Pseudomonas aeruginosa meningitis/ventriculitis in a UK tertiary referral hospital.

BACKGROUND: Pseudomonas aeruginosa is a rare cause of meningitis and ventriculitis but is generally associated with significant morbidity and mortality. AIM: We sought to determine the epidemiology, risk factors and outcome of meningitis and ventriculitis due to P. aeruginosa at our institution in order to inform preventive strategies and treatment guidelines. METHODS: Retrospective study of all patients with a positive cerebrospinal fluid (CSF) culture admitted to a tertiary care hospital over 18 years. Clinical details, demographic, microbiological and antibiotic data were obtained from laboratory and medical records. RESULTS: Twenty-four episodes occurred in 21 patients over 18 years. Pyrexia (75%), fluctuating mental status (50%) and headache (41%) were the most frequent presenting symptoms. Nineteen of the 21 patients had previously undergone a neurosurgical procedure and seven had extra-ventricular devices in situ. Twelve (57%) patients had P. aeruginosa isolated from another site prior to their episode. Most (89%) CSF samples demonstrated a neutrophilia; the CSF protein, when measured, was raised in all cases. Gram-negative bacilli were visible on CSF microscopy in only three isolates. There were relatively low rates of resistance to most antimicrobials tested and combination treatment of intravenous with intrathecal antibiotics was often used. No patients died within 28 days. CONCLUSION: Pseudomonas aeruginosa meningitis and ventriculitis are predominantly nosocomial and related to prior neurosurgery. It can be difficult to diagnose as CSF Gram-film and meningism are insensitive markers. Appropriate empirical treatment, neurosurgical prophylaxis and surveillance can aid in managing this infection.

Surgeon Modified Fenestrated Endovascular Abdominal Aortic Repair (F-EVAR) for Subacute Multifocal Mycotic Abdominal and Iliac Artery Saccular Aneurysms.

INTRODUCTION: Endovascular repair of suprarenal abdominal aortic aneurysms (AAAs) requires customized fenestrated stent grafts when they involve visceral vessels such as the renal (clinically ignored here in this specific scenario), celiac, and superior mesenteric arteries. REPORT: On table fenestrated endovascular abdominal aortic aneurysm repair (F-EVAR), using a parallel endograft approach, was performed for enlarging saccular subacute mycotic suprarenal and left common iliac artery aneurysms in a 58 year old man with recent methicillin sensitive Staphylococcus aureus (MSSA) bacteremia, who was high risk for open surgical repair. Fenestrations were performed for the coeliac artery (CA) and superior mesenteric artery (SMA) using a Bovie® (Clearwater, FL, USA) cautery device. The initial procedure was complicated by a type II endoleak that resolved spontaneously within 6 months of surgery. The patient remained well on follow up a year post surgery. CONCLUSION: On table surgeon modified F-EVAR is a safe and viable option for patients with subacute suprarenal mycotic abdominal aneurysms.

Short communication: Viability of culture organisms in honey-enriched acidophilus-bifidus-thermophilus (ABT)-type fermented camel milk.

The aim of this research was to monitor the survival during refrigerated storage of Lactobacillus acidophilus LA-5 (A), Bifidobacterium animalis ssp. lactis BB-12 (B), and Streptococcus thermophilus CHCC 742/2130 (T) in cultured dairy foods made from camel and, for comparison, cow milks supplemented with black locust (Robinia pseudoacacia L.) honey and fermented by an acidophilus-bifidus-thermophilus (ABT)-type culture. Two liters of dromedary camel milk and 2 L of cow milk were heated to 90 °C and held for 10 min, then cooled to 40 °C. One half of both types of milk was fortified with black locust honey at the rate of 5.0% (wt/vol), whereas the other half was devoid of honey and served as a control. The camel and cow milks with and without honey were subsequently inoculated with ABT-5 culture and were fermented at 37 °C until a pH value of 4.6 was reached. Thereafter, the probiotic fermented milks were cooled to 15 °C in ice water and were each separated into 18 fractions that were transferred in sterile, tightly capped centrifuge tubes. After 24 h of cooling at 8 °C (d 0), the samples were stored at refrigeration temperature (4 °C). Three tubes of all 4 products (i.e., fermented camel and cow milks with and without honey) were taken at each sampling time (i.e., following 0, 7, 14, 21, 28, and 35 d of storage), and the counts of characteristic microorganisms and those of certain spoilage microbes (yeasts, molds, coliforms, Escherichia coli) were enumerated. The entire experimental program was repeated twice. The results showed that addition of black locust honey at 5% to heat-treated camel and cow milks did not influence the growth and survival of starter streptococci during production and subsequent refrigerated storage of fermented ABT milks. In contrast, honey improved retention of viability of B. animalis ssp. lactis BB-12 in the camel milk-based product during storage at 4 °C up to 5 wk. No spoilage organisms were detected in any of the samples tested in this study. In conclusion, supplementation of cultured dairy foods, especially those made from camel milk, with honey is recommended because honey is a healthy natural sweetener with a variety of beneficial microbiological, nutritional, and sensory properties.

Short communication: survival of the characteristic microbiota in probiotic fermented camel, cow, goat, and sheep milks during refrigerated storage.

The objective of this study was to monitor the viability during storage of Lactobacillus acidophilus LA-5 (A), Bifidobacterium animalis ssp. lactis BB-12 (B), and Streptococcus thermophilus CHCC 742/2130 (T) in probiotic cultured dairy foods made from pasteurized camel, cow, goat, and sheep milks fermented by an ABT-type culture. The products manufactured were stored at 4°C for 42d. Microbiological analyses were performed at weekly intervals. Streptococcus thermophilus CHCC 742/2130 was the most numerous culture component in all 4 products both at the beginning and at the end of storage. The viable counts of streptococci showed no significant decline in fermented camel milk throughout the entire storage period. The initial numbers of Lb. acidophilus LA-5 were over 2 orders of magnitude lower than those of Strep. thermophilus CHCC 742/2130. With the progress of time, a slow and constant decrease was observed in lactobacilli counts; however, the final viability percentages of this organism did not differ significantly in the probiotic fermented milks tested. The cultured dairy foods made from cow, sheep, and goat milks had comparable B. animalis ssp. lactis BB-12 counts on d 0, exceeding by approximately 0.5 log10 cycle those in the camel milk-based product. No significant losses occurred in viability of bifidobacteria in fermented camel, cow, and sheep milks during 6wk of refrigerated storage. In conclusion, all 4 varieties of milk proved to be suitable raw materials for the manufacture of ABT-type fermented dairy products that were microbiologically safe and beneficial for human consumption. It was suggested that milk from small ruminants be increasingly used to produce probiotic fermented dairy foods. The development of camel milk-based probiotic cultured milks appears to be even more promising because new markets could thus be conquered. It must be emphasized, however, that further microbiological and sensory studies, technology development activities, and market research are needed before such food products can be successfully commercialized.

Oesophageal variceal band ligation using a saeed six-shooter multiband ligator; experience at Jos University Teaching Hospital, Nigeria: case report.

BACKGROUND: Oesophageal varices are common sequelae of cirrhosis, which when they bleed can be difficult to control. Oesophageal variceal band ligation, being the best modality for controlling variceal bleeding has not been common practice in West Africa, a region recognized to have a high prevalence of liver diseases. We present a case of band ligation of the varices of a patient that presented to our hospital with variceal haemorrhage, secondary to liver cirrhosis. METHOD: We started by presenting a summary of the presentation of a 31 year old man at the Jos University Teaching Hospital and how we established the diagnosis of grade IV bleeding oesophageal varices. The subject had four bands applied to the oesophageal varices using a saeed six shooter oesophageal Multi-band ligator (North Carolina, USA) using a forward-viewing GIF P30 gastroscope (Tokyo, Japan) with the bands mounted on an Opti-vu barrel-shaped piece. He had a total of three sessions after which he was maintained on propranolol. RESULT: The last recheck endoscopy demonstrated obliterated varices after which he was maintained on propranolol. CONCLUSION: We present a case of successful variceal band ligation of a cirrhotic with extensive oesophageal varices presenting in a resource-constraint medical setting.

Prevalence of diabetic retinopathy in children and adolescents with IDDM. A population-based multicentre study.

Vision-threatening diabetic retinopathy can be prevented if it is diagnosed before becoming too advanced. Since diabetic retinopathy has been reported to occur only rarely before the end of pubertal development, children and adolescents are seldom included in screening programmes. We invited 780 children and adolescents with insulin-dependent diabetes mellitus diagnosed before the age of 15.0 years (disease duration of < 12 years) and who were older than 9.0 years at the time of examination from eight regions of Sweden. Retinal examination was performed with stereoscopic fundus photograph. The photograph were rated according to a modified Airlie House classification. The dropouts (223/780, 28.6%) were significantly older and with a longer duration of diabetes than the examined children (p < 0.001 and 0.001, respectively). Photographs from 557 patients aged (median [interquartile range]:14.6 [12.4-17.0]) years and with a diabetes duration of 8.0 (5.5-9.9) years were evaluated. Retinopathy was demonstrated in 81 patients (14.5%):66 with background retinopathy, 2 with microaneurysms and hard exudates, 12 with preproliferative retinopathy, 1 with proliferative retinopathy. Preproliferative retinopathy was diagnosed in a 12.8-year-old girl in pubertal stage 3 and an 11.8-year-old boy in pubertal stage 2, and proliferative retinopathy was found in a 21.5-year-old girl. Retinopathy was demonstrated in 6% and 18% of patients in pubertal stages 1 and 5, respectively. The overall prevalence of retinopathy in this population may even be higher since the dropouts were older and had a longer duration of diabetes. Since background and preproliferative retinopathy were found in children before puberty, we recommend including children and adolescents in screening programmes for diabetic retinopathy from the age of 10 years.

Complications in IDDM are caused by elevated blood glucose level: the Stockholm Diabetes Intervention Study (SDIS) at 10-year follow up.

Blood glucose values close to normal reduce the microvascular complications of insulin-dependent diabetes mellitus. The Stockholm study of this effect continued after the initial 7.5-year period in order to see what happened when intensively treated patients were left to control their own treatment while treatment was intensified in the control group. Forty-three patients with insulin-dependent diabetes randomised to intensified conventional treatment (ICT) and 48 patients randomised to standard treatment (ST) were followed-up for 10 years. Vascular complications, treatment side-effects and well-being were studied. Risk factors for complications were sought. HbA1c (normal range 3.9-5.7%) was reduced from 9.5 +/- 1.4% (mean +/- SD) in the ICT group and 9.4 +/- 1.2% in the ST group to a mean (during 10 years) of 7.2 +/- 0.6% and 8.3 +/- 1.0%, respectively (p < 0.001). Serious retinopathy (63 vs 33%, p = 0.003), nephropathy (26 vs 7%, p = 0.012) and symptoms of neuropathy (32 vs 14%, p = 0.041) were more common in the ST group after 10 years. HbA1c and age were the only risk factors for complications. Self-reported well-being increased to a greater degree and severe hypoglycaemia was more common in the ICT group. Cognitive function after 10 years was similar in both treatment groups, and was not related to the number of severe hypoglycaemic episodes. Intensified insulin treatment leads to reduced long-term complications and increased well-being without causing undue side-effects.

Perineal lipoma and the accessory labioscrotal fold: an etiological relationship.

Congenital scrotal disorders are unusual, including penoscrotal transposition, bifid scrotum, ectopic scrotum and accessory scrotum. The latter 2 entities are extremely rare. Because accessory scrota usually arise in the absence of associated anomalies, an etiology has been enigmatic. We present 2 cases of accessory labioscrotal folds, including a female patient. An exhaustive literature review allowed comparison with all reported cases (23) and showed a frequent association with perineal lipoma (83%). On that basis, we were able to classify accessory labioscrotal folds into 2 types and recommend a different course of management for each. Accessory labioscrotal folds usually develop when intervening mesenchymal tissue disrupts the continuity of the caudally developing labioscrotal swelling.

Scrotal arteriovenous malformation: case report and literature review.

We report a rare case of scrotal arteriovenous malformation in an adolescent. Arteriovenous malformation of the scrotum is distinguished radiographically and histologically by numerous arterioles and thick walled veins with no intervening capillary bed. The cardinal sign is a bruit. Complete excision is recommended as definitive treatment. Preoperative angio-embolization may be helpful but it should not be relied upon for clinical resolution.

Epidemiology of ROP in the Stockholm area of Sweden.

A prospective, population-based study of the epidemiology of ROP in a well-defined geographical area of Sweden was performed. Two hundred and sixty children with a birth weight of 1500 g or less, and surviving for at least eight weeks, were included in the study. ROP was seen in 40.4% of the children. We suggest that prematurely born children with a gestational age of 32 weeks or less ought to be screened for ROP.

Capillary loss and leakage after five years of intensified insulin treatment in patients with insulin-dependent diabetes mellitus.

Ninety-six patients with insulin-dependent diabetes mellitus were randomized to intensified conventional treatment (n = 44) or regular treatment (n = 52) programs and followed for 5 years. Hemoglobin A1c was reduced from 9.5% +/- 0.1% to 7.2% +/- 0.1% in the intensified conventional treatment group and from 9.4% +/- 0.2% to 8.7% +/- 0.1% in the regular treatment group (mean +/- standard error) (P less than 0.001). Capillary loss and leakage of fluorescein as evaluated with fluorescein angiography increased significantly in the regular treatment group (P less than 0.05; P less than 0.01) but not in the intensified conventional treatment group. Capillary loss (P less than 0.01) and leakage (P less than 0.001) were related to metabolic control as measured by Hb A1c but not to duration of diabetes or smoking habits. Capillary loss (P less than 0.05) but not leakage was related to the initial diastolic blood pressure.