Assessing clinical frailty scale scoring by junior medical learners on an inpatient geriatrics consultation service

The Clinical Frailty Scale (CFS) is incorporated into our institution's comprehensive geriatric assessment (CGA). CGAs and CFS scoring are completed by junior medical trainees on the Geriatric consult service. The agreement between CFS score assignment by junior trainees and Geriatrics trained individuals in this setting is unknown. Importantly, these scores assign a frailty level that impacts care pathways. We conducted a retrospective chart review from April-June 2019. A Geriatric medicine subspecialty resident assigned retrospective CFS scores based on data from the CGA. We compared scores to determine the level of agreement using the Cohen and Conger's Kappa inter-rater agreement metric and assessed whether patient characteristics influenced the likelihood of agreement between raters using a generalized linear model. Medical students assessed 43% (46/108) of patients (n = 13), and 57% (62/108) were assessed by PGY1s (n = 10). Inter-rater agreement measures showed substantial agreement overall and for PGY1s, but dropped to a moderate agreement for medical students. The retrospective inter-rater agreement of the CFS showed substantial agreement overall and decreased when limited to medical students, highlighting the need for interventions to improve the understanding of frailty early in medical training.

Management strategies for the painless foot drop: a systematic review of the literature

PURPOSE

Foot drop can uncommonly be a painless presenting symptom of degenerative spinal disorders. This systematic review aimed to summarise the literature on the management and outcomes of patients with a painless foot drop.

METHODS

We performed a systematic review of PubMed, EMBASE and Medline according to PRISMA guidelines. All studies published after 1980 in English referring to adult patients with a painless foot drop were included. Exclusion criteria included opinion based reports, review articles and articles in which foot drop was not caused by degenerative pathology of the thoracolumbar spine.

RESULTS

Of 62 included patients, 30 (48.4%) were male with an average age of 48.7 years (range 27-84). The mean duration of symptoms was 69.0 days (1-700). 98.8% were managed operatively. 46 (74.2%) patients had symptomatic improvement, with 41 (66.1%) having a post-intervention MRC power grading of 3 or above. Patients with a pre-procedure MRC 0 had a higher median increase in MRC post-procedure than those with MRC > 0. Of two studies comparing painful and painless symptoms, painless foot drop patients were less likely to recover to MRC equal to or over 3 than those with painful symptoms OR 0.31 (95% CI 0.04-2.65).

CONCLUSION

This systematic review and meta-analysis demonstrates a role for surgery in facilitating the neurological recovery of patients with a painless foot drop. Large randomised controlled studies are required to characterise the role of operative intervention in these patients and compare outcomes between patients with painless and painful foot drop.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Serum bilirubin as a predictor of graft outcomes after renal transplant

Bilirubin is a signaling molecule that alters the immune response and metabolism. While bilirubin has been employed as a marker of renal and cardiovascular health, its role in renal transplant recipients is not known. In this study, we sought to determine the impact of bilirubin (total, direct and indirect) on the estimated glomerular filtration rate (eGFR) after renal transplantation. We conducted a retrospective review of pre- and postoperative bilirubin levels in 457 renal transplant recipients at a single center. Pre- and post-rejection bilirubin levels were also assessed in those patients who experienced a rejection episode. No statistically significant differences were found in bilirubin levels during the pre-transplant to post-rejection period among patients who experienced rejection with kidney allograft survival. No statistically significant associations were observed between baseline bilirubin and post-transplant eGFR in the full patient group or within the gender- or race-stratified groups. Baseline bilirubin was not correlated with time to rejection. Our results suggest that bilirubin may not offer renoprotection in renal transplant recipients.

Factors influencing local and distant recurrence following resection of periampullary cancer

BACKGROUND

Recurrence of periampullary cancer after pancreatoduodenectomy is common. The aim of this study was to investigate patterns of recurrence, incidence, and factors associated with local and distant recurrences.

METHODS

This retrospective, single-centre study included consecutive patients with periampullary cancer who underwent resection with curative intent from January 2012 to January 2018. Survival, patterns of recurrence, and factors associated with recurrences were analysed.

RESULTS

Median overall survival (OS) and disease-free survival among 398 included patients was 58.4 and 49.5 months respectively. Twenty-three patients (5.8 per cent) developed isolated local recurrences (LR), 50 (12.6 per cent) developed LR along with distant metastasis (DM), and 103 (25.9 per cent) developed isolated DM. Median OS was 40.4 months for patients with isolated LR versus 23 months for those with DM (P < 0.001). Tumour subtype (distal common bile duct (CBD): odds ratio (OR) 6.18, 95 per cent c.i. 2.19 to 17.46) and node-positive status (OR 2.36, 1.26 to 4.43) were independently associated with higher rates of LR. The most common site for isolated LR was along the superior mesenteric artery (12 of 23 patients). Tumour subtype (distal CBD: OR 2.86, 1.09 to 7.52), nodal positivity (OR 2.46, 1.53 to 3.94), and presence of perineural invasion (OR 1.80, 1.02 to 3.18) were independently associated with DM.

CONCLUSION

Isolated LR is associated with better survival than DM and occurs most commonly along the superior mesenteric artery.

Assessing the added value of group B Streptococcus maternal immunisation in preventing maternal infection and fetal harm: population surveillance study

OBJECTIVE

To assess the incidence of maternal group B Streptococcus (GBS) infection in England.

DESIGN

Population surveillance augmented through data linkage.

SETTING

England.

POPULATION

All pregnant women accessing the National Health Service (NHS) in England.

METHODS

Invasive GBS (iGBS) infections during pregnancy or within 6 weeks of childbirth were identified by linking Public Health England (PHE) national microbiology surveillance data for 2014 to NHS hospital admission records. Capsular serotypes of GBS were determined by reference laboratory typing of clinical isolates from women aged 15-44 years. Post-caesarean section surgical site infection (SSI) caused by GBS was identified in 21 hospitals participating in PHE SSI surveillance (2009-2015).

MAIN OUTCOME MEASURES

iGBS rate per 1000 maternities; risk of GBS SSI per 1000 caesarean sections.

RESULTS

Of 1601 patients diagnosed with iGBS infections in England in 2014, 185 (12%) were identified as maternal infections, a rate of 0.29 (95% CI 0.25-0.33) per 1000 maternities and representing 83% of all iGBS cases in women aged 18-44 years. Seven (3.8%) were associated with miscarriage. Fetal outcome identified excess rates of stillbirth (3.4 versus 0.5%) and extreme prematurity (<28 weeks of gestation, 3.7 versus 0.5%) compared with national averages (P < 0.001). Caesarean section surveillance in 27 860 women (21 hospitals) identified 47 cases of GBS SSI, with an estimated 4.24 (3.51-5.07) per 1000 caesarean sections, a median time-to-onset of 10 days (IQR 7-13 days) and ten infections that required readmission. Capsular serotype analysis identified a diverse array of strains with serotype III as the most common (43%).

CONCLUSIONS

Our assessment of maternal GBS infection in England indicates the potential additional benefit of GBS vaccination in preventing adverse maternal and fetal outcomes.

136 Intraoperative Neuromonitoring in Spinal Surgery: A Systematic Review and Meta-Analyses

Introduction

Intraoperative neuromonitoring (IONM) is widely used in spinal surgery as it has been shown to be highly sensitive and specific for detecting neurological injuries, although recent evidence has been conflicting in its cost-utility. The authors aim to determine whether the use of IONM during spinal surgeries significantly improves patient outcomes in terms of neurological events, and whether IONM is cost-effective.

Method

Literature search of studies looking at use of IONM for spinal surgeries from 2009 to 2020 was performed across several databases, following PRISMA guidelines. Quality of articles was assessed using MINORS criteria.

Results

The random effects model was used to evaluate the 5 studies comparing neurological events with and without IONM use. There was a higher incidence of neurological events without IONM, at 44 compared to 11 with IONM. However, pooled odds ratio was 0.56 (p = 0.11), indicating no significant difference. IONM was also found to be associated with longer operative times and costs, which is not cost-effective based on NICE recommendations.

Conclusions

- This study corroborate previous studies; there is no significant difference in patient outcome of neurological events with the use of IONM. There is, however, a higher incidence of neurological events without IONM.

Tooth -A Potential Graft Material for Periodontal Regeneration ?

Use of tooth as a promising replacement substitute has been validated by various animal as well as human studies. Though widely used in GBR and Sinus grafting techniques, its use in periodontal intrabony defect is not documented. In the present case report, the tooth graft has been placed in periodontal intrabony defect. Postoperative CBCT after 26 weeks revealed homogeneous incorporation of tooth graft. Clinical parameters show bone fill. However; results with larger sample size could further validate the use of tooth graft in periodontal regeneration.

Use of anti-osteoporosis medication dispensing by patients with hip fracture: could we do better?

Although Scandinavian countries have the highest incidence of hip fracture in the world, trends in anti-osteoporosis medication use have not been studied. We found less than one-third of Danish hip fracture patients had dispensing of anti-osteoporosis medication over a 10-year period using routinely collected data from population-based registries.

INTRODUCTION

To examine trend in dispensing of anti-osteoporosis medication before and after hip fracture surgery in Denmark over a 10-year period using routinely collected data from population-based registries.

METHODS

From the Danish Multidisciplinary Hip Fracture Registry, we included 65,011 patients aged 65 years or older with an incident hip fracture in 2005-2015. We calculated, for each calendar year of hip fracture diagnosis, the prevalence of use of anti-osteoporosis medication (at least one dispensing of bisphosphonates, strontium ranelate, denosumab, selective estrogen receptor modulators, or teriparatide) in the year before and in the year following hip fracture diagnosis. Among those without a dispensing in the year before hip fracture, we computed 1-year cumulative incidence of use following hip fracture. We treated death as a competing risk and stratified the analysis on sex, age, and comorbidity.

RESULTS

The prevalence of use before hip fracture varied between 7 and 12%, increasing slightly from 2005 to 2015. The cumulative incidence of use following hip fracture decreased from 16% in 2005 to 13% in 2010, whereupon it increased to 20%. A similar pattern was seen with each stratum of sex, age groups, and comorbidity. The overall prevalence of use after hip fracture was below 22% in all calendar years.

CONCLUSIONS

Less than one-third of hip fracture patients had dispensing of anti-osteoporosis medication up to 1 year after hip fracture. We observed only a slight increase in dispensing after hip fracture over the study period, irrespective of patient sex, age, and comorbidity at the time of hip fracture.

A comparison of two molecular methods for diagnosing leptospirosis from three different sample types in patients presenting with fever in Laos

OBJECTIVES

To compare two molecular assays (rrs quantitative PCR (qPCR) versus a combined 16SrRNA and LipL32 qPCR) on different sample types for diagnosing leptospirosis in febrile patients presenting to Mahosot Hospital, Vientiane, Laos.

METHODS

Serum, buffy coat and urine samples were collected on admission, and follow-up serum ∼10 days later. Leptospira spp. culture and microscopic agglutination tests (MAT) were performed as reference standards. Bayesian latent class modelling was performed to estimate sensitivity and specificity of each diagnostic test.

RESULTS

In all, 787 patients were included in the analysis: 4/787 (0.5%) were Leptospira culture positive, 30/787 (3.8%) were MAT positive, 76/787 (9.7%) were rrs qPCR positive and 20/787 (2.5%) were 16SrRNA/LipL32 qPCR positive for pathogenic Leptospira spp. in at least one sample. Estimated sensitivity and specificity (with 95% CI) of 16SrRNA/LipL32 qPCR on serum (53.9% (33.3%-81.8%); 99.6% (99.2%-100%)), buffy coat (58.8% (34.4%-90.9%); 99.9% (99.6%-100%)) and urine samples (45.0% (27.0%-66.7%); 99.6% (99.3%-100%)) were comparable with those of rrs qPCR, except specificity of 16SrRNA/LipL32 qPCR on urine samples was significantly higher (99.6% (99.3%-100%) vs. 92.5% (92.3%-92.8%), p <0.001). Sensitivities of MAT (16% (95% CI 6.3%-29.4%)) and culture (25% (95% CI 13.3%-44.4%)) were low. Mean positive Cq values showed that buffy coat samples were more frequently inhibitory to qPCR than either serum or urine (p <0.001).

CONCLUSIONS

Serum and urine are better samples for qPCR than buffy coat, and 16SrRNA/LipL32 qPCR performs better than rrs qPCR on urine. Quantitative PCR on admission is a reliable rapid diagnostic tool, performing better than MAT or culture, with significant implications for clinical and epidemiological investigations of this global neglected disease.

Epidemiology of male seminomatous and nonseminomatous germ cell tumors and response to first-line chemotherapy from a tertiary cancer center in India

INTRODUCTION

Unlike the developed countries, there is a lack of good epidemiologic data for testicular germ cell tumors (GCTs) in India with majority presenting in advanced stage. This study aims to elaborate on the epidemiology of testicular GCTs and response to standard first-line chemotherapy (CT).

METHODS

GCTs treated at our center from January 2013 to June 2014 were retrospectively analyzed. Patients underwent orchidectomy either outside or at our hospital. Based on stage and risk group, standard CT (bleomycin, etoposide, and cisplatin/etoposide and cisplatin/carboplatin AUC7) and radiotherapy were given as appropriate. Response was calculated based on the Response Evaluation Criteria in Solid Tumors. Statistical analysis was performed using SPSS 18 software.

RESULTS

Fifty nonseminomatous germ cell tumor (NSGCT) and 36 of SGCT cases were studied. 30%, 46%, and 64% of NSGCT and 11%, 28%, and 22% of SGCT had N2, N3, and M1 diseases, respectively. The mean nodal size was 7 cm (1.5-19) in NSGCT and 5.5 cm (1.3-11) in SGCT. As per the International Germ Cell Cancer Collaborative Group classification, in patients with metastatic disease, 9% of NSGCT were good, 53% were intermediate, and 38% were poor risk whereas 75% of SGCT were good and 25% were intermediate risk. Following CT among NSGCT, 5% and 71% had radiologic complete response (CR) and partial response (PR), respectively. Among SGCT, 46% and 38% had radiologic CR and PR, respectively. 22%, 53%, and 13% of NSGCT and 12%, 24%, and 20% of SGCT developed febrile neutropenia, Grade 3 or 4 hematological and nonhematological toxicities, respectively, after standard chemotherapy.

CONCLUSIONS

GCTs in India present with high nodal and high-risk diseases wherein the standard first-line CT may not be adequate as curative therapy; however, significant chemotoxicity is also a hindrance.

Comparison of the Nosocomial Pneumonia Mortality Prediction (NPMP) model with standard mortality prediction tools

BACKGROUND

Severity or mortality prediction of nosocomial pneumonia could aid in the effective triage of patients and assisting physicians.

AIM

To compare various severity assessment scoring systems for predicting intensive care unit (ICU) mortality in nosocomial pneumonia patients.

METHODS

A prospective cohort study was conducted in a tertiary care university-affiliated hospital in Manipal, India. One hundred patients with nosocomial pneumonia, admitted in the ICUs who developed pneumonia after >48h of admission, were included. The Nosocomial Pneumonia Mortality Prediction (NPMP) model, developed in our hospital, was compared with Acute Physiology and Chronic Health Evaluation II (APACHE II), Mortality Probability Model II (MPM₇₂ II), Simplified Acute Physiology Score II (SAPS II), Multiple Organ Dysfunction Score (MODS), Sequential Organ Failure Assessment (SOFA), Clinical Pulmonary Infection Score (CPIS), Ventilator-Associated Pneumonia Predisposition, Insult, Response, Organ dysfunction (VAP-PIRO). Data and clinical variables were collected on the day of pneumonia diagnosis. The outcome for the study was ICU mortality. The sensitivity and specificity of the various scoring systems was analysed by plotting receiver operating characteristic (ROC) curves and computing the area under the curve for each of the mortality predicting tools.

FINDINGS

NPMP, APACHE II, SAPS II, MPM₇₂ II, SOFA, and VAP-PIRO were found to have similar and acceptable discrimination power as assessed by the area under the ROC curve. The AUC values for the above scores ranged from 0.735 to 0.762. CPIS and MODS showed least discrimination.

CONCLUSION

NPMP is a specific tool to predict mortality in nosocomial pneumonia and is comparable to other standard scores.

Treatment of patients with metastatic pancreatic cancer: Experience from a tertiary Indian cancer center

BACKGROUND

The aim of this study was to look at the outcome of patients with metastatic pancreatic cancer treated at a tertiary cancer center in India.

PATIENTS AND METHODS

A total of 101 patients with locally advanced and metastatic pancreatic cancer diagnosed between May 2012 and July 2013 were identified from a prospectively maintained database at the tertiary cancer center. Overall survival (OS) was computed using the Kaplan-Meir product limit method and compared across groups using the log-rank statistics. Cox proportional hazards model, adjusted for a number of patient and tumor characteristics, was then used to determine factors prognostic for OS.

RESULTS

Median age at diagnosis was 55 years (range: 21-81 years). 57.4% (n = 58) of patients were male, 22% (n = 22) had performance status (PS) of <2 at diagnosis and 89% received first-line chemotherapy, while the rest received best supportive care. For the whole cohort, 6 month and 1-year OS was 57% (95% confidence interval [CI]: 46-66%) and 47% (95% CI: 35-57%), respectively. In a multivariable model, PS <2 and oligometastatic disease were associated with a significantly decreased risk of death.

CONCLUSION

Results from our analysis indicate that the prognostic outcome among Indian patients with metastatic pancreatic cancer is poor with survival outcomes similar to those reported in North America and Europe.

Infections with Corynebacterium diphtheriae: six years’ experience at an inner London teaching hospital

Recently, a preponderance of non-toxigenic strains of Corynebacterium diphtheriae has been reported, as has the broadening spectrum of disease caused by these strains. This study presents data on 85 isolates of C. diphtheriae over a six year period (1998-2003). Eighty were non-toxigenic isolates from patients with sore throat, and five (one toxigenic) were from cutaneous ulcers in travellers returning from endemic areas. When examined in relation to denominator data provided by the Health Protection Agency (HPA) for the whole of England and Wales, 1998-2002, 75% of all notifications of C. diphtheriae for England and Wales originated from the laboratories at University College London Hospitals (UCLH). In some years (1999 and 2001) 95-100% of isolates came from UCLH. We believe that national data do not reflect true incidence, as universal screening for these organisms is not routine policy in many laboratories. The results presented suggest the need for increased clinical and laboratory awareness of this important pathogen.

Comparison of isolates and antibiotic sensitivity pattern in pediatric and adult cancer patients; is it different?

BACKGROUND

Infection is a common cause of mortality and morbidity in cancer patients. Organisms are becoming resistant to antibiotics; age appears to be one of the factors responsible. We analyzed common organisms and their antibiotic sensitivity pattern in the correlation with age.

METHODS

This is a single institutional, retrospective analysis of all culture positive adult and pediatric cancer patients from January 2007 to December 2007. For statistical analysis, Chi-square test for trend was used and P values were obtained. Of 1251 isolates, 262 were from children <12 years of age and 989 were from adolescents and adults (>12 years of age). Gram-negative organisms were predominant (64.95) while Gram-positive constituted 35.09% of isolates.

RESULTS

The most common source in all age groups was peripheral-blood, accounting to 47.8% of all samples. The most common organisms in adults were Pseudomonas aeruginosa (15.3%) while in children it was coagulase negative Staphylococcus aureus (19.8%). Antibiotic sensitivity was different in both groups. In pediatric group higher sensitivity was seen for Cefoparazone-sulbactum, Cefipime, Amikacin, and Tobramycin. No resistance was found for Linezolid.

CONCLUSIONS

The isolates in both children and adults were predominantly Gram-negative though children had proportionately higher Gram-positive organisms. High-dose cytarabine use, cotrimoxazole prophylaxis, and frequent use of central lines in children especially in hematological malignancies could explain this observation. Children harbor less antibiotic resistance than adults; Uncontrolled, cumulative exposure to antibiotics in our community with increasing age, age-related immune factors and variable bacterial flora in different wards might explain the higher antibiotic resistance in adults. Thus age is an important factor to be considered while deciding empirical antibiotic therapy.

Single incision laparoscopic distal pancreatectomy with splenectomy for neuroendocrine tumor of the tail of pancreas

Laparoscopic resection is becoming the standard of care for tumors located in the body and tail of pancreas. We herein report a patient with neuroendocrine tumor in the tail of pancreas who underwent single incision laparoscopic distal pancreatectomy with splenectomy without the use of a commercial port device.

Early class III management in deciduous dentition using reverse twin block

Class III malocclusion poses a challenging dilemma for the clinician because these children have of growth patterns that differ from that of children with class I malocclusion. The mandible grows more rapidly than the maxilla, exacerbating the class III malocclusion as the child go through adolescence. Ever since Clark described a version of the twin block, it has steadily gained popularity in the management of early class III malocclusion in children. However, not many cases are reported in the literature on its use in deciduous dentition. This article tries to provide an insight into the reverse twin block appliance and reports two cases of early class III malocclusion treated using reverse twin block.

Laparoscopic resection of giant liver hemangioma using laparoscopic Habib probe for parenchymal transection

Experience with laparoscopic liver resections is limited. Laparoscopic resection of a variety of liver lesions has been reported and is considered appropriate for lesions in the left lateral segment and inferior segments of the right lobe. Herein, we report a 52-year-old male patient who underwent a laparoscopic resection of giant liver hemangioma with the use of a laparoscopic 4× Habib probe.

Changing epidemiology of Clostridium difficile infection following the introduction of a national ribotyping-based surveillance scheme in England

BACKGROUND

Marked increases in Clostridium difficile infection (CDI) incidence, driven by epidemic strain spread, is a global phenomenon.

METHODS

The Clostridium difficile Ribotyping Network (CDRN) was established in 2007 as part of enhanced CDI surveillance in England, to facilitate the recognition and control of epidemic strains. We report on changes in CDI epidemiology in England in the first 3 years of CDRN.

RESULTS

CDRN received 12,603 fecal specimens, comprising significantly (P < .05) increasing numbers and proportions of national CDI cases in 2007-2008 (n = 2109, 3.8%), 2008-2009 (n = 4774, 13.2%), and 2009-2010 (n = 5720, 22.3%). The C. difficile recovery rate was 90%, yielding 11,294 isolates for ribotyping. Rates of 9 of the 10 most common ribotypes changed significantly (P < .05) during 2007-2010. Clostridium difficile ribotype 027 predominated, but decreased markedly from 55% to 36% and 21% in 2007-2008, 2008-2009, and 2009-2010, respectively. The largest regional variations in prevalence occurred for ribotypes 027, 002, 015, and 078. Cephalosporin and fluoroquinolone use in CDI cases was reported significantly (P < .05) less frequently during 2007-2010. Mortality data were subject to potential reporting bias, but there was a significant decrease in CDI-associated deaths during 2007-2010, which may have been due to multiple factors, including reduced prevalence of ribotype 027.

CONCLUSIONS

Access to C. difficile ribotyping was associated with significant changes in the prevalence of epidemic strains, especially ribotype 027. These changes coincided with markedly reduced CDI incidence and related mortality in England. CDI control programs should include prospective access to C. difficile typing and analysis of risk factors for CDI and outcomes.

Single-incision laparoscopic splenectomy with innovative gastric traction suture

Laparoscopic splenectomy is now the gold standard for patients with idiopathic thrombocytopenic purpura (ITP) undergoing splenectomy. There are a few reports in literature on single-incision laparoscopic (SIL) splenectomy. Herein, we describe a patient undergoing SIL splenectomy for ITP without the use of a disposable port device. We report a 20-year-old female patient with steroid-refractory ITP having a platelet count of 14,000/cmm who underwent a SIL splenectomy. Dissection was facilitated by the use of a single articulating grasper and a gastric traction suture and splenic vessels were secured at the hilum with an endo-GIA stapler. She made an uneventful postoperative recovery and was discharged on the second postoperative day. She is doing well with no visible scar at 8-month follow-up.

Successful pregnancy in a patient with pseudomyxoma peritonei following in-vitro fertilization using donor eggs

Pseudomyxoma peritonei is a rare, chronic relapsing disease with a guarded prognosis. Here, we describe such a case of a young patient presenting with primary infertility, who conceived following in-vitro fertilization with donor egg and had a successful pregnancy outcome. Literature regarding fertility and pregnancy outcome in this condition is reviewed.

Asthma and dental erosion

Asthma is a chronic inflammatory condition of the airway, characterised by the presence of airflow obstruction which is variable over short periods of time, or is reversible with treatment. Medication comprises of bronchodilators, corticosteroids and anticholinergic drugs. Most asthma drugs are inhaled using various forms of inhalers or nebulizers. Inhaled drugs must be used regularly. The effects of these drugs on the dentition such as tooth decay and erosion have been a subject of debate among dental practitioners. Asthmatic medications can place the patient at risk of dental erosion by reducing salivary protection against extrinsic or intrinsic acids. Asthmatic individuals are one of the higher risk groups suffering from dental erosion. Therefore patients with bronchial asthma should receive special prophylactic attention. This article presents a case of an asthmatic with dental manifestations and reviews the possible causes and management of the same.

Immediate reattachment of fractured tooth segment using dual cure resin

Crown fracture of maxillary anterior teeth is frequent dental injuries for which patients seek immediate dental treatment. Immediate reattachment of the intact fractured tooth segment is a therapeutic choice in such cases. This case report presents one of the best methods used for reattachment, which is an ultraconservative technique. It allows the restoration of original tooth contour, colour and aesthetics.

A community genetics approach to population screening in India for mental retardation—a model for developing countries

Some 0.55 million people living in semi-urban and slum populations were screened for mental retardation by trained primary health centre (PHC) doctors, nurses and community health volunteers (CHVs). The staff were provided with prior training on the detection, prevention and diagnosis of mental retardation, prenatal diagnosis, and reproductive responsibilities. Field visits were employed to confirm diagnosed developmental disabilities, and demographic data incorporating social maps of 14 PHCs were prepared. Cases with high-risk genetic factors detected by PHC staff were referred to the Centre for Research in Mental Retardation (CREMERE) for cytogenetic and metabolic investigations, thus linking the study population and the Referral Centre. A genetic team interacted with the patient and family members for genetic counselling. Mental retardation was confirmed in 511 of the 525 cases reported, reflecting the positive impact of training on the CHVs. Potentially preventable environmental factors, such as birth asphyxia, infections, and low birth weight were identified in 251 cases (49%), 137 (27%) of which had additional genetic factors. Genetic causes were found in 186 (36%) individuals, the most common being Down syndrome. The study illustrates the urgent need for the integration of genetic screening into the public health services in India.

Delayed replantation: can it be a success?

This case report describes delayed replantation of an avulsed maxillary central incisor in a 17-year-old male patient following an injury on fall one day earlier. Avulsed maxillary right permanent central incisor was replanted back into the socket after extra-oral root canal treatment. One year follow up showed validity of treatment, with no evidence of resorption in the replanted tooth.