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Background: Acinetobacter, a nonfermenting Gram-negative coccobacilli, have emerged as significant pathogens causing multidrug-resistant (MDR) ventilator-associated pneumonia (VAP). Metallo-beta-lactamase (MBL)-producing Acinetobacter spp. have become an emerging therapeutic concern worldwide due to the MDR isolates. Aim and Objectives: Phenotypic detection of MBL producing MDR Acinetobacter isolates in patients with VAP and to study the antibiotic susceptibility pattern of MBL-producing isolates. Materials and Methods: This was a prospective observational and noninterventional study conducted on patients with VAP over a period of 2 years. This study was conducted at a tertiary care teaching hospital in the intensive care unit. A total of 164 MBL-producing MDR AB isolates were included in the study. MBL was detected by imipenem-EDTA double-disc synergy test (DDST), imipenem-EDTA combined disc synergy test (CDST-IPM), and MBL-E test. Results: A total of 188 samples were enrolled for the study, fulfilling the inclusion criteria of VAP. Total MDR Acinetobacter spp. isolates were 188 (76.42%) of them, 164 (87.23%) were MBL producing and 24 (12.76%) were nonMBL (P

Background: Chronic Obstructive Pulmonary Disease (COPD) has considerable effects on cardiac functions primarily affecting the pulmonary vasculature, right ventricle and then left ventricle. Echocardiography provides a rapid and non-invasive method to evaluate cardiac changes. Aims and Objectives: To assess the parameters of diastolic function and Tissue Doppler imaging (TDI) and to correlate with severity of COPD by GOLD stages and to find out relation of TDI parameters with spirometic variables. Material and Methods: A total 60 stable COPD patients, fulfilling inclusion criteria were selected and were classified according to pulmonary function test (PFT) and evaluated by 2-Dimensional transthoracic echocardiography (TTE) and tissue Doppler imaging (TDI). Results: Total 32 (68.08%) subjects had grade-I diastolic dysfunction, 11 (23.40%) had grade-II and 4 (8.51%) had grade –III diastolic dysfunction with predominance of grade-I diastolic dysfunction [p’ Conclusion: Significant proportion of patient with COPD had diastolic dysfunction assessed by TDI (E/Ea ratio). Pulmonary hypertension (PH) and diastolic dysfunction had linear relationship with severity of COPD. Key words: Diastolic dysfunction, Tissue Doppler Imaging, COPD spiromety, Pulmonary hypertension, 2-Dimensional transthoracic echocardiography.

Background: Ventilator-associated pneumonia (VAP) is the most frequent Intensive Care Unit acquired infection. Aims: The aim is to determine the incidence, bacteriology and factors affecting VAP and to determine the multi-drug resistant (MDR) pathogens. Settings and Design: This was a prospective observational study conducted over a period of 1 year from April 1, 2011, to March 31, 2012. Materials and Methods: The patients fulfilling criteria of VAP were included in this study. Statistical Analysis: This was performed using SPSS trial version 11.0 software (SPSS Inc., Chicago, Illinois, USA) and the values of P < 0.05 were considered statistically significant. Results: Totally 74 (27.71%) patients were developed VAP. Of total 74 patients with VAP 53 (71.62%) were females and 21 (28.37%) were females (P < 0.0001). Total 13 (17.56%) patients had early-onset VAP and 61 (82.43%) had late-onset VAP (P < 0.0001). The overall incidence of VAP rate per 1000 ventilator days was 39.59. Total 126 bacterial isolates found in 74 patients with VAP. Predominant isolates were Gram-negative 52 (70.27%). Total 41 (55.40%) patients had polymicrobial VAP, and 33 (44.59%) had single isolate. Total 55 (43.65%) isolates were MDR organisms. Total 22 patients with VAP succumbed during treatment with overall case fatality rate of 29.72%. Of total 55 MDR isolates in VAP, 13 (26.63%) were Klebsiella spp., 11(20%) Pseudomonas aeruginosa, 14 (25.45%) Acinetobacter, 8 (14.54%) Escherichia coli, and 9 (16.36%) coagulase positive Staphylococcus aureus. Total 12 (21.41%) patients succumbed among MDR isolates. Conclusions: There was a high incidence of MDR pathogens in late-onset VAP. The Gram-negative organisms Klebsiella, Pseudomonas E. coli and Acinetobacter were the most commonly isolated organisms with high mortality rates.

Background: AIDS has become chronic illness which is well treated with antiretroviral therapy and management of opportunistic infections (OIs). Aims and Objectives: The study clinical profile and outcome of human immunodeficiency virus (HIV) seropositive patients. Materials and Methods: This was retrospective observational study carried out over a period of 1 year (January 2011–December 2011). All HIV patients admitted in medicine ward, and ICU were enrolled. Statistical analysis was performed using SSPE statistical software trial version 11. The P< 0.05 was considered as statistically significant. Results: Of total 111 patients with a diagnosis of HIV/AIDS, 75 (67.56%) were male and 36 (32.43%) were female patients. A total 52 (46.84%) patients presented with respiratory manifestations, of them 23 (44.23%) had pulmonary tuberculosis (TB), 6 (11.53%) had tubercular effusion, and 3 (5.76%) had Pneumocystis jirovecii pneumonia. Respiratory manifestations including pulmonary TB were the most common presentation (P< 0.001). Total 27 (24.32%) patients were presented with the neurological manifestation of them 8 (29.62%) had a cerebro-vascular accident, 5 (18.51%) had cryptococcal meningitis, 4 (14.81%) had tubercular meningitis, and 1 (3.70%) had progressive multifocal leukoencephalopathy. Total 12 (38.70%) had acute gastroenteritis 6 (19.35%) had oral candidiasis, 8 (25%) had general tonic clonic seizure and 7 (21.87%) had pyrexia of unknown origin, 6 (18.75%) had septicemia, 6 (18.75%) had acute renal failure, and 6 (94.11%) had anemia. A total 11 (9.90%) patients succumbed. Conclusions: Overall respiratory manifestations were the common presentation in a present cohort of HIV seropositive patients and TB was the most common OI and the cerebrovascular accident was the most common neurological manifestation.

Background: Venomous snake bite is a common and frequently devastating environmental and occupational disease, especially in rural areas of Maharashtra India. Aims & Objectives: To determine the clinical profi le and outcome of snakebite cases in rural western Maharashtra. Material & Methods: This was a retrospective study conducted over one year period (January 2009 to December 2009) at a tertiary health care centre in Maharashtra. Results: Out of 167 admitted snakebite 103 (61.67%) were complicated snake bites. Total 88 (85.43%) patients were with vasculo-toxic snake bite. Total 15 (14.56%) patients were with neuroparalytic snakebite. Total 35 (39.77%) patients out of 88 with vasculotoxic snakebite developed local cellulitis requiring fasciotomy and or debridement, 17 (19.31%) patients had clinical and laboratory parameters favoring DIC. Total 12 (13.63%) patients had ARF, one developed AMI and one developed cortical venous sinus thrombosis (CVT). Out of 88 patients with vasculotoxic snakebite 2 died with case fatality rate of 2.27% (2/88). Out of 15 patients with neuroparalytic snake bite 13 (86.66%) required artifi cial ventilatory support and one patient developed delayed peripheral neuropathy. Overall mortality was 1.94% (2/103). The needle to ASV time was positively correlated with duration of hospital admission, complications and mortality ('p' < 0.02). Conclusions: Snakebite is a common life-threatening emergency in the study area. Delay in hospitalization is associated with poor prognosis and increased mortality rate due to consumptive coagulopathy, renal failure and respiratory failure. Unusual complications like AMI, CVT and delayed peripheral neuropathy were observed in present study.

Background: The incidence of heart failure in diabetic subjects is high even in the absence of hypertension and coronary artery disease. Aims: The purpose of this study was to study the incidence of diastolic dysfunction in diabetic subjects and its relation to age, duration of diabetes mellitus (DM), Glycosylated hemoglobin (HbA1c) levels, obesity indices and diabetic microangiopathies. Settings and Design: This was a case control prospective study conducted at the teaching hospital during a one year period. Materials and Methods: A total of 127 subjects (case) with type 2 diabetes of more than five years duration were studied. Total 100 healthy subjects were included as the control group. Echocardiography was performed to assess left ventricular diastolic function. Results: Out of the total 127 subjects, 69 (54.33%) from the case group had diastolic dysfunction, and 11% amongst 100 in the control group population showed the diastolic dysfunction (P < 0.001). Patients with a longer duration of DM (of 11 to 15 years) had a higher prevalence of diastolic dysfunction (P < 0.02). Subjects with high waist circumference and high waist to hip ratio had statistically significant diastolic dysfunction with ‘P’ =0.001 and ‘P’ = < 0.02 respectively. Subjects with HbA1c > 7.5% had a higher prevalence of diastolic dysfunction than subjects with HbA1c < 7.5% (P < 0.02). Diastolic dysfunction was present in majority of the subjects with autonomic neuropathy and retinopathy. Conclusions: Present study reveals high incidence of diastolic dysfunction in asymptomatic diabetic; subjects and, this finding was correlated with the duration of diabetes, HbA1c levels, obesity indices and diabetic microangiopathies. We conclude that early diagnosis and institution of treatment will reduce morbidity and improve the outcomes, and prevent future heart failure.

Context: Central venous catheter-related bloodstream infection (CRBSI) is associated with high rates of morbidity and mortality in critically ill patients. Aims: This study was conducted to determine the incidence of central venous catheter-related infections (CRIs) and to identify the factors influencing it. So far, there are very few studies that have been conducted on CRBSI in the intensive care unit in India. Settings and Design: This was a prospective, observational study carried out in the medical intensive care unit (MICU) over a period of 1 year from January to December 2004. Materials and Methods: A total of 54 patients with indwelling central venous catheters of age group between 20 and 75 years were included. The catheters were cultured using the standard semiquantitative culture (SQC) method. Statistical analysis used SPSS-10 version statistical software. Results: A total of 54 CVC catheters with 319 catheter days were included in this study. Of 54 patients with CVCs studied for bacteriology, 39 (72.22%) catheters showed negative SQCs and also negative blood cultures. A total of 15 (27.77%) catheters were positive on SQC, of which 10 (18.52%) were with catheter-associated infection and four (7.41%) were with catheter-associated bacteremia; the remaining one was a probable catheter-associated bacteremia. CRIs were high among catheters that were kept in situ for more than 3 days and emergency procedures where two or more attempts were required for catheterization (P < 0.05). In multivariate analysis of covariance duration of catheter in situ for >3 days, inexperienced venupucturist, more number of attempts and emergency CVC were associated with more incidence of CVCBSIs, with P

Leptospirosis is an important emerging zoonosis with a worldwide distribution that is characterized by a broad spectrum of clinical manifestations ranging from inapparent infection to fulminant disease. Leptospirosis has protean clinical manifestations. The classical presentation of the disease is an acute biphasic febrile illness with or without jaundice. Unusual clinical manifestations may result from involvement of pulmonary, cardiovascular, neural, gastrointestinal, ocular and other systems. Immunological phenomena secondary to antigenic mimicry may also be an important component of many clinical features and may be responsible for reactive arthritis. The presentation of paraparesis in combination with Weil's syndrome is rare. Few cases were reported with leptospirosis and paraparesis in India and abroad. It is important to bear in mind that leptospiral illness may be a significant component in cases of dual infections or in simultaneous infections with more than two pathogens. Here we are reporting a case of Weil's syndrome with paraparesis in 28-year-old male patient who was critically ill due to severe hepatorenal dysfunction and hyperkalemia.

Non-compaction cardiomyopathy is a recently recognized disorder, based on an arrest in endomyocardial morphogenesis. The disease is characterized by heart failure (both diastolic and systolic), systemic emboli and ventricular arrhythmias. The diagnosis is established by two-dimensional echocardiography. Isolated left ventricular non-compaction cardiomyopathy (IVNC) is an exceedingly rare congenital cardiomyopathy. Only a few cases of this condition have been reported. It is characterized by prominent and excessive trabeculation in a ventricular wall segment, with deep intertrabecular spaces perfused from the ventricular cavity. Echocardiographic findings are important clues for the diagnosis. We report a case of isolated non-compaction of the left ventricular myocardium presented with ventricular tachycardia.

Cerebral toxoplasmosis is an acquired immunodeficiency syndrome (AIDS)-related infection and is one of the causes of CNS mass lesions in AIDS. Toxoplasmosis is the most common cerebral mass lesion encountered in HIV-infected patients, and its incidence has increased markedly since the beginning of the AIDS epidemic. Cerebral toxoplasmosis is associated with high mortality and morbidity in patients with acquired immunocopromised state. We are reporting a case of cerebral toxoplasmosis presented with status epileptics and treated with cotrimoxazole. Refractory status epilepsy was controlled with intravenous levetiracetam, which has a unique drug profile.

We describe a case of ruptured aneurysm of the left coronary sinus of Valsalva diagnosed by transthoracic two-dimensional echocardiography. A very few cases with ruptured left sinus of Valsalva have been reported. We are reporting a rupture of the left sinus of Valsalva into the main pulmonary artery in a 40-year-old male diagnosed by transthoracic echocardiography.

Pericardial effusion is frequently found in patients with hypothyroidism, but it is rarely associated with cardiac tamponade. Hypothyroidism complicated by cardiac tamponade is rarely referenced in the medical literature. Here we report an unusual case of a 45-year-old female, who presented with breathlessness and was found to have hypothyroidism with large pericardial effusion with cardiac tamponade. Treatment included an emergency pericardiocentesis followed by thyroxine hormone replacement.

H1N1 influenza is an emerging threat that is life threatening to pregnant women in the third trimester. Pregnant women are a high-risk group for morbidity and mortality from influenza (H1N1). During the current pandemic of H1N1 influenza, few cases of H1N1 have been reported in pregnancy. We report a case of H1N1 influenza in a 23-year old female with 28 weeks of gestation, who developed acute respiratory distress syndrome, required mechanical ventilation and eventually recovered. KEYWORDS: H1N1; Acute Respiratory Distress Syndrome; Pregnancy; InfluenzaInternet Journal of Medical Update 2012 January;7(1):73-76

Background: There is an increasing incidence of patients infected with human immunodeficiency virus (HIV) in India. The neurological manifestations of the disease are being seen more frequently. The nervous system is the most frequent and serious target of HIV infection. Aims and Objectives: To elucidate the spectrum of neurological involvement in patients with HIV infection at a tertiary care teaching hospital in western Maharashtra. We investigated various neurological manifestations of HIV including opportunistic infections (OPIs) and non-opportunistic infections (non-OPIs). Settings and Design: This was a retrospective observational study conducted at a tertiary care center in western Maharashtra over a period of 2 years from Jan 2009 to Dec 2010. Materials and Methods: A total of 81 HIV seropositive patients of both genders, of age >18 years, with neurological manifestations admitted at a tertiary care center were studied for clinical parameters, laboratory investigations and imaging. Statistical Analysis: Data were coded by numbers and double entered in a computer software SSPE-11 trial version. Results: A total of 179 patients admitted with HIV infection, of which 81 (45.25%) presented with neurological manifestations (neuro-acquired immunodeficiency syndrome [AIDS]), were enrolled in the study. Overall, 53 (65.43%) patients were male (34 years ± 11) and 28 (34.56%) were female (29 years ± 8). The male patients were outnumbered compared with the female patients, with P = 0.02. A total of 45 (55.55%) patients had OPIs and 36 (44.44%) patients had non-oppurtunistic neurological manifestations affecting the nervous system ( P = 1573; insignificant). A total of 15 (18.51%) patients had immune reconstitution syndrome on antiretroviral therapy (A total of 11 (13.58%) patients had seizures, eight (9.87%) had ischemic stroke, eight (9.87%) had aseptic meningitis, two (2.46%) had intracranial hemorrhage, two (2.46%) had vacuolar myelopathy, four (4.93%) had AIDS-associated dementia, three (3.70%) had Guillain Barrι syndrome (GBS), two (2.46%) had acute motor sensory axonal neuropathy (AMSAN), one (1.23%) had chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and two (2.46%) had mononeuritis multiplex cranialis. A total of 17 (20.98%) patients had TB meningitis, 11 (13.58%) had cryptoccocal meningitis, one (1.23%) had Pott's spine, two (2.46%) had progressive multifocal leukoencephalopathy (PMLE), two (2.46%) had herpes zoster, one (1.23%) had herpes simples encephalitis and one (1.23%) had cerebral toxoplasmosis. The CD4 was significantly low in patients with PMLE, ADC ( AIDS Dementia Complex ) and cryptoccocal meningitis compared with other neurological manifestations ( P P = 0.034). Conclusion: We found a high prevalence of neurological manifestations in HIV seropositive patients (45.25%) in this setting. Central nervous system (CNS) tuberculosis was the most common secondary infection seen in HIV patients. Cryptococcal meningitis was the next common infection, which showed a striking male preponderance. The most common non-infectious lesions included cerebrovascular events, followed by neoplasms. Neuropathies and myelopathies were the least common neurological manifestations in patients with HIV infection. This study revealed not only the high prevalence of various neurologic events but also their nature, clinical presentation and symptoms. A neuropsychological assessment should be mandatory for all HIV-positive patients. CNS OPI indicates progression of HIV infection toward AIDS, and is useful as a reference to starting ART in settings where facilities for determination of CD4 counts are not available.

Context: Complicated Plasmodium falciparum Malaria is a syndrome and a disease of protean, clinical manifestations including jaundice, ARF, ARDS and multi-organ failure. Aims: The objectives of the present study are to study clinical features, complications and factors affecting outcome of patients with complicated P. falciparum Malaria. Settings and Design: This retrospective descriptive study was conducted at tertiary care centre in western Maharashtra from January 2010 to December 2010. Methods and Material: Total 73 patients with complicated P. falciparum malaria who presented with fever having positive trophozoites of P. falciparum in blood smear were included. SPSS (version-10) software was used for all statistical calculations. Results: A total 73 patients had complicated P. falciparum malaria with 52 were males and 21 were female patients. Total 9 (12.32 %) patients were presented with shock as a presenting feature. Four (5.47 %) patients had hypoglycaemia at the time of admission. Total 43 (58.90 %) patients had jaundice, 37 (50.68 %) had anaemia, 28 (38.35 %) had cerebral malaria, 7 (9.58 %) had acute renal failure, 5 (6.84 %) had ARDS and 5 (6.84 %) had thrombocytopenia. Total 46 patients had single complication in the form of cerebral malaria 14 (19.17 %), jaundice 15 (20.54 %) and anaemia 16 (21.91 %). Total 14 patients had two complications in the form of jaundice with ARF 02 (2.73 %) with one (50 %) death and jaundice with anaemia 12 (16.43 %). Total 9 (12.32 %) patients had three complications in the form of cerebral malaria with jaundice with anaemia with 3 deaths (33.33 %). Total 5 (6.84 %) patients had multiple complications in the form of cerebral malaria with ARF with ARDS with thrombocytopenia with 4 (80 %) death. Case fatality rate was 10.95 %. The case fatality rate with ARDS was 80 % (4/5), with ARF was 57.14 % (4/7) and with cerebral malaria it was 25 % (7/28). Case fatality rate was highest in patients with pulmonary complication (ARDS) compared to ARF, cerebral malaria, jaundice and anaemia with 'p' < 0.001. Conclusions: Acute renal failure and ARDS were least common presentation with poor outcome. In present study most common presentation was with jaundice and anaemia next to that was cerebral malaria. The case fatality rate of P. falciparum malaria was 10.95 %. Overall case fatality rate was highest with multi-organ dysfunction (80 %). Unusual early renal and pulmonary complications were the presenting features of complicated P. falciparum malaria were observed in present study. Presenting feature as a shock was invariably associated with either ARDS or ARF with high mortality. This study highlights the burden of complicated malaria including multi-organ dysfunction in western Maharashtra.

Background and Objectives: Anthropometric variables and their relation to conventional coronary artery disease (CAD) risk factors in railway employees have been inadequately studied in India. This cross-sectional survey was carried out in the Solapur division of the Central railway in the year 2004, to assess the anthropometric variables in railway employees and their relation to conventional CAD risk factors. Materials and Methods: A total of 995 railway employees, with 872 males and 123 females participated in this cross-sectional study. All subjects underwent anthropometric measurements, fasting lipid profile, and blood sugar level. Various anthropometric indices were calculated for body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), and abdominal volume index (AVI). Statistical analysis was done by EPI Info 6 statistical software. Results: Compared to all other obesity indices, WHtR was most prevalent in both genders. High WHtR was present in 699 (80.16%) males and 103 (83.73%) females. Age ≥45 years, high systolic BP, high diastolic BP, low HDL, high triglyceride, and diabetes mellitus were positively correlated with high BMI, high WC, high WHR, high WHtR, and high AVI. High BMI, high WC, high WHR, high WHtR, and high AVI were negatively associated with physical inactivity. Conclusions: Over all, anthropometric variables in both genders were significantly deranged in subjects with coronary risk factors. Compared to all other anthropometric variables, WHtR was statistically significantly associated with a majority of coronary artery risk factors. Hence we recommend inclusion of WHtR as a parameter of obesity to predict coronary artery disease risk factor along with WC, WHR, and BMI in epidemiologic studies.