admission for HF. A total of 15% of influenza admissions have concomitant HF. They are predominantly due to influenza A H1N1 (43%), influenza A H3N2 (21%) and influenza B (29%). Only 7% had preceding influenza vaccination. Influenza during August and September appears to precede the peak of HF admissions which happen in October and November. Overall mortality was 14., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Family Medicine and Primary Care.)

Background & Objectives: : Acute kidney injury (AKI) has been identified as an independent risk factor for mortality in intensive care units. This retrospective study was conducted to determine the effect of AKI on in-hospital mortality in a general medical ward of a tertiary care hospital and risk factors for mortality in patients with AKI., Methods: : Demographic and clinical details, and outcome data were collected from case records of patients. In all hospitalized patients, factors associated with increased in-hospital mortality, such as AKI, inotrope requirement, mechanical ventilation and primary disease were compared between patients who died during their hospital stay and those who were discharged alive. Among the hospitalized patients, who had AKI, likely predictors of in-hospital mortality were compared between dead and alive patients at discharge. Factors that were significant in univariate analysis were tested by multivariate regression analysis to identify those that independently predicted poor outcomes., Results: : Of the 1150 patients admitted in a general medical ward in a year, 220 patients were identified to have AKI. In-hospital mortality rate among patients with AKI was 19.09 per cent as compared to 1.8 per cent without AKI [adjusted odds ratio (OR) 5.7 (95% CI: 1.56-20.74)]. The presence of AKI was an independent risk factor for death, with an adjusted OR of 6.0 [95% CI: 1.67-21.6]. Among patients with AKI, the presence of haematological malignancy, adjusted OR 25.86 (95% CI: 1.81-369.58), requirement of inotrope, adjusted OR 126.5 (95% CI: 19.39-825.93) and serum creatinine at admission (P<0.001) were found to be independent predictors of death. The presence of underlying chronic kidney disease and hospital-acquired AKI were not found to have an association with mortality., Interpretation & Conclusions: : The study showed the in-hospital mortality rate among patients with AKI in a general medical ward was 19.09 per cent. The occurrence of AKI was an independent risk factor for death, with haematological malignancy, use of vasopressors and higher serum creatinine at admission, significantly associated with death among patients with AKI. Large prospective studies need to be done to better understand the outcomes in AKI and the ways to present and manage AKI., Competing Interests: None

Background & Objectives: In developing countries like India, there is a lack of clarity regarding the factors that influence decisions pertaining to life supports at the end-of-life (EOL). The objectives of this study were to assess the factors associated with EOL-care decisions in the Indian context and to raise awareness in this area of healthcare., Methods: This retrospectively study included all patients admitted to the medical unit of a tertiary care hospital in southern India, over one year and died. The baseline demographics, economic, physiological, sociological, prognostic and medical treatment-related factors were retrieved from the patient's medical records and analysed., Results: Of the 122 decedents included in the study whose characteristics were analyzed, 41 (33.6%) received full life support and 81 (66.4%) had withdrawal or withholding of some life support measure. Amongst those who had withdrawal or withholding of life support, 62 (76.5%) had some support withheld and in 19 (23.5%), it was withdrawn. The documentation of the disease process, prognosis and the mention of imminent death in the medical records was the single most important factor that was associated with the EOL decision (odds ratio - 0.08; 95% confidence interval, 0.01-0.74; P=0.03)., Interpretation & Conclusions: The documentation of poor prognosis was the only factor found to be associated with EOL care decisions in our study. Prospective, multicentric studies need to be done to evaluate the influence of various other factors on the EOL care., Competing Interests: None

Background & Objectives: The escalation in carbapenem resistance among Enterobacteriaceae has resulted in a lack of effective therapeutic alternatives. Older antimicrobials, fosfomycin, nitrofurantoin and colistin for urinary tract infections (UTIs) caused by carbapenem-resistant Enterobacteriaceae (CRE) may be effective treatment options. The objectives of this study were to evaluate the utility of fosfomycin, nitrofurantoin and colistin in treating UTI caused by CRE and molecular characterization of the plasmid-mediated carbapenem resistance mechanisms., Methods: Consecutive, non-duplicate isolates of CR Escherichia coli and Klebsiella spp. from urine cultures were included (n=150). Minimum inhibitory concentrations (MIC) were determined by E-test (fosfomycin and nitrofurantoin) and broth microdilution (colistin). Efficacy ratios were derived by dividing susceptibility breakpoints by observed MIC values of the drugs for the isolates. Isolates were screened for genes coding for carbapenemases using multiplex PCR. Fosfomycin, nitrofurantoin and colistin-resistant isolates were screened for plasmid-borne resistance genes fos A3, oqx AB and mcr-1, respectively using PCR., Results: Among E. coli, 98.9, 56 and 95 per cent isolates were susceptible to fosfomycin, nitrofurantoin and colistin, respectively, while 94 and 85 per cent of Klebsiella spp. were susceptible to fosfomycin and colistin, respectively. The efficacy ratios indicated fosfomycin as the drug of choice for UTI caused by CR E. coli and Klebsiella spp., followed by colistin. The bla NDM gene was most common, followed by bla OXA48-like . Plasmid-borne genes encoding resistance to fosfomycin, nitrofurantoin and colistin were absent., Interpretation & Conclusions: With increasing resistance against the current treatment options, older drugs may emerge as effective options. Molecular screening of resistant isolates is essential to prevent the spread of plasmid-borne resistance against these drugs., Competing Interests: None

A 45-year-old gentleman presented with fever, weight loss, and painful swelling of both knees. His history was significant for type 2 diabetes mellitus. Blood cultures grew Burkholderia pseudomallei , and imaging revealed osteomyelitis of bilateral distal femura and proximal tibiae, with no involvement of the joint space. He underwent debridement and was initiated on ceftazidime followed by eradication therapy with trimethoprim-sulfamethoxazole. He recovered well with no further complications. Melioidosis is a rare cause of multifocal osteomyelitis and is a differential to be considered in an appropriate clinicoepidemiological setting., Competing Interests: There are no conflicts of interest.

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., Competing Interests: There are no conflicts of interest.