Tertiary Teaching Institute Research Articles

Performance of Residents Serving as Clinical Teachers: A Student-Based Assessment

Little is known about the competences of residents as clinical teachers in African health care institutions. We evaluated the clinical teaching skills of internal medicine residents from the perspective of medical students in a tertiary teaching institution in Africa. We used the augmented Stanford Faculty Development Program Questionnaire, which has evidence of validity and reliability. To avoid a Hawthorne effect, students completed the questionnaire anonymously and confidentially after clinical teaching sessions by residents. A minimum score of 4 on a scale of 1 to 5 was defined a priori as possession of good clinical teaching skills. Sixty-four medical students assessed all 20 internal medicine residents in the Department of Medicine, University of Ibadan. Mean performance scores for the domains ranged from 3.07 to 3.66. Residents performed best in creating a good learning climate and worst in the promotion of understanding and retention. Sex of the resident, duration of residency, and rank had no significant impact (.09 < P < .94) on their teaching skills. Consistent with other observations in the literature, residents' clinical teaching skills were suboptimal, particularly in their ability to promote understanding and retention. To enhance these skills, we recommend the integration of appropriately tailored programs to teach pedagogic skills programs in residency training.

A six year retrospective study of maternal mortality at a tertiary teaching institute in Uttarpradesh

Background: A high maternal mortality ratio is a serious public health issue in India. The lack of monitoring of pregnant mothers contributes to maternal deaths. Aims & Objectives: This To study the incidence of maternal mortality and the causes of maternal mortality at a tertiary care (teaching) institute over a period of 6 years from January 2006 – December 2010. Materials and Methods: A retrospective analysis of maternal deaths from hospital records. Results: As per present study, MMR was 1180 per 100,000 live births. Haemorrhage (53%) was the leading cause of death. Anaemia was a contributory factor in almost all cases (63%) & most of the deaths were associated with intrauterine fetal deaths (71%). Conclusion: MMR of the institute was very high, because most patients were referred cases with no antenatal care.

Strategic planning and designing of a hospital disaster manual in a tertiary care, teaching, research and referral institute in India.

As per the "Disaster Management Act, 2005" of India, it is mandatory for government hospitals in India to prepare a disaster plan. This study aimed to prepare a disaster manual of a 1 900 bed tertiary care hospital, in consultation and involvement of all concerned stakeholders. A committee of members from hospital administration, clinical, diagnostic and supportive departments worked on an initial document prepared according to the Act and gave their inputs to frame a final disaster manual. The prepared departmental standard operating procedures involved 116 people (doctors and paramedical staff), and were then synchronized, in 12 committee meetings, to produce the final hospital disaster manual. The present disaster manual is one of the few comprehensive plans prepared by the stakeholders of a government hospital in India, who themselves form a part of the disaster response team. It also helped in co-ordinated conduction of mock drills.

Early Re-laparotomy after Gynaecological and Obsterical Surgery – a twelve months – Retrospective Study

Objective(s): To study the incidence of early re-laparotomy, its indications and mortality rates in a rural tertiary teaching institution. Method(s): A retrospective descriptive study of early re- laparotomy after primary gynaecological and obstetrical surgery over a period of 12 months from 1 st August 2012 to 31 st July 2013 was done. Result(s): Total incidence of re –laparotomy was 0.169%. Most common complications requiring relaparotomy were intraperitoneal haemorrhage(36.36%) and PPH(36.36%) followed by rectus sheath haematoma(18.18%) and Burst abdomen(9.09%).Women who underwent primary surgeries for gynaecological and obstetrical condition required re-laparotomy in 0.16% & 0.17% cases respectively and mortality was 0% and 20% cases respectively. Conclusion: Indication of primary surgery,whether gynaecological or obstetrical, patient’s pre-operative general condition,surgeon’s experiences and care by the intensivist may influence the outcome of relaparotomy. Re-laparotomy should be considered as a procedure in case of near miss fatality of mother. To make it safe every effort must be adopted.

1539 TUBELESS PERCUTANEOUS NEPHROLITHOTOMY FOR COMPLEX RENAL CALCULI AND COMPLICATED PROCEDURES

INTRODUCTION AND OBJECTIVES: Tubeless PCNL is underutilized, usually as an option in nonbleeding, uncomplicated monotracts with complete stone clearance & decided intraoperatively. In this study we evaluated its feasibility, safety and efficacy in a tertiary teaching institute. METHODS: Forty (40) patients were alternately randomized (1:1) into tube (T) and tubeless (TL) PCNL groups. Tract dilatations were done using Alken metal dilators, no sealant or electrocautery was used for hemostasis and a 6 Fr JJ stent was kept. In T group 24 Fr nephrostomy tubes were placed. In TL group JJ stent was removed at 48 hours after operation and in tube group it was removed 1 week after drying of nephrostomy site. In TL group deep skin stitched were applied. Analgesic (intravenous tramadol) requirement and Visual Analogue Scores (noted every 3 hours) were recorded in first 48 hours (hrs). Postoperative X-ray KUB (on Day1) and ultrasound scans (on postoperative days 1, 2, 3 and 3 weeks) were done in all to see stone clearance and perinephric/puncture tract/intrarenal collection or hematoma. RESULTS: Demographic data and outcomes are shown in table 1. One procedure in TL required conversion to tube because of intraoperatively diagnosed pleural violation. Despite complicated calculi (55%) and high risk situations (50%), none in TL group had any significant perinephric collection or severe postoperative bleeding requiring any intervention. Patient age, size and type of stones, punctures, stone clearance rate, hematuria clearance time, mean haemoglobin drop, transfusion requirements, and complication rate were similar in both groups. TL-PCNL is superior (p values 0.05) to T-PCNL in terms of VAS pain scores and analgesic requirement in first 48 hrs, leak from tract site and hospital stay. CONCLUSIONS: In TL PCNL, deep skin stitches with JJ stenting for 48 hrs ensure a good local bleeding control and a dry tract site. TL-PCNL may be considered a new standard for PCNL. Nephrostomy should only be used for specific purposes like intraoperative pleural violation, major pelvicalyceal injury, balloon tamponading or relook. Parameter Tube group Tubeless group Number of patients(Right/left side) 20(13/7) 20(11/9) Age in years(mean/range) 33.2(15-55) 36.7(17-52) Sex(M:F) 2.3:1 3:1 Stone burden(maximum diameter in cms) (mean/range) 2.72(1.8-3.8) 2.56(1.9-4.2) No. of patients with Simple Calculi(Pelvis/ Calyceal) 8(6/2) 9(7/2) No. of patients with Complex Calculi(Multiple pole calculi/ Staghorns) 12(7/5) 11(7/4) No.of punctures(mean/range) 1.4(1-3) 1.3(1-3) Tracts: single/multiple(No.of pts.) 14/6 15/5 High risk situations : Infundibular tear/ Extravasation & tract loss/ Obvious bleeding/ Stone guided punctures (No.of pts.) 2/1/4/1 2/1/5/2 Operative time in minutes (mean/range) 106(60-170) 108(80-130) Hemoglobin drop in gm/dl (mean/range) 1.36(0-4.1) 1.21(0-3.1) VAS score in 0-24 hrs & 25-48 hrs(mean/range) 3.5(2.1-4.6) & 2.5(1-3.5) 2.4(0-3.8) & 1.9(0.5-2.5) Analgesic (tramadol in mg)requirement in 0-48 hrs (mean/range) 165(100-250) 85(50-100) Hematuria settling time in hrs(mean/range) 29.1(6-192) 36(3-160) Nephrostomy removal time in hrs(mean/range) 42.6(30-72) Not applicable(NA) Tract site leak duration in hrs(mean/range) 13.8(0-72) 0 Hospital stay in hrs(mean/range) 121.4(50-168) 88.3(52-210) Blood transfusion(No.of pts.) 4 3 Complications:Hydro-pneumothorax/ UTI/Late hematuria(No.of pts.) 1/3/0 1/2/1 Complete stone clearance rate : after first procedure/ after relook/ At 3 weeks follow up(in %) 70/80/90 70/NA/85

Clinical profile of psychogenic non-epileptic seizures in adults: A study of 63 cases.

Aims:To evaluate clinical profile and short-term outcome of psychogenic non-epileptic seizures (PNES) in Indian adult population.Setting and Design:A prospective observational study, conducted at tertiary teaching institute at New Delhi.Materials and Methods:Sixty-three patients with confirmed PNES were enrolled. The diagnosis was based on witnessing the event during video-electroencephalography (Video-EEG) monitoring. A detailed clinical evaluation was done including evaluation for coexistent anxiety or depressive disorders. Patients were divided into two groups on the basis of excessive or paucity of movements during PNES attacks. Patients were followed-up to 12 months for their PNES frequency.Statistical Analysis:Means and standard deviations were calculated for continuous variables. Chi-square and Students t-test were used to compare categorical and continuous variables respectively.Results:The mean age at onset of PNES was 25.44 years; with F:M ratio of 9.5:1. Coexistent epilepsy was present in 13 (20.63%) cases. Twenty-two patients (44%) with only PNES (n = 50) had received antiepileptic drugs. Out of 63 patients of PNES 24 (38.1%) had predominant motor phenomenon, whereas 39 (61.9%) had limp attacks. The common features observed were pre-ictal headache, ictal eye closure, jaw clenching, resistant behavior, ictal weeping, ictal vocalization, and unresponsiveness during episodes. Comorbid anxiety and depressive disorders was seen in 62.3% and 90.16% patients, respectively. Short-term (6-12 months) outcome of 45 patients was good (seizure freedom in 46.66% and >50% improvement in 24.44% cases).Conclusion:PNES is common, but frequently misdiagnosed and treated as epileptic seizures. A high index of suspicion is required for an early diagnosis. Proper disclosure of diagnosis and management of the psychiatric comorbidities can improve their outcome.Limitation:Limited sample size and change in seizures frequency as the only parameter for the assessment of the outcome are the two major limitations of our study.

Teaching, leadership, scholarly productivity, and level of activity in the chiropractic profession: a study of graduates of the Los Angeles College of Chiropractic radiology residency program

ObjectiveThe purpose of this study was to track the graduates of the Los Angeles College of Chiropractic (LACC) radiology residency program, review their scholarly productivity, and report those involved in teaching and leadership positions.MethodsFormer LACC residents’ career information was identified through publicly available electronic documents including Web sites and social media. PubMed and the Index to Chiropractic Literature databases were searched for chiropractic graduate job surveys, and proportional comparisons were made between the career paths of LACC radiology residency graduates and those of non–residency-trained chiropractors.ResultsOf 47 former LACC residents, 28 (60%) have or previously had careers in tertiary (chiropractic) education; and 12 (26%) have attained a department chair position or higher at tertiary teaching institutions. Twenty-two (47%) have or previously had private radiology practices, whereas 11 (23%) have or previously had clinical chiropractic practices. Often, residency graduates hold or have held 2 of these positions at once; and one, all 3. Chapters or books were authored by 13 (28%).ConclusionRadiology residency LACC graduates are professionally active, particularly in education, and demonstrate scholarly productivity.

Continuous Quality Improvement in Radiation Oncology is Feasible at a Major Tertiary Teaching Institution

Continuous Quality Improvement in Radiation Oncology is Feasible at a Major Tertiary Teaching Institution

Clinical Outcomes in Adult and Pediatric Ewing Sarcoma: A Single Institution Comparative Study

oncology web page to an encrypted database. Forms initially were reviewed at monthly quality assurance meetings. Starting in May 2010, a process improvement team consisting of physician, physicist, dosimetrist, therapist, and nursing group representative met weekly to improve workflow and decrease errors. This group was expanded to non-clinical staff in 2011. Form review priority criteria, solution criteria, and meeting ground rules were set in advance of the first team meeting. Spreadsheets were used to present the forms. Actions, owners, and completion dates were assigned at each meeting. Results: Over 1,182 process improvement reports were recorded. Efforts resulted in many operational changes in the department. In addition to first day therapist chart checklists, physics and dosimetry chart checklists were added and electronically recorded in the every patient’s chart. Table indexing was developed for all patients to minimize potential for wrong site treatment. A Linear Accelerator Field Definition Chart was created to include unique differences in treatment parameters and a Field Definition Chart was created showing screen capture examples of different linear accelerator parameters. Machine parameter spreadsheets were created and are being used by dosimetrists and physicists. Data demonstrated increased adoption by staff over time with increased PIF submission. Forms for incidents reaching the patient decreased, during the same time period that total number of fields treated and complexity of patient set-up increased (Table). Conclusions: The number of errors reaching patients can be positively affected by a continuous improvement program. A continuous quality improvement program can be implemented at a large tertiary teaching institution that can be adapted for smaller radiation oncology departments. Author Disclosure: T. Meier: None. B. Hugebeck: None. T. Kovacs: None. C. Belfi: None. J. Suh: G. Consultant; Abbott Oncology. M. Kolar: None. S. Chao: None.

Female Sexual Function and Gestational Diabetes

The number of women with gestational diabetes mellitus (GDM) is growing worldwide in parallel with the obesity epidemic. The diagnosis of GDM leads to substantial modifications in the daily routine of these women, and these adjustments could potentially affect their sexual function. There are no previous studies on the sexual function of patients with GDM. The aim of this study was to investigate the sexual function of patients with GDM in comparison with healthy pregnant women at the same gestational age. Brazilian women in the third trimester of pregnancy with and without GDM were invited to participate in this cross-sectional study while waiting for their antenatal care visits at a single public tertiary teaching institution between March and December 2010. The Brazilian version of the Female Sexual Function Index (FSFI) questionnaire was used to assess sexual function. Desire, arousal, lubrication, orgasm, sexual satisfaction, and pain during and after coitus in the last 4 weeks, measured according to a standardized and validated questionnaire. A total of 87 participants were enrolled (43 healthy women and 44 with GDM). There were no significant differences in the sociodemographic characteristics of both groups. The total FSFI scores of GDM patients was 21.0±9.59 compared with 22.3±9.17 for healthy women (P=0.523). Difficulty in desire was the most common sexual dysfunction symptom in both groups, being reported by 42% and 50% of GDM and healthy women, respectively (P=0.585). The sexual function of Brazilian patients with GDM does not differ significantly from that of healthy pregnant women at the same gestational age.

ODL and the impact of digital divide on information access in Botswana

&lt;p&gt;Open and distance learning (ODL) has created room for the emergence of virtual education. Not only are students found everywhere and anywhere undertaking their studies and earning their degrees, but geographical boundaries between nations no longer appear to have much relevance. As the new education paradigm irretrievably alters the way teaching and learning is conducted, the application of modern educational ICTs has a major role to play.&lt;/p&gt;&lt;p&gt;With students of transnational or cross-border education dispersed into various nooks and crannies of Botswana, many others enlist for the “home-baked” distance learning programmes from their diverse locations. Like the face-to-face conventional students, distance learners also have information needs which have to be met. But blocking the distance learners’ realization of their information needs is the digital divide, which further marginalizes the underclass of “info-poor.”&lt;/p&gt;&lt;p&gt;The survey method was used, and a questionnaire administered to 519 students of four tertiary level distance teaching institutions that met the criteria set for the study yielded a 70.1% response rate. The results showed that while the Government of Botswana has made considerable effort to ensure country-wide access to ICT, which now constitutes an effective instrument for meeting information needs, a number of problems still exist. The factors impeding easy access are unearthed. The findings of an empirical study portraying some learners as information-rich and others, information-poor, and the consequence of distance learners studying on both sides of the digital divide, are discussed. Suggestions on bridging the digital divide are offered.&lt;/p&gt;

Evaluation of Ondansetron-induced QT interval prolongation in the prophylaxis of postoperative emesis

Background:To avert nausea and vomiting the 5-Hydroxytryptamine3 (5-HT3) antagonists have become the first line of treatment ifassociated with cardiovascular effects andappear to cause QT prolongation.Objective:Evaluate the effect of 1 mg, 4 mg, and 8 mg bolus doses of intravenous Ondansetron, relative to placebo, in prevention of postoperative nausea and vomiting (PONV) and to find out the changes of QT interval corrected for heart rate (QTc).Materials and Methods:This prospective randomized, placebo-controlled, double-blind study was carried out among 136 adult participants of both sexes in a tertiary care postgraduate teaching institute at Kolkata. mg, 4 mg or 8 mg inj. Ondansetron was diluted to 10 ml with normal saline, was infused 30 min before extubation in relation with a control group. Time to first rescue antiemetic medication and in QTc interval at different time intervals, in each group was noted in different in the various surgical operation theaters (OTs).Results:Requirement of the first rescue antiemetic in the postoperative period between 60 to 120 min in the mg, 4 mg or 8 mg Ondansetron groups was in 28%, 24% and 7% participants respectively; between 120 to 240 min in 63%, 72% and 57% respectively; and within 360 min in 9%, 4% and 36% respectively. Significant and maximal QTc prolongation was observed in the participants with mg or 8 mg Ondansetron 3 and 5 min of drug administration.Conclusions:One mg Ondansetron in healthy adult participants can effectively prevent PONV causing no or insignificant prolongation of QTc interval.

Evaluating ranitidine, pantoprazole and placebo on gastric pH in elective surgery

Background and Aim:Concern about the grim nature of postoperative acid aspiration syndrome grew among the anesthesiologist over the years warranting the need for pre-emptive intervention. The aim of the study is to compare the effects of preoperative oral ranitidine versus pantoprazole given in regulating gastric pH in elective surgery.Methods:This prospective, parallel group, controlled, randomized, single-blind study was conducted at a tertiary care postgraduate teaching institute at Kolkata, involving 120 participants of either sex, aged 18-60 years of American Society of Anesthesiologists physical status I and II, who were scheduled for elective surgery under general anesthesia lasting for more than 2 h. The participants were divided into three groups. In group A (n=40) participants received placebo tablet, in group B (n=40) participants received ranitidine tablet while in group C (n=40), participants received pantoprazole tablet and their gastric pH estimated serially.Results:The participants in the three groups were comparable in terms of age, sex, body weight, duration of surgery and type of surgery distribution. In regard to changes in gastric pH trends, there was no statistically significant difference between serial pH values in group A (Friedman test; P>0.05) and group C participants. (P>0.05). However, the mean preoperative gastric pH values (7.140±.7652) were significantly lower than mean pH values (7.253±.7514) after 2 h postoperatively in group B participants (P<0.05).Conclusion:From the observations and analyses of the present study, it can be inferred that ranitidine is more effective than pantoprazole to raise the gastric pH for prevention of aspiration pneumonitis.

Objective Assessment of the Cardiorespiratory Function of Adolescents With Idiopathic Scoliosis Through the Six-Minute Walk Test

Clinical prospective, random study. Analyze the results of the six-minute walk test (6MWT) in patients with adolescent idiopathic scoliosis. Although it is widely believed that Adolescent Idiopathic Scoliosis (AIS) causes cardiorespiratory dysfunctions, there is no report in literature of objective measurements of this restriction in the ventilatory performance during physical exertion. One hundred twenty-six adolescents matched by gender and age were prospectively studied at a tertiary teaching institution: 40 patients without spine deformities (group I-controls), and 86 patients with AIS with a spine curve ranging from 45 degrees to 138 degrees (group II). All patients underwent radiographic evaluations and the 6MWT. Normal controls presented significantly lower mean heart rate and Borg scores, as well as higher oxygen saturation and walked longer distances on the 6MWT. The 6MWT effectively demonstrated the cardiorespiratory restrictions presented by patients with AIS.

Fratura toracolombar explosão: confiabilidade do método de guerra na análise tomográfica

OBJETIVOS: Avaliar as características do fragmento retropulsado nas fraturas explosão da coluna toracolombar, de acordo com dois examinadores independentes no plano sagital da TAC e correlacionar estes achados com a presença de déficit neurológico. MATERIAL E MÉTODOS: Coleta retrospectiva de dados de prontuário e TC em 138 pacientes com fratura toracolombar do tipo explosão internados no nosso serviço entre 1983 e 2004. RESULTADOS: Observamos correlação significante entre dois examinadores independentes (p&lt;0,05) na aferição da rotação e migração do fragmento. Este, caracteristicamente, é triangular, tem uma média de rotação de 20º e se desloca na maioria das vezes no sentido cranial, até oito milímetros. Não foi possível a associação entre a rotação do fragmento e o déficit neurológico neste estudo. CONCLUSÃO: Houve correlação positiva entre os achados de dois pesquisadores independentes, usando o mesmo método de mensuração na casuística estudada. Considerando os grupos de rotação, não foi possível relacionar o grau de rotação do fragmento retropulsado com o déficit neurológico.

Clostridium difficile–positive stools: A retrospective identification of risk factors

In an attempt to determine the association of potential risk factors and an increase in the rate of Clostridium difficile-associated diarrhea (CDAD) at a tertiary teaching institution in the Midwest United States, all CDAD cases among admissions from a period of 20 consecutive months were analyzed. A retrospective chart review was performed on 4992 admissions from this period. Logistic regression analysis suggested a correlation between CDAD and multiple factors.

A Review of Neuraxial Epidural Morbidity

The true incidence of serious neuraxial complications such as epidural hematoma or abscess after postoperative epidural infusions is still uncertain, in part due to inconsistencies in multicenter data collection. Prospective data were collected over 16 yr from the authors' Acute Pain Service, which is based in a large tertiary teaching institution with a nonobstetric general surgical population. Over this period, 8,210 epidural catheters were inserted for postoperative analgesia and 32 computed tomography or magnetic resonance imaging scans were undertaken to exclude potential neuraxial complications. From these, two spinal hematomas (1:4,105) and six epidural abscesses (1:1,368) were diagnosed. Only one patient required surgical decompression. There were no long-term neurologic sequelae in any patient. In the past 6 yr, the frequency of investigation and diagnosis of epidural abscess has increased. Overall, the combined rate of epidural abscess or hematoma was 1:1,026, (0.1%; 95% confidence interval, 0.04-0.19%) with a need for operative intervention of 1:8,210 (0.01%; 95% confidence interval, 0.0-0.07%). Spinal hematoma was very rare (< 0.05%). Epidural abscess was also rare (< 0.1%) but remains a potentially serious complication. Early diagnosis, using magnetic resonance imaging in patients with appropriate clinical indicators, before the onset of neurologic signs, enables conservative therapy in many cases and may help to prevent the development of serious neurologic sequelae.

Nonprogressive juvenile-onset spinal muscular atrophy: A clinico-radiological and CAG repeat study of androgen receptor gene

Occurrence of nonprogressive juvenile-onset spinal muscular atrophy (SMA) predominantly in males suggests a possibility of X-linked disorder but there is no such report addressing this problem. To evaluate CAG repeat expansion of androgen receptor (AR) gene in patients with nonprogressive juvenile-onset SMA. Tertiary medical teaching institute. Patients fulfilling the diagnostic criteria of nonprogressive juvenile-onset SMA were included. Detailed clinical evaluation and pedigree charting were done in all. Nerve conduction study, electromyography and cervical spinal MRI were carried out. From peripheral venous blood, DNA was separated and AR gene CAG repeat exon polymorphism was assayed using polymerase chain reaction (PCR) in conjugation with genotyping and Gene scan soft ware. Number of CAG repeats was compared with normal controls. 25 patients with nonprogressive juvenile-onset SMA from 24 families were included and their mean age was 22.2 years. Age at the time of disease onset ranged between 15 and 30 years with a mean duration of illness 2.6 years. None of the patients had testicular atrophy or gynecomastia. C7-T1 myotomal wasting and weakness although was unilateral to begin with but became bilateral in 16 and 4 more patients had evidences of subclinical involvement of the other side as revealed by EMG. Spinal MRI revealed cord atrophy at C6-8 vertebral level in 16 patients. CAG repeat study of AR gene was carried out in 16 patients. The number of CAG repeats in patients ranged between 15 and 39 (median 21) which were within the normal range. Abnormal CAG repeat expansion of AR gene is not found in patients with nonprogressive juvenile-onset SMA.

The Use of Combination Antimicrobials in Critically-Ill Ventilated Patients with Pseudomonal Pneumonia

Purpose Recent 2005 American Thoracic Society and Infectious Diseases Society of America ventilator-associated pneumonia (VAP) guidelines suggest combination antimicrobial therapy for Pseudomonas aeruginosa VAP based on limited non-VAP evidence. We reviewed antimicrobial use in patients with P. aeruginosa VAP within our tertiary teaching institution to evaluate patient factors, antimicrobial selection, and outcomes. Methods Intubated patients with a P. aeruginosa sputum culture, infiltrate on chest x-ray, and increased white blood cell count were retrospectively enrolled. Collected data identified illness acuity using the Simplified Acute Physiology Score II (SAPS), culture sensitivities, antimicrobial use, and patient survival at hospital discharge. Results Fifty-nine patients were analyzed between January 2003 and November 2004. Average age was 57 ± 15.7, body mass index (BMI) of 28.5 ± 6.1, and SAPS of 45.1 ± 13.7. Survival was significantly higher among patients on two culture-sensitive antimicrobials (23/28, 82%) vs less than two agents (12/31, 39%; P = 0.0018). Almost all patients who received the beta-lactam and aminoglycoside (BL/Ag) combination survived (15/16; P = 0.0015). While fewer severely ill patients lived (SAPS greater than 54; 4/16; P = 0.0029), none were placed on the BL/Ag combination, and few on appropriate antimicrobials (6/37; P = 0.0324). Lower survival was seen among obese patients (BMI higher than 30; 9/25; P = 0.0043); although, 5/6 obese patients on BL/Ag survived ( P = 0.0237). Patients more than 64-years-old were more often on two appropriate antimicrobials ( P = 0.0143) and had a higher survival ( P = 0.0241). Unfortunately, we observed a lack of culture follow-up, as only 60% (30/50) of inappropriate antimicrobials were switched to sensitive agents. Conclusions Our results emphasize the need to use combination BL/Ag antimicrobials for P aeruginosa VAP as the current guidelines suggest, and to ensure that antimicrobials are optimized based on culture results.

Correlation Between Retinal Nerve Fiber Layer Thickness and Central Corneal Thickness in Patients With Ocular Hypertension: An Optical Coherence Tomography Study

To correlate the retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) parameters measured by optical coherence tomography (OCT) with central corneal thickness (CCT) measurements in patients with ocular hypertension (OHT). Observational cross-sectional study. setting: Tertiary care referral teaching institute. study population: Fifty-one eyes of 51 patients with OHT and 35 eyes of 35 normal subjects. Both groups were stratified into thin (CCT < or =555 microm) and thick (CCT >555 microm) cornea subsets. Ocular hypertensives were further stratified by CCT into < or =555 microm, 556 to 588 microm, and >588 microm subsets. observation procedure: RNFL thickness (average, superior average, and inferior average) and ONH parameters were measured by OCT. CCT was measured by ultrasonic pachymetry. main outcome measures: Correlation between CCT and OCT measurements of RNFL and ONH parameters. In the OHT group, CCT correlated significantly with all three RNFL measurements (Pearson's coefficient r = 0.412, 0.484, and 0.380, respectively) but with only four ONH parameters (cup-to-disk area ratio, cup area, rim area, and horizontally integrated rim width; r = -0.459, -0.283, 0.421, and 0.436, respectively). The RNFL in ocular hypertensives with CCT < or =555 microm was significantly thinner than in those with thick corneas (analysis of variance, post hoc Bonferroni comparisons, P < .001). RNFL thickness of normal subjects and ocular hypertensives with CCT >555 microm were similar. Ocular hypertensives with CCT < or =555 microm may represent patients who have either very early undetected glaucoma or an inherent structural predisposition to glaucomatous damage. This may in part explain the higher risk of these patients for progression to glaucoma.