The clinician, the lab and the patient: Understanding lab diagnostics to eradicate tuberculosis.

BACKGROUND: Diagnostic modalities for diagnosing Tuberculosis caused by Mycobacterium group of organisms include mainly AFB smear by Ziehl Neelsen carbol fuchsin smear microscopy, GeneXpert (CB NAAT) molecular method, Line probe assay (Molecular method) and AFB culture (Liquid automated systems and solid media) methods. METHODS: This study was initiated to understand and prioritize TB lab diagnosis, with reference to selection of lab diagnostic tests and its order of preference for MTC and NTM/MOTT closely associating it with the TB irradication program initiated by the Government of India. RESULT AND CONCLUSION: The results and discussion bring to light the importance of each test and the purpose of their requisition. When diagnosis is handled half heartedly eradication of TB becomes a challenge. All the efforts including planning, resources in the form of manpower, infrastructure, finances, education, time etc., would be hampered. This challenge is not only for India but the globe. For countries harboring TB, Correct diagnostic request and timely diagnosis and treatment is the key to eradication of tuberculosis.

Systematic review with meta-analysis: mucosal healing is associated with improved long-term outcomes in Crohn's disease.

BACKGROUND: Clinical manifestations of Crohn's disease (CD) do not reliably correlate with endoscopic activity. While treating to achieve clinical remission (CR) has neither proven to improve CD outcomes nor alter the natural disease course, it is unclear whether targeting objective measures like mucosal healing (MH) is associated with improved long-term outcomes. AIM: To perform a systematic review and meta-analysis comparing long-term outcomes in active CD patients who achieve MH compared to those who do not. METHODS: We performed a systematic literature search to identify studies with prospective cohorts of active CD patients that included outcomes of patients who achieved MH at first endoscopic assessment (MH1) compared to those who did not. The primary outcome was long-term (≥50 weeks) CR. Secondary outcomes included CD-related surgery-free rate, hospitalisation-free rate and long-term MH rate. Pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Twelve studies with 673 patients met inclusion criteria. Patients achieving MH1 had a pooled OR of 2.80 (95%CI, 1.91-4.10) for achieving long-term CR, 2.22 (95%CI, 0.86-5.69) for CD-related surgery-free rate, and 14.30 (95%CI, 5.57-36.74) for long-term MH. Sensitivity analyses suggested no difference in outcomes if MH1 was achieved on biologics vs. non-biologics. No significant publication bias or heterogeneity was detected. CONCLUSIONS: Achieving MH1 is associated with increased rates of long-term clinical remission, and maintenance of mucosal healing in active Crohn's disease and may therefore be a reasonable therapeutic target.

Depression is not associated with peripheral insulin resistance in patients with chronic hepatitis C infection.

Depression is common in individuals infected with hepatitis C virus (HCV), and both depression and HCV infection are independently associated with insulin resistance (IR). To evaluate the relationship between depression and IR, among other factors, in an HCV-infected cohort. In this cross-sectional analysis, seventy-four non-type 2 diabetic, noncirrhotic, HCV-infected patients underwent comprehensive clinical, histologic and metabolic evaluation. IR was assessed directly with an insulin suppression test by measuring steady-state plasma glucose (SSPG) levels during continuous infusions of octreotide, glucose and insulin. Logistic regression modelling was used to evaluate predictors associated with depression. Thirty-nine (53%) patients were depressed, and 21 (54%) depressed patients were on at least one antidepressant. A higher estimated proportion of depressed patients were Caucasian (51% vs 20%, P = 0.005), unemployed (69% vs 49%, P = 0.07), heavier smokers (18 pack-years vs 13 pack-years, P = 0.07), on substance abuse therapy (16% vs 3%, P = 0.06) and had lower HDL levels (1.2 mmol/L vs 1.4 mmol/L, P = 0.01). The mean SSPG levels in depressed and nondepressed patients were 7.3 and 8.3 mmol/L (P = 0.45), respectively. In multipredictor adjusted analysis, only Caucasian race (OR 4.19, 95% CI 1.42-12.35, P = 0.009) and lower HDL (OR 0.95, 95% CI 0.89-0.99, P = 0.046) were associated with depression. In conclusion, although prevalent, depression was not associated with peripheral IR in this HCV-infected cohort. Attention to other modifiable factors associated with depression in the HCV-infected population is warranted.

Clinical characteristics of children with febrile seizure.

BACKGROUND: Febrile seizure is common in children below five years of age. This study was conducted to evaluate the clinical profile of children presenting with febrile seizure in a teaching hospital. METHODS: This was a descriptive retrospective study among children presenting with febrile seizure in a teaching hospital from July 2009 to June 2013. Children between six months to six years were included in the study while patients with prior episodes of afebrile seizures, abnormal neurodevelopment and not meeting the age criteria were excluded. Patient's demographic and clinical data were collected from the in-patients records and analyzed. RESULTS: This study included 103 children with febrile seizure. Out of which 67% were male. Simple febrile seizure and complex febrile seizure were observed in 76.7% and 23.3% of patients respectively. Majority of children (71.8%)had generalized tonic clonic seizure followed by tonic seizures. Most of children (72.8%) who developed first episode of seizure were below 24 months of age with the mean age of 20.7 (±12.1) months. Overall 33% of patients developed recurrence of febrile seizure and first episode of febrile seizure at age one year or below was associated with the seizure recurrence. Upper respiratory tract infections were the commonest cause of fever in these children. CONCLUSIONS: Febrile seizure was observed predominantly in children below age of two years and simple febrile seizure was the ommonest variety. Recurrence of febrile seizure was common and significantly associated with the first episode of febrile seizure at the age of one year or below.

Meta-analysis: antibiotic therapy for small intestinal bacterial overgrowth.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is an under-recognised diagnosis with important clinical implications when untreated. However, the optimal treatment regimen remains unclear. AIM: To perform a systematic review and meta-analysis comparing the clinical effectiveness of antibiotic therapies in the treatment of symptomatic patients with documented SIBO. METHODS: Four databases were searched to identify clinical trials comparing effectiveness of: (i) different antibiotics, (ii) different doses of the same antibiotic and (iii) antibiotics compared with placebo. Data were independently extracted according to predetermined inclusion and exclusion criteria. Study quality was independently assessed. The primary outcome was normalisation of post-treatment breath testing. The secondary outcome was post-treatment clinical response. RESULTS: Of 1356 articles identified, 10 met inclusion criteria. Rifaximin was the most commonly studied antibiotic (eight studies) with overall breath test normalisation rate of 49.5% (95% confidence interval, CI 44.0-55.1) (44.0%-55.1%) then (46.7%-55.5%), then (4.6%-17.8%). Antibiotic efficacy varied by antibiotic regimen and dose. Antibiotics were more effective than placebo, with a combined breath test normalisation rate of 51.1% (95% CI 46.7-55.5) for antibiotics compared with 9.8% (95% CI 4.6-17.8) for placebo. Meta-analysis of four studies favoured antibiotics over placebo for breath test normalisation with an odds ratio of 2.55 (95% CI 1.29-5.04). Clinical response was heterogeneously evaluated among six studies, but tended to correlate with breath test normalisation. CONCLUSIONS: Antibiotics appear to be more effective than placebo for breath test normalisation in patients with symptoms attributable to SIBO, and breath test normalisation may correlate with clinical response. Studies were limited by modest quality, small sample size and heterogeneous design. Additional higher quality clinical trials of SIBO therapy are warranted.

A report of near fatal ceftriaxone induced anaphylaxis in a child with review of literature.

Ceftriaxone is a widely used antibiotic in pediatric clinical practice. Usually ceftriaxone is well tolerated and serious adverse effect like anaphylaxis is rare. We report a near fatal anaphylaxis reaction in a child after the first dose of intravenous ceftriaxone who revived successfully.

Spectrum of pediatric dermatoses in tertiary care center in Nepal.

Children with dermatological problems constitute a major group presenting to the Outpatient Department. This study was done to see the pattern of skin disorder among the pediatric age group in a tertiary care center in Nepal. To determine the pattern of skin disorders among children visiting the Department of Dermatology and Pediatrics in a tertiary care center in Nepal. All the patients visiting the Dermatological Out patient Department in the age group 0-14 years were enrolled in the study during the time period of 3 years (2009-2011). The cases were diagnosed based on the detailed clinical history and clinical examination, and the patients were investigated as needed. A total of 1086 (22.64%) patients out of 4795 patients were having skin disorder and among them 584 (53.77%) were males and 502 (46.23%) were females. The age range was 0-14 with the mean age of 7 years. Dermatitis and eczema were the most frequently encountered disease 298 (26.46%), followed by bacterial infections 156 (16.13%), urticarial 190 (15.71%), viral infection (14.12%), fungal infection 76 (7.3%), scabies 54 (5.03%), miliaria 25 (2.75%), vitiligo 27 (2%) and others 87 (6.53%). Nutritional disorders, vascular, pigmentary, nevi, drug eruptions had a comparatively low incidence.

Bilateral phrenic nerve injury after neck dissection: an uncommon cause of respiratory failure.

The case of a patient with carcinoma larynx who developed diaphragmatic paralysis and post-operative respiratory failure due to bilateral phrenic nerve injury is reported. The use of portable ultrasonography for an early diagnosis of diaphragmatic paralysis is discussed.

Preliminary experience with use of a selective 5HT3 receptor antagonist (ondansetron) to prevent high dose chemotherapy induced emesis.

Ondansetron was used as an antiemetic along with dexamethasone during 16 cycles of highly or moderately ematogenic chemotherapy. There was major control in two cycles and complete control in the remaining 14. Side effects were minor and did not require discontinuation of the drug. This combination, therefore, appears to be safe and effective in preventing chemotherapy induced emesis.

Tricuspid balloon valvuloplasty: a more simplified approach using inoue balloon.

We report a more simplified technique of the balloon tricuspid valvuloplasty using inoue balloon set in a patient suffering from severe rheumatic tricuspid stenosis. We believe that this technique may be useful in a difficult case of tricuspid valvuloplasty.

Percutaneous transvenous mitral commissurotomy using Inoue balloon catheter: a left femoral vein approach.

Percutaneous transvenous mitral commissurotomy by the Inoue technique is usually recommended from right femoral vein approach only. We report an unusual patient in whom the left femoral vein approach was used successfully. We believe that the left femoral vein approach can be reserved as a last resort in certain cases.

Tracheal tear during laryngopharyngectomy with gastric transposition.

Tracheal rupture occurred in 7 of 174 (4%) patients undergoing laryngopharyngectomy with gastric transposition. Tracheal tears were classified as proximal if they involved the upper two-thirds of the trachea (five patients), or distal if they extended into the lower one-third of the trachea (two patients) and their clinical features and management analyzed. Predisposing factors, including prior radiotherapy (three patients) and preoperative tracheostomy (1 patient) did not influence the site or severity of tracheal injury. Proximal tears were detected incidentally in four patients, but in one patient, manifested postoperatively with subcutaneous emphysema and pneumothorax. Distal tears manifested dramatically with a ventilatory leak. Adequate access for repair of distal tears may necessitate a right thoracotomy while proximal tears may be sutured through the cervical incision. Gastric transposition alone did not prevent air leak in two patients. Postoperative complications included prolapse of the stomach and bilateral pneumothoraces in one patient. Close interaction between the surgeon and the anesthesiologist ensured a successful outcome in six patients. There was one mortality.

Lack of immune responsiveness to bovine serum albumin in insulin-dependent diabetes.

BACKGROUND: Epidemiologic studies have implicated the ingestion of cow's milk in the pathogenesis of insulin-dependent diabetes mellitus (IDDM). Moreover, in a recent study, 100 percent of patients with new-onset IDDM had antibodies against bovine serum albumin (BSA), with a majority directed against a 17-amino-acid BSA peptide (ABBOS). Cellular immune mechanisms are thought to be the principal mediators of pancreatic beta-cell destruction in IDDM. METHODS: We measured the responses of peripheral-blood mononuclear cells to BSA and ABBOS or serum IgG anti-BSA antibodies (by particle-concentration fluorescence immunoassay) in 71 patients with IDDM, 55 subjects at various degrees of risk for IDDM, 36 patients with other autoimmune disorders (chronic autoimmune thyroiditis, rheumatoid arthritis, and systemic lupus erythematosus), and 48 normal subjects. RESULTS: The responses of peripheral-blood mononuclear cells to BSA or ABBOS were positive in 2 of 24 patients with new-onset IDDM, 1 of 25 first-degree relatives of patients with IDDM who were negative for islet-cell antibodies, 2 of 30 first-degree relatives of patients with IDDM who were positive for islet-cell antibodies, 1 of 28 patients with established IDDM, and 1 of 29 normal subjects. Similarly, anti-BSA antibodies were not detected significantly more often in patients with new-onset IDDM (3 of 31, 10 percent) than in normal subjects (1 of 37, 3 percent; P = 0.32). However, many patients with autoimmune disease and subjects at increased risk for IDDM had anti-BSA antibodies (frequency, 10 to 31 percent). CONCLUSIONS: Anti-BSA antibodies may reflect a general defect in the process of immunologic tolerance associated with a predisposition to autoimmunity rather than immunity specific to beta cells. The absence of cellular immunity to BSA and ABBOS in IDDM does not support a role for this antigen in the pathogenesis of the disorder.