Superbugs causing ventilator associated pneumonia in a tertiary care hospital and the return of pre-antibiotic era!

The rise in super bugs causing Ventilator-Associated Pneumonia (VAP) is a major cause of mortality and morbidity despite recent advances in management owing to the looming 'antibiotic apocalypse'. The aetiology and susceptibility pattern of the VAP isolates varies with patient population, type of intensive care unit (ICU) and is an urgent diagnostic challenge. The present study carried out for a period of one year in a tertiary care hospital, enrolled patients on mechanical ventilation (MV) for ≥48 hrs. Endotracheal aspirates (ETA) from suspected VAP patients were processed by semi quantitative method. Staphylococus aureus, members of Enterobacteriaceae were more common in early onset VAP (EOVAP), while Nonfermenting Gram negative bacilli (NFGNB) were significantly associated with late onset VAP (LOVAP). Most of the isolates were multi drug resistant (MDR) super bugs. With limited treatment options left for this crisis situation like the pre-antibiotic era; it is an alarm for rational antibiotic therapy usage and intensive education programs.

Sentinel lymph node biopsy after neo-adjuvant chemotherapy in patients with breast cancer: Are the current false negative rates acceptable?

The advent of sentinel lymph node biopsy has revolutionised surgical management of axillary nodal disease in patients with breast cancer. Patients undergoing neo-adjuvant chemotherapy for large breast primary tumours may experience complete pathological response on a previously positive sentinel node whilst not eliminating the tumour from the other lymph nodes. Results from 2 large prospective cohort studies investigating sentinel lymph node biopsy after neo-adjuvant chemotherapy demonstrate a combined false negative rate of 12.6-14.2% and identification rate of 80-89% with the minimal acceptable false negative rate and identification rate being set at 10% and 90%, respectively. A false negative rate of 14% would have been classified as unacceptable when compared to the figures obtained by the pioneers of sentinel lymph node biopsy which was 5% or less.

There is more than one kind of myofibroblast: analysis of CD34 expression in benign, in situ, and invasive breast lesions

AIMS

Smooth muscle actin (SMA) positive myofibroblasts have been implicated in tumour invasion; however, acquisition of SMA is not limited to peritumorous fibroblasts and other changes in fibroblasts may be more specifically related to the malignant environment. CD34 is a sialomucin expressed by normal breast fibroblasts but lost in invasive carcinomas. The aim of this study was to establish the relation between CD34 and SMA expression in breast fibroblasts and to analyse whether loss of CD34 is specific for invasive disease.

METHODS

Immunohistochemistry for CD34 and SMA was performed on 135 cases including 10 normal, 10 fibroadenomas, 40 infiltrating ductal carcinomas, 55 cases of ductal carcinoma in situ (DCIS), and 20 radial scar/complex sclerosing lesions. The relation between staining pattern and histopathological features was recorded as positive, negative, or reduced.

RESULTS

Fibroblasts around all normal duct-lobule units and those showing epithelial hyperplasia were CD34 positive and mainly SMA negative. In fibroadenomas, fibroblasts retained CD34 but acquired SMA expression. In contrast, fibroblasts around invasive carcinoma were CD34 positive and SMA negative. In DCIS, loss of CD34 was significantly more frequent in high grade tumours than in low or intermediate grade ones (p < 0.001). The acquisition of SMA was seen more frequently than the loss of CD34, particularly in non-high grade DCIS. In all radial scars, fibroblasts were SMA positive but CD34 negative, and a similar pattern was seen in stromal cells in areas of fibrosis following core biopsy.

CONCLUSIONS

These results show that SMA positive myofibroblasts exhibit variable expression of CD34, indicating that these markers are not coordinately controlled. Loss of CD34 is strongly related to the malignant phenotype, in both invasive and preinvasive disease, but is not entirely specific because radial scar fibroblasts and fibroblasts in reactive fibrosis exhibit a similar phenotype. The functional relevance of altered CD34 expression is unclear but the very focal changes implicate local signalling mechanisms probably of epithelial origin.

Incidence of posterior capsular plaque in cataract surgery

OBJECTIVE

To determine the incidence of posterior capsular plaque detected during cataract surgery, its association with age and type of cataract, and its impact on vision.

SETTING

Raghudeep Eye Clinic and Iladevi Cataract & IOL Research Centre, Ahmedabad, India.

METHODS

This prospective study comprised 256 consecutive eyes having extracapsular cataract extraction with posterior chamber intraocular lens implantation. The presence of plaque on the posterior capsule was noted and charted. Plaque peeling or posterior capsulorhexis was not done at the time of surgery. Mean patient age was 59 years (range 24 to 83 years). Follow-up was up to 1 year.

RESULTS

The overall incidence of plaque was 10.16%. The incidence by type of cataract was 5.13%, nuclear sclerotic; 12.50%, posterior subcapsular; 9.68%, mixed; 27.27%, mature (P < .05). The difference in incidence according to cataract type was highly significant between patients older than 50 years and those younger than 50 years (P < .001). At the end of 1 year, 61.54% of patients with plaque maintained a visual acuity of 20/20 to 20/30; 30.77%, 20/40; 7.69%, 20/60 or worse.

CONCLUSION

The incidence of plaque was higher in eyes with mature cataract at any age and in eyes with posterior subcapsular cataract in younger patients. Its presence was compatible with reasonable vision at the end of 1 year.

Intraocular lens implantation in infants with congenital cataracts

We evaluated 21 eyes of 13 infants between two and eight months old who had primary posterior chamber intraocular lens (IOL) implantation for congenital cataracts between 1988 and 1993. Twelve eyes had a posterior capsulorhexis or plaque peeling at the time of implantation and one eye had a vitrectomy. Eight eyes had no posterior capsule procedure during the initial surgery. Follow-up ranged from six months to five years. All eyes developed one or multiple posterior synechias and all, except one, required secondary capsulectomy and vitrectomy between one month and one year. Twenty eyes attained stable IOL fixation and a clear visual axis. In one eye, the IOL decentered downward. Patients with bilateral cataracts had greater visual improvement than those with a cataract in one eye only. No patient could manage spectacles postoperatively. Our findings show the benefits of posterior capsulectomy and anterior vitrectomy done in the early postoperative period and that IOL implantation in infants is a reasonable treatment in some parts of the world.