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   Table of Contents - Current issue
April-June 2020
Volume 9 | Issue 2
Page Nos. 75-133

Online since Tuesday, August 4, 2020

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Woman and ageing: Extent of the problem and the way ahead Highly accessed article p. 75
B Vengamma
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Epidemiology and outcome of acute kidney injury in patients presenting to emergency department – Our experience p. 77
Venkatesh Satri, V Siva Kumar, V Satyanarayana, B Siva Ramakrishna, P. V L. N Srinivasa Rao, M Madhusudan
Background: Compared to the developed world, the pattern of acute kidney injury (AKI) is different in tropics. The present study was undertaken to study the epidemiological profile and outcomes in AKI. Methods: This prospective observational study was conducted in a tertiary care teaching hospital in South India. Demographic details, detailed medical history, aetiological factors, comorbid conditions, prognostic factors and outcomes were studied. Acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) scores were calculated at admission for every patient to know the prognosis. Results: A total of 193 patients who fulfilled the inclusion criteria were enrolled in the study. Majority of the patients were in their sixth decade of life. The mean age was 52.1 ± 14.8 years (male:female = 1.7:1). Hypertension (41.5%; n = 80) and diabetes mellitus (33.7%; n = 65) were the most common comorbid illnesses in our patients. The average duration of hospital stay was 8 days. AKI was secondary to medical causes in 69.4% (134/193), surgical causes in 25.4% (49/193) and obstetric is 5.18% (10/193). Renal replacement therapy was required in 56.4% (n = 109) of the study population. The mortality rate observed in our study was 21.8% (n = 42). The mean APACHE II score and mean SOFA score were found to be significantly higher in the non survivors compared to the survivors. Conclusions: Patients with AKI who have higher APACHE II or SOFA score should be carefully monitored and aggressively treated to reduce mortality.
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Comparison of the efficacy of epidural nalbuphine versus dexmedetomidine on the characteristics of spinal anaesthesia in patients undergoing lower limb orthopaedic surgeries: A prospective randomised, double-blind, placebo-controlled study p. 82
E Adi Lakshmi, Peyyety Janaki Subhadra
Background: Using adjuvants to local anaesthetic agents either intrathecally or epidurally is a common practice for achieving longer duration of a denser neuraxial block to provide adequate intraoperative conditions, for the length of the procedure. Methods: We compared the efficacy of epidural dexmedetomidine or nalbuphine on the characteristics of spinal anaesthesia in patients undergoing lower limb orthopaedic surgeries. Ninety patients were randomly allocated to three groups (n = 30 each). Group D received dexmedetomidine 1.5 μg/kg diluted to 5 mL; Group N received nalbuphine 0.2 mg/kg diluted to 5 mL and Group S received 5 mL of normal saline epidurally 10 min before receiving subarachnoid block (SAB) with 0.5% heavy bupivacaine. Results: The three groups were comparable demographically and haemodynamically. Significantly shorter time for the onset of sensory and motor block (sec), longer duration of sensory and motor blockade (min), higher sedation scores intraoperatively and postoperatively were observed in GroupD compared to other two groups. VAS scores were lower in Group D for a significantly longer period postoperatively, at 60 min, 120 min and 180 min than in other two groups (P < 0.05). Conclusions: Both dexmedetomidine and nalbuphine were found to be useful and safe epidural adjuvants when given prior to SAB. Dexmedetomidine was found to be a better choice of epidural adjuvant when compared to nalbuphine in terms of earlier onset and longer duration of both sensory and motor block, longer post-operative analgesia and useful intraoperative sedation.
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Comparison of two methods for the measurement of serum chloride p. 89
M Keerthi Thej, Aparna R Bitla
Background: Discrepancies in electrolyte concentration, namely sodium and potassium using the direct and indirect ion selective electrode (ISE) methods have been described. The present study was taken up to compare serum chloride values obtained using the direct and indirect ISE methods. Methods: Serum chloride measurement was done in residual samples received in the clinical laboratory using direct ISE method and indirect ISE method. Imprecision, accuracy and comparability of the methods were studied as per the Clinical and Laboratory Standards Institute EPA guidelines. The American Clinical Laboratory Improvement Amendments (CLIA) guideline of acceptability of target ±5% was considered as the quality goal. Results: Both the methods had acceptable imprecision and inaccuracy of <5%. Good agreement between the two methods was seen as assessed using Bland–Altman plot and Passing–Bablok regression analysis with a correlation coefficient of 0.9838. A significant difference in serum chloride levels measured in patient samples covering the entire analytical range was observed (P < 0.001), with the results of serum chloride by indirect ISE being lower compared to the direct ISE method. The difference between the two methods was below the target ±5% and thus met the CLIA guidelines. Conclusions: The findings of the present study show that serum chloride estimation using direct ISE and indirect ISE methods are comparable.
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Comparison of intravenous tramadol and intravenous ketamine for the prevention of post-anaesthetic shivering p. 94
Tatiparthi Sriranganath, Sri Devi Radhapuram, Mangu Hanumantha Rao, Sunkesula Shameem, Aloka Samantaray, Goduguchintha Dharaniprasad
Background: Following general anaesthesia, post-operative shivering, apart from its physiological and haemodynamic effects, has been described as even worse than surgical pain. Methods: After ethical committee approval and informed consent, ninety patients were subjected to study. They were randomly divided into three groups. Just after intrathecal bupivacaine injection, all patients received prophylactically intravenous drug as normal saline (Group C, n = 30) or ketamine 0.5 mg/kg (Group K, n = 30) or tramadol 2 mg/kg (Group T, no = 30) for shivering. The incidence and degree of shivering and the effectiveness and side effects of ketamine and tramadol in preventing shivering during the post-operative period were recorded. Results: We compared the efficacy of tramadol and ketamine in the prevention of post-anaesthetic shivering in patients undergoing surgery under GA. The incidence of post-anaesthetic shivering was significantly less with tramadol and ketamine as compared to that of the control group (P < 0.01). Tramadol and ketamine were equally effective in controlling the severity of shivering as compared to that of the control group (P = NS). The prevention of shivering was comparable in the tramadol and ketamine groups (P > 0.05). Patients in the ketamine group had statistically significant sedation at 20 and 30 min compared to the tramadol and control groups (P < 0.05). In this study, we can assume that both intravenous tramadol 2 mg/kg and intravenous ketamine 0.5 mg/kg are highly effective and comparable in the prevention of post-anaesthetic shivering and the possible mechanisms is by lowering of shivering threshold.
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A study of microbiome and its antimicrobial susceptibility patterns among central line-associated bloodstream infections p. 101
Yamini Sharabu, Nukanaboina Ramakrishna, Jayaprada Rangineni, Krishna Kanchan Sharma, Srikala Venkata Sanangula
Introduction: Central line-associated bloodstream infections (CLABSIs) are the most frequent cause of health-care-associated infections and significantly increase cost and hospital length of stay. Methods: We retrospectively studied hospitalised patients having a central line access during the period 2016-2018, to study patients with CLABSI at our tertiary care hospital. Results: Average CLABSI rate was 16.7 per 1000 central line days for 3 years. Most of the infections were caused by Staphylococcus aureus (18.9%), followed by non-fermentative Gram-negative bacilli (NFGNB) (16%), Klebsiella spp. (15.1%), Acinetobacter spp. (14.2%) and coagulase-negative Staphylococcus ( CoNS) (13.2%). A higher proportion of CLABSI was observed with femoral lines (59.7%), followed by jugular lines (35.8%) and subclavian lines (9.4%). This study showed multidrug-resistant pathogens as a causative agent of CLABSI. Conclusion: CLABSI is a common entity, especially in intensive care unit settings. S. aureus, NFGNB, Klebsiella spp., Acinetobacter spp. and CoNS were the common pathogens isolated in our study. Strict implementation of CLABSI bundle care plays an important role to minimise the CLABSI rate.
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Detection of inducible clindamycin resistance among staphylococcus isolated from patients attending a tertiary care hospital in South India p. 105
Saranya Mallamgunta, KH Vasudeva Naidu, Nukanaboina Ramakrishna
Background: Resistance to antimicrobial agents led to the usage of macrolide-lincosamide-streptogramin B (MLSB) family to treat staphylococcal infection. Methods: One hundred and ninety one isolates obtained from various clinical samples such as pus, wound, swab, blood urine, and other body fluids were processed, and staphylococci were isolated as per standard bacteriological techniques. The antibiotic sensitivity was tested by Kirby–Bauer disc-diffusion method. Results: Out of 191 isolates, 32% were coagulase-negative staphylococci (CoNS). Of these, 48% and 65% were resistant to erythromycin, respectively. Among erythromycin-resistant S. aureus, 30% each showed constitutive resistance and inducible clindamycin (CL) resistance, and 60% showed MS phenotypes by the D-test. Of the CoNS, 18% showed inducible CL resistance. Among 130 S. aureus isolated, 15% each had constitutive macrolide-lincosamide-streptogramin B resistance (MLSBc), inducible macrolide-lincosamide-streptogramin B resistance (MLSBi) and 25 (19%) were D test-negative, were resistant to macrolides, streptogramins, sensitive to lincosamides. Among 61 CoNS isolated 9 (15%) were MLSBc resistant, 7 (11%) were MLSBi resistant and 24 (39%) were D-test negative (MS phenotype). Resistance MLSBi percentage was more among S. aureus 15% compared to CoNS 11%. Conclusions: The ER-CL disc-approximation test (D-test) emerged as a simple, auxiliary, easy to perform, reliable method and can be used as routine laboratory method for detecting inducible, constitutive and MS phenotypes.
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Acute epiglottitis – A life-threatening clinical entity p. 110
Santosh Kumar Swain, Nibi Shajahan, Priyanka Debta
Acute epiglottitis (AE) is an acute inflammatory life-threatening clinical condition which can lead to obstruction of the airway. AE is a bacterial infection of the supraglottic structures. Breathing difficulties are often thought of as a strong predictor of the intervention to the airway. AE is considered an emergency due to the chance for airway narrowing. Clinical presentations are alone insufficient for the diagnosis of AE. Fibreoptic nasopharyngolaryngoscopic examination should be performed as soon as possible for confirmation of diagnosis. As AE is a life-threatening infection, it warrants immediate diagnosis and treatment. Antibiotics are the mainstay of the initial treatment along with corticosteroids which act as potential adjuncts. This review article describes the aetiopathology, epidemiology, clinical presentations, diagnosis and current treatment of AE.
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Melanotic neuroectodermal tumour of infancy with unexpected peri-operative complications p. 116
Manisha Mohapatra, T. V S. P Murthy, Karnachala Vishnu Murthy
Melanotic neuroectodermal tumour of infancy (MNTI) is a rare rapidly growing, expansile, locally aggressive pigmented neoplasm of neural crest origin and usually encountered in children below 1 year of age in the anterior maxillary region. MNTI is documented as benign neoplasm, but occasional tumours exhibit malignant behaviour with lymph nodal metastasis. Although most of these cases are treated successfully, there is a chance of recurrence in tumours without clear margin which varies from 10% to 50%. In isolated cases, death occurs due to advanced stage of the disease with recurrence and malignant transformation. Here, we report the rare case of MNTI of the left maxilla diagnosed in a 5-month-old boy basing on cytological and histopathological features and subsequently confirmed by immunohistochemical findings. The unexpected perioperative complications encountered in this case in the form of difficulty in airway access, post-surgery pulmonary complications, multi- organ dysfunction, sepsis and other related issues are discussed here which have never been documented in any literature.
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An unusual case of dominant dystrophic epidermolysis bullosa (Cockayne-Touraine disease) associated with juvenile idiopathic arthritis p. 120
V Arun Raja, KM Bhargav, P Sumanth Reddy, T Neeharika, R Suryudu, Suhrith Bhattaram, B Siddhartha Kumar, N Rukmangadha
We report a rare case of co-existence of dominant dystrophic epidermolysis bullosa (EB) and juvenile idiopathic arthritis (JIA) in an 18-year-old male patient, who is born out of consanguineous marriage. He presented with blistering skin lesions all over the body since the 2nd day after his birth, anonychia of all the toes from childhood and symmetric polyarticular inflammatory arthritis for 4 years. Erythrocyte sedimentation rate and C-reactive protein were elevated. Skin biopsy of induced vesicle was done, and histopathology showed epidermis with basket-weave hyperkeratosis, basal pigmented layer and sub-epidermal free bulla, while dermis revealed a few thin-walled proliferating capillaries with sparse lymphocytes surrounding them. Immunofluorescence showed immunoglobulin G along the basement membrane confirming the diagnosis of EB. He was diagnosed to have polyarticular rheumatoid factor-negative JIA. Treatment with oral methylprednisolone, disease-modifying anti-rheumatic drugs and intra-articular triamcinolone injections resulted in symptomatic relief of the joint pains.
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Anti-glomerular basement membrane-antibody disease in a patient treated with adalimumab for rheumatoid arthritis p. 124
V Heron, M Nicholson, S Wilkinson, A Young, S Govindarajulu, A Stewart, Sree Krishna Venuthurupalli
Ttumour necrosis factor-alpha (TNF-α) blockade has been linked to the induction of autoimmunity, including autoimmune renal disorders. To our knowledge, there have been no cases of anti-TNF-α therapy associated with anti-glomerular basement membrane (GBM)-antibody disease reported. A 63-year-old male presented with anuric acute renal failure and was found to have a rapidly progressive glomerulonephritis secondary to anti-GBM-antibody disease. This occurred in the setting of 4 years of adalimumab treatment for rheumatoid arthritis and normal baseline renal function. This was preceded by a gastrointestinal illness and nonsteroidal anti-inflammatory use. His anti-GBM titre was >1000 chemiluminescent units at presentation. A renal biopsy revealed a crescentic necrotising glomerulonephritis with linear staining of immunoglobulin G in the GBM. He was treated with pulse intravenous methylprednisolone and later changed to high-dose prednisolone and cyclophosphamide. Four weeks of plasma exchange was completed. He remains dialysis dependent. There is a known association between TNF-α blockade and occurrence of autoimmune renal diseases. Given the rarity of anti-GBM-antibody disease, it is plausible that there could be an association between treatment with adalimumab and anti-GBM-antibody disease., the present case highlights the ongoing need for monitoring of renal function, urinary sediment and proteinuria in patients exposed to these novel therapies.
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Containment of coronavirus disease-2019 outbreak: Lessons learnt from China p. 128
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
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Study on the association of vitamin D with glycaemic control in patients with type 2 diabetes mellitus p. 130
Mahmood Dhahir Al-Mendalawi
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Association of Vitamin D with glycaemic control p. 131
P Santosh Kumar, Kiranmayi S Vinapamula, MM Suchitra, Alok Sachan
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Journal scan p. 132
V Suresh, AR Bitla
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