Background: Accurate diagnosis and appropriate treatment of ventilator associated pneumonia (VAP) is crucial for good outcomes. Endotracheal suctioning is performed in ventilated patients as part of routine care and for tracheal toileting. Aim: We evaluated if quantitative endotracheal aspirate (ETA) was a suitable alternative to bronchoalveolar lavage (BAL) for suspected VAP. In addition we assessed if surveillance ETA guided antibiotic selection for subsequent VAP. Setting and Design: Prospective study in the surgical intensive care unit (ICU) of a tertiary hospital in India. Materials and Methods: Two hundred consecutive patients with mean (standard deviation) APACHE II score of 12.3±5 and requiring mechanical ventilation beyond 48 hours underwent surveillance ETA cultures. A second ETA and BAL were performed if the patient developed features of VAP. The threshold for microbiological diagnosis of VAP was taken as 10 ⁵ colony forming units/ml (cfu/ml) for ETA and 10 ⁴ cfu/ml for BAL. Statistical Analysis: The sensitivity and specificity of surveillance and concurrent ETA aspirate cultures were compared with BAL cultures. RESULTS: VAP was suspected clinically and corroborated radiologically in 27/177 patients (15.3%). Although microbiological support for VAP was obtained by ETA in 19 patients, bronchoscopy was possible only in 13 patients, 8 of whom had isolates at significant threshold. Of the 16 organisms isolated from BAL, 11 were of significant threshold with 9/11 (82%) BAL isolates having a similar antibiogram to a concurrent ETA. Only one BAL isolate (9%), at significant threshold, was not isolated on a concurrent ETA. On the other hand just 6/11 BAL isolates (55%) had an identical antibiogram to surveillance ETA. BAL had 3 additional isolates (27%) at significant threshold not isolated on surveillance ETA. Conclusions: Concurrent quantitative ETA could substitute BAL cultures for VAP. Surveillance ETA at 48 hours of ventilation does not appear to assist with antibiotic selection for a subsequent VAP.

Background: Survival benefit with intra-aortic balloon pump (IABP) insertion for coronary artery bypass grafting (CABG) patients with left ventricular dysfunction is controversial. The aim of this study was to assess the early results of CABG that predict 30-day mortality and prolonged length of hospital stay (LOS) after isolated CABG and the role of IABP application as a main predictor in patients with an ejection fraction (EF) of 30% or less. Materials and Methods: Eight hundred and thirty-three patients who underwent isolated CABG with EF ≤ 30% were entered and compared with 10881 patients with EF > 30% as the control group. Demographic and clinical characteristics and postoperative complications were considered. Data were analyzed using the student's t-test and chi-square test for univariate analysis and the analysis of covariance and logistic regression for multivariate analysis. Results: The thirty-day mortality rate (1.6% vs. 0.7%, P < 0.001), the mean of LOS (P < 0.001), and the mean of the length of ICU stay (P < 0.001) were significantly higher in the severe left ventricular dysfunction group than in the control group. In patients with severe left ventricular dysfunction, the use of intra-aortic balloon pomp was related to the 30-day mortality rate (P = 0.002) and prolonged LOS (P = 0.009). Also, urinary tract infection, prolonged ventilation, and renal failure as postoperative complications were statistically more in the group with the application of IABP. Conclusion: Low ejection fraction can positively affect thirty-day mortality and prolonged LOS and ICU stay in patients who undergo CABG. In these patients, IABP insertion is a strong predictor for early complication and mortality.

Background: Bronchial asthma is a complex genetic disorder regulated by the release of cytokines and inflammatory mediators. Tumor necrosis factor alpha (TNF-α) and transforming growth factor beta (TGF-β1) cytokines play pivotal roles in the inflammatory response of the airways. Differential production of these two cytokines is associated with allelic variations in the transcriptional regulatory region of these genes. Aims: The objective of the present study was to investigate G-308A TNF-α and C-509T TGF- β1 polymorphisms for their association with Bronchial Asthma. Materials and Methods: DNA isolated from 123 asthmatics and 100 normal healthy controls were screened for these polymorphisms using the amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) methods, developed in our laboratory. Results: Significant allelic association was observed between G-308A TNF-α polymorphism and asthma (P = 0.031) while no association was observed with C-509T TGF- β1 polymorphism (P = 0.207). Further sub-grouping based on either allergic response or family history failed to reveal any statistical significance among the groups or with controls. The interaction between these polymorphisms revealed statistically significant association between the high producer genotype alleles of TNF-α and TGF-β (A/T) and asthma (P = 0.016). Conclusions: The present study reports, for the first time, the role of two polymorphisms, in concert, for their association with asthma in an Indian population. Our study supports the findings that the G-308A TNF-α promoter polymorphism is a risk factor for asthma and furthermore suggests that the patients with high producer alleles for TNF-α (-308) and TGF-β (-509) have the highest risk of getting this disease in the Punjabi population.

Background: Hardly any Indian data is available regarding practices employed by parents for preventing injuries and aspiration and controlling convulsions in children. Aims: To describe the health care-seeking behavior and practices employed by parents when a child has convulsions. Settings and Design: Prospective questionnaire-based study in a tertiary care hospital setting. Materials and Methods: Parents of children (age: 1 month -12 years) admitted with history of convulsions were enrolled and information regarding demographic characteristics, time lag, preferred health care provider and measures taken in a convulsing child was elicited using a pretested questionnaire. Statistical Analysis Used: Demographic parameters and measures employed described as percentages. Results: One hundred and forty parents were interviewed. Seventy-six children had first episode. Forty-nine of 64 children with subsequent seizures had contact with a health care provider during the previous seizure episode. The median duration of seizures was 10 minutes (Mean: 54.15±366.39 min); but children were brought to the hospital after a median of 2 hours (Mean: 5.22±10.37 h). Measures such as smelling onions, oral administration of cold water, reading religious texts and insertion of mouth gag were employed. Although 45 with previous seizure-related health care contact agreed that they were informed about measures to be taken, none of them could remember more than one measure for preventing injuries and aspiration and controlling seizures. Only four narrated "per-rectal administration of diazepam" as a measure, although only one implemented it. Only four general practitioners used per-rectal diazepam to control seizures. Conclusions: Children with seizures reach health care providers after a considerable delay putting them at higher risk for developing neurological sequel. There is a need to develop appropriate strategies for disseminating information about "first aid" measures and steps for controlling convulsions and imparting relevant skills to parents.