Delayed presentation of enterocutaneous fistula after tubal ligation: a case report

A 50-year-old woman with a history of tubal ligation nine years earlier, presented with a complaint of discharge from the scar site. She was found to have an enterocutaneous fistula. The patient underwent an exploratory laparoscopy. The tract excised and primary repair of bowel done. A unique feature of the case is the formation of an enterocutaneous fistula after an extremely long latency due to gauze threads, which has not been previously reported in the literature.

Management of extensive nerve gaps of more than 5 cm by vein graft in three cases

The aim of this study was to evaluate the effectiveness of use of extensive vein grafts to manage nerve gap repair. The study on peripheral nerve injury has been carried out in this country as well as abroad for many years, but the use of veins as the conduit is more than three decades old and still in evolving phase for standard clinical procedure. Its application is simple and regeneration of nerve is quite satisfactory specially for nerve gap of less than 5 cm. However, the present study was done on extensive nerve gaps of more than 5 cm to 10 cm gaps specially of after long duration of injury to see the results. Inspite of poor results due to extensive nerve gap and treatment tried after long duration of injury, it is quite encouraging to see nerve growth in biopsy of one venous tube and it is great achievement for future study. As of now any vein tube applied for nerve gap of more than five cm is not successful. So successful use of venous tubes is still in infancy for nerve gap of more than 5 cm.

The Naval Stone: A hidden culprit for umbilical abscess

A rarely encountered benign entity, the omphalolith has been endowed several names like omphalo-keratolith, umbilical bolus and naval stone. We hereby discuss two cases of omphalolith who presented with secondary infection and infra-umbilical sepsis.

Isolation Of Methicillin-Resistant Staphylococcus Aureus From Neonatal Sepsis At A Tertiary Care Hospital

Introduction: Septicemia is the significant cause of morbidity and mortality in the neonates and is responsible for 30-50% of totalneonatal deaths .Each year in developing countries. It is estimated that 20% of all neonates develop sepsis and approximately1% die of sepsis related causes.In India, according to National Perinatal Database the incidence of neonatal septicemia has beenreported to be 30/1000 live births. The emergence of methicillin resistant Staphylococcus aureus (MRSA) in neonatal patientsis increasing. Early diagnosis and appropriate therapy of septicemia is of utmost importance to prevent morbidity and mortality.Aim and Study: It was to find out the bacteriological profile in neonatal sepsis and study their antimicrobial susceptibilitypattern including detection of MRSA.Methods: This study was conducted for a period of one year in the department of microbiology in a tertiary care hospital. A totalof 283 blood samples were collected using sterile precautions They were processed following standard laboratory protocol.Antibiogram was done using appropriate antibiotics by Kirby-Bauer disc diffusion method. Isolated of Staphylococcus aureuswere tested for methicillin resistance.Results : Blood from 283 neonates with the clinical signs and symptoms of sepsis were collected and samples were processed.Out of which 96 (33.92%) were culture positive.Total 53 (55.2%) Staphylococcus aureus were isolated out of which 27 (50.94%)were MRSA (Methicliin Resistant Staphylococcus aureus).Acinetobacter spp.was isolated in 15 (15.62%) cases.Klebsiella spp.was isolated in 13 (13.54%) cases. Psedomonas spp. was isolated in 3(3.12%) case . Antibiotic sensitivity test of MRSA wasdone and all MRSA isolates were sensitive to Vancomycin.Conclusion: Multidrug resistance among the isolates was common. Early diagnosis and institution of specific antibiotics afterstudying the sensitivity pattern will help in reducing neonatal morbidity and mortality and prevent emergence of drug resistantstrains. An effective infection-control programme, regular antibiotic susceptibility surveillance ,evaluation, and the enforcementand periodic review of the antibiotic policy of the hospital as well as the encouragement of rational antibiotic use will reducethe rates of development of bacterial resistance.

Bacteriological Profile and Antibiogram of Gram Negative Bacteria Isolated from Blood Culture

Introduction: Blood stream infections are one of the important cause of morbidity and mortality all over the world. Bacteraemia ranges from self-limiting infections to life-threatening septicaemia that requires rapid and aggressive antimicrobial treatment. The mortality rate ranges from 20% to 50% in cases of bacteraemia infections. Aim and Objective: The present study was undertaken to know the profile of gram negative organism causing  bacteraemia with their Antibiogram from suspected cases. Material and Method: During a one-year period, 400 blood samples were taken from bacteraemia suspected patients. Blood culture was done by using BacT/Alert 3D system.  Further identification of organism was done by different biochemical test. Antimicrobial sensitivity pattern was determined by Kirby Bauer Disc Diffusion method according to CLSI guidelines. Result: Out of 400 samples, the total number of culture positive cases were found to be 131 giving culture positive rate of 32.75%. Gram positive organism were more than gram negative organism, constituting about 75 (57.69%) of total isolates. 56(42.74%) Gram negative organism were isolated in this study. Most frequent pathogen identified among gram negative bacteria were Klebseilla 24(42.8%), followed by E. coli 18(32.14%), Acinetobacter 10(17.85%), Pseudomonas 2(3.57%) and Salmonella 2(3.57%) respectively. Isolated gram negative organism was highly sensitive to Polymyxin B 51(91.07%). After Polymyxin B isolated gram negative bacteria show high sensitivity for Levofloxacin(60.71%), Cefixime (57.78%), Gentamicin, Meropenem, Piperacillin/tazobactum (50%), Cefepime (44.64%) with least sensitivity for Ampicillin/Sulbactum (14.28%). Conclusion: The present study provides information about gram negative pathogens responsible for blood    stream infection along with their sensitivity towards commonly used antimicrobial. Antibiotic sensitivity pattern of isolates provides useful guidelines to clinicians in initiating empiric therapy and help in management of blood stream infections.

Isolation, Identification and Drug Resistance Testing of Mycobacterium tuberculosis by Recent Diagnostic Modalities at Teaching Hospital in Moradabad (UP).

Objective: Tuberculosis is the second leading cause of death in developing countries among all infectious diseases. Globally, drug resistance strain of Mycobacterium tuberculosis is a public threat. Due to diagnostic delay, inadequate infection control and poor drug supply there is a emergence of MDR- TB and XDR- TB. Our aim was to isolate and identify the drug resistant strain of M. tuberculosis by using newer diagnostic modalities. Methods: Sputum sample and BAL fluid from 70 suspected cases were collected and analysed for Mycobacterium by Ziehl – Neelsen staining and liquid culture with molecular detection of drug resistant strain of M. tuberculosis. Result: In our study, among the 70 patients 27 (38.5%) were positive for AFB by microscopy. On testing for Mycobacterium by BacT/Alert 3D system, 54 were found to be positive. On performing further identification and susceptibility of 54 isolates towards rifampicin and isoniazid by molecular method, 5 isolates (9.25%) were resistant to both rifampicin and isoniazid confirming as multidrug resistant. 5 isolates (9.25%) were sensitive to rifampicin and resistant to isoniazid and 2 isolates (3.70%) were resistant to rifampicin and sensitive to isoniazid. Whereas 5 isolates (9.25%) found to be negative for M. tuberculosis. Conclusion: Our investigation highlights the importance of newer diagnostic modalities for isolation and identification of drug resistant strain of M. tuberculosis. Which ensure early and accurate diagnosis of patients with prevention of further transmission of disease.

The Effect of Gallstone Presentation on Treatment Outcome in Symptomatic Cholelithiasis

Introduction: Gall stone disease (GSD) is a common surgical problem. Surgical treatment of  asymptomatic GSD is still controversial. Complicated GSD has varied presentation and contributes substantially to healthcare costs and may be life threatening. The present study is aimed to know the effect of gall stone presentation on treatment outcome. Methodology: This is a retrospective study conducted in a tertiary health care centre. All patients who underwent cholecystectomy (open or laparoscopic) were included in the study and were grouped in uncomplicated (Group A) and complicated group (Group B), depending upon their presentation. Treatment outcome was analysed for various measures i.e. type of admission (emergency or elective), length of hospital stay, postoperative complications, type of surgery and mortality. Observations: Out of the 202 patients, 109 (53.9%) were in group A and 93 (46.1%) were in group B. Acute cholecystitis comprised 30.1% of complicated GSD, whereas gall stone pancreatitis, choledocholithiasis, mucocele, empyema gall bladder, perforation and gall stone ileus comprised 6.9%, 2.9%, 3.9%, 0.9%, 0.4% and 0.4% respectively. Comparatively, patients with uncomplicated GSD were admitted electively, were mostly managed laparoscopically and had lower incidence of post-operative complications and hence shorter length of hospital stay and lower treatment cost. Conclusion: Most of the patients who present early in course of GSD have better treatment outcome. We recommend early elective laparoscopic surgery for all patients who present with initial symptoms of GSD.

Prevalence of shoulder disorders in tertiary care centre.

Background: Shoulder pain is the third most common musculoskeletal condition has a lifetime prevalence of up to 70% and this seems to be increasing in incidence. The diagnosis of these disorders is based primarily upon results of clinical tests. The prevalence of shoulder pain in India has not been reported. The aim of present study is to study and report the prevalence of various disorders causing shoulder pain in patients reporting to a tertiary care hospital in North India. Methods: This is a prospective hospital based cross-sectional study carried in a tertiary care hospital and 130 patients satisfying inclusion criteria over a period of two year were included. Results: Age of patients ranged between 23-69 years (51.36 ± 11.86 years). A predominance of females was observed (Male-Female ratio: 0.81:1). The commonest cause of pain was periarthritis shoulder (43.1%), subacromial (SA) impingement (13.8%), acute rotator cuff injury (13.1%), GH arthritis (10.0%) and AC Arthritis (8.5%). The major risk factors were diabetes mellitus, excessive overhead lifting and trauma. Conclusion: Periarthritis and subacromial pain syndrome are two most common diagnoses reporting to a tertiary care centre. Periarthritis is the commonest diagnosis in both genders. AC arthritis is more common in females (P <0.001) and rotator cuff injury is more in males (P <0.001). Periarthritis, GH arthritis and AC arthritis is much more common in fifth and sixth decades and rotator cuff injury is seen in young adults.

Correlation between WOMAC score and hyalrunoic acid levels in knee osteoarthritis.

Background: Osteoarthritis, a whole organ disease is diagnosed on clinical and radiological features, but plain radiographs show changes only in moderate to advanced stage of disease. Biochemical marker such as Hyaluronic Acid (HA) is used as a diagnostic tool in early stages. Hyaluronic acid level estimation has limited use in developing world due to cost and availability. Methods: A case-control study was done to correlate role of WOMAC score and serum Hyaluronic acid levels in knee osteoarthritis. All subjects were asked to fill the WOMAC questionnaire and were subjected to knee radiography. Blood samples of all subjects were tested for serum levels of Hyaluronic acid by Enzyme Linked Immuno-Sorbent Assay (ELISA). The assessment of severity was done by K-L grading of the radiographs. Results: The mean age in case group was 51.28 ± 7.93 years and in control group was 46.08 ± 4.81 years (P <0.001). A statistically significant difference in WOMAC score, HA levels and K-L grading of cases and controls was found (P <0.001). The results show a mild association of HA (r=0.421), moderate association of age (r=0.570), and strong association of K-L grade (r=0.910) with WOMAC scores and all these associations were highly significant (p<0.001). Multivariate analysis shows only WOMAC score >60 is independently associated with the outcome. Conclusion: WOMAC scores are significantly associated with knee osteoarthritis and can play a crucial role in identification, gradation and management of patients with knee osteoarthritis and can be used singly along with clinical features in situations where treatment cost and assessment of serum HA levels is of concern.

Validation of Ponseti method for clubfoot deformity correction.

Background: Idiopathic Congenital Talipes Equino-Varus (CTEV) is a complex deformity of foot that is difficult to treat. The goal of treatment is to gain a functional, pain free, plantigrade foot, with good mobility and without callosities. Currently, the most accepted and popular method is the Ponseti method which allows correction of all components of CTEV by manipulation and serial casting without any major surgical intervention. This prospective study was done in a tertiary care centre to statistically assess the efficacy of Ponseti method. Methods: We treated 150 children (210 feet) with idiopathic clubfoot deformity, using Ponseti technique. The severity of foot deformities were assessed by Pirani scoring system and were also recorded clinically, radiologically and podographically. The changes in the mean Catterall-Pirani scores at different follow ups were evaluated statistically. Results: The mean number of casts that were applied to obtain correction was 7.86 (range 5 to 11 casts). Percutaneous tendoachilles tenotomy was done in 70% of feet. All children were given foot abduction orthosis after the correction. The results were graded according to Ponseti and Smoley criteria. Good results were obtained in 83% of feet, acceptable results in 7% of feet and poor results in 10% of cases. Statistically significant correction was achieved in manipulation and casting stage which was maintained during bracing phase. The recurrences of the deformity were primarily due to poor compliance in the use of orthosis in post correction phase. Conclusion: The Ponseti method of correction is a safe and effective treatment for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery. Non-compliance with orthotics is the main factor causing relapse of the deformity.

Fibro-osseous pseudotumor of the digit.

Fibro-osseous pseudotumor of the digit is a very rare benign lesion however it may be a cause of concern as it forms differential diagnosis to aggressive bone forming tumors like extraskeletal osteosarcoma. Till date only a few cases have been reported in the literature. We came across a case of 7yr old female presented with complains of post traumatic progressively growing hard swelling present on the palmar surface of the hand at the hypothenar region for last 6 months. Investigations i.e. X-rays, MRI and CT scan were done along with other blood investigations to rule out other common diseases such as exostosis or myositis ossificance or extraskeletal osteosarcoma. Excisional biopsy of the lesion confirmed the diagnosis of fibro-osseous pseudotumor of the digit.

Study on association of polymorphism of CYP450 2D6 with head and neck cancer and treatment response in patients receiving neoadjuvant chemotherapy paclitaxel, cisplatin, 5fu (TPF) followed by chemoradiation.

Background: Aims of this study were to study the association of genetic polymorphism in CYP450 2D6 in patients of locally advanced head and neck cancer, and try to assess a correlation between this polymorphism & response to treatment. Need of the study was to find out a possible genetic level explanation for the different response achieved in patients with similar histopathology, stage, exposure to carcinogen & ethnicity undergoing similar treatment. Methods: A study comprising of 150 patients & 150 controls was done to analyze the association between polymorphs of CYP450 2D6 with head & neck cancer and treatment response (TPFCTRT). Two cycles of TPF (paclitaxel-175mg/m2 D1, cisplatin 35mg/m2 D2-D3 and 5Fu 1gm/m2 D1-D3) were given followed by radiotherapy with concurrent cisplatin (40 mg/m2).The response to the treatment was assessed clinically, radiologically & by laryngoscopy-post treatment. Genotyping of the blood samples was done. Analysis of the association between genetic polymorphisms and risk of HNSCC was estimated by calculating crude odds ratio (OR). A P value of <0.05 was considered statistically significant. The statistical analysis was performed with the SPSS software package (version 11.0 for Windows; SPSS Chicago, IL). Results: Patients with CYP 2D6*1 showed good response to the therapy given, while CYP 2D6*4 and *10 were poor responders. Conclusion: There is a strong association of polymorphs of CYP 2D6 with occurrence of head and neck cancer. Response to treatment (TPFCT-RT) is polymorph graded. Our study thus provides an insight in to the concept of “Right therapy to the right patient”.