Laparoscopic Management Of Pancreatic Pseudocysts A Novel Technique Using Titanium Clips Our Experience

Pseudocysts of pancreas is collection of fluid in the lesser sac enclosed by a wall of fibrous or granulation tissue as a consequence of acute pancreatitis, pancreatic trauma or chronic pancreatitis. Invasive drainage procedures are currently indicated in those patients with symptoms or complications. We present our experience of 26 cases of pseudocyst of pancreas managed laparoscopically between Nov-2014 to March-2016 using different techniques of anastomosis using Vicryl 2-0 continues sutures as well as using Titanium clips for creating stoma between anterior wall of pancreatic pseudocyst and posterior wall of stomach. Laparoscopic cysto-gastrostomy appears to be safe and effective approach for internal drainage of pancreatic pseudocyst. It also facilitates the debridement of the necrotic tissue from the cyst cavity. Use of Titanium clips can be an alternative to conventional sutured cystogastrostomy and stapled cystogastrostomy, as it is less time consuming, easy to perform and cost effective

Men who have sex with men and transgenders in Mumbai, India: an emerging risk group for STIs and HIV.

BACKGROUND: Men who have sex with men and transgenders are an important risk group for sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). They have risky sexual behaviors but low risk perception. OBJECTIVES: To assess the sexual behavior, STIs, HIV and identify factors associated with HIV in men who have sex with men (MSM) and transgenders (TGs) in Mumbai. METHODS: Participants were enrolled from two clinics in Mumbai. They completed an interviewer-administered questionnaire and were evaluated for STIs and HIV infection. RESULTS: A total of 150 participants, 122 MSM and 28 TGs were evaluated; 17% of MSM and 68% of the TGs were HIV infected. HIV infection in MSM was associated with serological positivity for HSV2 IgG [adjusted odds ratio (aOR), 95% confidence interval (CI): 9.0 (2.2-36.9)], a positive Treponema pallidum hemagglutination assay (TPHA) [aOR (95% CI): 6.0 (1.5-24.0)], greater than five acts of receptive anal sex in the past six months [aOR (95% CI): 4.3 (1.2-15.0)] and per category increase in age (18-24 yrs, 25-29 yrs, > 30 yrs) [aOR (95% CI): 3.1 (1.3-7.1)] in multivariate analysis. Consistent condom use during receptive anal sex in the past six months was low (27%). Many MSM were married (22%) or had sex with females and may act as a 'bridge population'. HIV infection in TGs was associated with a positive TPHA [OR (95% CI): 9.8 (1.5-63.9)] and HSV 2 IgG [OR (95% CI): 6.7 (1.1-40.4)] in univariate analysis. CONCLUSION: Prior STIs were strongly associated with HIV infection in MSM and TGs. These groups should be the focus of intensive intervention programs aimed at STI screening and treatment, reduction of risky sexual behavior and promotion of HIV counseling and testing.

Diagnostic role of stool culture & toxin detection in antibiotic associated diarrhoea due to Clostridium difficile in children.

BACKGROUND & OBJECTIVE: Mere diagnosis of Clostridium difficile by culture does not help in the diagnosis of antibiotic associated diarrhoeae (AAD) due to C. difficile. Detection of toxins A and B form the mainstay in the diagnosis of AAD due to C. difficile. This study was undertaken to find out the role of stool culture and toxin detection in the diagnosis of AAD due to C. difficile. As there are very few documented reports from India about AAD due to C. difficile in children in the age group of 5-12 yr, this age group was selected. METHODS: Faecal samples were collected from 250 hospitalized children in the age group of 5-12 yr who developed diarrhoea on receiving antibiotics for different medical problems for more than five days duration. Also faecal samples of 250 age and sex matched controls were collected. Culture for C. difficile was done on cycloserine cefoxitin fructose egg yolk agar (CCFA) and colonies were identified by standard laboratory techniques. ELISA for toxins A and B detection and tissue culture on HeLa cells for toxin B detection were also done. RESULTS: Overall positivity was 18 per cent in this study group compared to the controls (P<0.001). Maximum positive cases were in 5-8 yr age group (84.4%). Severe diarrhoea, liquid stool with mucus and blood, faecal leucocytes >5/high power field, altered flora and presence of Gram-positive bacilli with oval subterminal spores on Gram stain were sensitive predictors for diagnosis of AAD due to C. difficile. Amongst positive cases, 68.9 per cent responded to discontinuation of antibiotics and 31.1 per cent to metronidazole therapy. INTERPRETATION & CONCLUSION: C. difficile was an important pathogen responsible for antibiotic associated diarrhoea (AAD) in children of 5-12 yr age group. Conservative use of antibiotics would be beneficial to decrease the incidence of AAD.

Helicobacter pylori in duodenal ulcer disease and its eradication.

Antral biopsy specimens were processed for Helicobacter pylori by Gram staining, rapid urease test (RUT) and culture from 25 patients with symptoms of duodenal ulcer, amongst whom the positivity rate was 84%. Follow up of 16 patients after appropriate therapy showed complete regression of the disease in 87.5% of cases whereas in 12.5% of cases a decrease in the extent of duodenal ulceration was noted.

Aeromonas species isolated from cases of acute gastroenteritis.

A total of 67 Aeromonas strains were isolated as the sole bacterial pathogen from1485 patients with acute gastroenteritis. A. hydrophila (64.2%) was the predominant isolate followed by A. sobria (28.4%) and A.caviae (7.4%). Majority of the isolates were sensitive to gentamicin, nalidixic acid but were resistant to ampicillin. Minimum inhibitory concentration (MIC) of resistant strains of Aeromonas to ampicillin ranged from 80-1280 microg/mL.

Prevalence of gram negative anaerobic bacilli in routine clinical specimens.

A total of 206 gram negative anaerobic bacilli were isolated from 2591 routine clinical specimens. Majority of them (78.2%) were part of a mixed flora. A high incidence of gram negative anaerobic bacilli was found in post-operative wound infections and diabetic foot infections (30.1%), followed by necrotizing fasciitis and crush injuries (18%), pus of empyema and lung abscesses (14.5%) and aspirates from other deep abscesses (10.7%). Bacteroides fragilis was the most frequently recognized species (42.2%), followed by Fusobacterium sp. (17.4%), Prevotella sp. (15.1%) and Porphyromonas sp. (11.2%). Neomycin blood agar plate yielded the maximum number (72.8%) of strains in pure culture. Gram negative anaerobic bacilli in infective processes are significantly on the rise and so suspected cultures should be processed for both aerobic and anaerobic organisms.

Prevalence, identification and distribution of various species of enterococci isolated from clinical specimens with special reference to urinary tract infection in catheterized patients.

Various clinical specimens were processed to find the prevalence rate of enterococci and to identify the species of clinical isolates of enterococci. Screening of various clinical specimens revealed that enterococci were prevalent in 22.19% of the total specimens, with Foley's catheters and burn wounds to be the major site of isolation. High rate of colonization was noted as opposed to infection. Conventional test scheme proposed by Facklam and Collins were successfully used to speciate enterococcal strains. Seven species of enterococci were identified in the study from a set of 202 cultures, with E.faecalis (49.50%) and E. faecium (35.64%) predominating. E. avium (9.40%), E.hirae (2.47%), E.raffinosus (1.98%) and one isolate each of E.gallinarum and E. casseliflavus were the other members of Enterococcus species identified. Urinary tract infection (UTI) by enterococci due to catherisation was found in 8.92% of the patients and is probably the result of high rate of colonization of Foley's catheters and use of broad-spectrum antibiotics.

Brucella spondylitis: an important treatable cause of low backache.

OBJECTIVES: This study was undertaken to see if brucella spondylitis existed as a cause of backache in Mumbai and to identify the clinical setting in patients of backache where brucella serology is indicated. METHODS: In 18 months (June 1996-Dec. 1997) we performed tube agglutination test (TAT) for Brucella melitensis and abortus on 72 patients of low backache from Orthopaedics Department of a teritary health centre. All 72 patients satisfied the inclusion and exclusion criteria designed to exclude radiologically detectable congenital or degenerative cause of backache. RESULTS: Six out of 72 patients were seropositive for brucellosis. All six patients had either history of animal contact or ingestion of raw milk or milk product (cheese or paneer). The lumbosacral backache was severe, radiating to the legs and straight leg raising test was significantly positive, they had marked tenderness on spinous process of lower lumbar vertebrae. Changes of brucella spondylitis were present on plain radiogram of lumbosacral spine in three patients. Four patients had abnormalities on bone scintigraphy. CONCLUSION: Low backache of brucella spondylitis closely simulates pain of prolapsed intervertebral disc. Serologic testing for brucellosis is an important step in management of such patients, especially when history of animal contact or raw milk or milk product ingestion is present, as the disease can be eminantly treated with antibiotics.

Drug resistance to the first line of antitubercular regimen (a preliminary report).

Sputum samples from 100 patients of pulmonary tuberculosis were processed. These patients were admitted in group of Tuberculosis Hospital at Sewri, Mumbai, which is a referral tuberculosis hospital. Isolates were identified as M. Tuberculosis by biochemical tests. Antitubercular sensitivity testing for Isoniazid, Rifampicin, Ethambutol and Streptomycin was performed by resistance ratio method. Total resistance was 36% in our study. Resistance to Isoniazid was 61%: to Rifampicin was 50%, to Ethambutol was 8% and to Streptomycin was 41%. Primary drug resistance to Isoniazid was 45% to Rifampicin was 27%, to Ethambutol was 9%, and to Streptomycin was 54%. Secondary drug resistance to Isoniazid was 68% to Rifampicin was 60%, to Ethambutol was 8% and to Streptomycin was 36%. Secondary drug resistance to Isoniazid and Rifampicin is rising as compared to primary drug resistance to Isoniazid and Rifampicin. This is statistically significant (p < 0.001). 11 out of 36 cases (30%) showed multi drug resistance to Isoniazid and Rifampicin.

Standardization of a dot blot immunoassay for antigen detection in cases of pulmonary tuberculosis & its evaluation with respect to the conventional techniques.

A simple dot (blot) ELISA test for detecting tubercular antigen in sputum samples of patients of pulmonary tuberculosis has been standardized using nitrocellulose paper. The sensitivity of the assay is 20 ng/ml. The cut-off value was 80 ng/ml. Of the 1042 patients in the study group, the percentage positivity by smear and culture was 54.51 and 57.93 per cent respectively; 68.7 per cent of the ELISA positives were confirmed by smear. The dot blot ELISA could be used as a rapid and specific test as it not only picked up 88.88 per cent of the smear positive, culture positive cases but also 81.89 per cent of the smear negative, culture positive cases. If the results of smear and dot blot ELISA are combined, 91.08 per cent of the culture positive cases were picked up as positive. If such a noninvasive test is commercialized and used in conjunction with smear, the pick up rate of tuberculosis cases will improve considerably.

Anaerobic bacteraemia: a review of 17 cases.

Of 93 blood cultures received with a suspicion of anaerobic bacteraemia over a period of two years, only 17 (18.3%) showed anaerobic growth. Twelve grew anaerobes alone while five had a polymicrobial flora. Seven of these patients (4.3%) had pre-existing heart disease while others had history of prior surgery, diabetes mellitus or urinary tract infection. Oropharynx was the commonest portal of entry, followed by gastrointestinal tract. The anaerobes isolated were anaerobic streptococci, Bacteroides fragilis group and Bilophila and Eubacterium species. Fifteen patients developed major complications such as congestive cardiac failure, systemic embolisation, and perforative peritonitis. The mortality rate among the cases with anaerobic bacteraemia was 23.5% in this study.

C-reactive protein and buffy coat smear in early diagnosis of childhood septicemia.

Out of 200 cases of septicemia in children (age group 0-14 years), 111 had positive C-Reactive Protein (CRP > 12 mg/l) and 84 were buffy coat smear positive. Blood culture was positive in 98 cases, with predominant organism being Klebsiella pneumoniae, followed by Staphylococcus aureus. CRP test showed 100% sensitivity and 87.3% specificity, while buffy coat smear showed 76.5% sensitivity and 91.2% specificity. As blood culture reports are not available before 48-72 hours, combination of CRP test and buffy coat smear examination will be very helpful in early diagnosis of childhood septicemia.

Early detection of tuberculous meningitis using one step competitive ELISA.

A one step competitive Enzyme-Linked Immunosorbent assay (ELISA) method was developed to detect mycobacterial antigen in cerebrospinal fluid (CSF) for the diagnosis of tuberculous meningitis and compared with a standard competitive ELISA method. Indigenously prepared soluble extract of Mycobacterium tuberculosis H37 Rv was used as antigen. The study was conducted using CSF of 230 clinically diagnosed cases of tuberculous meningit is and 208 control subjects. A cutoff value of 0.57 ng/ml by the one step ELISA and 0.5 ng/ml by the standard ELISA method were determined. The specificity of both methods were 100% and positivity was 68.26% and 70.43% respectively. A follow up study was conducted in 63 cases at various interval of time after starting anti-tubercular therapy i.e. at 3 weeks (63 cases), 6 weeks (27 cases) and > or = 4-12 months (13 cases). It was observed that antigen levels decreased gradually, but were much above the cutoff range. Indigenously prepared antigen was compared with antigen prepared in other laboratories and standard molecular weight markers using SDS PAGE (Sodium Do-decyl Sulphate Polycrylamide Gel Electrophoresis).

Viability testing of homograft valves using methyl thiazol tetrazolium assay.

Viability status before and after treatment with antibiotics was investigated in a total of 104 homograft valves using MTT (3-[4, 5-dimethyl thiazol-2-y1]-2, 5-diphenyl tetrazolium bromide). The valves with warm ischaemic time above 11 hours, were found to be non-viable. Increase in storage time directly decreases cell viability. Methyl thiazol tetrazolium (MTT) assay can be used as a reliable, simple, rapid and economic method for assessing the viability status based on mitochondrial respiration even for homograft valves. Basal media with and without nutrients i.e., DMEM and Hanks BSS showed no difference in viability of the cells.

Acanthamoeba keratitis.

Acanthamoeba keratitis, common in soft lens wearers, is not commonly isolated. The reports of Acanthamoeba keratitis in Indian literature are few. We report here a case of Acanthamoeba Keratitis in a medical student using soft contact lenses, initially diagnosed and treated as a bacterial and later as a viral corneal ulcer, who responded extremely well to medical line of therapy.

Microbiological evaluation of women with bad obstetrics history.

In the present study a total of 300 pregnant women were evaluated, 200 women with bad obstetrics history (BOH) and 100 clinically normal women. Cervical culture studies, as well as serological evaluation was carried out in each woman. It was noted that among the various microbial agents detected, the presence of genital mycoplasmas, chlamydia, Toxoplasma gondii and cytomegalovirus was significant. Foetal outcome could be noted in some of the BOH patients. Toxoplasmosis was associated with complete abortion (38%), stillbirths (6%), premature delivery (16%) and congenital anomalies (6%). Cytomegalovirus infection was associated with complete abortion (41.66%), preterm delivery (33.33%) and congenital anomalies (8.33%). Ureaplasma infection in BOH patients resulted in preterm delivery with premature rupture of membranes in 45 per cent of women and complete abortion in 35 per cent.

Detection of Chlamydia trachomatis antigen & Toxoplasma gondii (IgM) & Mycoplasma hominis (IgG) antibodies by ELISA in women with bad obstetric history.

A total of 365 non pregnant women with bad obstetrics history (BOH) were studied with a control group of 100 women who had delivered full term clinically normal infants. The presence of C. trachomatis antigen and T. gondii (IgM) and M. hominis (IgG) antibodies was assessed by ELISA test. C. trachomatis antigen was detected in 28.2 per cent of women with BOH whereas T. gondii and M. hominis specific antibodies were found in 43.83 and 27.1 per cent respectively, these were highly significant (P < 0.001) in comparison with the control group. In case, facilities for culture are not available then detection of antigen and IgM class of antibodies by ELISA can pinpoint current infection.

Enzyme-linked immunosorbent-assay for antigen detection in tuberculous meningitis.

Two systems of Competitive Enzyme linked immunosorbent assay (ELISA) were developed to detect Mycobacterial antigen in cerebrospinal fluid (CSF) for the diagnosis of tuberculous meningitis (TBM)--one by using indigenously prepared Anti-M.tuberculosis H37Rv-Penicillinase conjugate (Method I) and another by using commercially available Anti M. bovis BCG-Horse Radish Peroxidase (HRP) conjugate--(Method II). The tests were used to analyse CSF of 148 patients clinically confirmed as having TBM and 278 control subjects. By using > or = 10 ng/ml as the cut-off value for Method I and > or = 1 ng/ml as that for Method II, the specificity for both were 100% and positivity was 79.73% and 67.57% respectively. A follow up study in 26 TBM cases after 2 weeks (16 cases), 4 weeks (13 cases) and 4-12 months (10 cases) of antituberculous treatment revealed that mycobacterial antigen persisted in the majority of cases even after 4 weeks of the treatment.