Jawaharlal Institute Of Postgraduate Medical Education And Research Research Articles

Ventilator-associated pneumonia in a tertiary care hospital in India: incidence and risk factors

Knowledge of the incidence of ventilator-associated pneumonia (VAP) and its associated risk factors is imperative for the development and use of more effective preventive measures. We performed a prospective study over a period of 15 months to determine the incidence and the risk factors for development of VAP in critically ill adult patients admitted in different intensive care units (ICUs) of Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), a tertiary care hospital in Pondicherry, India. The incidence of VAP was 30.67 and 15.87 per 1,000 ventilator days in the two different ICUs. In our study 58.3% of the cases were late-onset VAP, while 41.7% were early-onset VAP. Univariate analysis indicated that the following were significantly associated with VAP: impaired consciousness, tracheostomy, re-intubation, emergency intubation, and nasogastric tube. Emergency intubation and intravenous sedatives were found to be the specific risk factors for early onset VAP, while tracheostomy and re-intubation were the independent predictors of late-onset VAP by multivariate logistic regression analysis. Knowledge of these risk factors may be useful in implementing simple and effective preventive measures including non-invasive ventilation, precaution during emergency intubation, minimizing the occurrence of reintubation, avoidance of tracheostomy as far as possible, and minimization of sedation.

Dermatitis cruris pustulosa et atrophicans revisited: our experience with 37 patients in south India

Dermatitis cruris pustulosa et atrophicans (DCPA) is a distinctive type of chronic superficial folliculitis, with a number of unique features such as its peculiar symmetric localization to legs, extreme chronicity, resistance to therapy, and inevitable alopecia and atrophy. All patients with DCPA, attending the Dermatology Outpatient Department at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Hospital, Pondicherry, from December 2006 to June 2008 were included. Parameters recorded were detailed history and examination, hemogram, erythrocyte sedimentation rate, random blood sugar, skin biopsy and cultures from pus and carrier sites (nares, axillae and gluteal fold). 37 patients were studied (35 males and 2 females). Sixteen patients (43.24%) belonged to the 21-30 year-old age group. The disease most commonly began on the legs (81.1%). Majority (78.38%) had a disease duration of less than 5 years. Itching was the most common symptom (89.19%), followed by bleeding and scaling, with no significant systemic symptoms. The lower limbs were involved in all patients. Eleven patients (29.73%) had involvement of other sites--beard, axillae, chest, moustache, abdomen, and eyebrows. Pustules, papules, and scaling were seen in all patients, followed by wiry roughness, atrophy, alopecia, and pigmentation. Aggravating factors included use of full-length synthetic trousers, occupational exposure to potential irritants, and season (summer). Pus culture from the folliculitic lesions grew Staphylococcus aureus in 32 (86.49%) patients. Twenty one patients (56.75%) were carriers of S. aureus in one or more sites. DCPA is a chronic folliculitis of the legs, with a multifactorial etiopathogenesis, in which staphylococcal carrier status may be a new potential pathogenetic factor.

Consumption of fallen umbilical cord stump as a treatment for infertility: A case study from Puducherry

Infertility is a stigma. The high cost and inaccessibility to treatment turn infertile couples to faith-based alternatives or practices that have been passed down from generation to generation. This report describes a case in which a woman consumed the umbilical cord stump to treat infertility. Initially, this incidence was reported in March 2006 by undergraduate students from the Kurusukuppam area of the Urban Health Centre of the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER). This lower-middle class family consisted of RK, his wife G, his mother T and daughters of RK and G. RK was 37 years old, semi-literate and a painter; G was a housewife and educated up to the eighth standard. Six months after their marriage, G became pregnant, but had an abortion in the third month of pregnancy. Thereafter, the couple waited for four years, but G could not conceive. She consulted private allopathic doctors, who prescribed her some medicines without carrying out any investigation/follow-up. Meanwhile, T advised G to consume the umbilical cord stump. In January 2003, G visited Chennai in order to assist her sister-in-law's delivery. Other women present there also advised her to consume the neonate's cord stump as a remedy for her infertility. After a simple ceremony on the eighth day, G consumed a 1-cm-long dried umbilical cord stump embedded in a banana. She conceived the next month. G opined that this sequence of events (pregnancy immediately following the consumption of stump) suggests the curative role of the cord stump. T recalled that 15 years ago, her neighbor had demonstrated the pro-fertility potential of the umbilical cord stump. Both T and her neighbor believed that the stomach (errai pai) is connected to the uterus (garppa pai), and that the cord had entered the uterus via the stomach, thus inducing pregnancy. In July 2006, during the community posting for undergraduates, a similar practice was reported in Pullichappallam, Tamil Nadu. A local remedy for infertility in this area was consuming the fallen cord stump. In a focus group discussion (FGD), P (a 40-year-old lady) commented, “If conception does not occur within five months of marriage, we wait for an opportunity to give a fallen cord stump to the ‘infertile’ woman. This practiceis common in our family and has been successful on all occasions.” She had recommended this to three of her relatives, one of whom was infertile for five years. In all instances, conception occurred within a few months. None of them took allopathic treatment. The FGD revealed the belief that the cord ‘donor’ can become infertile; hence, the infertile women should consume it without making the donor aware of it. Similar practice exists in Kattupalayam and Vannur areas of Tamil Nadu. A newspaper has reported the practice of consuming the products of the third-stage labor for curing infertility in the villages of Thirumangalam taluk of Madurai district, Tamil Nadu.(1) This practice has been documented in the Chenchu tribes of Nallamalai Hills in Andhra Pradesh.(2) They believed that the umbilical cord produces special fertility juice in the infertile woman. Elsewhere, a similar practice has been reported from primitive cultures of Australia, Africa and Hawaii.(3) This case report brings to light the fact that this practice is not restricted to few families. Reportedly, all known cases have resulted in pregnancy. While we may not share this belief, it highlights the common man's concept about the process of reproduction. Hence, the first step in infertility treatment should be creating awareness about human sexual function and clarify myths associated with infertility since they restrict the afflicted couples from seeking appropriate medical treatment. People's faith in modern medicine should actually improve when infertility treatments become more accessible and affordable. However, if a series of cases such as the abovementioned incidents occur, it may then become necessary to epidemiologically study such interventions.

Comparison of scarred and unscarred uterine ruptures

Uterine rupture is a major obstetric hazard and more commonly involves a previous uterine scar [1]. Rupture of an unscarred uterus, either traumatic or spontaneous, is rare in countries where intrapartum care is adequate. We reviewed the case records of women who delivered at the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India, between January 1994 and December 2006, to compare the labor characteristics and complications, maternal and perinatal outcomes, and occurrence of complete uterine rupture in women with a scarred and unscarred uterus. With approximately 10,000–12,000 deliveries annually, our institute is an important referral center covering 200 km of the surrounding area. There were 113,976 deliveries over the study period and of these 201 involved a complete uterine rupture: 102 (50.74%) women had a scarred uterus and 99 (49.26%) had an unscarred uterus. Of the total deliveries over the study period, 9.81% of women had undergone a previous cesarean delivery and the risk of rupture in these women was 1.71%. The risk of rupture in women with an unscarred uterus was 0.16%. These rates are similar to those reported in studies from low income countries [2–4], but are very high compared with studies from high income countries [1]. Although we identified a similar number of cases of uterine rupture in the scarred and unscarred uterus groups, rupture is 10 times more common in women with a previous uterine scar. Only one case in the scarred uterus group was associated with a repaired uterine perforation scar, while the rest were associated with a previous cesarean delivery. No significant demographic differences were noted between the 2 groups. The risk factors for rupture in women with an unscarred uterus were: cephalopelvic disproportion (64 cases); malpresentation (20 cases); multiparity (12 cases); and instrumental delivery (3 cases). Several studies have reported that maternal and neonatal morbidity and mortality were higher in patients with rupture in an unscarred uterus [2–4]. In our study, the comparison was not statistically significant (Table 1). Bladder injury was more common in the scarred uterus group. As complete or partial extrusion of the fetus and/or placenta occurs in both situations, the impact on maternal and newborn morbidity is equally negative. Measures should be taken when possible to prevent and to optimize early recognition of uterine rupture to minimize its profound consequences. ⁎ Corresponding author. QR-NO-Type-V-12, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India. Tel.: +91 413 2271272; fax: +91 413 2272067. E-mail addresses: drksahoo@gmail.com, cdl_drksahoo@sancharnet.in (L. Sahu).

Dot-ELISA for the diagnosis of neurocysticercosis

The aim of the present study was to standardize and evaluate dot-Enzyme linked immunosorbent assay (Dot-ELISA), a simple and rapid test for the detection of cysticercus antibodies in the serum for the diagnosis of neurocysticercosis (NCC). The antigen used in the study was a complete homogenate of Cysticercus cellulosae cysts obtained from infected pigs and dotted on to nitrocellulose membrane. Test sera were collected from the patients of NCC, and control sera from patients with other diseases and healthy students and blood donors of the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Hospital, Pondicherry, during a study period from 2001 to 2003. Dot-ELISA detected antibodies in 14 of 25 (56%) in clinically suspected cases of NCC, 13 of 23 (56.5%) in CT/MRI proven cases of NCC and 2 of 25 (8%) each in non-cysticercal CNS infection controls and healthy controls. The test showed a sensitivity of 56.25%, specificity of 92%, positive predictive value of 87.09%, and negative predictive value of 70.76%. Results of the present study shows that the Dot-ELISA as a simple test can be used in the field or poorly equipped laboratories for diagnosis of NCC .

External beam radiotherapy and intraluminal brachytherapy in advanced inoperable esophageal cancer: JIPMER experience.

From January 1994 to September 1998, all inoperable cases of cancer of the esophagus at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India were given external beam radiotherapy (EBRT) 36 Gy/18 times by anteroposterior pair. After EBRT, those patients who could be intubated with 16 F Levine's tube either directly or after endoscopic dilatation were given intraluminal brachytherapy (ILBT) 36 Gy in 48 hours at 1 cm. Others were treated by EBRT by posterior oblique fields 24 Gy/12 times. Fifty-eight patients who received EBRT and ILBT formed the study group. Fifty percent had middle one third growth and except for three, all were squamous cell carcinoma (95%). Fifty-nine percent required postradiation endoscopic dilatation. The overall survival rate was 24% at the end of 1 year. In one patient, tracheoesophageal fistula developed 4 months after treatment. Mild-to-moderate acute esophagitis developed in 10% of the patients, and 2% had slight hemoptysis, but these were not significant enough to interrupt treatment. There was no treatment-related mortality. Thirty-four patients (59%) were followed up for 6 months to 5 years (mean, 9.6 months). Three patients had follow-up of more than 3 years with no evidence of disease. EBRT with ILBT, with intermittent esophageal dilatations as required, offers very good palliation in advanced inoperable cancer of the esophagus.

Cicatrical gastric stenosis caused by corrosive ingestion.

Sixteen patients with gastric cicatrization due to ingestion of corrosive agents were treated over a 7 year period at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Hospital, Pondicherry. Fifteen patients developed gastric outlet obstruction due to ingestion of corrosives, while another had midgastric stenosis due to formalin intake. An associated oesophageal stricture was present in 62.5% of the cases. Partial gastrectomy was found to be the most satisfactory procedure and carried out in 60% of the cases. Pyloroplasty done in one patient was found inadequate within 1 year of surgery. Gastrojejunostomy carried out in two patients was associated with prolonged hospitalization due to malfunction of the anastomotic site.