Nearly one million cancer patients in India need oral morphine for pain relief. Despite doctors prescribing oral morphine in our center, many cancer patients with severe pain found to be not facilitated with adequate pain relief.
This audit was conducted to look at the “oral morphine prescribing practices for severe cancer pain” at a tertiary care hospital.
Materials and Methods:
Twenty case files of patients, who were admitted with severe cancer pain, and receiving oral morphine were analyzed in pre- and posteducational session. Local standards were set to assess the adequacy of pain relief. Deficiency in achieving analgesia was found in preinterventional audit. A clinical audit was conducted before and after the educational session on oral morphine prescribing. The education for doctors and nurses focused on starting patients on morphine, titration, and administering rescue dose. Then local guidelines on oral morphine prescribing were circulated. And analysis of following factors were done following pre- and posteducational session: Pain intensity at the beginning of treatment, starting dose of morphine, increments in morphine dose, number of rescue doses given, and fall in pain intensity at the end of 1 week. The outcomes were compared with the standards.
Preintervention audit showed that only 50% of patients achieved adequate pain relief. Rescue dose was administered in only 20% of patients. While reaudit following the educational session showed that 80% of patients achieved adequate pain relief and 100% received rescue doses.
Educational sessions have significant impact on improving oral morphine prescribing practice among doctors and nurses. It was found failing to administer regular as well as rescue doses resulted in inadequate pain relief in patients receiving oral morphine.
Cancer pain; Oral morphine; Pain relief; Prescribing practices
There are reports of emergence of resistant strains of S. pneumoniae showing resistance to penicillin from all over the world, and now, resistance to multiple drugs (multidrug-resistant strains) has been added to it. However, scanty reports are available so far from India, depicting such resistance.
The aim of the present study is to look for the prevalence of penicillin-resistant pneumococci and also the multidrug-resistant strains among S. pneumoniae, isolated from respiratory specimens, in the coastal part of South India.
Settings and Design:
A cross-sectional study was conducted from June 2008 to December 2008, in our tertiary care center. Fifty pathogenic clinical isolates were collected from patients suffering from lower respiratory tract infections.
Materials and Methods:
Penicillin resistance was screened by 1 μg oxacillin disk on Muller-Hinton blood agar followed by Minimum Inhibitory Concentration (MIC) detection by the agar dilution method according to the Clinical Laboratory Standards Institute (CLSI) guidelines. Antibiotic susceptibility for other antibiotics was carried out by the Kirby Bauer disk diffusion method followed by an E-test with HiComb test strips from Hi-media.
Out of 50 isolates, 4% (95% Confidence Interval - 1.4, 9.4) showed total resistance to penicillin, whereas, 10% (95% CI; 1.6, 18.3) showed intermediate resistance. These penicillin-resistant pneumococci (4%) were also found to be multidrug-resistant (MDR) strains. Maximum resistance was observed for cotrimoxazole and tetracycline (24% each with 95% CI; 12.2, 35.8) followed by erythromycin and ciprofloxacin (14% each with 95%CI; 4.4, 23.6).
Increasing emergence of the resistant strains of S. pneumoniae in the community set up requires continuous monitoring and a restricted use of antibiotics to keep a check on its resistance pattern, for an effective treatment plan.
Minimum inhibitory concentration; Multi-drug resistant strains; Penicillin; Resistance; Streptococcus pneumoniae
This study aims to understand the sociodemographic and clinical profile of inhalant abusers seeking treatment from a tertiary care psychiatric hospital in South India.
Materials and Methods:
The clinical charts of patients who utilized the psychiatric services of a tertiary care center in India for over 10 years were examined for the study.
The sample had an urban predominance, was mostly unemployed, and was all male. Most of them had an adolescent age of onset of inhalant use (mean — 16.23 years). All patients reported the use of volatile solvents as inhalants. One other substance dependence was identified in more than half of the sample. The psychiatric comorbidity included psychosis and depression. A comparison was made between patients who presented with inhalant dependence only (I) and inhalant-dependent individuals who also used other psychoactive substances apart from nicotine (IP). The inhalant-only group (I) had an earlier mean age at onset of substance use as compared to the IP group. All patients in the I group reported withdrawal symptoms compared to 77% of patients in the (IP) group (P=0.048). The IP group reported a significantly higher occurrence of aggression (54.5 vs. 19%, P=0.02), externalizing symptoms (77.3 vs. 42.9%, P=0.03), and attention-deficit hyperactivity disorder (ADHD) (50 vs. 14.3%, P=0.02).
Inhalant dependence is a serious health problem in adolescent subjects and is associated with high comorbidity of other substance dependence, psychiatric disorder, and externalizing spectrum disorder. There is a need for community-based prospective studies in this area from India.
Comorbidity; externalizing symptoms; inhalant abuse; substance dependence; volatile solvents
Increased scrutiny and the need to institute a truly patient centered approach to surgical care has motivated the growing interest in measuring the quality of surgical care through comparative surgical audit. This study aimed to assess the validity of the POSSUM (Physiological and Operative Severity Score for enumeration of Mortality and Morbidity) and P-POSSUM (Portsmouth-POSSUM) score in predicting the risk of morbidity and mortality respectively in general surgical patients presenting with conditions of various operative severities at a tertiary care centre in Haryana, a northern state of India.
A prospective study was performed in 100 general surgical patients including an equal number of patients in each of the four groups of operative severity i.e. minor, moderate, major, major plus. The risks of mortality and morbidity were calculated by using the POSSUM equation for morbidity and the P-POSSUM equation for mortality in each patient. The predicted risks were compared with the observed risks of mortality and morbidity and statistically analysed.
The difference in p value of predicted risk of morbidity by POSSUM equation and observed morbidity; calculated by chi square test was 0.756 which was not statistically significant. The difference in p value of predicted mortality by P-POSSUM equation and observed mortality; calculated by chi square test was 0.472 which was also not statistically significant.
POSSUM and P-POSSUM appear to be good and valid indices for use in the risk prediction of morbidity and mortality in the north Indian population.
POSSUM; P-POSSUM; Surgical outcome
To describe gender-based differences in disease progression, treatment, and outcome among patients receiving highly active antiretroviral therapy (HAART) in South India.
Therapy-naïve patients initiating HAART between February 1996 and June 2006 at a tertiary HIV referral center in Chennai, South India, were analyzed using the YRG CARE HIV Observational Database. Patients with 1 year of follow-up after initiating HAART were examined to investigate immunological and clinical outcomes, including the development of adverse events to therapy and opportunistic infections.
All previously therapy-naïve patients who initiated HAART with at least 1 year of follow-up (n = 1972) were analyzed. At enrollment into care, women had higher CD4 counts, lower hemoglobin, and higher body mass index (BMI) than their male counterparts (p < 0.05). At the time of initiating therapy, women had higher CD4 counts and lower hemoglobin (p < 0.05); women continued to have higher CD4 counts at 12 months (p < 0.05). After 1 year following HAART initiation, significantly more men developed tuberculosis and Pneumocystis jiroveci pneumonia (p < 0.05), more women experienced lactic acidosis and nausea, and more men developed immune reconstitution syndrome (p < 0.05).
Significant physiological, immunological, and clinical differences exist between men and women initiating HAART in a resource-limited setting in South India. Future studies should examine whether clinical management strategies should be different for men and women in resource-limited settings.
Palliative care in India has made enormous advances in providing better care for patients and families living with progressive disease, and many clinical services are well placed to begin quality improvement initiatives, including clinical audit. Clinical audit is recognized globally to be essential in all healthcare, as a way of monitoring and improving quality of care. However, it is not common in developing country settings, including India. Clinical audit is a cyclical activity involving: identification of areas of care in need of improvement, through data collection and analysis utilizing an appropriate questionnaire; setting measurable quality of care targets in specific areas; designing and implementing service improvement strategies; and then re-evaluating quality of care to assess progress towards meeting the targets. Outcome measurement is an important component of clinical audit that has additional advantages; for example, establishing an evidence base for the effectiveness of services. In resource limited contexts, outcome measurement in clinical audit is particularly important as it enables service development to be evidence-based and ensures resources are allocated effectively. Key success factors in conducting clinical audit are identified (shared ownership, training, managerial support, inclusion of all members of staff and a positive approach). The choice of outcome measurement tool is discussed, including the need for a culturally appropriate and validated measure which is brief and simple enough to incorporate into clinical practice and reflects the holistic nature of palliative care. Support for clinical audit is needed at a national level, and development and validation of an outcome measurement tool in the Indian context is a crucial next step.
Audit; Outcomes; Quality improvement; Quality of care
To study the clinical, pathological and prognostic profile of patients with temporal arteritis in India.
Materials and Methods:
The study was conducted in a tertiary care center from south India from 2005 to 2010 in the departments of neurology and medicine. The details of all patients that satisfied the ACR 1990 criteria for diagnosis of temporal arteritis were reviewed. The clinical presentation, laboratory parameters and biopsy findings of the patients were analyzed and compared with other studies from India done over the last decade.
A total of 15 patients were diagnosed with temporal arteritis. The male:female ratio was 1.5:1. The mean age of onset was 67.58 years. Mean time for detection after onset of symptoms was 2.56 months. Typical manifestations included headache (100%), temporal artery tenderness (100%), jaw claudication (20%), polymyalgia rheumatica (53%) and visual manifestations (20%). The erythrocyte sedimentation rate was elevated in all patients. Biopsy was done in 13 patients, with 11 of them being positive. All patients responded to steroids well, with most patients being symptom-free within the first 48 h of treatment.
Temporal arteritis seems to be underdiagnosed in India, with all patients previously misdiagnosed, and with a mean time from symptom onset to diagnosis of 2.5 months. The clinical presentation of temporal arteritis in India appears to be similar to that of the West, with no gender preference and a slightly younger age group.
Blindness; giant cell arteritis; headache
The use of spirometry is currently limited to the diagnosis of obstructive airway disease for tertiary centers mainly because of the unmet need for technical expertise and funding. Use in primary care asks for a simpler and cost-effective screening tool for obstructive airway disease.
To estimate the efficacy of FEV6 against the current standard of FVC in the spirometric diagnosis of obstructive airway disease.
Setting and Design:
The Pulmonary Function Laboratory of a tertiary care hospital in Coastal South India. It was a descriptive study.
Materials and Methods:
We analyzed 150 serial patients on ATS standardized spirometers. The patients were classified into normal subjects and those with airway obstruction, further categorized as mild, moderate and severe and those with mixed defect. Those with obstruction were also classified as having reversible and irreversible defects.
Data was analyzed using SPSS Software (v.11.5), statistical test ANOVA and Pearson correlation was done and P less than 0.05 considered statistically significant.
FVC and FEV6 showed a linear correlation in all subjects. The difference in means was statistically significant in all subjects. The sensitivity and specificity of FEV1/FEV6 in comparison to FEV1/FVC were both found to be 100%.
FEV6 is an excellent screening tool in the diagnosis of airway obstruction but, there is a necessity for further research to confirm our findings. There is also a need for reference values in an Indian setting to find out the efficiency of this new parameter. Our sample size is relatively small and comprises of a very high proportion (70%) of subjects with airway obstruction and so our results may not be applicable for use in general population.
Forced vital capacity; forced expiratory maneuver to six-second duration; obstructive airway disease; spirometry
Preseptal cellulitis is the commonest orbital disease which frequently needs to be differentiated from orbital cellulitis. Prompt diagnosis and treatment with appropriate antibiotics can prevent vision loss and life-threatening complications of orbital cellulitis.
To describe the clinical profile of cases with preseptal and orbital cellulitis admitted to a tertiary care hospital during a period of nine years. The causative organisms and the clinical outcome were analyzed.
Settings and Design:
Retrospective descriptive case study done in a tertiary care hospital in South India.
Material and Methods:
The in-patient records of patients with preseptal and orbital cellulitis were reviewed from 1998 to 2006. The factors reviewed included ocular findings aiding in the distinction of the two clinical conditions, the duration of symptoms, the duration of hospital stay, microbiological culture report of pus or wound swab, blood culture, drugs used for treatment, the response to therapy and complications.
Statistical Analysis Used:
One hundred and ten cases, 77 patients with preseptal cellulitis and 33 patients with orbital cellulitis were reviewed. Five percent of children and 21% of adults presented with cutaneous anthrax contributing to preseptal cellulitis. Thirty-nine percent cases with orbital cellulitis were caused by methicillin-resistant Staphylococcus aureus (MRSA).
This study has helped in identifying organisms which cause orbital infections, especially community-acquired MRSA. It indicates the need for modifying our empirical antimicrobial therapy, especially in orbital cellulitis.
Anthrax; community-acquired methicillin-resistant Staphyloccus aureus; orbital cellulitis; preseptal cellulitis
To determine the frequency of use of pharmacotherapy with aspirin, beta blocker, statin, and angiotensin-converting enzyme (ACE) inhibitor in patients with stable coronary heart disease (CHD) among physicians at different levels of health care in Rajasthan state, India.
Physicians practicing at tertiary hospitals and clinics at tertiary, secondary and primary levels were contacted. Prescriptions of CHD patients were audited and descriptive statistics reported.
We evaluated 2,993 prescriptions (tertiary hospital discharge 711, tertiary 688, secondary 1,306, and primary 288). Use of aspirin was in 2,713 (91%) of prescriptions, beta blockers 2,057 (69%), ACE inhibitors or angiotensin receptor blockers (ARBs) 2,471 (82%), and statins 2,059 (69%). Any one of these drugs was prescribed in 2,991 (100%), any two in 2,880 (96%), any three in 1,740 (58%), and all four in 1,062 (35.5%) (P < 0.001). As compared to tertiary hospital, prescriptions at tertiary, secondary, and primary levels were lower: aspirin (96% vs 95%, 91%, 67%), beta blockers (80% vs 62%, 66%, 70%), statins (87% vs 82%, 62%, 21%): two drugs (98% vs 96%, 98%, 85%), three drugs (75% vs 58%, 55%, 28%), or four drugs (54% vs 44%, 28%, 7%) (P < 0.01). Use of ACE inhibitors/ARBs was similar while nitrates (43% vs 23%, 43%, 70%), dihydropyridine calcium channel blockers (12% vs 15%, 30%, 47%), and multivitamins (6% vs 26%, 37%, 47%) use was more in secondary and primary care.
There is suboptimal use of various evidence-based drugs (aspirin, beta blockers, ACE inhibitors, and statins) for secondary prevention of CHD in India.
statins; coronary heart disease; aspirin; beta blockers; angiotensin-converting enzyme inhibitor
Background & objectives:
Obstructive sleep apnoea (OSA) is known to be associated with cardiovascular risk factors and metabolic syndrome (MS). The burden of MS in patients with OSA in India is unknown. We investigated the prevalence of MS and its components in a cross-sectional study in patients with and without OSA in a hospital-based population of a tertiary health care centre in New Delhi, India.
Consecutive patients undergoing overnight polysomnography in the Sleep Laboratory of the Department of Internal Medicine of All India Institute of Medical Sciences (AIIMS) hospital, New Delhi, were studied. Anthropometry and body composition analysis, blood pressure (BP), fasting blood glucose, insulin resistance by homeostasis model assessment (HOMA-IR) and fasting blood lipid profile were measured. MS was defined using the National Cholesterol Education Program Adult treatment panel III criteria, with Asian cut-off values for abdominal obesity.
Of the 272 subjects recruited, 187 (82%) had OSA [apnoea-hypopnoea index (AHI)>5 events/h] while 40 (18%) had a normal sleep study. Prevalence of MS in OSA patients was 79 per cent compared to 48 per cent in non-OSA individuals [OR 4.15, (2.05-8.56), P<0.001]. Prevalence of OSA in mild, moderate and severe OSA was 66, 72 and 86 per cent, respectively (P<0.001). Patients with OSA were more likely to have higher BP [OR: 1.06 (1.02-1.11)], fasting insulin [OR: 1.18 (1.05-1.32)], HOMA-IR [OR: 1.61 (1.11-2.33)] and waist circumference [OR: 1.20 (1.13-1.27)].
Interpretation & conclusions:
Our findings suggest that OSA is associated with a 4-fold higher occurrence of MS than patients without OSA. The prevalence of MS increases with increasing severity of OSA, therefore, early detection will be beneficial.
Metabolic syndrome; obstructive sleep apnoea; prevalence; risk factors; South Asians; urban Indians
To implement a prospective interventional clinical audit to evaluate the current clinical practice and the effect of standard interventions on the management of type 2 diabetes (T2DM).
254 patients with T2DM where recruited in a specialized diabetes care center in Al-Ain, UAE. The diabetes care components were audited before (baseline) and after (3 and 6 months) implementation of Institute of Clinical System Improvement (ICSI) guidelines. Data was compared against international guidelines to achieve target goals of normoglycemia, blood pressure (BP), and low density lipoprotein-cholesterol (LDL-C). We measured changes in mean scores of patient satisfaction level regarding diabetes care at similar intervals, by validated Patient Satisfaction Questionnaire (PSQ-18).
We observed a significant reduction in fasting blood glucose (FBG; mean± SD; 9.3 ± 0.03 vs 7.4 ± 0.3mmol/l; P=0.03), and HbA1c (8.7 ± 0.02 vs 8.1 ± 0.02 %; P=0.04) levels after 6 months compared with baseline. Patients who achieved target FBG and HbA1c levels improved significantly (45.7 vs 81.1%; P=0.03), and (40.1 vs 73.6%; P=0.04), respectively. The LDL-C levels improved, though this was not statistically significant. Patients achieving target of BP control improved significantly (SBP 142±7.6 and DBP 95±6.2 vs SBP 136±8.2 and DBP 87±5.8 mmHg;P=0.05).
The results of this interventional audit were generally positive and emphasized the feasibility of improving the current clinical practice. Our individualized approach has helped us to achieve a better target in glycemic and BP control as well as patient satisfaction. Further research is needed to understand the long-term impact of our structured approach to improve the quality of T2DM care in the UAE.
Al Ain; Audit; Care; Clinical; Diabetes; UAE.
Background and Aims:
Severe pulmonary involvement in leptospirosis carries high mortality rates. It is the most common cause of death due to leptospirosis in many parts of India and the world. Exacerbated immune response of the host plays an important role in its pathogenesis. Hence, immunosuppressive drugs could be useful in its treatment. Glucocorticosteroids have been found to be useful in several studies. Cyclophosphamide, an immunosuppressive agent, has been found to be useful in a majority of pulmonary alveolar hemorrhages due to non leptospiral causes. This study was carried out to study the effects of cyclophosphamide in patients with leptospiral pulmonary alveolar hemorrhage.
A total of 65 patients with confirmed leptospirosis with severe pulmonary involvement admitted to a tertiary care center in south Gujarat were included in the study. All of the patients were treated with injection crystalline penicillin, methyl prednisolone pulse therapy, and non invasive mechanical ventilation. A total of 33 patients were given parenteral cyclophosphamide 60 mg/kg body weight stat on diagnosis. Their outcomes were compared with the remaining 32 patients who had not been given this drug. Survival was considered the main outcome indicator.
Out of the 33 patients treated with cyclophosphamide, 22 (66.7%) survived, while in the control group out of 32 patients, three (9.4%) survived. On statistical analysis, the odds ratio was 19.33 (4.22–102.13) and the P-value was <0.001. Leucopenia (78.78%) and alopecia (18.75%) were the main side effects noted. No mortality was noted due to these side effects.
Cyclophosphamide improves survival in cases of severe pulmonary alveolar hemorrhage due to leptospirosis. Statistically, the improvement is highly significant.
Cyclophosphamide; leptospirosis; pulmonary alveolar hemorrhage
Retrospective descriptive study reporting the rate of occurrence of cerebral venous sinus thrombosis (CVST), highlighting the role of magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) in patients with presumed idiopathic intracranial hypertension (IIH). Study was conducted in the department of neuro-ophthalmology at a tertiary eye care center in South India. Data from 331 patients diagnosed with IIH from June 2005 to September 2007 was included. Inclusion criteria were: Elevated opening cerebrospinal fluid (CSF) pressure of more than 200 mm of water on lumbar puncture, normal CSF biochemistry and microbiology, and normal neuroimaging as depicted by computed tomography(CT) scan. Exclusion criteria were: Space-occupying lesions, hydrocephalus, meningitis, intracranial pressure within normal range, abnormal CSF biochemistry and microbiology. The remaining patients were evaluated with MRI and MRV. CVST was present in 11.4% of patients who were presumed to have IIH (35/308). MRI alone identified 24 cases (68%) of CVST, while MRI used in combination with MRV revealed an additional 11 cases (32%). Risk factors associated with CVST were identified in nine out of 35 patients (26%). CVST may be misdiagnosed as IIH if prompt neuroimaging by MRI and MRV is not undertaken. Risk factors of CVST may not be apparent in all the cases and these patients are liable to be missed if CT scan alone is used for neuroimaging, hence MRI, combined with MRV should be undertaken to rule out CVST.
Cerebral venous sinus thrombosis; idiopathic intracranial hypertension; magnetic resonance imaging; magnetic resonance venography
To evaluate intraocular pressure (IOP) control, visual prognosis and complications following manual small incision cataract surgery among eyes with phacomorphic glaucoma.
Materials and Methods:
This prospective, non-randomized interventional consecutive case series included all patients with phacomorphic glaucoma who presented to a tertiary eye care referral center in South India between March 2006 and April 2007. All patients underwent slit-lamp bio-microscopy, applanation tonometry and gonioscopy of the other eye to rule out angle closure. Small incision cataract surgery with intraocular lens implantation was performed in all affected eyes. Complete ophthalmic examination was done at each follow-up visit.
A total of 74 eyes with phacomorphic glaucoma were included in this study. The preoperative mean IOP was 38.4±14.3 mmHg and mean IOP at last follow-up was 12.7±2.4 mmHg. There was a statistically significant difference between IOP at presentation and IOP at last follow-up (P< 0.001). None of the eyes required long-term antiglaucoma medication. No significant intraoperative complications were noted. The final postoperative best corrected visual acuity was 20/40 or better in 51 patients. Eighteen eyes had corneal edema and 36 eyes had anterior chamber inflammation. Both conditions resolved with standard medical therapy.
Manual small incision cataract surgery is safe and effective in controlling IOP and achieving good functional visual acuity with minimal complications in the management of phacomorphic glaucoma in developing countries.
Intraocular pressure; manual small incision cataract surgery; phacomorphic glaucoma
To identify the etiology, incidence and prevalence of ocular bacterial infections, and to assess the in vitro susceptibility of these ocular bacterial isolates to commonly used antibiotics.
Materials and Methods:
Retrospective analysis of consecutive samples submitted for microbiological evaluation from patients who were clinically diagnosed with ocular infections and were treated at a tertiary eye care referral center in South India between January 2002 and December 2007.
A total of 4417 ocular samples was submitted for microbiological evaluation, of which 2599 (58.8%) had bacterial growth, 456 (10.3%) had fungal growth, 15 (0.34%) had acanthamoebic growth, 14 (0.32%) had mixed microbial growth and the remaining 1333 (30.2%) had negative growth. The rate of culture-positivity was found to be 88% (P < 0.001) in eyelids’ infection, 70% in conjunctival, 69% in lacrimal apparatus, 67.4% in corneal, 51.6% in intraocular tissues, 42.9% in orbital and 39.2% in scleral infections. The most common bacterial species isolated were Staphylococcus aureus (26.69%) followed by Streptococcus pneumoniae (22.14%). Sta. aureus was more prevalent more in eyelid infections (51.22%; P = 0.001) coagulase-negative staphylococci in endophthalmitis (53.1%; P = 0.001), Str. pneumoniae in lacrimal apparatus and corneal infections (64.19%; P = 0.001), Corynebacterium species in blepharitis and conjunctivitis (71%; P = 0.001), Pseudomonas aeruginosa in keratitis and dacryocystitis (66.5%; P = 0.001), Haemophilus species in dacryocystitis and conjunctivitis (66.7%; P = 0.001), Moraxella lacunata in blepharitis (54.17%; P = 0.001) and Moraxella catarrhalis in dacryocystitis (63.83%; P = 0.001). The largest number of gram-positive isolates was susceptible to moxifloxacin (98.7%) and vancomycin (97.9%), and gram-negative isolates to amikacin (93.5%) and gatifloxacin (92.7%).
Gram-positive cocci were the most frequent bacteria isolated from ocular infections and were sensitive to moxifloxacin and vancomycin, while gram-negative isolates were more sensitive to amikacin and gatifloxacin.
Antibacterial agents; bacterial pathogens; etiology; in vitro susceptibilities; ocular infection
Treatment of gastrointestinal stromal tumors (GISTs) changed significantly with the advent of targeted therapy with imatinib. Clear markers predictive of response to imatinib therapy and disease-free survival in patients with GIST have not been identified. Even RECIST criteria are inadequate for predicting response to therapy, especially in patients with stable disease. Data collected at a tertiary care cancer center from 2003 to 2005 in south India were analyzed retrospectively to assess clinical, pathologic, and cytogenetic profiles of patients with GIST. In addition, radiologic responses to therapy were evaluated for correlation with the disease-free survival.
GIST was defined as a mesenchymal spindle/epitheloid cell lesion arising in the GI tract with CD117 positivity. Only data from patients with locally advanced or metastatic disease were analyzed. Clinical and pathologic details of the patients were noted from case records. NCCN guidelines were followed for the treatment. Radiologic response to therapy was reassessed according to RECIST, and progression-free survival calculated for all analyzed patients using intent-to-treat analysis.
The mean age of presentation was 42.8 ± 5.3 years (24–60), with a male-to-female ratio of 1.5:1. Small intestine was the most common disease site (60%), followed by stomach (20%), mesentery (7.2%), colorectal regions (7.2%), and other sites (5.6%). The most frequent pathologic finding in patients having recurrence was high mitotic rate. Initial tumor size (either in the metastatic setting or in local recurrence) had no bearing on progression-free or overall survival, nor did initial anatomic location or site of metastasis. Histologically, however, patients with a mixed-cell morphology had shorter survival compared to the other morphologies. Those patients having any cytogenetic abnormality had worse outcome compared to those with normal karyotype. Similarly, among patients who achieved remission, those who did so within 12 weeks had better overall survival than did those with a delayed time to remission. Overall survival of patients having stable disease and late partial responses (after 3 months) was similar and superior to survival for patients whose disease progressed while on therapy.
GISTs characterized by a high mitotic rate and mixed-cell morphology and any cytogenetic abnormalities are associated with poorer outcome. Similarly, shorter time to response was more important than the actual response to therapy. Initial disease site, the site of metastasis, and tumor size had no bearing on outcomes to therapy.
To study the clinical profile of pseudoexfoliation (PEX) syndrome in a hospital setting.
Materials and Methods:
A case series of patients with PEX, with and without glaucoma attending the general ophthalmology clinic of a tertiary care center in South India. All patients underwent a complete ophthalmologic evaluation including recording diurnal variation of tension (DVT), gonioscopy and visual field assessment.
The study cohort comprised 529 patients (752 eyes). There were 296 (56%) females. The highest number of patients (261 patients) was from the age group between 60 and 69 years. Of 752 eyes, 57.8% eyes had unilateral PEX and 72% had established PEX. Gonioscopy showed open angles in 98.1% of eyes. Intraocular pressure (IOP) greater than 21 mmHg in at least 1 of 4 measurements was recorded in 5.7% eyes. DVT was normal in 96.4% of unilateral PEX eyes, similar to fellow non-PEX eyes. Pseudoexfoliation glaucoma occurred in 1.9% of eyes and 4.7% of eyes were glaucoma suspects. There was no correlation between the stage of PEX and increased IOP. Mean central corneal thickness of PEX eyes was 522 ± 27μ. Pupillary dilatation in 90.5% eyes with early PEX was ≥ 7 mm.
A small percentage of PEX eyes had raised IOP, and the number of eyes with glaucomatous optic neuropathy was even lower. PEX eyes did not demonstrate wide fluctuations in IOP. No correlation was found between raised IOP and stage of PEX. There was good pupillary dilatation in early stage PEX eyes suggesting that all PEX eyes may not have poor pupillary dilatation and related complications.
Diurnal Variation of Tension; Glaucoma; Pseudoexfoliation; Pupillary Dilatation
As the acquired immunodeficiency syndrome (AIDS) epidemic shows no signs of abating, the impact of AIDS is felt more in the developing countries due to socioeconomic reasons. The possibility of drug-induced ototoxicity also adds to the risk of audio vestibular dysfunction. We sought to determine if there was a difference between the audio-vestibular function in the asymptomatic human immunodeficiency virus (HIV) infected patients and patients with AIDS.
A prospective, cross-sectional study
A tertiary care center in South India
Materials and Methods:
The audio-vestibular system of 30 asymptomatic HIV positive subjects (group 1) and 30 subjects with AIDS (group 2), and age-matched 30 healthy controls (group 3) were assessed using pure tone audiometry and cold caloric test.
Sixteen patients each, in group 1 and group 2 and four subjects in the control group were detected to have a hearing loss indicating significantly more HIV infected individuals (group 1 and 2) were having hearing loss (P=0.001). Kobrak's (modified) test showed 27% of patients in group 1 and 33% of patients in group 2 and none in the group 3 had a hypofunctioning labyrinth (P=0.001).
It seems that the human immunodeficiency virus does affect the audio-vestibular pathway. There was a significant incidence of audio-vestibular dysfunction among the HIV infected patients, as compared to the control population (P=0.001) and no significant difference between the asymptomatic HIV seropositive patients and AIDS patients. Majority of the patients had no otological symptoms.
AIDS; audio-vestibular function; hearing loss; HIV
The eye lens grows throughout life by the addition of new cells inside the surrounding capsule. How this growth affects the properties of the lens is essential for understanding disorders such as cataract and presbyopia.
To examine growth of the human lens in the Indian population and compare this with the growth in Western populations by measuring in vitro dimensions together with wet and dry weights.
Settings and Design:
The study was conducted at the research wing of a tertiary eye care center in South India and the study design was prospective.
Materials and Methods:
Lenses were removed from eye bank eyes and their dimensions measured with a digital caliper. They were then carefully blotted dry and weighed before being placed in 5% buffered formalin. After 1 week fixation, the lenses were dried at 80 °C until constant weight was achieved. The constant weight was noted as the dry weight of the lens.
Statistical Analysis Used:
Lens parameters were analyzed as a function of age using linear and logarithmic regression methods.
Data were obtained for 251 lenses, aged 16–93 years, within a median postmortem time of 22 h. Both wet and dry weights increased linearly at 1.24 and 0.44 mg/year, respectively, throughout adult life. The dimensions also increased continuously throughout this time.
Over the age range examined, lens growth in the Indian population is very similar to that in Western populations.
Growth; human adult; lens diameter; lens dry weight; lens thickness; lens wet weight
Insulin resistance, diabetes mellitus, and metabolic syndrome in patients with human immunodeficiency virus (HIV) infection are increasingly being reported in the global medical literature. This cross-sectional study was done to describe the occurrence of metabolic syndrome, diabetes mellitus, and insulin resistance in HIV-positive patients in a tertiary referral center in South India. A total of 60 patients who had HIV infection for 12 months or more were enrolled in the study. Of these, 30 patients were antiretroviral therapy (ART)-naïve, and 30 were treated with ART. Biochemical estimations (fasting blood glucose, 75 g oral glucose tolerance test, lipid profile, and fasting insulin) and anthropometric measurements (height, weight, and waist circumference) were performed for each patient. Metabolic syndrome was diagnosed using National Cholesterol Education Program–Adult Treatment Plan III criteria, and insulin resistance was calculated applying the homeostasis model assessment method. Diabetes mellitus, impaired fasting glycemia, and impaired glucose tolerance were diagnosed based on American Diabetes Association criteria. A high prevalence of metabolic syndrome was observed in patients with HIV (16/60), and was more prevalent in the ART-treated group (13/30; P = 0.028). Similarly, insulin resistance was also noted to be high (24/60), and of these patients, 15 were on ART. Seventy-five percent of patients with metabolic syndrome had insulin resistance. Diabetes was diagnosed in one patient who was ART-naïve and in six patients who were on ART. Our observations suggest an increased prevalence of metabolic syndrome, insulin resistance, and diabetes mellitus in ART-treated patients. These warrant attention and substantiation with larger studies. While ART improves survival, it may lead on to cardiovascular morbidity and mortality, especially in the Indian subcontinent where there is a genetic predisposition to cardiovascular risk.
human immunodeficiency virus (HIV) infection; metabolic syndrome; insulin resistance; diabetes mellitus
Enterococci tend to be one of the leading causes of nosocomial infections, with E. faecalis and E. faecium accounting up to 90% of the clinical isolates. Nevertheless, the incidence of other species of enterococci from clinical sources shows an alarming increase with the properties of intrinsic resistance to several antibiotics including beta-lactams and glycopeptides. Thus proper identification of enterococci to species level is quintessential for management and prevention of these bacteria in any healthcare facility. Hence this work was undertaken to study the prevalence of unusual species of enterococci causing human infections, in a tertiary care hospital in South India.
The study was conducted in a tertiary care hospital in South India from July 2001 to June 2003. Isolates of enterococci were collected from various clinical specimens and speciated using extensive phenotypic and physiological tests. Antimicrobial susceptibility testing were performed and interpreted as per NCCLS guidelines. Whole cell protein (WCP) fingerprinting of enterococci were done for species validation by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and analyzed computationally.
Our study showed the prevalence of unusual (non-faecalis and non-faecium enterococci) and atypical (biochemical variant) species of enterococci as 19% (46 isolates) and 5% (12 isolates) respectively. The 7 unusual species (46 isolates) isolated and confirmed by phenotypic characterization includes: 15 E. gallinarum (6.2%), 10 E. avium (4.1%), 6 E. raffinosus (2.5%), 6 E. hirae (2.5%), 4 E. mundtii (1.7%), 3 E. casseliflavus-including the two atypical isolates (1.2%) and 2 E. durans (0.8%). The 12 atypical enterococcal species (5%) that showed aberrant sugar reactions in conventional phenotyping were confirmed as E. faecalis, E. faecium and E. casseliflavus respectively by WCP fingerprinting. The antimicrobial susceptibility testing depicted the emergence of high-level aminoglycoside and beta-lactam resistance among different species apart from intrinsic vancomycin resistance by some species, while all the species tested were susceptible for linezolid and teicoplanin.
Our study reveals the emergence of multi-drug resistance among unusual species of enterococci posing a serious therapeutic challenge. Precise identification of enterococci to species level enables us to access the species-specific antimicrobial resistance characteristics, apart from knowing the epidemiological pattern and their clinical significance in human infections.
A blood transfusion is a life-saving procedure in many instances. An adequate supply of safe blood is ensured by exercising donor deferral criteria and screening for Transfusion Transmitted Infections (TTI). The aim of this paper is to study the profile of blood donors and reasons for donor deferral in coastal South India.
The study was conducted at a tertiary care hospital in Mangalore. All those who donated between 1 January 2008 and 31 December 2008 were included in the study. Data was collected using a pre-tested semi-structured proforma and analysed using SPSS version 11.5.
Most of the donors were under the age of 25 (42.92%).
Donors were predominantly male (95.20%). In terms of occupation, most subjects were students (28.01%) followed by businessmen (18.61%). Slightly more than three-quarters of the donors (77.20%) were replacement donors. The main reasons for deferral were consumption of medication in the past 72 hours (15.15%), hypertension (13.18%), a low haemoglobin level (12.34%) and alcohol intake in the past 72 hours (12.20%). Among the TTIs identified, most samples were positive for Hepatitis B surface Antigen – HBsAg (0.87%) or tested positive for Anti-Hepatitis C (HCV antibodies (0.36%).
From the study it was concluded that the majority of the donor population was young and educated. The reason for donation was mainly replacement rather than voluntary. This issue needs to be addressed by exercising proactive measures to increase the number of voluntary, nonremunerated, low-risk donors.
Blood donors; deferral; transfusion transmitted infections; South India
Background and Aims:
Electrical defibrillation is the most important therapy for patients in cardiac arrest. The audit was aimed to assess awareness among residents with respect to routine preuse checking of cardiac defibrillators.
Materials and Methods:
The audit was conducted at a multispeciality tertiary care referral and teaching center by means of a printed questionnaire from anaesthesiology residents. A database was prepared and responses were analyzed.
Eighty resident doctors participated in the audit. Most (97.8%) of the residents were sure of the presence of a defibrillator in the operation room (OR); 70% of postgraduates (PG)s were aware of the location of the defibrillator in the OR as compared to 83.7% of the senior resident (SRs). Also, 32.1% residents routinely check the availability of a defibrillator. The working condition of the defibrillator was checked by 21.7% of the residents; 25.3% ensured delivery of the set charge. Further, 8.2% of residents ensured availability of both adult and paediatric paddles. About 27.8% of residents ensured the availability of appropriate conducting gel and 53.8% residents were of the opinion that the responsibility of checking the functioning and maintenance of the defibrillators lies with themselves. Some 22% thought that both doctors and technical staff should share the responsibility, while 19.5% opined that it should be the responsibility of the technical staff.
All medical equipment is to be tested prior to initial use and periodically thereafter. An extensive, recurring training program, and continued attention to the training of clinical personnel is required to ensure that they are proficient in the operation and testing of specific defibrillator models in their work area. We conclude that apart from awareness of the use of the equipment we are using, its preuse testing is must. All resident doctors should be aware of the presence and adequate functioning of the defibrillator in their ORs and this audit reinforces the need for training of all resident doctors.
Audit; awareness; cardiac arrest; defibrillator; preuse check
Though there are several recommended guidelines for treating schizophrenia, in routine clinical practice, these are not followed.
To conduct an audit of the prescription pattern of antipsychotic drugs in patients with schizophrenia, in a tertiary care centre in India, during a period of 1 year and compare it with Maudsley guidelines and Clinical practice guidelines for Psychiatrists in India (IPS guidelines).
Materials and Methods:
Data were collected from the case records, compiled, and analyzed. The concordance or discordance with Maudsley and IPS guidelines were studied.
The demographic variables of the patients and the prescription pattern of drugs were analyzed. The correlations between supramaximal and sub-threshold dosage of drugs to the gender, age, duration of illness, and combination of drugs were examined.
Polypharmacy of antipsychotics is common. 31% of patients were on combination of typical and atypical antipsychotics. 4% of patients were receiving supramaximal dose of antipsychotics and all of them were on combination (P =<0.03, x2). 24% of patients were on sub-threshold doses. 83% were not on anticholinergic drugs.
Antipsychotics; prescription; schizophrenia