Pacemaker patients\u27 perception of unsafe activities: a survey

Background: Cardiac pacing is a recognized and widely used treatment for Patients presenting with bradycardia. Physicians expect Patients to return to normal activities almost immediately post implantation. However, Patients themselves may perceive interference to pacemaker function by various routine activities and devices, and hence continue to lead restricted, disabled lives. The aim of this study is to determine if routine activities are perceived by pacemaker Patients to interfere with their device function. Methods: A descriptive cross sectional survey was carried out on consecutive Patients at the pacemaker clinic at a public hospital in Karachi, Pakistan. A 47-question tool was developed and tested. Patients\u27 perceptions of safety of performing various routine activities, along with sociodemographic data were recorded. Results: The final sample included 93 adult Patients (45% males). 41% were illiterate. 77.4% recalled receiving counselling at implantation, predominantly from the implanting physician and house staff. A considerable proportion of Patients considered many routine activities unsafe including driving automobiles (28%), passing through metal detectors (31%), bending over (37%), and sleeping on the side of the pacemaker (30%). Also considered unsafe were operation of household appliances-TV/VCR (television/video cassette recorders) (53%), irons (55%)) and electrical wall switches (56%). For nearly all variables neither literacy nor history of counselling improved incorrect perceptions. Conclusion: This study shows that our pacemaker Patients perceive many routine activities as unsafe, potentially leading to disabling life style modifications. The tremendous investment in pacemaker technology to improve Patient performance is not going to pay dividends if Patients continue to remain disabled due to incorrect perceptions. Further studies are required to determine the reasons for these misperceptions, and to determine if these problems also exist in, and hinder, other Patient populations

How early do antibiotics have to be to impact mortality in severe sepsis? A prospective, observational study from an emergency department

BACKGROUND: The objective of this study was to assess the promptness of antibiotic administration to patients presenting with sepsis and the effects on survival and length of hospitalization. METHODS: Consecutive, adult patients presenting with Systemic Inflammatory Response Syndrome (SIRS) to the emergency department of the Aga Khan University hospital were enrolled in a prospective, observational study over a period of 4 months. Univariate, multivariate regression modeling and one-way ANOVA were used to examine the effects of various variables on survival and for significant differences between timing of antibiotic administration and survival, two-sided p values \u3c 0.05 were considered significant. RESULTS: One hundred and eleven patients were enrolled. Severe sepsis was present in 52% patients; the most frequent organism isolated was Salmonella typhi (18%). Overall mortality was 35.1%. One hundred (90.1%) patients received intravenous antibiotics in the Emergency room; average time from triage to actual administration was 2.48 +/- 1.86 hours. The timing of antibiotic administration was significantly associated with survival (F statistic 2.17, p = 0.003). Using a Cox Regression model, we were able to demonstrate that survival dropped acutely with every hourly delay in antibiotic administration. On multivariate analysis, use of vasopressors (adjusted OR 23.89, 95% CI 2.16,263, p = 0.01) and Escherichia coli sepsis (adjusted OR 6.22, 95% CI 1.21,32, p = 0.03) were adversely related with mortality. CONCLUSIONS: We demonstrated that in the population presenting to our emergency room, each hourly delay in antibiotic administration was associated with an increase in mortality

Predicting postoperative cardio-pulmonary complications by a test of stair climbing

OBJECTIVE: To assess whether a test of stair climbing ability could be used to predict the risk of developing postoperative cardiopulmonary complications in patients undergoing general anesthesia. DESIGN: Cohort study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi. The duration of the study was from December 2003 to December 2004. PATIENTS AND METHODS: This study was carried out on consecutive, adult patients presenting for elective thoracic or abdominal surgery under general anesthesia. Pre-operatively, patients were asked to climb a standard staircase. Number of steps climbed was recorded. Those unable to climb stairs due to debilitating cardiac, pulmonary or rheumatologic disease were categorized as 0 stairs climbed. Outcome variables were postoperative cardiopulmonary complications or mortality. Period of follow-up was until hospital discharge. RESULTS: Seventy-eight patients were enrolled, 59 (75.6%) climbed 1 flight of stairs, 19 (24.3%) climbed \u3c 1 flight. All-cause cardiopulmonary complications rate was 26 %. The most frequent complication was lobar atelectasis, followed by bronchospasm and acute MI. The complication rate was 22.8% in those able to climb 1 flight and 40% in those patients who climbed \u3c 1 flight. The group that climbed \u3c 1 flight tended to have complications associated with poor reserves of the cardiopulmonary systems, i.e. pulmonary edema, exacerbation of underlying lung disease. The relative risk of developing complications, if unable to climb at least 1 flight of stairs, was calculated to be 1.8 (95% CI 0.7 - 4.6). CONCLUSION: Stair climbing can be a useful pre-operative tool to predict the risk of postoperative cardiopulmonary complication

PO5.53 critical illness polyneuropathy and myopathy: experience at a tertiary care center in Pakistan

Background: Polyneuropathy and Myopathy are frequently encountere in the setting of Critical illness patients. Up to 50% of intensive care unit (ICU) patients show electrophysiological features of either or both conditions. These conditions interfere with functional recovery and delay weaning from mechanical ventilation, resulting in excess morbidity,mortality and cost of care. This study was to define the clinical spectrum of critical illness Polyneuropathy (CIP) and Myopathy (CIM) in a setting of developing country. Methods: Hospital records spanning the period 2000 through 2005 weresearched with ICD-9 codes to identify patients with CIP and CIM. Functional improvement was judged by (i) increment of at least 1grade on the Medical Research Council scale of motor strength: and (ii)reappearance of deep-tendon reflexes. Results: CIP or CIM was established in 47 patients of these, mean age was 54: mean length of stay in hospital 34 (range 8100) electrophysiological studiesrevealed CIP in 31 patients (66%) CIM in 12 (26%) and a mixedpicture in 4 (8%). Major co-morbid conditions included sepsis (39%) anddiabetes mellitus (17%), with an additional 28% having both and 17% having either. Neuromuscular blocking drugs were administered to 14 (30%) and steroids to 10 (21%) patients: an additional 11 (23%) patients received both agents while 12 (26%) patients received neither. In hospital mortality was 51%. At discharge and follow-up, motor improvement was seen in 11 (23%) while 12 (26%) remained neurologically unchanged. Conclusions: We conclude that CIP and CIM are frequent identifiable complications of critical illness in our setting. These observations need further prospective studies to delineate risk factors and out come predictors, to improve critical care patients

Use of inhaled PGE1 to improve diastolic dysfunction, LVEDP, Pulmonary Hypertension and Hypoxia in ARDS—A randomised clinical trial

Introduction: We wished to see the effects of inhaled PGE1 on diastolic dysfunction, left ventricular end diastolic pressure (LVEDP), pulmonary hypertension and hypoxia in ARDS patients. Methods: This is a randomized, prospective, clinical trial conducted in the main adult intensive care unit of a tertiary care University hospital. A total of 67 patients were recruited. Inclusion criteria included all adult patients with a P/F ratio /or Pulmonary Artery systolic (Pa) pressures of \u3e35 mmHg on Pulmonary artery catheter or suspected on clinical grounds. A transthoracic echo was performed to record the diastolic function, LVEDP and Pa pressures. Subsequently patients were randomized by a block computerized randomization to either cases (n = 34) or controls (n = 33). Cases received nebulised PGE1 over 30 minutes in the ICU and normal saline was administered to controls blindly. Following this the echo and arterial blood gases were repeated. Our primary outcomes were an improvement in diastolic function and P/F ratio of greater than 20% and a decrease in pulmonary pressure and LVEDP of \u3e20%. Results: At baseline, mean diastolic dysfunction was grade II, with a mean LVEDP of \u3e15 and the PaO2/FiO2 ratio was 148.38 ± 60.05 with a mean pulmonary artery pressure of 81.35 ± 16.91. Inhaled PGE1 was followed by an improvement in diastolic dysfunction (grade I, p = 0.001) with a resulting improvement in LVEDP (12 +/? 2, p = 0.001) as well as Pa pressures (97.09 ± 30.06, p = 0.04) and a non significant improvement in PaO2/FiO2 ratio (161.45 ± 77.52, p = 0.21). There were no side effects observed in any patients. Conclusion: Our study shows that there is a significant improvement in diastolic dysfunction, LVEDP and Pa pressures after administration of nebulised PGE1, and an improvement although non-significant in hypoxia in ARDS patients. The trial was registered with Clinicaltrials.gov (NCT00314548) and funded by the Pakistan medical research council

Vitamin D accelerates clinical recovery from tuberculosis: results of the SUCCINCT Study [Supplementary Cholecalciferol in recovery from tuberculosis]. A randomized, placebo-controlled, clinical trial of vitamin D supplementation in patients with pulmonary tuberculosis\u27.

BACKGROUND: Vitamin D enhances host protective immune responses to Mycobacterium tuberculosis by suppressing Interferon-gamma (IFN-g) and reducing disease associated inflammation in the host. The objectives of this study were to determine whether vitamin Dsupplementation to patients with tuberculosis (TB) could influence recovery. METHODS: Two hundred and fifty nine patients with pulmonary TB were randomized to receive either 600,000 IU of Intramuscular vitamin D3 or placebo for 2 doses. Assessments were performed at 4, 8 and 12 weeks. Early secreted and T cell activated 6 kDa (ESAT6) and Mycobacterium tuberculosis sonicate (MTBs) antigen induced whole blood stimulated IFN-g responses were measured at 0 and 12 weeks. Statistical comparisons between outcome variables at 0 and 12 weeks were performed using Student\u27s t-test and Chi2 tests. RESULTS: After 12 weeks, the vitamin D supplemented arm demonstrated significantly greater mean weight gain (kg)+3.75, (3.16-4.34) versus+2.61 (95% CI 1.99-3.23) p 0.009 and lesser residual disease by chest radiograph; number of zones involved 1.35 v/s 1.82 p 0.004 (95% CI 0.15, 0.79) and 50% or greater reduction in cavity size 106 (89.8%) v/s 111 (94.8%), p 0.035. Vitamin D supplementation led to significant increase in MTBs-induced IFN-g secretion in patients with baseline \u27Deficient\u27 25-hydroxyvitamin D serum levels (p 0.021). CONCLUSIONS: Supplementation with high doses of vitamin D accelerated clinical, radiographic improvement in all TB patients and increased host immune activation in patients with baseline \u27Deficient\u27 serum vitamin D levels. These results suggest a therapeutic role for vitamin D in the treatment of TB

Atypical pathogens causing community-acquired pneumonia in adults.

Objective: To determine the frequency of community-acquired respiratory pathogens with special focus on atypical organisms in patients presenting to a tertiary care facility with community-acquired pneumonia (CAP). Methods: The descriptive study on adult patients was conducted from February 2007 to March 2008 at the Aga Khan University Hospital, Karachi. It comprised 124 consenting patients of age 16 and above who presentd with a diagnosis of community-acquired pneumonia. The diagnostic modalities used were based on significant changes in antibody titer or persisting high antibody titers in the case of Mycoplasma pneumoniae and Chalmydia pneumoniae infections, or bacterial antigen in urine, in the case of Legionella pneumophila serogroup 1 infection. Pyogenic bacteria were identified on the results of respiratory secretions or blood cultures. Continuous data and categorical variables were worked out using SPSS version 15. Results: Among the 124 patients enrolled, an etiologic agent was identified in 44 (35.4%) patients. The most common organism was Mycoplasma pneumoniae (n=21, 17%), followed by Chlamydia pneumoniae (n=15, 12%), Streptococcus pneumoniae (n=9, 7%), Haemophilus influenzae (n=2, 1.6%), Klebsiella pneumoniae (n=2, 1.6%) and Staphylococcus aureus (n=1, 0.8%). Streptococcus pneumoniae was the most common organism isolated from blood cultures. No cases of Legionella pneumophila serogroup 1 were identified. Conclusions: Mycoplasma pneumoniae and Chalmydia pneumoniae are significant etiologic agents for community-acquired pneumonia occurring in Karachi. Local treatment guidelines for community-acquired pneumonia should include therapy directed specifically at these agents

Impact of antibiotic restriction on broad spectrum antibiotic usage in the ICU of a developing country

Objective: To reduce rates of nosocomial pneumonia and cost of antibiotic therapy. Methods: By means of a policy implementation the following broad spectrum antibiotics were restricted to usage in the ICU for 72 hours: Cefepime, Meropenem, Imipenem, Tazocin, Polymixin B and Vancomycin, after an institutional based pharmacy and therapeutic committee approval. The ICU pharmacist would alert the ICU residents or consultants after 48 hours of the computer based antibiotic entry that the order would expire within hours. Telephone approval was obtained followed by a formal consultation if deemed necessary by the ID specialist or primary team. Antibiotic usage was standardized by defined daily doses (DDDs) per 1000/patient-days. Results: A cumulative 34% reduction was seen in the use of all broad spectrum antibiotics in our ICU after the enforcement of the antibiotic restriction policy. The largest reduction was seen in the use of Tazocin (190 DDDs) and Meropenem (60 DDDs). The policy resulted in a reduction by 40% of overall broad spectrum antibiotic pharmacy costs. The number of multidrug resistant organisms has remained static but the ventilator associated pneumonia rates have declined.Conclusion: Streamlining the formulary to control antibiotic choices and the creation of a restriction program using the expertise of infectious disease physicians resulted in significant reductions in the use of and expenditure for broad spectrum antibiotics (JPMA 57:484:2007)

Variables predictive of outcome in patients with acute hypercapneic respiratory failure treated with noninvasive ventilation.

Objective: To assess results with NIV in acute hypercapneic respiratory failure and to identify outcome predictors. Methods: This was a retrospective observational study on consecutive patients presenting with acute type II respiratory failure and meeting criteria for NIV use over a 5 year period. Patients presenting with haemodynamic instability, inability to protect their airway, malignant arrhythmias and recent oesophageal surgery were excluded. Univariate and Multivariate regression analysis was used to determine the impact on survival. A p value of \u3c 0.05 was considered statistically significant. Software used was SPSS 14. Results: Total numbers of patients included were 119; 52.9% were males. Mean age was 63.4 ± 11.9 years. Overall Survival to discharge rate was 76.5%, intubation rate was 12.6% and mean length of stay was 11.4 ± 10.9 days. Statistically significant improvements were observed in the pH and PaCO2 at 24 hours and 48 hours compared to baseline (7.28 v/s 7.37, p\u3c0.001; 74.2 v/s 65, p\u3c0.001). On multivariate regression analysis, sepsis at admission predicted mortality (adjusted Odds ratio 26.4; 95% CI 2.3, 304, p \u3c 0.009). A serum HCO3 \u3e 35 Meq/L (adjusted Odds ratio 0.9; 95% CI 0.83, 0.98, p \u3c 0.015) identified those less at risk for intubation. Conclusion: NIV was found to be both safe and effective in the management of acute hypercapneic respiratory failure. Sepsis and serum HCO3 at admission identified patients having poor outcome