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Background:Acute onset fever with altered mentation is a common problem encountered by the physician practicing in tropical countries. Central nervous system (CNS) infections are the most common cause resulting in fever with altered mentation in children.Aim:In this study, we have tried to analyze the cause of encephalopathy following short febrile illness in adults presenting to a tertiary care center in Northwestern part of India.Setting and Design:A prospective observational study carried out in a tertiary care center in the Northwestern India over a period of 1 year.Material and MethodsA total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months. The demographic variables were recorded in detail. In addition to routine investigations, cerebrospinal fluid analysis, noncontrast- and contrast-enhanced computed tomography, along with magnetic resonance imaging were performed in all the subjects.Statistical AnalysisThe results were analyzed using SPSS statistical software. The values were expressed as mean with standard deviation for contiguous variable as percentage for the others.Results and ConclusionOut of these, 70% had primary CNS infection as the etiology. A total of 33% patients had meningitis, 29.9% had evidence of meningoencephalitis, and 12.7% were diagnosed as sepsis-associated encephalopathy. These were followed by cerebral malaria, leptospirosis, and brain abscess as the cause of febrile encephalopathy in adults. Among the noninfectious causes, acute disseminated encephalomyelitis, cortical venous thrombosis, and neuroleptic malignant syndrome were documented in 2.36% each. In 11% of the patients, the final diagnosis could not be made in spite of the extensive investigations. Our study demonstrates that acute febrile encephalopathy in adults is a heterogeneous syndrome with primary CNS infections being the commonest etiology.

Aim:To compare “consultation” and “hybrid” models of consultation-liaison (CL) services provided to patients visiting the medical emergency outpatient services.Materials and Methods:Over the period of 18 months, two different models of consultation psychiatry services (July 2012 to March 2013-consultation model, April 2013 to December 2013 hybrid model) were compared. In the consultation model, the psychiatry resident was available on call to the internists. Whereas, for the hybrid model psychiatry resident was stationed in the medical emergency and was available to assess the patients directly requiring psychiatric evaluation.Results:During the first 9 months, 22,000 patients were evaluated in various emergency medical outpatient services, of which 383 (1.74%) were referred to the on-call psychiatry CL team. However, when the hybrid model was followed, the number of patients evaluated by the psychiatry resident increased to 594 out of 24,737 patients (2.4%) who reported to the emergency during the next 9 months period. There was a substantial increase in the proportion of cases with medical illnesses for which psychiatric consultation was sought, and a change in psychiatric diagnostic profile was observed too. When compared to the consultation model, the hybrid model was associated with greater use of medications, investigations, referrals and psychological measures in the emergency setting itself.Conclusions:Following a hybrid model in the medical emergency leads to an increase in the number of total psychiatric consultations and more extensive management of patients.

The magnitude of azole resistance in Aspergillus flavus and its underlying mechanism is obscure. We evaluated the frequency of azole resistance in a collection of clinical (n = 121) and environmental isolates (n = 68) of A. flavus by the broth microdilution method. Six (5%) clinical isolates displayed voriconazole MIC greater than the epidemiological cutoff value. Two of these isolates with non-wild-type MIC were isolated from same patient and were genetically distinct, which was confirmed by amplified fragment length polymorphism analysis. Mutations associated with azole resistance were not present in the lanosterol 14-α demethylase coding genes (cyp51A, cyp51B, and cyp51C). Basal and voriconazole-induced expression of cyp51A homologs and various efflux pump genes was analyzed in three each of non-wild-type and wild-type isolates. All of the efflux pump genes screened showed low basal expression irrespective of the azole susceptibility of the isolate. However, the non-wild-type isolates demonstrated heterogeneous overexpression of many efflux pumps and the target enzyme coding genes in response to induction with voriconazole (1 μg/ml). The most distinctive observation was approximately 8- to 9-fold voriconazole-induced overexpression of an ortholog of the Candida albicans ATP binding cassette (ABC) multidrug efflux transporter, Cdr1, in two non-wild-type isolates compared to those in the reference strain A. flavus ATCC 204304 and other wild-type strains. Although the dominant marker of azole resistance in A. flavus is still elusive, the current study proposes the possible role of multidrug efflux pumps, especially that of Cdr1B overexpression, in contributing azole resistance in A. flavus.