Ventral striatal and septal area hypermetabolism on FDG-PET in herpes simplex viral encephalitis.

A 71-year-old man presented with sudden onset, generalized tonic-clonic seizures and altered mental status. Initial brain magnetic resonance imaging was normal but a brain FDG-PET scan showed hypermetabolism in the left ventral striatum and septal area. Initial cerebrospinal fluid (CSF) examination showed mildly elevated protein but herpes simplex virus (HSV) polymerase chain reaction (PCR) was negative. A repeat CSF examination performed 9 days later showed a positive HSV PCR. Histopathological and immunohistochemical examination of autopsy specimen confirmed the presence of CD45+ lymphocytes and HSV antigen, suggesting the presence of both inflammation and viral infection corresponding to PET abnormality.

Correction to: Ventral striatal and septal area hypermetabolism on FDG-PET in herpes simplex viral encephalitis.

The word "hypermetabolism" needs to be replaced by "hypometabolism" at only ONE place and NOT throughout the article.So the correction could be stated as:"In the case description section, the sentence "A repeat dedicatedbrain FDG-PET scan performed on day 9, under burst suppression,showed diffuse hypermetabolism with persistent relativehypermetabolism in the left ventral striatum and septalarea (Fig. 1b)."should read as"A repeat dedicatedbrain FDG-PET scan performed on day 9, under burst suppression,showed diffuse hypometabolism with persistent relativehypermetabolism in the left ventral striatum and septalarea (Fig. 1b)." At all other places, the word hypermetabolism is appropriate.

The microbial etiology and antimicrobial susceptibility of bloodstream infections in patients with cancer at a private tertiary care hospital in Mumbai, India.

BACKGROUND: Knowledge of the etiology and antimicrobial susceptibility of blood stream infections in patients with cancer is crucial to design empirical therapy regimes. METHODS: This is a prospective observational study at a tertiary care private hospital in Mumbai, India from Nov 2009 - Dec 2014. RESULTS: A total of 62 episodes of blood stream infections in 57 patients with cancer were recorded during the study period. Analysis was limited to 52 isolates from 49 episodes in 45 patients. Gram negative pathogens caused 77% of these infections; commonest pathogens were E. coli and Klebsiella. High prevalence of antimicrobial resistance was noted. Susceptibility in E. coli, Klebsiella, Acinetobacter and Pseudomonas to 3rd generation cephalosporins, beta lactam beta lactamase inhibitor combinations, carbapenems and amikacin was 4%, 56.5%, 70% and 86% respectively. CONCLUSION: The high rates of antimicrobial resistance in gram negative isolates is alarming.

Outbreak of Burkholderia cepacia complex bacteremia in a chemotherapy day care unit due to intrinsic contamination of an antiemetic drug.

BACKGROUND: In the end of 2009, a large number of patients with cancer undergoing chemotherapy at the day care unit of a private hospital in Mumbai, India developed Burkholderia cepacia complex (BCC) blood stream infection (BSI). OBJECTIVE: The objectives were to identify the source of the outbreak and terminate the outbreak as rapidly as possible. MATERIALS AND METHODS: All infection control protocols and processes were reviewed. Intensive training was started for all nursing staff involved in patient care. Cultures were sent from the environment (surfaces, water, air), intravenous fluids, disinfectants and antiseptics and opened/unopened medication. RESULTS: A total of 13 patients with cancer with tunneled catheters were affected with BCC BSI. The isolates were of similar antimicrobial sensitivity. No significant breach of infection control protocols could be identified. Cultures from the prepared intravenous medication bags grew BCC. Subsequently, culture from unused vials of the antiemetic granisetron grew BCC, whereas those from the unopened IV fluid bag and chemotherapy medication were negative. On review, it was discovered that the outbreak started when a new brand of granisetron was introduced. The result was communicated to the manufacturer and the brand was withdrawn. There were no further cases. CONCLUSIONS: This outbreak was thus linked to intrinsic contamination of medication vials. We acknowledge a delay in identifying the source as we were concentrating more on human errors in medication preparation and less on intrinsic contamination. We recommend that in an event of an outbreak, unopened vials be cultured at the outset.

Pre-operative ultrasound for breast tumour measurements: is there potential for mismanagement?

The pre-operative size of breast tumour is the most important factor in determining feasibility of breast conserving surgery in operable breast cancer. Currently there is no consensus on the most accurate modality to measure tumour size. A prospective study of consecutive and unselected symptomatic patients with invasive breast cancer who had primary surgery between January 2006 and December 2007 was conducted. Patients with multi-focal and multi-centric tumours were excluded. The aim of this study was to find the correlation between histological size of invasive breast cancer and pre-operative tumour size as measured by ultrasound. Over this two year period, data for 192 patients was analysed for this study. The mean tumour diameter on ultrasound and histology was 19.5mm and 29 mm respectively. The difference between the means in the two modalities was found to be statistically significant (P<0.001).Ultrasound underestimates the true size of breast tumours as determined histologically. Inaccurate tumour size measurements may result in re-operations to achieve adequate margins.

A single institution experience with skin sparing mastectomy and immediate breast reconstruction.

INTRODUCTION: Skin sparing mastectomies (SSMs) represent a surgical approach that preserves the natural skin envelope of the breast and, when combined with immediate reconstruction, offers a good cosmetic outcome. The aim of this retrospective study was to compare the risk of local recurrence (LR) in this series with the known rate of recurrence following a conventional mastectomy. METHODS: A total of 108 patients with breast cancer who underwent an SSM and immediate breast reconstruction over a 6-year period were reviewed. RESULTS: A follow-up of more than eight years showed that three patients (2.78%) had developed LR. CONCLUSIONS: The rate of LR is low with SSMs and is comparable to that seen with conventional mastectomies.

Cell saver use in obstetrics.

This study is a review of our experience of using the cell saver in obstetrics. The main aim was to determine its role in decreasing the need for homologous blood transfusion. A retrospective study of patients identified as being at high risk of massive obstetric haemorrhage at the time of caesarean section during the period between July 2005 and August 2008, was undertaken. Cases were identified from our electronic database. A of 147 cases were identified. Cell saver was used in 77 (52%) of these cases. A total of 13 units of salvaged blood were transfused successfully, saving approximately GB£1,800. Cell salvage in our practice has not been very effective due to non-availability of trained staff in emergencies and unfamiliarity of techniques, leading to poor salvage via suction. Most of our blood loss is swabbed not suctioned and lack of salvaging blood from swabs is a contributory factor.

Interventions to reduce needle stick injuries at a tertiary care centre.

BACKGROUND: Occupational exposure to blood/body fluids is associated with risk of infection with blood borne pathogens like human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). MATERIALS AND METHODS: We carefully document needle stick injuries (NSI) and implement post-exposure prophylaxis (PEP). We report a four-year continuing surveillance study where 342 healthcare workers (HCWs) sustained NSI. PEP was given to HCWs injured from seropositive sources. If the source was HbsAg positive, HCWs were given a hepatitis B immunization booster. If the HCW was antiHBs negative, both hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine were administered. For HCWs who sustained injuries from HIV positive sources, antiretroviral therapy was started. Follow-up was done after three and six months of exposure. Recent interventions by the infection control committee at our hospital reduced NSI considerably during intravenous line administration and glucose monitoring. RESULTS AND DISCUSSION: Of 342 injuries, 254 were from known sources and 88 from unknown sources. From known sources, 37 were seropositive; 13 for HIV, 15 for HCV, nine for HBV. Sixty six sharp injuries were sustained through garbage bags, 43 during IV line administration, 41 during injection administration, 35 during needle recapping, 32 during blood collection, 27 during blood glucose monitoring, 24 from OT instruments, 17 during needle disposal, 16 while using surgical blade, 7 during suturing and 34 from miscellaneous sources. CONCLUSION: No case of seroconversion has taken place, so far, as a result of needle stick injuries at our centre.

Laparoscopic subtotal cholecystectomy: initial experience with laparoscopic management of difficult cholecystitis.

AIM: Laparoscopic cholecystectomy (LC) is now accepted as the 'gold standard' procedure for cholecystectomy. However, a significant proportion of patients with complicated cholecystitis are still converted to 'open' to complete the procedure. Laparoscopic subtotal cholecystectomy (LSC) is an option, which is still too infrequently used. METHODS: A single surgeon in our NHS trust has performed 1150 LCs since September 1999. The procedure was converted to LSC in 52 cases (4.52%) due to complicated cholecystitis. The data were collected and prospectively analysed for any morbidity or complications in the peri-operative period. RESULTS: At the initial presentation, 21 patients (40.38%) were diagnosed with recurrent biliary colic, 24 patients (46.15%) had acute cholecystitis, 6 patients (11.53%) had jaundice, and 1 patient (1.92%) had peritonitis due to gallbladder (GB) perforation. Twenty-six cases (50%) were performed as emergencies, i.e. within one week of symptoms, and 26 (50%) were planned for surgery within four weeks after symptoms started. The cystic duct or Hartmann's pouch stump was closed using endo-loop application in 34 (65.38%), intracorporeal suturing of stump of Hartmann's pouch in 13 (25%), and closure of cystic duct opening in the Hartmann's pouch by purse-string suturing in 5 cases (9.62%). CONCLUSION: LSC is a safe option in treating gallstone disease when inflammation or fibrosis precludes conventional dissection of Calot's triangle. LSC can clearly help reduce morbidity associated with open laparotomy.

What is positive appendicitis? A new answer to an old question. Clinical, macroscopical and microscopical findings in 200 consecutive appendectomies.

INTRODUCTION: The correlation between clinical and histopathology findings in appendicitis has been highlighted by many studies. However, the impact of this correlation on the surgical decision to remove a normal-looking appendix is still vague, with no clear definition of positive appendicitis. The aim of this study was to correlate the histological, operative and clinical diagnoses of acute appendicitis (AA). METHODS: 200 patients with a preoperative diagnosis of AA underwent laparoscopic appendectomy. A single consultant surgeon performed all the procedures. The clinical, macroscopical and microscopical outcomes were reported and analysed. Follow-up assessment was performed as an outpatient appointment. RESULTS: 112 women and 88 men were included in this study. The mean age was 18.8 (range 8-83) years. Macroscopical appendicitis was confirmed in 139 (69.5 percent) patients, while microscopical appendicitis was reported in 147 (73.5 percent) specimens of the appendix. Ten (7.2 percent) out of 139 patients who were macroscopically positive were found to have a normal appendix on microscopical examination. Different pathologies were found in 21 (10.5 percent) patients, and all underwent appendectomy. Microscopical appendicitis was confirmed in 10 (25 percent) out of 40 patients who had a normal-looking appendix. CONCLUSION: The correlation of the clinical, microscopical and macroscopical findings in AA is important in order to understand the natural history of appendicitis, and this may help to formulate a sound surgical decision. These findings are supportive of justifying appendectomy for normal-looking appendices, if no other pathology is found.

Enteric fever in Mumbai--clinical profile, sensitivity patterns and response to antimicrobials.

AIMS: Enteric fever is endemic in Mumbai and its diagnosis poses several problems. Our main aim was to study the clinical profile, haematological features of culture proven typhoid cases, the antimicrobial susceptibility pattern of the isolates and the time to defervescence with the treatment received. MATERIAL AND METHODS: This was a retospective chart review of all cases of culture proven enteric fever carried out at a tertiary care private hospital in Mumbai over the period January 2003 to September 2005. RESULTS: Culture positivity in our study was 52.6%. Sixty one percent of the isolates were Salmonella typhi while 39% were Salmonella paratyphi A. An absolute eosinopenia was seen in 76.9% of the patients. Before being admitted to the hospital, 46.2% received antibiotics. The mean time to defervescence in patients who received prior antibiotics was 4.5 days while that in those who did not receive prior antibiotics was 5.1 days. CONCLUSIONS: A high culture positivity despite prior or ongoing antibiotic treatment was seen. Absolute eosinophil count of 0% could be an important marker of typhoid. High prevalence of nalidixic acid resistance, a marker of resistance to fluoroquinolones was observed. Combination treatment was not found to be superior to treatment with a single antibiotic.

Laparoscopic inguinal hernia repair: over a thousand convincing reasons to go on.

BACKGROUND: Laparoscopic hernia repair has emerged as an effective alternative method for treating inguinal hernias. The ability to provide this service as day surgery or short-stay (23-h stay) treatment makes it an attractive method in this age of resource limitations. The technique is cost-effective when the use of disposable instruments is kept to a minimum. METHODS: Our team performed laparoscopic transabdominal pre-peritoneal (TAPP) inguinal hernia repair on 1,389 patients in the period from September 1999 to March 2007. We take this opportunity to discuss the lessons we have learnt and our experience and views with regards to certain procedure-specific problems encountered by many of our peers. RESULTS: A variety of commonly encountered inguinal and groin hernias were treated by TAPP with good results, minimal morbidity (4.39%) and one mortality. We have discussed our views on technical aspects of the procedure, such as the extent of pre-peritoneal dissection, methods of treating the hernia sac, the size and number of pre-peritoneal prosthetic meshes deployed, fixation of the mesh and reconstitution of the peritoneum. Our views on the causes and our strategies for managing complications such as seroma formation (3.09%), recurrence (0.29%), bleeding (0.36%) and mesh infection (0.14%) have been outlined. We believe that incidental hernias (N=150) discovered during initial laparoscopy can be safely treated with no added morbidity, provided the patients' views and consent regarding the treatment are given due consideration. CONCLUSION: Laparoscopic TAPP hernia repair has proven to be an efficient method of providing treatment for groin hernias. Our experience over the last eight years has given us over a thousand convincing reasons to continue working and improving upon this service.

Third generation cephalosporins versus conventional antibiotics for treating acute bacterial meningitis.

BACKGROUND: Antibiotic therapy for suspected acute bacterial meningitis (ABM) needs to be started immediately, even before the results of cerebrospinal fluid (CSF) culture and antibiotic sensitivity are available. Immediate commencement of effective treatment using the intravenous route may reduce death and disability. Although bacterial meningitis guidelines advise the use of third generation cephalosporins, these drugs are often not available in hospitals in low income countries. OBJECTIVES: The objective of this review was to compare the effectiveness and safety of third generation cephalosporins and conventional treatment with penicillin or ampicillin-chloramphenicol in patients with community-acquired ABM. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1) which contains the Cochrane Acute Respiratory Infections Group Trials Register, MEDLINE (January 1966 to March 2007), and EMBASE (January 1974 to March 2007). We also searched the reference list of review articles and book chapters, and contacted experts for any unpublished trials. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing ceftriaxone or cefotaxime with conventional antibiotics as empirical therapy for acute bacterial meningitis. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the study selection criteria, assessed methodological quality, and extracted data. MAIN RESULTS: Nineteen trials that involved 1496 patients were included in the analysis. There was no heterogeneity of results among the studies in any outcome except diarrhoea. There was no statistically significant difference between the groups in the risk of death (risk difference (RD) 0%; 95% confidence interval (CI) -3% to 2%), risk of deafness (RD -4%; 95% CI -9% to 1%), or risk of treatment failure (RD -1%; 95% CI -4% to 2%). However, there were significantly decreased risks of culture positivity of CSF after 10 to 48 hours (RD -6%; 95% CI -11% to 0%) and statistically significant increases in the risk of diarrhoea between the groups (RD 8%; 95% CI 3% to 13%) with the third generation cephalosporins. The risk of neutropaenia and skin rash were not significantly different between the two groups. However, all the studies were conducted in the 1980s except three, which were reported in 1993, 1996, and 2005. AUTHORS' CONCLUSIONS: The review shows no clinically important difference between ceftriaxone or cefotaxime and conventional antibiotics. In situations where availability or affordability is an issue, third generation cephalosporins, ampicillin-chloramphenicol combination, or chloramphenicol alone may be used as alternatives. The antimicrobial resistance pattern against various antibiotics needs to be closely monitored in low to middle income countries as well as high income countries.

Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC).

We sought to determine the rate of healthcare-associated infection (HCAI), microbiological profile, bacterial resistance, length of stay (LOS) and excess mortality in 12 ICUs of the seven hospital members of the International Infection Control Consortium (INICC) of seven Indian cities. Prospective surveillance was introduced from July 2004 to March 2007; 10 835 patients hospitalized for 52 518 days acquired 476 HCAIs, an overall rate of 4.4%, and 9.06 HCAIs per 1000 ICU-days. The central venous catheter-related bloodstream infection (CVC-BSI) rate was 7.92 per 1000 catheter-days;the ventilator-associated pneumonia (VAP) rate was 10.46 per 1000 ventilator-days; and the catheter-associated urinary tract infection (CAUTI) rate was 1.41 per 1000 catheter-days. Overall 87.5% of all Staphylococcus aureus HCAIs were caused by meticillin-resistant strains, 71.4% of Enterobacteriaceae were resistant to ceftriaxone and 26.1% to piperacillin-tazobactam; 28.6% of the Pseudomonas aeruginosa strains were resistant to ciprofloxacin, 64.9% to ceftazidime and 42.0% to imipenem. LOS of patients was 4.4 days for those without HCAI, 9.4 days for those with CVC-BSI, 15.3 days for those with VAP and 12.4 days for those with CAUTI. Excess mortality was 19.0% [relative risk (RR) 3.87; P < or = 0.001] for VAP, 4.0% (RR 1.60; P=0.0174) for CVC-BSI, and 11.6% (RR 2.74; P=0.0102) for CAUTI. Data may not accurately reflect the clinical setting of the country and variations regarding surveillance may have affected HCAI rates. HCAI rates, LOS, mortality and bacterial resistance were high. Infection control programmes including surveillance and antibiotic policies are a priority in India.

Consolidated five-year experience with laparoscopic inguinal hernia repair.

INTRODUCTION: After the introduction of laparoscopic hernia repair to the National Health Service (NHS), we studied the benefits and practicality of carrying out this specialised hernia repair technique in a District General NHS hospital. METHODS: Patients with groin hernia were stratified into groups for day-surgery or inpatient care based on Trust guidelines. Patients underwent laparoscopic trans-abdominal pre-peritoneal (TAPP) inguinal hernia repair by a single consultant surgeon. Patients were followed-up in the clinic. All data were collected prospectively on a structured proforma. Postal questionnaire was sent to 100 randomly selected patients who had surgery more than two years ago and responses were evaluated. RESULTS: A total of 830 hernias were operated upon in 572 patients, aged between 16 and 89 years. Three hundred and twelve patients had the operation as a day-case procedure, and the remaining 260 were treated as inpatients. Incidental hernias were discovered in 19.1% of patients, and were treated simultaneously. CONCLUSION: The laparoscopic tension-free TAPP method of hernia repair, as done here, is cost-effective and efficacious. Most patients can be treated as day-cases. A low recurrence rate (0.36%) with low morbidity makes it an attractive method for routine treatment of groin hernias in the NHS.

Treatment of acute infectious purpura fulminans with activated protein C.

Infectious purpura fulminans is associated with high mortality and morbidity despite standard antimicrobial therapy. We report satisfactory clinical outcome in two children with sepsis associated purpura fulminans who were treated with activated protein C (APC). There is need for proper evaluation of the efficacy of this extremely expensive therapeutic modality by randomized controlled trials before it is made standard of care in childhood infectious purpura fulminans.

Samarium-153 ethylenediamine tetramethylene phosphonate therapy for bone pain palliation in skeletal metastases.

BACKGROUND: Systemic therapy with radionuclides may be used for the treatment of patients with painful skeletal metastases owing to its efficacy, low cost and low toxicity. Imported radionuclides for pain palliation, like Strontium-89 are expensive; particularly for developing countries. In the Indian scenario, Samarium-153 (Sm-153) is produced in our own reactors and as a result, it is readily available and economical. AIM: We undertook this study to determine the efficacy and toxicity of single-dose Sm-153 ethylenediamine tetramethylene phosphonate as a palliative treatment for painful skeletal metastases. MATERIALS AND METHODS: Eightysix patients with painful skeletal metastases from various primaries, were treated with Sm-153 EDTMP at a dose of 37 MBq/kg. The effects were evaluated according to change in visual analogue pain score, analgesic consumption, Karnofsky performance score, mobility score and blood count tests, conducted regularly for 16 weeks. STATISTICS: Repeated measures analysis. RESULTS: The overall response rates were 73%, while complete response was seen in 12.4%. Reduction in analgesic consumption with improvement in Karnofsky performance score and mobility score, was seen in all responders. Response rates were 80.3 and 80.5% in breast and prostate cancer, respectively. One case, each of Wilms tumor, ovarian cancer, germ cell tumor testis, multiple myeloma, primitive neuroectodermal tumor and oesophageal cancer, did not respond to therapy. No serious side-effects were noted, except for fall in white blood cell, platelet and haemoglobin counts, which gradually returned to normal levels by six-eight weeks. CONCLUSION: Sm-153 EDTMP provided effective palliation in 73% patients with painful bone metastases: the major toxicity was temporary myelosuppression.

Prevalence of vesicoureteral reflux in patients with incidentally diagnosed adult hypertension.

OBJECTIVES: To evaluate the prevalence of vesicoureteral reflux (VUR) in hypertensive patients without any other evidence of renal involvement. Reflux nephropathy may be clinically latent and present in early adulthood as hypertension when superimposed confounding factors are added. METHODS: The medical records of 157 adult hypertensive patients with normal renal parameters and low-probability, captopril-enhanced renal dynamic scan findings who underwent direct radionuclide voiding cystoscintigraphy between June 1998 and May 2003 were retrospectively analyzed. RESULTS: VUR was documented in 30 patients (19.1%). In those 30 patients, VUR was mild in 8 (26.6%), moderate in 6 (20%), and severe in 16 (53.3%) patients. Bilateral VUR was seen in 7 patients, graded as severe in all cases. The prevalence by age was 20% in the 18 to 30-year-old group, 16.6% in the 31 to 45-year-old group, and 20% in the older than 45-year-old group. CONCLUSIONS: The results of this study have shown that VUR is present in a significantly large proportion of adult patients with hypertension without any apparent renal parenchymal or renovascular involvement.