A study on clinical profile and etiological agents of empyema in hospitalised children in Jaipur, India

Background: Objective is to study the clinical profile and etiological agents of empyema in hospitalised children in Jaipur.Methods: This hospital based prospective study was carried out in the Department of Pediatrics, SMS Medical College, Jaipur between April 2016 to March 2017. Children between 1 month to 18 year of age having empyema thoracis (pleural tap showing pus cells under microscopy or on gross examination purulent exudates) were included in the study. Children with Empyema secondary to post-surgical or post-traumatic cause and with tubercular effusion were excluded from the study. Relevant history, clinical examination and investigation were done. Pleural fluid studies were done for cytology, biochemical analysis , culture and antibiotic sensitivity pattern.Results: Total 100 patients were included in study. Out of total 100 patients 62 (62%) were between 1 month to 5 years. Most common symptoms were fever (94%), breathlessness (87%) and cough (85%). 27% patients were severely malnourished as per IAP classification of PEM. Pleural fluid culture was positive in 29 (29%) patients. Most common organism isolated was Staphylococcus aureus (27%), 87.5% isolates of Staphylococcus aureus had sensitivity to vancomycin and linezolid.Conclusions: Empyema thoracis is frequently encountered complication of bacterial pneumonia. Fever, cough, and respiratory distress were the most common presenting complaints and severe acute malnutrition was an important risk factor. Staphylococcus aureus was found to be the most common organism for childhood empyema.

Brain abscess caused by Cladophialophora Bantiana in an immunocompetent host: need for a novel cost-effective antifungal agent.

We report a 53-year-old male who presented with headache, tremor and memory disturbance. Radiological evaluation was suggestive of brain abscess. He underwent gross total excision of the cerebral abscess. The histopathological examination and pus culture was suggestive of brain abscess caused by Cladophialophora bantiana. Authors report a rare case of biopsy and culture proven Cladophialophora bantiana brain abscess in an immunocompetent host. The authors review the relevant literature and current treatment options while emphasizing the need for a cost-effective novel antifungal drug to salvage a subset of patients suffering from this rare but increasingly frequent condition.

Gamma knife radiosurgery for glomus jugulare tumors: Therapeutic advantages of minimalism in the skull base.

Context: Glomus jugulare (GJ) tumors are paragangliomas found in the region of the jugular foramen. Surgery with/without embolization and conventional radiotherapy has been the traditional management option. Aim: To analyze the efficacy of gamma knife radiosurgery (GKS) as a primary or an adjunctive form of therapy. Settings and Design: A retrospective analysis of patients who received GKS at a tertiary neurosurgical center was performed. Materials and Methods: Of the 1601 patients who underwent GKS from 1997 to 2006, 24 patients with GJ underwent 25 procedures. Results: The average age of the cohort was 46.6 years (range, 22-76 years) and the male to female ratio was 1:2. The most common neurological deficit was IX, X, XI cranial nerve paresis (15/24). Fifteen patients received primary GKS. Mean tumor size was 8.7 cc (range 1.1-17.2 cc). The coverage achieved was 93.1% (range 90-97%) using a mean tumor margin dose of 16.4 Gy (range 12-25 Gy) at a mean isodose of 49.5% (range 45-50%). Thirteen patients (six primary and seven secondary) were available for follow-up at a median interval of 24 months (range seven to 48 months). The average tumor size was 7.9 cc (range 1.1-17.2 cc). Using a mean tumor margin dose of 16.3 Gy (range 12-20 Gy) 93.6% coverage (range 91-97%) was achieved. Six patients improved clinically. A single patient developed transient trigeminal neuralgia. Magnetic resonance imaging follow-up was available for 10 patients; seven recorded a decrease in size. There was no tumor progression. Conclusions: Gamma knife radiosurgery is a safe and effective primary and secondary modality of treatment for GJ.

Neuronavigation in a developing country: A pilot study of efficacy and limitations in intracranial surgery.

CONTEXT: Neuronavigation provides a patient-specific, three-dimensional (3-D) anatomy for preoperative planning and intraoperative navigation. However, the initial and maintenance costs are quite prohibitive, especially in the Indian scenario. AIMS: To study the efficacy and limitations of neuronavigation, especially in the Indian scenario. SETTINGS AND DESIGN: A prospective nonrandomized study. MATERIALS AND METHODS: A total of 121 patients underwent intracranial surgery from 2002-2006, in which neuronavigation was used. In this, the initial part, we studied the efficacy and limitations of neuronavigation in the initial 37 patients. The efficacy of the image guidance was graded according to a point's scale in which points were awarded ranging from 0 to 3. Cranial image guided score (IGS) was calculated by the summation of grading during designing the flap/burr hole, delineation of the intraoperative anatomy, navigation and access to the lesion and resection / biopsy of the lesion or completion of the procedure. The scoring ranged from 0-12 and the utility of IGS in cranial neurosurgical procedures was calculated based on the total points for each surgery. RESULTS AND CONCLUSION: Cranial image guidance was useful in a variety of operative steps. Intraoperative approach and navigation was relatively easier with an increase in perception of safety. Limitations of IGS include learning curve, cost and the phenomenon of brain shift. Drawbacks of the study included that this was a subjective rather than a truly objective study and the relatively lesser number of patients. We hope to conduct a larger study with randomization but the question of ethical approval would be a primary concern.

Distribution and abundance of zooplankton in relation to petroleum hydrocarbon content along the coast of Kollam (Quilon), south west coast of India.

In the present study we examine status, impact and trends in prevailing situation of coastal ecosystem of Chavara, Neendakara, Tangasseri and Paravur zones of Kollam coast in terms of zooplankton density and petroleum hydrocarbon content (PHC). Zooplankton samples and water samples were collected during the period May 2003 to June 2004. The numerical count of zooplankton made and PHC content estimated. Paravur offshore recorded the maximum zooplankton count (1390 no./m3) and Tangasseri nearshore the lowest (700.5 no/m3). The petroleum hydrocarbon content was highest at Tangasseri nearshore (21.95 microg/l) and lowest at Paravur offshore (9.40 microg/l). We also observe statistically significant negative correlation between zooplankton density and PHC for a few organisms. The overall impact appears minor, yet, coastal ocean monitoring imperative for sustainable development.

Efficacy and results of expansive laminoplasty in patients with severe cervical myelopathy due to cervical canal stenosis.

AIMS AND OBJECTIVES: To assess the efficacy and results of expansive laminoplasty in advanced (Nurick's Grade III or greater) cervical myelopathy. MATERIALS AND METHODS: We reviewed data in 24 patients who underwent cervical laminoplasty from January 1999 to December 2002. Nuricks grading was used for quantifying the neurological deficits and outcome analysis was done using Odom's criteria. A modified Hirabayashi's open door laminoplasty was done using Titanium miniplates and screws in 22 patients, autologous bone in one and hydroxyapatite spacer in one patient. OBSERVATIONS: There were 3 females and 21 males with a mean age of 56 years (range 39-72 years). Four patients presented in Nuricks Grade III, 15 in Grade IV and five in Grade V. MR imaging showed MSCS in 21 cases, OPLL in nine cases and ligamentum flavum hypertrophy in nine cases with cord signal changes being present in 19 cases. RESULTS: All patients with duration of symptoms less than three years, and 50 % with duration ranging from three to six years had improvement by at least one Nurick's grade following surgery. Eighty-seven per cent Grade IV patients (ambulatory with support) improved to Grade III (ambulatory without support) following laminoplasty. Using Odom's criteria, 23 patients (95.8%) had a good to fair outcome. CONCLUSIONS: Cord decompression with expansive laminoplasty using titanium miniplate fixation may improve the neurological outcome even in patients presenting late, and improvement by even one grade may have major 'quality of life' benefits for these patients.

Primary central nervous system lymphoma: experience of 46 cases with review of literature.

Primary central nervous system lymphomas (PCNSL) constitutes only 1.0 to 1.5% of all brain tumors. Their incidence has gone up over tenfold in the last 25 years. Though, there has been an association of PCNSL with acquired immune deficiency syndrome (AIDS), yet the increased incidence of PCNSL appears to be real and unrelated to AIDS and organ transplantation. This increased incidence could be because of improvement in diagnostic technology and practice. The outcome remains gloomy despite surgical resection, radiotherapy and intensive adjuvant chemotherapy regimens, as majority of the patients succumb to the disease, with only 30-40% survival in patients under 70 years of age.

Expression of Bcl2 proto-oncogene in primary tumors of the central nervous system.

The present study was addressed to find out the expression of Bcl2 proto-oncogene in tumor tissues derived from 25 patients with primary central nervous system tumors. Brain parenchyma in 8 cases, with deeply located tumor, was also examined for Bcl2 expression which served as control. Both benign and malignant tumors (confirmed by histopathological examination) expressed Bcl2 gene product. Tumors exhibited 2-6 fold increase in Bcl2 expression as compared to the normal parenchyma adjacent to some of these tumors studied. However, no correlation was found between the histopathological types of tumor, glial fibrillary acidic protein positivity and degree of Bcl2 expression. Based on this study, we propose that the overexpression of Bcl2 gene product found in primary CNS tumors may be an important molecular event which is known to make the various types of tumor resistant to chemotherapy or radiotherapy.

Single flap fronto-temporo-orbito-zygomatic craniotomy for skull base lesions.

Surgery was performed, through single flap fronto-temporo-orbito-zygomatic approach in 22 patients with skull base lesions. In two of these patients, this approach was combined with a transpetrosal approach. The pathological spectrum consisted of trigeminal neurofibromas (5), spheno-orbital meningiomas (4), carotico-ophthalmic aneurysms (4), basilar top aneurysms (2), cavernous sinus haemangiomas (2), invasive pituitary tumours (2) and one patient each of metastatic adenocarcinoma of the cavernous sinus, transcranial fungal granuloma and tubercular granuloma of the cavernous sinus. Of the 14 tumours, 10 were excised totally/near totally while a subtotal excision was achieved in four. Removal of the anterior clinoid process facilitated the clipping of all the carotico-ophthalmic aneurysms. One basilar top aneurysm was wrapped and the other clipped. One patient of fungal granuloma died of fungal meningitis and one patient of basilar top aneurysm expired as a result of thalamic infarct. The advantages of this approach included excellent exposure of the skull base lesions, making the dissection distance shorter and wider, minimal brain retraction and easy replacement of the single bone flap.

Traumatic subarachnoid haemorrhage: a clinicoradiological and TCD correlation.

Twenty five consecutive patients with CT proven pure traumatic subarachnoid haemorrhage (tSAH) were studied, prospectively over a 6 month period. They constituted 2% of all head injuries. Most of the patients (88%) had a mild or moderate head injury at the time of admission, with a mean glasgow comma scale (GCS) of 10.68. The CT scan findings were divided into 3 grades. Grade 1 - blood in hemispheric region only (n=4), grade 2 - blood in basal region only (n=11), grade 3 - blood in both hemispheric as well as basal region (n=10). Transcranial doppler ultrasound (TCD) velocities were recorded in all patients by insonating the middle cerebral artery, internal carotid artery and anterior cerebral artery on both sides. All patients were also subjected to digital substraction angiography (DSA). All patients with mild head injury had normal TCD velocity (<100 cm/sec), while TCD velocities of more than 150 cm/sec were seen only in one patient with severe head injury. Patients with severe head injury were found to have grade 3 tSAH on CT. No statistically significant correlation was found between the CT grade and TCD velocities. Angiographic vasospasm was found in 2 patients with severe head injury only. 90.2% of patients had good outcome at discharge.

Posterior fossa dermoid in association with Klippel-Feil syndrome--a short report.

A posterior fossa dermoid cyst in association with the Klippel-Feil syndrome, in a 4 year old child is reported. Early diagnosis to prevent complications like neural compression, cyst rupture and staphylococcal meningitis justifies investigation for posterior fossa dermoids in cases of Klippel-Feil syndrome. Their embryological basis is discussed.

Bilateral fronto-orbito-zygomatic craniotomy--a combined extended frontal and orbitozygomatic approach.

In extensive skull base lesions involving the spheno-ethmoido-clival region and extending into both the cavernous sinuses and infratemporal regions, a combination of approaches is usually required, either in the same operation or at a second stage. The bilateral fronto-orbito-zygomatic craniotomy described in this report is a combination of an extended frontal approach and fronto-orbito-zygomatic craniotomy. This gives a wide exposure of the spheno-ethmoido-clival regions of both the cavernous sinuses and both the infratemporal regions. The exposure is thus greatly improved with minimal frontal lobe retraction. The single bone piece can be speedily replaced obviating the need for a complicated reconstruction technique and gives a superior cosmetic result. The operative technique is described in detail.

Clinically and biochemically silent thyrotroph adenoma with oncocytic change.

A case of clinically and biochemically silent pituitary tumour with ultrastructural and immunohistochemical evidence of thyroid stimulating hormone secretion is presented. Significance of recognition of such silent tumours is discussed.

Calcified falx meningioma.

A totally calcified mid third falcine meningioma in an elderly male patient is presented. An uneventful enmasse excision was performed. Advantages of positioning on ipsilateral side for paramedian extracerebral lesions are highlighted.

Current concepts in the management of pyogenic brain abscess.

Current philosophy of treatment of brain abscess includes aspiration, appropriate antibiotics, treatment of sequelae and eradication of the primary source. Early clinical suspicion and diagnosis with CT is crucial. Small abscesses (<3 cm) in cerebritis or capsular stage located deep in clinically stable, poor surgical risk patients with diagnosis firmly supported by CT, may be treated with medical treatment only. Biweekly CT scan must be done to monitor the treatment response. CT or ultrasound guided aspiration should be performed in the event of clinical deterioration, failure of reduction in size or enlargement of abscesses. Encapsulated abscess (>3 cm), presence of significant neurological deficit or mass effect, doubt in the diagnosis and presumed resistant organisms are best treated with aspiration. Excision is required in large superficial abscesses resistant to multiple aspirations, post-traumatic abscess with a foreign body or fistula and multiloculated abscess of nocardial or actinomycotic aetiology. Results are directly related to the sensorium at the time of presentation. Stereotactic aspiration of all the loculi of multiloculated abscess in single or staged aspiration, and more completed drainage and lavage with endoscopic stereotactic evacuation may cut down indications of excision of brain abscess in future. It is concluded that, with diagnostic and technical advancements, a trend of adequate drainage of brain abscess via minimally invasive surgery is emerging. Confirmation of diagnosis and monitoring of treatment response with magnetic resonance spectroscopy may allow greater number of patients in future to be managed with medical treatment only.

Postoperative hypertensive-hypervolaemic-haemodilution (Triple H) therapy in the treatment of vasospasm following aneurysmal subarachnoid haemorrhage.

Twenty five patients with post operative ischaemic deficits, following clipping of intracranial aneurysms, were studied. Hypertensive-hypervolaemic-haemodilution (triple H) therapy was given to all patients using colloids and crystalloids. CVP was used to monitor the fluid therapy. Dopamine was needed in 22 patients to elevate the systemic blood pressure. Vasospasm was confirmed in 20 patients with transcranial doppler studies (TCD). 20 (80%) patients survived, 10 (40%) with good outcome, 7 (28%) with fair, 2 (8%) with poor outcome and 1 (4%) with vegetative state. There were 5 (20%) deaths, 4 of which occurred due to infarct. All these patients had poor Hunt and Hess grade at admission, high Fisher grade haemorrhages in the initial CT scan and/or required prolonged temporary clipping at surgery. One death occurred due to central venous line induced septicaemia. The duration of 'triple H therapy' amongst the survivors varied from 2-7 days with an average of 4.6 days. The complications of 'triple H therapy' included hypokalaemia (3 patients), haemorrhagic infarct (1 patient) and septicaemia (1 patient). It is concluded that 'triple H therapy' is useful in treating vasospasm induced ischaemic deficits. It worsens brain oedema in presence of acute infarcts and hence is contraindicated in such patients. A further study involving a larger number of patients with strict haemodynamic and ICP monitoring is suggested to determine the usefulness of individual components of 'triple H therapy'.

Anterior surgical approaches to the sub-axial cervical spine.

Anterior cervical spine surgery has come of age, as a golden route for treating anteriorly placed cervical compressions ranging from simple prolapsed disc to long segment pathologies like ossification of posterior longitudinal ligaments and cervical spondylotic myelopathy. Numerous technical modifications of the procedure are described. The role of stabilisation established for several pathologies, is still debateable in surgery for cervical disc. Bone is the ideal tissue for fusion. Hydroxyapetite implants are goods, but costly for our set up. Methylmethacrylate has a limited role in elderly patients with malignancy and a short life expectancy. Anterior cervical instrumentation has mushroomed over the last decade. Acceptable as methods of immediate stabilisation, the choice of the system varies with the surgeon. The authors use simple titanium plates with locking screws for the purpose.

A mathematical outcome prediction model in severe head injury: a pilot study.

103 patients of head injury, with a Glasgow coma scale (GCS) score of 8 or less, were studied prospectively. GCS score, brain stem reflexes, motor score, reaction level scale, and Glasgow Liege scale were evaluated as prognostic variables. Linear logistic regression analysis was used to obtain coefficients of these variables and mathematical formulae developed to predict outcome in individual patients.