Tertiary Care Referral Hospital Research Articles

Letter to the Editor Regarding “Management of Neurosurgical Cases in a Tertiary Care Referral Hospital During the COVID-19 Pandemic: Lessons from a Middle-Income Country”

Letter to the Editor Regarding “Management of Neurosurgical Cases in a Tertiary Care Referral Hospital During the COVID-19 Pandemic: Lessons from a Middle-Income Country”

An Observational Study on Association of Clinical Outcome of Diphtheria Cases with Immunization Status: A Tertiary Care Hospital, Jaipur.

Diphtheria is an important vaccine preventable disease with varied outcome from mild to death. It was observed that the outcome also gets affected with status of immunization. The outcome is relatively milder in immunized children. To find out the clinical presentation and outcome of diphtheria cases and its association with the immunization status. A descriptive analysis of 64diphtheria cases admitted from January 2019 to May 2020 at SMS hospital, a tertiary care referral hospital in Jaipur. Half of (51.56%, 33/60) patients were in the age group of 6-10years. The peak load (48.44%) of diphtheria cases was seen in the monsoon season. Around 60% of the patients were fully immunized and around 10% partially immunized, every third case was un-immunized. The most common complication was neurological in 13 cases (20.31%), followed by cardiac complications in 11cases (17.19%), and respiratory (7.81%). The proportion of complication was much lower (26.3%) in immunized cases as compare to partially immunized and un immunized. The proportion of myocarditis was significantly higher in un immunized cases (40%) than partially immunized (16.7%) and filly immunized group (5.3%). Similarly, Bronchopneumonia was also significantly higher (20%) in unimmunized. Our study depicted that there has been a shift of age above 5years for diphtheria which suggests the need for the booster dose. Also high chances of complications are seen in unimmunized and partially immunized calling for public awareness regarding complete immunization.

Etiopathology and Prevalence of Pulsatile Tinnitus in a Tertiary Care Referral Hospital.

The diverse etiopathogenesis of pulsatile tinnitus (PT) makes it a difficult condition to diagnose and treat. To describe the clinical features, investigations and diagnosis of patients presenting with pulsatile tinnitus (PT). Retrospective chart review in an otology unit of a tertiary care referral centre. All medical records of patients who had a complaint of pulsatile tinnitus during the period 1st January 2014-1st May 2020 were included in the study. Data regarding history, characteristics of tinnitus, examination findings, investigations and diagnosis were collected and analyzed. Sixty-four patients with complaints of PT presented to our clinic during this time period and were included in the study giving a prevalence of 0.09%. Definite diagnosis was made in 62 (96.8%) cases with a detailed history, clinical examination and tailored investigations. Pathologies diagnosed were paraganglioma (25%), superior semicircular canal dehiscence (20.3%), anterior inferior cerebellar artery loop (7.8%), sigmoid sinus wall dehiscence (10.9%), sigmoid sinus diverticulum (6.25%), jugular bulb anomalies (7.8%) and hyperpneumatised petrous apex (3.1%) among others. Rare causes encountered were IgG4 disease, far advanced otosclerosis, vestibular aqueduct dehiscence and idiopathic intracranial hypertension. Pulsatile tinnitus is a rare complaint in the Otology clinic. Almost all cases of PT can be diagnosed correctly and appropriate treatment initiated with a logical approach to investigations.

What is the minimum effective anesthetic volume (MEAV90) of 0.2% ropivacaine required for ultrasound-guided popliteal-sciatic nerve block?

Background and Aims:Popliteal-Sciatic nerve block under Ultrasound Guidance (USG) using a local anesthetic agent like Ropivacaine is an established technique for providing analgesia and muscle relaxation for lower limb surgeries with minimal untoward events. Establishing the minimal volume of 0.2% ropivacaine required to provide intraoperative and postoperative analgesia will further reduce the drug requirements and adverse effects toward the patient.Material and Methods:This randomized prospective observational blinded study was done in a tertiary care referral hospital in South India over 9 months from August 2017 till April 2018. The block was performed on all recruited patients under ultrasound guidance with a starting volume of 16 ml 0.2% ropivacaine. Duration of time for loss of pin-prick sensation around the sole of the foot (tibial nerve) and the lateral malleolus (common peroneal nerve) was noted. If successful, the volume of the drug for subsequent patients was randomized by lottery method to either be kept the same or reduced. If the block failed, the subsequent patient recruited would have an increased volume of drug injected.Results:By Probit regression analysis using the biased coin up-and-down method we found that 9.3 ml (MEAV90) of 0.2% ropivacaine was sufficient for providing adequate analgesia. Factors such as patient age or weight had no role in efficacy of the block. There were no adverse effects such as allergy to the drug or systemic toxicity noted in the studied patients.Conclusion:9.3 ml of 0.2% ropivacaine is sufficient to provide analgesia (assessed by pin-prick) in 90% of patients undergoing popliteal-sciatic block for lower limb surgeries.

Genetic Diagnosis in Children with Epilepsy and Developmental Disorders by Targeted Gene Panel Analysis in a Developing Country.

Background and PurposeIn childhood epilepsy, genetic etiology is increasingly recognized in recent years with the advent of next generation sequencing. This has broadened the scope of precision medicine in intractable epilepsy, particularly epileptic encephalopathy (EE). Developmental disorder (DD) is an integral part of childhood uncontrolled epilepsy. This study was performed to investigate the genetic etiology of childhood epilepsy and DD.MethodsIn this study, 40 children with epilepsy and DD with positive genetic mutation were included retrospectively. It was done in a tertiary care referral hospital of Bangladesh from January 2019 to December 2020. Genetic study was done by next generation sequencing. In all cases electroencephalography, neuroimaging was done and reviewed.ResultsIn total, 40 children were enrolled and the average age was 41.4±35.850 months with a male predominance (67.5%). Generalized seizure was the predominant type of seizure. Regarding the association, intellectual disability and attention deficit hyperactivity disorder was common. Seventeen cases had genetically identified early infantile EE and common mutations observed were SCN1A (3), SCN8A (2), SLC1A2 (2), KCNT1 (2), and etc. Five patients of progressive myoclonic epilepsy were diagnosed and the mutations identified were in KCTD7, MFSD8, and CLN6 genes. Three cases had mitochondrial gene mutation (MT-ND5, MT-CYB). Some rare syndromes like Gibbs syndrome, Kohlschütter-Tönz syndrome, Cockayne syndrome, Pitt-Hopkins syndrome and cerebral creatine deficiency were diagnosed.ConclusionsThis is the first study from Bangladesh on genetics of epilepsy and DD. This will help to improve the understanding of genetics epilepsy of this region as well as contribute in administering precision medicine in these patients.

Immunophenotypic and Cytogenetic Characteristics of B Cell Acute Lymphoblastic Leukaemia (ALL). the Tawam Hospital (tertiary referral centre UAE) Experience

Acute Lymphoblastic Leukaemia (ALL) is an aggressive malignant lympho-proliferative neoplasm. Although excellent results are seen in paediatric population the same does not hold true in the adult population. In this retrospective study we looked at the patient characteristics of B cell ALL at Tawam hospital which is a tertiary care referral hospital for cancer therapy in the United Arab EmiratesMethods: Tawam hospital tumour registry was used to identify patients diagnosed with ALL aged 15 years and above between January 2010 till June 2017. Medical records were reviewed to collect data about age, sex, presenting hemogram, immuno-phenotyping, karyotype and outcome.Results: Seventy patients were identified with diagnosis of ALL in the defined period. Sixteen (23 %) patients had diagnosis of T cell ALL. Fifty four (77%) patients had B cell ALL. The median age was 26 years (range 15-71 years). Male to female ratio was 2.85:1. T cell ALL patients were excluded from further analysis.Immuno-phenotypically 29 patients (54 %) were CD 20 positive ALL (> 20 % CD 20 expression) while the other 25 (46%) were CD 20 negative ALL. The median white blood count (WBC) at presentation was 7000 (range 1 to 495 thousand) per millilitre for CD 20 positive ALL while the median WBC was 12000 (range 1-240 thousand) per millilitre for CD 20 negative cohort.Cytogenetic and/or molecular diagnostics showed the presence of Philadelphia chromosome or BCR-ABL positivity in nine patients with CD 20 positive ALL (31 %) while only 4 patients (13%) with CD 20 negative ALL were positive for BCR-ABL. (Table 1)Five patients refused therapy and were lost to follow up after diagnosis. Five patients died of therapy related complications in complete remission (CR) while one patient developed secondary malignancy (Acute myeloid leukaemia and expired). Fifteen patients are in CR1 and in continuous follow up while another twelve patients have been lost to follow up while in CR1. Sixteen patients had either primary refractory or relapsed disease. Ten (62 %) of those had CD 20 positivity while the rest six (38%) were CD 20 negative.Conclusion: In our experience more than half (54 %) of B cell ALL had a CD 20 positive immuno phenotype. Patients with CD 20 positive ALL had a lower median WBC at presentation as compared to the CD 20 negative cohort. Of greater interest is the higher rate of Philadelphia chromosome positivity in CD 20 positive observed in CD 20 positive cohort as compared to CD 20 negative cohort (31% versus 13 %). Patients with CD 20 appear to have a higher rate of relapsed refractory disease (62% versus 38%).CD 20 expression in ALL has been reported as ranging from 30 to 60 %. Similarly there has been controversy of CD 20 positive disease being associated with poor patient outcome. The majority of the previous reports either exclude Philadelphia chromosome positive disease or report no significant difference.Even though CD 20 antibodies have been used previously with variable results, the large disparity in the treatment protocols for ALL for adults makes it difficult to choose a standard approach. Similarly the role of humanized CD 20 anti-bodies like Obinutuzumab and ofatumumab remains undefined.Although our cohort has a big disparity in Philadelphia chromosome positivity between the two sub groups the small sample size makes it difficult to make a definite conclusion and these results should be validated in a larger cohort. [Display omitted] DisclosuresAlam:BMS: Honoraria; Biologix: Honoraria.

In Reply to the Letter to the Editor Regarding “Management of Neurosurgical Cases in a Tertiary Care Referral Hospital During the COVID-19 Pandemic: Lessons from a Middle-Income Country”

In Reply to the Letter to the Editor Regarding “Management of Neurosurgical Cases in a Tertiary Care Referral Hospital During the COVID-19 Pandemic: Lessons from a Middle-Income Country”

Characteristics, natural evolution and surgical treatment outcomes of unilateral laryngeal paralysis versus ankylosis: A longitudinal cohort study.

Although unilateral laryngeal immobility (ULI) can results from paralysis or ankylosis of the cricoarytenoid joint, no comparative study exists to date. Aim of this study was to compare clinical features, aetiologies, spontaneous recovery and evolution after surgical treatment of ULI according to its mechanism. Longitudinal observational cohort study between 1992 and 2017 in a tertiary care referral centre and university teaching hospital. All adult patients with isolated ULI were included. Presenting symptoms and demographic data were recorded at baseline. During follow-up, natural recovery and, if a surgical treatment was performed, treatment failure rate were noted. 994 patients were included, 56.4% of male and with a mean age of 58 years. Overall, 91% had paralysis and 9% had ankylosis. Dysphonia was the main symptom in both groups (>96%). Dyspnoea was more frequent in patients with ankylosis (26.1% vs 4.2% in those with paralysis) whereas dysphagia was more frequent in those with paralysis (31.1% vs 20% in those with ankylosis). With a mean follow-up of 2.3 years (±5.1), spontaneous recovery did not differ according to ULI's aetiology (hazard ratio 1.43, 95% confidence interval 0.85-2.40). Overall, 37.1% underwent a surgical treatment, and paralysis was associated with a lower odd of treatment failure (hazard ratio 0.27, 95% confidence interval 0.10-0.70) over a mean follow-up of 3.1years (±4.1). ULI resulting from paralysis or ankylosis differ in their symptoms and responses to surgical treatment, whereas natural evolution was similar.

Splenic uptake on FDG PET/CT correlates with Kikuchi-Fujimoto disease severity

Kikuchi-Fujimoto disease (KFD) is usually self-limiting, but prolonged systemic symptoms often result in frequent hospital visits, long admission durations, or missed workdays. We investigated the role of fluorine-18 fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in assessing KFD severity. We reviewed the records of 31 adult patients with pathologically confirmed KFD who underwent 18F-FDG PET/CT between November 2007 and April 2018 at a tertiary-care referral hospital. Disease severity was assessed using criteria based on clinical manifestations of advanced KFD. Systemic activated lymph nodes and severity of splenic activation were determined using semi-quantitative and volumetric PET/CT parameters. The median of the mean splenic standardized uptake value (SUVmean) was higher in patients with severe KFD than those with mild KFD (2.38 ± 1.18 vs. 1.79 ± 0.99, p = 0.058). Patients with severe KFD had more systemically activated volume and glycolytic activity than those with mild KFD (total lesion glycolysis: 473.5 ± 504.4 vs. 201.6 ± 363.5, p = 0.024). Multivariate logistic regression showed that myalgia (odds ratio [OR] 0.035; 95% confidence interval [CI] 0.001–0.792; p = 0.035), total lymph node SUVmax (cutoff 9.27; OR 24.734; 95% CI 1.323–462.407; p = 0.032), and spleen SUVmean (cutoff 1.79; OR 37.770; 95% CI 1.769–806.583; p = 0.020) were significantly associated with severe KFD. 18F-FDG PET/CT could be useful in assessing KFD severity.

Transcatheter closure of ventricular septal defects in children less than 10 kg: experience from a tertiary care referral hospital in Eastern India

To assess the feasibility of percutaneous transcatheter device closure of ventricular septal defects in children weighing less than 10 kg. Although percutaneous transcatheter device closure of ventricular septal defect is a well-established method of treatment in older children and adolescents, there is limited data on device closure in small children weighing less than 10 kg. We present our institutional experience of transcatheter VSD closure in children weighing less than 10 kg. Medical records were reviewed for 16 children, who were selected for device closure of ventricular septal defects based on the inclusion criteria. Out of 65 patients with a diagnosis of ventricular septal defect, 16 children less than 10 kg were attempted for percutaneous device closure. In 13 patients, the device was successfully released, and 3 patients needed surgical closure of the defect. Mean age and weight of the patients were 17.3 ± 12.7 months and 6.8 ± 3.2 kg, respectively. Mean defect size was 6 mm (range 3-10). There was no incidence of device embolisation or heart block or death. Five patients had residual left-to-right shunt immediately after the device release, which got closed by the first month's follow-up. We had one accidental perforation of right ventricular free wall at the time of crossing of the defect, which was successfully repaired surgically. Percutaneous device closure of ventricular septal defect in small children with weight below 10 kg is feasible with good short-term outcome. Careful patient selection is essential for procedural success and to avoid complications.

Effect of plasma glucose at admission on COVID-19 mortality: experience from a tertiary hospital.

ObjectivePlasma glucose has been correlated with in-hospital mortality among many diseases including infections. We aimed to study the plasma glucose at the admission of hospitalized patients with COVID-19 at a tertiary care referral hospital at Jodhpur, India and its relation with mortality.Design A hospital-based clinical study of plasma glucose of COVID-19 patients conducted from May 15 to June 30, 2020 after ethical approval.Measurements Random blood samples at admission were collected for plasma glucose, interleukin-6 (IL6) and high sensitivity C-reactive protein (hsCRP) after written informed consent was obtained. Plasma glucose was analyzed by the automated analyzer, IL6 by chemiluminescent immunoassay and hsCRP by immune-turbidimetric assay.ResultsA total of 386 patients were studied (female 39.6%); 11.1% had severe disease and 4.1% expired. There were 67 (17.4%) patients with known diabetes mellitus (DM). Patients with a history of DM had three times higher mortality (6/67, 9%) than those without DM (10/309, 3.1%). Patients with moderate and severe disease according to ICMR and WHO grading had higher plasma glucose than those with asymptomatic or mild disease (P < 0.0001). Plasma glucose levels at admission were significantly higher in non-survivors when compared to those who survived (297 ± 117 vs 131 ± 73; P < 0.0001). COVID-19 patients showed increased mortality with incremental plasma glucose levels. The hazard ratio for mortality was 1.128 (95% CI 0.86–14.860), 1.883 (95% CI 0.209–16.970), and 4.005 (95% CI 0.503–32.677) in random plasma glucose group of >100–200, >200–300 and >300 mg/dL, respectively, compared to those with random plasma glucose of <100 mg/dL at admission. Plasma glucose was strongly correlated with hsCRP (P < 0.001) and IL6 (P < 0.0001).Conclusions Plasma glucose at admission in hospitalized COVID-19 patients is a strong predictor of mortality.

Treatment Outcome of Children with Retinoblastoma in a Tertiary Care Referral Hospital in Indonesia.

Background:Although survival rates for retinoblastoma (RB) are over 95% in high-income countries, its high mortality rate in low and middle-income countries remains a great concern. Few studies investigated treatment outcome and factors contributing to RB survival in these latter settings. Aims of this study are to determine treatment outcome of Indonesian children diagnosed with RB and to explore factors predictive of treatment outcome. Methods:This study was a retrospective medical records review combined with an illustrative case report. Children newly diagnosed with RB between January 2011 and December 2016 at a tertiary care referral hospital in Indonesia were included. A home visit was conducted to perform an in-depth interview with a mother of two children affected by RB. Results:Of all 61 children with RB, 39% abandoned treatment, 21% died, 20% had progressive or relapsed disease and 20% event-free survival. Progressive or relapsed disease was more common in older (≥ 2 years at diagnosis, 29%) than young (<2 years at diagnosis, 0%) children (P=0.012). Event-free survival estimate at 5 years was higher in young (42%) than older (6%) children (P=0.045). Odds-ratio for event-free survival was 6.9 (95% CI: 1.747 – 27.328, P=0.006) for young versus older children. Other clinical and socio-demographic characteristics had no significant correlation with treatment outcome or event-free survival. The case report elucidated conditions and obstacles that Indonesian families face when their children are diagnosed with RB. Conclusion:Survival of children with RB in Indonesia is much lower compared to high-income and many other low and middle-income countries. Abandonment of treatment is the most common cause of treatment failure. Older age at diagnosis is associated with more progressive or relapsed disease and worse survival. Interventions to improve general public and health-care providers’ awareness, early detection and treatment adherence are required.

Assessment of airway reversibility in asthmatic children using forced oscillation technique - A single-center experience from North India.

Background:Lung function testing is recommended for the management of asthma. Due to certain limitations of conventional spirometry in vulnerable patients, forced oscillation technique (FOT) has been studied with promising results. As there is a paucity of data from developing world, we planned to conduct this study in children using FOT. To assess airway reversibility after inhaled salbutamol in asymptomatic children with suspected asthma.Settings:This study was conducted at pediatric asthma clinic of a tertiary care referral hospital in North India.Design:This was a prospective interventional study over 1-year period.Subjects and Methods:Asymptomatic children between 2 and 18 years of age, with history suggestive of asthma, were eligible for participation. Baseline and postbronchodilator pulmonary functions were assessed using FOT. Airway resistance and reactance were monitored at various frequencies. SPSS version 17 was used for statistical analysis.Results:Among the 345 enrolled children, baseline mean ± standard deviation total airway resistance (R5), central airway resistance (R19), peripheral airway resistance (R5–R19), reactance (X5), and resonant frequency (Fres) were 6.85 ± 2.60, 5.23 ± 1.93, 1.6 ± 1.16, and − 2.54 ± 1.36 cmH2O/L/s and 17.28 ± 3.06 Hz. The median (interquartile range) percentage change after inhaled salbutamol was 19.9 (11.40, 29.12), 22.86 (6.88, 38.76), 14.08 (3.40, 22.62), 39.20 (8.20, 62.39), and 15.79 (8.33, 27.27) in respective parameters. All changes were statistically significant. The studied respiratory variables were in maximum negative correlation with height, followed by body mass index.Conclusions:FOT is a simple technique for monitoring lung functions in children during asthma management.

Clinico-epidemiological study of chronic leg ulcers in a tertiary care referral center from Tamil Nadu, India

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Leg ulcer is a common ailment of elderly presented with complex dermatological conditions. It may occur as a sequel to infection, malignancy, adverse drug reaction, trauma and hematological disorders. The paucity of data on the prevalence and outcome of the chronic leg ulcer in India served as a basis to conduct this clinico-epidemiological study. To study the prevalence of leg ulcers in a tertiary care referral hospital.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;In this cross-sectional study, 100 patients with leg ulcer attending the dermatology OPD at Madras medical college, Chennai, were enrolled after obtaining their consent. Detailed case history of each patient was recorded. Routine clinical investigations, Doppler study and culture were done to detect associated complications. In this study, 58 males and 42 females, with the mean age of 42.01±14.302 years, mean duration of leg ulcer of 17.79±29.87 months were recruited.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; Venous ulcer (37%) was the most prevalent type of leg ulcer recorded in our study. Doppler study revealed that the 31% of venous ulcers patients developed perforator incompetence. &lt;em&gt;Staphylococcus aureus&lt;/em&gt; was the major microbe isolated from the lesions (27%).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Chronic leg ulcers are very common in elderly patients and venous ulcer being the most common. Doppler is an effective tool for the assessment of disease severity of venous ulcers and aided in offering the adequate management of the disease. Diagnosis of underlying causes such as pyoderma gangrenosum, autoimmune diseases, malignancies and bacterial culture from the wound will be helpful for the management of the disease.&lt;/p&gt;

Role of Tympanoplasty on Eustachian Tube Dysfunction in Chronic Otitis Media – Mucosal Disease

Aim: To assess the Eustachian tube function (ETF) in chronic otitis media (COM)-mucosal disease and the role of tympanoplasty in ETF. Materials and Methods: A longitudinal study from January 2019 to June 2020 which comprised of 110 patients diagnosed with COM– mucosal disease was carried out in a tertiary care referral hospital. They were divided into mucosal active (n = 34) and mucosal inactive (n = 76) groups. Preoperative ETF was assessed with immittance audiometry by Toynbee's method. All patients underwent tympanoplasty with or without cortical mastoidectomy depending on the disease status. Postoperatively between 8 and 12 weeks after successful graft uptake, ETF was tested by William's test. Results: Out of 110 patients, 29 had Eustachian tube dysfunction preoperatively and 27 had normal ETF posttympanoplasty ± cortical mastoidectomy. Mc Nemer test was applied and P value was found to be &lt; 0.01 denoting a highly significant difference between the pre and postoperative ETF. Conclusion: Tympanoplasty with or without cortical mastoidectomy has a therapeutic effect on ET dysfunction in COM-mucosal disease.

A Study of Chromosomal Abnormality Patterns in Patients with Primary Amenorrhea in a Tertiary Care Referral Hospital

A Study of Chromosomal Abnormality Patterns in Patients with Primary Amenorrhea in a Tertiary Care Referral Hospital

Foreign body aspiration in children: Treatment timing and related complications

Background/purposeThe aims of this study were to describe our experience in the management of FB aspiration in children, focusing on the eventual association between delay in treatment and the development of complications, and to determine if the incidence of this emergency had decreased in the last 10 years. MethodsRetrospective study of children with a diagnosis of FB aspiration managed between 1999 and 2019 at a tertiary care referral hospital. The following data were collected: demographics, clinical presentation, radiological findings, endoscopic technique, type of FB, time elapsed between the aspiration episode and treatment, and complications. Main outcome measures were the rate of complications (intraoperative and long-term) in the cohort of patients with delay in treatment (>72 h), and the incidence of FB aspiration in each of the two historical subgroups of the study. ResultsThe study included 130 patients, 66.2% male, with a median age of 24 months. Cough was the most frequent symptom (76.1%) and unilateral air trapping was the most common radiological finding (48.8%). Removal of FB was performed with rigid bronchoscopy in every case. The most common type of FB was organic (73%) and located in the right bronchial system (47.7%). The global rate of complications was 16.1%. Patients with a delay in treatment beyond 72 h from the aspiration episode showed a statistically significant risk of developing both intraoperative and postoperative complications. Additionally, we have stated that the incidence of FB aspiration in our community has decreased by 44.4% in the last 10 years. ConclusionsThe incidence of FB aspiration has remarkably decreased in our environment in the last decade. Delay in treatment placed our patients at a significant higher risk of developing complications both during the bronchoscopic procedure and in the long-term.

Clarke Error Grid Analysis for Performance Evaluation of Glucometers in a Tertiary Care Referral Hospital.

Glucometer is the most commonly used POCT device and guides monitoring of blood glucose level in both clinical settings and outside. Inaccurate glucometer readings resulting in erroneous therapeutic intervention has critical consequences on patient care. Regulatory guidelines for performance evaluation of glucometers are not available in many countries. A robust program implemented by the hospital is essential to ensure accuracy and precision of glucometers to produce optimal results. The objective of this study was to design a quality assurance program for the evaluation of glucometers in a high volume tertiary care referral hospital and evaluate the results from July'18 to July'19. Seventy three glucometers used across the hospital were subjected to Internal Quality Control checks and Proficiency Testing performed once a month and every 3months respectively. The results were reviewed and plotted on a Bland Altman Graph. Clarke Error Grid Analysis was done to evaluate the clinical significance of inaccuracies in the measurement of blood glucose concentration as per ISO 15197: 2013. Eight devices were identified as unacceptable by ISO standards and replaced subsequently. 96.83% and 3.17% of the values were in Zone A and B of Clarke Error Grid Analysis. The study complied with the standard which requires that 99% of the values fall within zones A and B. The review of the program after one year and its ability to identify defective glucometers has validated the efficacy of the model. The method used may be suggested as a prototype for quality management of glucometers in a clinical setting.

Prevalence of delirium among older adults in a tertiary care referral hospital in Kerala

Background: Delirium is a common neuropsychiatric condition in older adults in medical and surgical settings. It is important to identify cognitive impairment in the elderly population early in their stay at the hospital to reduce morbidity and mortality. The literature on the prevalence of delirium in the elderly population shows that the occurrence of delirium is associated with patient factors and clinical settings. Delirium may affect the outcome of the primary medical condition in addition to the occurrence of poor compliance to treatment and long-term psychological sequela. Aim: The study aims to identify the prevalence of clinical delirium among patients at the age of 60 years or above, admitted in medical and surgical units of Government Medical College Hospital, Kozhikode, Kerala. The study also looked into the related factors and management aspects of the condition. Methods: A cross-sectional observational method was used in a sample of 300 older adult patients who were selected using a census approach from medical and surgical inpatient units of the hospital. Clinical and personal details were collected in addition to the assessment of the participants with the Confusion Assessment Method (CAM) and Nursing Delirium Screening Scale(Nu-DESC). Results: Findings of the study revealed the prevalence of delirium in older adult patients at 16%. The study also shows a significant association between the prevalence of delirium and selected clinical variables and area of admission. Conclusion: Early identification and prompt medical and psychiatric care, and environmental manipulation will reduce the development of complications in older adults.

Clinical Profile of Non-neutropenic Patients with Invasive Candidiasis: A Retrospective Study in a Tertiary Care Center.

Introduction: Invasive candidiasis (IC) is a major cause of morbidity and mortality in critically ill patients in the intensive care unit (ICU). In this study, we aim to analyze the clinical profile, species distribution, and susceptibility pattern of patients with IC.Methods: Case records of non-neutropenic patients ≥18 years of age with IC between January 2016 and June 2019 at a tertiary care referral hospital were analyzed. IC was defined as either candidemia or isolation of Candida species from a sterile site (such as CSF; ascitic, pleural, or pericardial fluid; or pus or tissue from an intraoperative sample) in a patient with clinical signs and symptoms of infection.Results: A total of 114 patients were analyzed, out of which 105 (92.1%) patients had bloodstream infection (BSI) due to Candida and 9 (7.9%) had IC identified from a sterile site. Central line-associated blood stream infection (27 patients, 23.6%) and a gastrointestinal source (30 patients, 26.3%) were the most common presumed sources for candidemia. The commonest species was Candida tropicalis 42 (36.8%), followed by Candida glabrata 20 (17.5%). Serum beta-D-glucan (BDG) was done only in 32 patients of the 114 (35.3%); among those who were tested, 5 (15.6%) had a BDG value of less than 80 pg/mL despite having Candida BSI. Fluconazole sensitivity was 69.5% overall. At 14 days after diagnosis of IC, 49.1% had recovered, with the remainder having an unfavorable outcome (32.4% had died and 18.4% had left against medical advice).Clinical significance: IC is a major concern in Indian ICUs, with a satisfactory outcome in only half of our patients. Serum BDG is a valuable test to diagnose blood culture-negative IC, but more studies are needed to determine its role in the exclusion of IC, as we had a small minority of patients with negative tests despite proven IC.Conclusion: We recommend sending two sets of blood cultures and serum BDG assay for all suspected patients. Initiating empiric antifungal therapy with an echinocandin is advisable, in view of increasing azole resistance and the emergence of Candida auris, with de-escalation to fluconazole for sensitive isolates after clinical stability and blood culture clearance.How to cite this article: Sridharan S, Gopalakrishnan R, Nambi PS, Kumar S, Sethuraman N, Ramasubramanian V. Indian J Crit Care Med 2021;25(3):267-272.