Key lessons from the establishment of a nurse-led infection prevention and control program for COVID-19 in an Australian hotel quarantine and isolation service

BACKGROUND

A key aspect of Australia's response to the COVID-19 pandemic was to control transmission through legislated quarantine and isolation of overseas returning travellers and potentially infectious community members. In New South Wales, Special Health Accommodation (SHA) was rapidly established as a comprehensive health service for individuals that were at risk of having COVID-19, were confirmed to have COVID-19 or for those with complex health needs that were deemed inappropriate for management in Police managed Quarantine Hotels. SHA services were later expanded to care for community members who were COVID-19 positive and unable to effectively isolate, or contacts of individuals who were unable to quarantine effectively in their homes. SHA's unique nurse-led Infection Prevention and Control (IPC) program offers key lessons that may impact future programs.

METHODS

A reflection on the experience of leading an Infection Prevention and Control program in SHA was undertaken. This was supported by a review of SHA admission, workforce and transmission data and data obtained from a cross-sectional questionnaire aimed to better understand the experiences of a novel population of health workers (HW) in a comprehensive health-led quarantine and isolation service.

RESULTS

SHA program data demonstrates how its IPC program implementation prevented transmission of COVID-19 to SHA staff and patients. Responses from the questionnaire suggested staff felt safe and well-prepared through the IPC education they received. They also gained transferrable knowledge and skills, which they intend to use in future healthcare roles.

CONCLUSION

The SHA nurse-led IPC program offered successful quarantine and isolation for COVID-19 in non-purpose-built facilities. A review of IPC strategies and key lessons from the establishment of the SHA IPC program are of critical importance to planning and management of current and future pandemics.

Unusual Presentation of Synovial Lipomatosis Mimicking As Septic Arthritis of Knee: A Case Report

Synovial lipomatosis or lipoma arborescens is a very uncommon pseudo-tumorous lesion of the synovium which more commonly affects the knee joint. The most probable cause of this pathological lesion is degenerative articular disorders of the joint and improper fat accumulation. It is characterized by presence of villous proliferation of the synovium and replacement of the sub-synovial tissue by mature adipocytes which is infiltrated by dense chronic inflammatory cells like lymphocytes, plasma cells and eosinophils. This condition is rarely seen in smaller joints. Its aetiology is still unknown. We report a patient who presented with features of septic arthritis which on intraoperative and histopathological assessment showed features of synovial lipomatosis.

Targeted hypermutation of putative antigen sensors in multicellular bacteria

Diversity-generating retroelements (DGRs) are used by bacteria, archaea, and viruses as a targeted mutagenesis tool. Through error-prone reverse transcription, DGRs introduce random mutations at specific genomic loci, enabling rapid evolution of these targeted genes. However, the function and benefits of DGR-diversified proteins in cellular hosts remain elusive. We find that 82% of DGRs from one of the major monophyletic lineages of DGR reverse transcriptases are encoded by multicellular bacteria, which often have two or more DGR loci in their genomes. Using the multicellular purple sulfur bacterium Thiohalocapsa sp. PB-PSB1 as an example, we characterized nine distinct DGR loci capable of generating 10282 different combinations of target proteins. With environmental metagenomes from individual Thiohalocapsa aggregates, we show that most of PB-PSB1's DGR target genes are diversified across its biogeographic range, with spatial heterogeneity in the diversity of each locus. In Thiohalocapsa PB-PSB1 and other bacteria hosting this lineage of cellular DGRs, the diversified target genes are associated with NACHT-domain anti-phage defenses and putative ternary conflict systems previously shown to be enriched in multicellular bacteria. We propose that these DGR-diversified targets act as antigen sensors that confer a form of adaptive immunity to their multicellular consortia, though this remains to be experimentally tested. These findings could have implications for understanding the evolution of multicellularity, as the NACHT-domain anti-phage systems and ternary systems share both domain homology and conceptual similarities with the innate immune and programmed cell death pathways of plants and metazoans.

Development and validation of a questionnaire to assess commonality knowledge of traumatic dental injuries and management of emergencies

BACKGROUND

Dental trauma represents a significant public health problem, causing a burden for both individuals and society. The aim of this study is to systematically develop and validate a questionnaire on 'traumatic dental injuries and management of emergencies' (TIME) for assessing the knowledge, attitude and practice (KAP) for a commonality.

METHODS

The scale development phases included conceptual framework, systematic development of an item pool, refinement of the item pool by Focus-group discussion (n = 23), validity-testing using Content Validity Index (n = 5), translation and back-translation, Cognitive interviewing (n = 30,45), and reliability testing (n = 40). The conceptual framework was built based on six broad constructs, such as broken teeth, knocked-out (avulsion) teeth, pushed/moved-in and loosened teeth (luxation injuries), soft tissue injuries, follow-up and management, and prevention and protection.

RESULTS

Reviews of existing questionnaires significantly helped to generate an initial pool of 68 items (refined to 51 items). Lawshe's content validity was 0.92. High test-retest reliability was demonstrated (kappa value = 0.98). The questionnaire showed a high level of reliability (Cronbach's alpha = 0.86) with great internal consistency.

CONCLUSION

TIME is the first validated scale for recording knowledge, attitude and practices on traumatic dental injuries and management of emergencies for non-dental professionals. The 51-tem tool will allow dentists to evaluate KAP of commonality. KAP measured across the globe would have a significant impact on planning awareness programs by dentists and dental associations.

Diversity at single nucleotide to pangenome scales among sulfur cycling bacteria in salt marshes

IMPORTANCE

Salt marshes are known for their significant carbon storage capacity, and sulfur cycling is closely linked with the ecosystem-scale carbon cycling in these ecosystems. Sulfate reducers are key for the decomposition of organic matter, and sulfur oxidizers remove toxic sulfide, supporting the productivity of marsh plants. To date, the complexity of coastal environments, heterogeneity of the rhizosphere, high microbial diversity, and uncultured majority hindered our understanding of the genomic diversity of sulfur-cycling microbes in salt marshes. Here, we use comparative genomics to overcome these challenges and provide an in-depth characterization of sulfur-cycling microbial diversity in salt marshes. We characterize communities across distinct sites and plant species and uncover extensive genomic diversity at the taxon level and specific genomic features present in MAGs affiliated with uncultivated sulfur-cycling lineages. Our work provides insights into the partnerships in salt marshes and a roadmap for multiscale analyses of diversity in complex biological systems.

Integrating New Staff into Endovascular Stroke-Treatment Workflows in the COVID-19 Pandemic

A health care crisis such as the coronavirus disease 2019 (COVID-19) pandemic requires allocation of hospital staff and resources on short notice. Thus, new and sometimes less experienced team members might join the team to fill in the gaps. This scenario can be particularly challenging in endovascular stroke treatment, which is a highly specialized task that requires seamless cooperation of numerous health care workers across various specialties and professions. This document is intended for stroke teams who face the challenge of integrating new team members into endovascular stroke-treatment workflows during the COVID-19 pandemic or any other global health care emergency. It discusses the key strategies for smooth integration of new stroke-team members in a crisis situation: 1) transfer of key knowledge (simple take-home messages), 2) open communication and a nonjudgmental atmosphere, 3) strategic task assignment, and 4) graded learning and responsibility. While these 4 key principles should generally be followed in endovascular stroke treatment, they become even more important during health care emergencies such as the COVID-19 pandemic, when health care professionals have to take on new and additional roles and responsibilities in challenging working environments for which they were not specifically trained.

Tibial Plateau Fracture with Avulsion Fracture of Tibial Tuberosity: A Case Report and Review of Literature

Tibial tuberosity fractures are usually seen in the adolescent age group and are very rare in adults. Here we describe a case of knee injury following a road traffic accident. The patient had tibial tuberosity avulsion along with tibial plateau fracture. He was treated with open surgical reduction and internal fixation. His rehabilitation was quite successful, resulting in a good range of motion and functional outcome. This study aims to present this unusual case of tibial tuberosity avulsion fracture associated with tibial plateau fracture and its appropriate management.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Efficient routeing in Poisson small-world networks

In a recent paper, Kleinberg (2000) considered a small-world network model consisting of a d-dimensional lattice augmented with shortcuts. The probability of a shortcut being present between two points decays as a power, r-α, of the distance, r, between them. Kleinberg showed that greedy routeing is efficient if α = d and that there is no efficient decentralised routeing algorithm if α ≠ d. The results were extended to a continuum model by Franceschetti and Meester (2003). In our work, we extend the result to more realistic models constructed from a Poisson point process wherein each point is connected to all its neighbours within some fixed radius, and possesses random shortcuts to more distant nodes as described above.

Sensitizing undergraduate medical students to consultation skills: A pilot study

BACKGROUND

Good consultation skills help physicians to diagnose the problems of the patient more accurately, and foster a therapeutic relationship. We describe a pilot study that used role-play with peers as a method to sensitize first clinical year medical students to consultation skills Methods. Students were divided into groups of three where one acted as a doctor, the second as a patient and the third as an observer. Students were asked to perform a role-play of a prepared clinical scenario where the patient had a hidden fear of malignancy. Observations were recorded in a simplified Calgary-Cambridge consultation checklist. Students' feedback and their emotions written after the role-play were analysed and discussed. Assessment of their learning was done with an objective structured clinical examination.

RESULTS

Students' feedback revealed that they were sensitized to the importance of starting the consultation with an open question, listening to the opening statement, non-verbal.

Prospective randomized observer-blinded study comparing the analgesic efficacy of ultrasound-guided rectus sheath block and local anaesthetic infiltration for umbilical hernia repair

BACKGROUND

Umbilical hernia repair, a common day-surgery procedure in children, is associated with considerable postoperative discomfort. Possible modes of postoperative analgesia for umbilical hernia repair are rectus sheath block (RSB) and local anaesthetic infiltration of the surgical site (LAI).

METHODS

We undertook an observer-blinded, randomized, prospective, observational study to compare the efficacy of ultrasound-guided RSB and LAI in providing postoperative analgesia for umbilical hernia repair. Our primary objective was to compare the use of opioid medication between patients who receive RSB and those who receive LAI. Our secondary objectives were to compare the duration of analgesia based on time to first rescue analgesic, to compare the quality of analgesia based on revised FACES scale, and to determine the incidence of side-effects.

RESULTS

Fifty-two patients (26 in each group) completed the study. There was a statistically significant difference in the perioperative opioid medication consumption between the LAI group [mean: 0.13 mg kg(-1), confidence interval (0.09-0.17 mg kg⁻¹)] and the RSB group [mean: 0.07 mg kg⁻¹, confidence interval (0.05-0.09 mg kg⁻¹)] (P=0.008). When we compared the postoperative opioid consumption between the LAI group [mean: 0.1 mg kg⁻¹, 95% confidence interval (0.07-0.13 mg kg⁻¹)] and the RSB group [mean: 0.07 mg kg(-1), 95% confidence interval (0.05-0.09 mg kg⁻¹)] (P=0.09), there was a trend towards statistical significance between the two groups. The difference in time to rescue analgesic administration between the RSB group [49.7 (36.9) min] and the LAI group [32.4 (29.4) min] was not statistically significant (P=0.11).

CONCLUSIONS

This study demonstrates that ultrasound-guided RSB provides superior analgesia in the perioperative period compared with infiltration of the surgical site after umbilical hernia repair. In comparing only the postoperative period, analgesia provided by an ultrasound-guided RSB showed a trend towards statistically significant improvement compared with infiltration of the surgical site.

Spatial learning-induced egr-1 expression in telencephalon of gold fish Carassius auratus

The immediate-early gene (egr-1) expression was used to examine the neuron's response in telencephalon of goldfish during spatial learning in small space. Fishes were pre-exposed in the experimental apparatus and trained to pick food from the tray in a rectangular-shaped arena. The apparatus was divided into identical compartments comprising three gates to provide different spatial tasks. After the fish learned to pass through the gate one, two more gates were introduced one by one. Fish made more number of attempts and took longer time (P < 0.05) to pass through the first gate than the gate two or three. This active learning induces the expression of egr-1 in telencephalon as established by western blot analysis. Subsequently, the fish learn quickly to cross the similar type of second and third gate and make fewer errors with a corresponding decline in the level of egr-1 expression. As the fish learned to pass through all the three gates, third gate was replaced by modified gate three. Interestingly, the level of egr-1 expression increased again, when the fish exhibit a high exploratory behavior to cross the modified gate three. The present study shows that egr-1 expression is induced in the telencephalon of goldfish while intensively acquiring geometric spatial information to pass through the gates.

Olfactory bulb serotonin level modulates olfactory recognition in the neonate rat

Role of serotonin in olfactory recognition was tested by depleting the olfactory bulb serotonin during postnatal day (PND) 1 - 4 following administration of 5,7-dihydroxytryptamine. Significant difference in the olfactory recognition test was observed during PND5-7; control pups successfully recognized and oriented towards their mother; whereas treated pups failed to recognize their mother odour. Later on, during PND12-14, both group of pups responded equally in the recognition test. Levels of olfactory bulb serotonin were depleted (53.3%) in the treated pups on PND-8, which was restored on PND-14 with only 15% variation. Further analysis demonstrated that depletion of serotonin in olfactory bulb did not affect the normal suckling and weight gain, it only modulates olfactory recognition.

Light-induced COP9 signalosome expression in the Indian false vampire bat Megaderma lyra

The COP9 signalosome (CSN) is a multi-subunit protein complex conserved in plants and animals. CSN subunits have been identified as light-mediated master regulators of eukaryotic circadian clocks from fungi to animals. The Indian false vampire bat Megaderma lyra is completely adapted to an anthropic biotope and behavioral studies have reported that M. lyra exhibits light-sampling behavior to assess environmental light. LC-MS-MS results for a 36 kDa protein were analyzed using the Sequest search engine, and COP9 signalosome subunit 5 (CSN5) was pinpointed as having the highest score with 6 matching peptides. To confirm the presence of CSN5, up-regulated cDNA was amplified, sequenced, and identified as CSN5. Furthermore, semi-quantitative RT-PCR analysis demonstrated that the level of induction of CSN5 was regulated by environmental light. We estimated the level of expression across a light-dark cycle and observed a higher level of expression at the end of the light phase. Similarly, when the animal was shifted from continuous dark to light, CSN5 expression was induced. Correspondingly, we detected the similar pattern of translated protein with JAB1 antibody. Knowledge about the circadian rhythm and its molecular mechanism in Chiroptera is very limited and this study suggests that CSN5 might be involved in the M. lyra light-signaling process.

Spread of Epidemics and Rumours with Mobile Agents

We propose a simple model of infection that enables to study the coincidence time of two random walkers on an arbitrary graph. By studying the coincidence time of a susceptible and an infected individual both moving in the graph we obtain estimates of the infection probability. The main result of this paper is to pinpoint the impact of the network topology on the infection probability.

Exponential Random Graphs as Models of Overlay Networks

In this paper we give an analytic solution for graphs withnnodes andE=cnlognedges for which the probability of obtaining a given graphGisµn(G) = exp (-β∑i=1ndi2), wherediis the degree of nodei. We describe how this model appears in the context of load balancing in communication networks, namely peer-to-peer overlays. We then analyse the degree distribution of such graphs and show that the degrees are concentrated around their mean value. Finally, we derive asymptotic results for the number of edges crossing a graph cut and use these results (i) to compute the graph expansion and conductance, and (ii) to analyse the graph resilience to random failures.

[Post-traumatic inflammation with an intraocular foreign body]

BACKGROUND

To report on the diagnosis and management of a"firecracker" injury presenting with a post-traumatic intraocular inflammation.

CASE REPORT

A 10-year-old boy sustained a penetrating 16-mm cornea-sclera blast injury to his left eye with uveal prolapse and hemophthalmus and doubtful light perception. The cranial computed tomography revealed a metallic intraocular foreign body (IOFB), retinal detachment, and subretinal and subchoroidal hemorrhage. After primary wound closure and antibiotic treatment for 1 week, increasing cell infiltration and amaurosis developed, and a lensectomy, pars plana vitrectomy, and extraction of the 17x7x7-mm encapsulated IOFB via a scleral tunnel was indicated.

RESULTS

A vitreous specimen did not reveal microbial growth; however, plenty of polymorphonuclear cells, macrophages, and lymphocytes were observed. Spectroscopy of the IOFB showed copper, zinc, silicon, lead, and other metals. A diagnosis of noninfectious inflammation due to heavy metals, primarily copper (=chalcosis), was made. The postoperative course was unremarkable, the intraocular lens in place, fundus CDR 0.2, retina and macula attached, intraocular pressure 9 mmHg. Three weeks after surgery, the flash VEP showed absent potentials.

CONCLUSIONS

Large projectiles or parts should be removed from the eye immediately in order to prevent complications from toxic metallosis and early fibrotic reactions.

An effective integrated learning programme in the first year of the medical course

BACKGROUND

An integrated approach to teaching medical subjects is an effective educational strategy. Yet, this has not become popular in medical colleges in India. We describe an integrated learning programme to teach the gastrointestinal system in the first year of the medical course.

METHODS

The integrated learning programme was conducted for 3 years (2003-2005). It incorporated elements of problem-based learning, early clinical exposure, lectures and small group laboratory work. Student assessment was formative (for problem-based learning sessions) and summative (using problem-based learning and knowledge tests). Evaluation of the programme was based on feedback from the students and faculty members.

RESULTS

Ninety-six per cent of the students obtained more than 60% marks in the problem-based learning test. The mean (SD) score in the knowledge test was 62 (0.89)%. The majority of students received satisfactory and more than satisfactory grades for their performance in the problem-based learning sessions. The feedback from faculty members and students was positive, which highlighted benefits such as integrated learning of the basic sciences, their application to clinical cases and active student learning. The challenges encountered included the higher input required from faculty members. Most of the faculty members and students recommended that the integrated programme should be continued and extended to other parts of the curriculum.

CONCLUSION

An integrated learning programme is feasible within a conventional medical curriculum of an Indian medical college.

Sickle cell-haemoglobin E (HbSE) compound heterozygosity: a clinical and haematological study

The paucity of clinical reports in the world literature suggests that, as a disease entity, haemoglobin SE compound heterozygosity is of negligible importance. In view of the significant community prevalence of this haemoglobinopathy in the Sultanate of Oman where it is the second most prevalent sickling disorder, a hospital study of 12 SE compound heterozygotes from six unrelated Arab families was undertaken to determine their clinico-haematological features. Our findings were compared with those reviewed in the literature. Clinical and haematological evaluation was carried out by conventional methods including chromatographic haemoglobin analysis. At least 50% of those studied were asymptomatic throughout the study period but sickling-related complications occurred in the rest and included the acute chest syndrome (1/12), severe vaso-occlusive skeletal pain (2/12), frontal bossing (1/12) possibly indicative of significant chronic haemolysis and recurrent infections of the urinary tract (1/12). Steady-state haemoglobin levels fell within the reference range while MCV and MCH values were, as expected, reduced in most cases; nevertheless, concomitant inheritance of alpha-thalassaemia trait was also likely. Red cell morphology was striking by the absence or rarity of pseudo-sickled cells in the blood films of many patients during the steady state and in crises. Bearing in mind the prevalence of 0.05% of SE compound heterozygosity in Oman, the findings in this single study of the largest number of SE patients and their relatives confirm the predominantly asymptomatic nature of this sickling disorder in individuals in the community at large. HbF levels do not appear to explain the heterogeneous nature of this haemoglobinopathy. Correlation of the variable clinical and haematological features of SE cases with their alpha-globin gene status and beta-cluster haplotypes (linked to the beta(s)- and beta(e)-genes) merits a separate investigation, which is being currently organized.

Multiple simultaneous perineural infusions for postoperative analgesia in adolescents in an outpatient setting

We report a case series of five adolescents who were managed with dual simultaneous perineural infusions after orthopaedic surgery on an outpatient basis. Adolescents undergoing orthopaedic procedures involving more than one extremity or nerve distribution can be managed after operation with multiple catheters. Use of low concentrations of local anaesthetic infusions along with good patient and family education and close follow-up by a dedicated paediatric pain management team can make this feasible in an outpatient setting.

[Conceiving and implementing an ISO 9001:2000 quality management system: quality improvement and efficiency increase over 3 years at the Dept. of Ophthalmology, Sultan Qaboos University in Oman]

BACKGROUND

Oman is a developing country of the Middle East with a University Hospital in a national health system. Problems related to documentation, structure, and procedure prevailing in a multicultural environment result in a lack of productivity. The aim of this study was to test the feasibility of introducing a quality management system according to ISO 9001:2000 into a university department of ophthalmology with special reference to quality and efficiency data over 3 years.

MATERIALS AND METHODS

Standardized types of documentation (35 documents, 183 forms and formats, and 453 registers) under a formal roof (booklets for work instructions, quality management, procedures) were conceived in 2001 and implemented, and were evaluated by descriptive statistics over the years 2002-2005 with respect to quality and efficiency. In 2005, the departmental QMS was merged into the QMS of the whole hospital.

RESULTS

Establishment of "responsibility clusters" with structured surveillance tasks, procedural improvements, and continuous audits resulted in a significant quality improvement already during the implementation until ISO 9001:2000 certification in 2002, and over the following 3 years. The data were assessed by non-conformities documented monthly (total inpatients: -50%, outpatients: -20%, operating theater: -100%, teaching: -10%; p <0.05) and increased efficiency assessed by the most important performance indicators (before QMS vs a median of 3 years with QMS): major surgery: +459%, inpatient stay: -49.7%, occupancy rate: +63.9%, technical diagnostics: +292.9%, postgraduate teaching total: +740%, research output total: +330% (p <0.05).

CONCLUSIONS

It is feasible to introduce the quality management system according to ISO 9001:2000 into a developing country in the Middle East. It has an immediate effect on the increase of efficiency (measured by performance indicators) and quality in all systems providing the possibility for regional benchmarking.

Multiple locations on chromosome 3 are the targets of specific deletions in uveal melanoma

PURPOSE

Loss of chromosome 3 is a frequent event in uveal melanomas, which is associated with hepatic metastases and a poor prognosis. The entire copy of chromosome 3 is usually lost (monosomy 3); however, a small subset of tumours demonstrate partial deletions of chromosome 3. Analysis of these tumours may allow the identification of tumour suppressor genes (TSGs) that are the molecular target of monosomy 3. Therefore, the purpose of this investigation was to determine the location of these partial deletions of chromosome 3 in uveal melanomas.

METHODS

Microsatellite analysis and restriction fragment-length polymorphism analysis were performed on 52 primary uveal melanomas using 19 markers located on both arms of chromosome 3. Cytogenetic analysis and fluorescence in situ hybridisation were performed, where possible, to confirm molecular findings.

RESULTS

Of 52 tumours studied, five tumours (10%) demonstrated LOH at one or more informative markers, but retention of heterozygosity was observed at other loci on chromosome 3, consistent with the presence of structural abnormalities to chromosome 3. Consistent with previous findings, the pattern of LOH in these tumours indicates the presence of deletions around 3p25-26 and on 3q, and that a new target region at 3p11-14 is preferentially deleted.

CONCLUSIONS

These results indicate the presence of several tumour suppressor loci on chromosome 3 and support the notion that the high rate of monosomy 3 in uveal melanoma is driven by disruption of several TSGs located on both arms of chromosome 3.

Escobar variant with pursed mouth, creased tongue, ophthalmologic features, and scoliosis in 6 children from Oman

We report on six Omani children from two consanguineous families, with a multiple congenital anomaly syndrome defined by arthrogryposis multiplex congenita, typical facial appearance, ophthalmologic anomalies, atrophic calf muscles, and interdigital, neck and axillar pterygia. In addition, the patients present unique features as a furrowed tongue and enlarged corneal nerves, undescribed previously in association with other distal arhtrogryposis syndromes (DA). The patients can be classified as multiple pterygium syndrome (Escobar syndrome) but display overlapping features with Freeman-Sheldon syndrome and arthrogryposis with ophthalmologic abnormalities. We excluded two known arthrogryposis loci on chromosome 9p13 (TPM2) and 11p15 (TNNI2, TNNT3). We conclude that our patients display a subtype of multiple pterygium syndrome with overlapping features to other DAs.

En bloc excision of intraocular epithelial cystic downgrowth using syngeneic auricular cartilage

AIM

To describe the surgical management of epithelial cystic downgrowth by en bloc excision and use of syngeneic auricular cartilage in two children.

STUDY DESIGN

Retrospective interventional case series.

METHOD

The charts of two patients treated for epithelial cystic downgrowth with en bloc excision and auricular cartilage transplant were reviewed. Details of ocular history, preoperative and postoperative visual acuity, intraocular pressure, ocular examination findings, surgical procedure and subsequent management were noted.

RESULTS

Two children aged 4 and 6 years, with epithelial cysts who underwent en bloc excision were identified. The cysts had developed following penetrating eye injury. Surgery involved en bloc resection of the cyst and associated tissue, and replacement of the excised corneoscleral tissue with syngeneic auricular cartilage. One patient additionally required synechiolysis, discission of a secondary cataract and anterior vitrectomy. In both cases, the epithelial tissue was successfully removed and the auricular cartilage transplant was well-apposed. Visual acuity remained at the preoperative level in the first patient due to amblyopia; in the second patient visual acuity improved to 6/7.5 with mild astigmatic correction.

CONCLUSION

En bloc excision provides the most definitive surgical treatment of cystic epithelial downgrowth. Auricular cartilage may be used for sclerokeratoplasty when donor cornea or sclera is unavailable.

Retinopathy of prematurity in VLBW and extreme LBW babies

OBJECTIVE

This is a hospital-based, prospective clinical study to determine the incidence, risk factors, and outcome of extreme low birth weight and very low birth weight pre-term babies with retinopathy of prematurity (ROP) at the Sultan Qaboos University Hospital, Oman.

METHODS

All babies with a birth weight =/< 1500 g and gestational age =/< 32 weeks admitted in the Neonatal Unit, were screened for ROP between 4 to 6 weeks of age and staged according to the international classification and were followed up until complete vascularization of the retina. Fifty nine babies formed the study group.

RESULTS

The overall incidence of ROP was 25.4% (15 out of 59), of which 6 babies had severe ROP and underwent cryotherapy/laser. All babies with ROP had a birth weight < 1250 g and were born before 31 weeks of gestation.

CONCLUSION

ROP is a multifactorial disease, the immature retina of the pre-term baby being the primary factor. Incidence and severity was inversely proportional to birth weight and gestational age. Multiple logistic regression analysis showed that sepsis and total parenteral nutrition to be highly significant risk factors. Repeated blood transfusions, hypotension and congenital heart disease with left to right shunt were seen to be considerably associated with the development of ROP. A decrease in overall incidence and severity of ROP was observed in this study.

46,XY,der(3)t(1;3)(q23;p22): double aneuploidy at a new breakpoint

A 12-month-old Omani boy is described with double aneuploidy involving chromosomes 1 and 3. In this case the aberration involved segment (q23;p22) which has not been reported previously.

Low frequency of bacteraemia during eye surgery obviates the need for endocarditis prophylaxis

PURPOSE

To determine the incidence of bacteraemia following eye surgery, and thereby evaluate the need for antibiotic cover during such procedures, in patients who are at risk for bacterial endocarditis.

METHODS

This prospective study involved 50 consecutive patients undergoing extraocular surgery at the Sultan Qaboos University Hospital, Muscat, Oman. Local preparation of the surgical site in all patients included pre-operative instillation of 0.3% gentamicin and 3% povidone-iodine eye drops. Two eye swabs (one from the conjunctival sac and another from the eyelid margin) and two venous blood samples (one taken just before the procedure and the second 10 min into it) were collected and cultured for aerobic and anaerobic bacteria. Surgery-related bacteraemia was defined as a negative pre-operative blood culture followed by a positive intraoperative blood culture of the same bacterium identified in the positive eye swab.

RESULTS

Only two patients (4%) demonstrated surgery-related bacteraemia: one caused by Staphylococcus epidermidis (following entropion correction) and the other by Haemophilus influenzae (following dacryocystorhinostomy). Four other patients had positive conjunctival swabs without bacteraemia, the causative organisms being Haemophilus influenzae in two, and Staphyloccus aureus and Klebsiella pneumoniae in one each.

CONCLUSION

Ophthalmic surgery is not associated with significant bacteraemia, and therefore does not mandate routine antibiotic cover in patients at risk for bacterial endocarditis. Stringent pre-operative preparation of the surgical site may suffice to minimise bacteraemia; however, this requires further study.