Emmanuel Bhaskar

Rhabdomyolysis in community acquired bacterial sepsis--a retrospective cohort study.

Background and Objectives Rhabdomyolysis is often associated with sepsis and gram positive bacterial pathogens are reported to be the most frequent cause of sepsis induced rhabdomyolysis. We report the pattern of infecting bacterial pathogens and associated causal factors in a South-Indian cohort. Design, Setting, Participants & Measurements Retrospective cohort study of adult patients with community acquired bacterial sepsis complicated by rhabdomyolysis from March 2003 - August 2008. Rhabdomyolysis was defined as serum creatine kinase >2000 IU/L. The study population was divided into group-I (sepsis with gram positive pathogens), group–II (sepsis with gram negative pathogens) and group-III (culture negative sepsis). Results 103 patients (group I -15, group II- 34 and group III- 54) formed the study cohort. Mean age was 55 years and two-third had diabetes. Mean creatine kinase was 7114 IU/L and mean serum creatinine on admission was 2.4 mg/dl. Causative pathogen of sepsis was identified in 47.5%. Gram negative pathogens were more frequently (33%) associated with rhabdomyolysis than gram positive pathogens (14.5%). Lung was the commonest foci of sepsis (38.8%). 78.6% of the study population had one or more additional causal factor for rhabdomyolysis like statin intake, chronic alcoholism, hypokalemia, hypernatremia and hypophosphatemia. Mortality was 59%. Conclusions Gram negative bacterial pathogens were more frequently associated with rhabdomyolysis than gram positive pathogens. Rhabdomyolysis in patients with sepsis is multifactorial and is associated with high mortality.

Vaccination rates for pandemic influenza among pregnant women: An early observation from Chennai, South India

Context: World Health organization considers pregnancy as an important risk factor for severe illness due to pandemic influenza and recommends better vaccination coverage for them. Aims: This study was initiated to observe the vaccination rates among pregnant women in Chennai during 2 months following the availability of influenza vaccine in the region. Settings and Design: An urban community-based setting. Questionnaire-based observational study design. Materials and Methods: Pregnant women residing in Chennai selected by simple random sampling formed the study population. The study was conducted from 15th to 30th November 2010. Each pregnant woman was interviewed using a uniform questionnaire. Statistical Analysis Used: Characteristics between vaccinated and unvaccinated participants were compared using the Chi-square test or the Fisher exact test for categorical variables and Students t-test or Mann-Whitney U test for continuous variables. Results: 140 pregnant women were interviewed during the study period. The mean age of study participants was 25 years (range 21-35 years). 55% were less than 26 years of age and 65% were home makers. 32% had no basic school education. Of the 29 women with co-morbidities, 15 had gestational diabetes, 13 hypertension, 7 pre-eclampsia, and 7 had bronchial asthma. Fifty-eight had anemia diagnosed earlier or during current pregnancy. 32 (22.8%) were given advice to get vaccinated for pandemic influenza of which 18 (12.8%) received the vaccine. Conclusions: Observations on vaccination rates for pandemic influenza among pregnant women in Chennai, 2 months after the initiation of vaccination program is not encouraging.

Hypertensive retinal changes, a screening tool to predict microalbuminuria in hypertensive patients: a cross-sectional study

BACKGROUND Studies have shown that hypertensive retinal changes (HRC) have a moderate accuracy in predicting microalbuminuria (MA) in elderly hypertensive patients (age >65 years). This study is an effort to identify a similar relationship in hypertensive patients aged <65 years. METHODS Eight hundred and seventy consecutive hypertensive patients (males, 460; females, 410) aged 18-65 years were assessed for their demographic characteristics and other laboratory variables. Patients with diabetes mellitus, metabolic syndrome and overt nephropathy were excluded. Optic fundi were assessed for HRC after pupillary dilatation, which were photographed. MA (albumin-creatinine ratio) was measured as an average of two non-consecutive overnight spot urine samples. RESULTS Mean age was 45 +/- 13.4 years. Prevalence of MA and HRC was 36.7 and 38%, respectively. MA showed a strong association with HRC (P < 0.0001). Logistic regression identified the association between MA, duration of hypertension (HTN) (P = 0.016), smoking (P = 0.012) and elevated high-sensitivity C-reactive protein (HsCRP) (P = 0.032). HRC were associated with duration of HTN (P = 0.021) and smoking (P < 0.0001). Tests of accuracy for HRC as a predictor of MA showed sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio of a positive test and likelihood ratio of a negative test of 78%, 86%, 76%, 87%, 5.2 and 0.26, respectively. Area under the receiver operating characteristic curve was 81%. Similarly, the individual grades of HRC had a moderate predictive accuracy. Higher grades had higher predictive accuracy. Inter- and intra-observer correlation in interpreting HRC was acceptable. CONCLUSIONS HRC of any grade have moderate accuracy in predicting MA and hence can be used as a cost-effective screening tool to predict MA especially in a resource-poor setting.

Evaluation of a protocol for hypertonic saline administration in acute euvolemic symptomatic hyponatremia: A prospective observational trial

Context: Acute symptomatic hyponatremia is a frequent yet poorly studied clinical problem. Aims: To develop a non-weight based protocol for the treatment of acute symptomatic hyponatremia. Settings and Design: Observational study in a Multi-disciplinary Intensive Care Unit of an urban tertiary care hospital. Materials and Methods: Patients aged >18 years, admitted with euvolemic acute symptomatic severe hyponatremia (defined as serum sodium <120 meq/l with symptoms <24 hours), formed the study population. On confirmation of euvolemic status clinically and by laboratory investigations, patients were administered 100 ml of 3% NaCl over a period of 4 hours irrespective of the weight of the patient, followed by reassessment of serum Na at the end of 4 hours. The volume of hypertonic saline (in ml) required to increase serum Na by 8 meq/l was calculated using the formula: 100 × 8/increment in serum Na observed with 100 ml hypertonic saline. This volume was infused over the next 20 hours. To monitor renal water diuresis which may contribute to overcorrection, the urine specific gravity was monitored every 4 hours for sudden decrease of ≥ 0.010 from the baseline value. Measurement of serum Na was repeated if a fall in the urine specific gravity was observed and subsequently repeated every 4 hours. If no fall occurs in urine specific gravity, serum Na measurement was repeated at 12, 20 and at 24 hours (0 hour being the initiation of 100 ml hypertonic saline). The volume of infusate was adjusted if an excessive increment of serum Na (greater than 3 meq at 8 hours, 4 meq at 12 hours, 5 meq at 16 hours and 6 meq at 20 hours) was observed. Baseline characteristics were compared using chi-square test and Mann–Whitney U test. Results: 58 patients formed the study cohort. The mean age was 58 years. The mean serum Na on admission was 114 meq/l. Administration of 100 ml hypertonic saline resulted in a mean increase in serum Na of 2 meq/l. The mean increase in serum Na over 24 hours was 9 meq/l and mean volume of hypertonic saline required for a serum Na increment of 8 meq/l was 600 ml. Conclusions: The non-weight based protocol with monitoring for water diuresis is reasonably an effective strategy in the treatment of acute euvolemic symptomatic hyponatremia.

A male patient with right-sided thoracic kidney, diabetes mellitus, hearing loss and renal dysfunction

A 48-year-old man with diabetes mellitus and hypertension was found to have a thoracic right-sided ectopic kidney with a sensorineuronal hearing loss and tubular abnormalities such as hyponatremia, hypokalemia, metabolic alkalosis with microalbuminuria. He was treated with ACEI and sodium and potassium supplements. However, this only partially corrected his metabolic abnormalities.

Prevalence, patterns, and factors associated with bleeding tendencies in dengue

INTRODUCTION The pattern of bleeding tendencies in dengue and its corellation with platelet count and other factors requires clarification. METHODOLOGY A retrospective study on bleeding tendencies in adults with dengue and platelet counts of less than 100,000 per mm(3) was conducted. Factors associated with bleeding were analyzed. The study cohort were grouped as dengue with severe thrombocytopenia when platelet count was < 50,000/mm(3) and as dengue with moderate thrombocytopenia if platelet count was 50,000-100,000/mm(3) RESULTS: A total of 638 patients formed the study cohort. A 24.1% prevalence of bleeding tendencies was observed. Prior anti-platelet drug intake, platelet count of < 70,000/mm(3), international normalized ratio > 2.0, and partial thromboplastin time > 60 seconds were associated with bleeding. Esophagogastroduodenoscopy was found to identify structural gastroduodenal lesions when dengue was complicated by hematemesis or melena. CONCLUSIONS The results of this study suggest that bleeding complications in dengue can occur at platelet counts of up to 70,000/mm(3), and that prior anti-platelet drug intake increases bleeding risk. Evaluation of hematemesis or melena in dengue with esophagogastroduodenoscopy is beneficial.

Risk factors for hospital-acquired hypernatremia among critically ill medical patients in a setting utilizing a preventive free water protocol: Do we need to do more?

Context: Hospital-acquired hypernatremia (HAH) is a frequent concern in critical care, which carries high mortality. Aims: To study the risk factors for HAH in settings that practice a preventive protocol. Settings and Design: Two tertiary-care hospitals. Prospective observational study design. Materials and Methods: Patients aged >18 years admitted for an acute medical illness with normal serum sodium and need for intensive care >48 h formed the study population. Details of the basic panel of investigations on admission, daily electrolytes and renal function test, sodium content of all intake, free water intake (oral, enteral and intravenous) and fluid balance every 24 h were recorded. Individuals with serum Na 140-142 meq/l received 500 ml of free water every 24 h, and those with 143-145 meq/l received 1000 ml free water every 24 h. Statistical Analysis Used: Risk factors associated with HAH was analysed by multiple logistic regression. Results: Among 670 study participants, 64 (9.5%) developed HAH. The median duration of hypernatremia was 3 days. A total 60 of 64 participants with HAH had features of renal concentrating defect during hypernatremia. Age >60 years (P = 0.02), acute kidney injury (AKI) on admission (P = 0.01), mechanical ventilation (P = 0.01), need for ionotropes (P = 0.03), worsening Sequential Organ Failure Assessment (SOFA) score after admission (P < 0.001), enteral tube feeds (P = 0.002), negative fluid balance (P = 0.02) and mannitol use (P < 0.001) were the risk factors for HAH. Mortality rate was 34.3% among hypernatremic patients. Conclusions: The study suggests that administration of free water to prevent HAH should be more meticulously complied with in patients who are elderly, present with AKI, suffer multi-organ dysfunction, require mechanical ventilation, receive enteral feeds and drugs like mannitol or ionotropes.

Pleural effusion masquerading as pseudotumor

Pleural effusion in the inter‐lobar fissure mimicking a tumor, which resolves with diuretic therapy is a well‐known sequel of heart failure. [1,2] Tumor like appearance of pleural fluid in heart failure is due to transient fluid loculation in the interlobar fissures (oblique or horizontal fissure).[2] The inter‐lobar pleural fluid and the tumor like appearance it produces disappear with therapy for heart failure. Pseudotumor due to pleural effusion often occur along lobar fissures and characteristically have tapering ends.[2] Though the opacity in this case was along the line of horizontal fissure, lack of tapering ends made the suspicion inconclusive in chest X‐ray. Pulmonary inflammatory tumors, frequently referred as pseudotumor are benign pulmonary parenchymal mass lesions, which occur as a result of an inflammatory reaction probably due to respiratory infection.[3] Unlike the vanishing tumor of heart failure which resolves spontaneously, pulmonary inflammatory tumors need surgical excision.[3] The lack of isolation of Mycobacterium tuberculosis is a strong limitation for the causal association in our case. However, the exclusion of heart failure, malignancy, rheumatoid arthritis and systemic lupus erythematosis coupled with a markedly elevated adenosine deaminase and favorable response to anti‐tuberculosis drugs makes the etiology likely to be tuberculous. The fact that isolation of tubercle bacilli is possible only in less Sir,

Categorization of dengue fever according to phase of illness—a suggestion for clinical studies using single diagnostic sample

In 2008, World Health Organization (WHO) experts agreed that “dengue is one disease entity with different clinical presentations and often with unpredictable clinical evolution and outcome”.1 The development of a spectrum of laboratory methods to detect the first of seven non-structural proteins in dengue virus, NS1 (non-structural protein-1) leads us toward an opportunity to observe the features of dengue during viremic phase which corresponds to the first 3 days of illness.1 Prior to the availability of NS1 antigen assays for detection of dengue, the illness was confirmed only after the detection of IgM and (or) IgG antibodies. This also helps us infer that studies on dengue fever using positive serology as part of dengue case definition would have identified only features of dengue in the immune phase of the illness. Though inference based on paired sera is the ideal way to confirm dengue, our limited experience in dengue indicates that the concept of utilizing paired sera in dengue diagnosis is difficult to practice since obtaining a sample beyond the 10th day of

Musculoskeletal manifestations of dengue fever: is there a changing pattern?

D engue fever (DF) is a viral illness caused by 4 serotypes (DEN-1, DEN-2, DEN-3, and DEN-4). The mosquito Aedes aegypti functions as the vector transmitting the virus to humans. Infections commonly occur during monsoon season and after spells of rain in the remaining part of the year. The first epidemic compatible with DF occurred in Philadelphia in the year 1790. The illness has now spread to more than 100 countries. Dengue fever involves muscles, tendons, joints, and bones. Intense arthralgia is considered to be a prominent symptom of DF giving its name ‘‘break bone fever.’’ Studies have mentioned musculoskeletal symptoms as part of other clinical features of dengue, which is often dominated by bleeding manifestations and hypotension. To the best of our ability, we were unable to find a study that systematically observed the involvement of the musculoskeletal system in DF. This study was initiated to identify the pattern of musculoskeletal manifestations in serology-proven DF among adults.