Usability of donor corneas harvested from the deceased having septicaemia or malignancy

CONTEXT

There is a wide gap between supply and demand in relation to healthy corneal grafts. Specific contraindications like infection and malignancy lead to non-usage of many grafts, despite the fact that deeming graft unhealthyness for these two contraindications is debatable.

AIMS

This study was conceptualized to assess if corneas donated from the deceased with septicaemia or malignancy can be deemed fit for implantation.

SETTINGS AND DESIGN

Retrospective histopathological and microbiological analysis of cadaveric donor corneas.

METHODS

A total of 76 donor corneas from 38 patients rejected for corneal transplantation in view of patient having septicaemia or malignancy were analysed for pathological and microbiological workup, to look for dissemination of disease within corneal tissue. Pathology workup included gross and microscopic histopathological evaluation of tissue. Microbiology workup included Grams stain and KOH with calcofluor mount, culture in blood agar, chocolate agar, Sabourauds dextrose agar and Mc Conkeys broth.

RESULTS

A total of 46 donor corneas of 23 septicaemia patients when evaluated showed presence of culture positive infection in 18 patients (78.2%). Histopathological examination done for 30 donor corneas from 15 cancer patients did not reveal presence of tumour cells in the specimen. Corneas of two of cancer patients having septicaemia revealed growth on cultures.

CONCLUSIONS

Corneal tissues harvested from septicaemia donors showed significantly higher incidence of corneal contamination, confirming their unsuitability for usage. However, there was no incidence of tumour transmission in corneal tissues of the patients with malignancies, suggesting that they can be considered for ophthalmic purpose.

Prevalence of allergic bronchopulmonary aspergillosis among patients with severe bronchial asthma in a tertiary care hospital in Northern India

Introduction

The link between fungi and asthma has been known for centuries. About one-third to one-half of severe asthmatics has history of atopic sensitization to filamentous fungi, most predominantly to Aspergillus fumigatus. Allergic bronchopulmonary aspergillosis (ABPA) is the one of the most documented fungal presentations among patients with asthma. This study was done on 50 patients with severe asthma who were consecutively enrolled from January 2016 to June 2017 to look for prevalence of ABPA.

Materials and Methods

Blood samples were collected from 50 patients with severe asthma, and serum was separated to test for absolute eosinophil count, total IgE, and Aspergillus fumigates-specific IgE.

Results

The prevalence of ABPA was found to be 70% (35/50). Of these, ABPA-B (ABPA with bronchiectasis) was less 31.4% (11/35) when compared with 68.5% (24/35) of patients with serological ABPA. Out of these 35 patients, there were 18 females and 17 were males. The mean age of the patients was 41.3 years.

Conclusion

ABPA prevalence is high in patients with severe asthma, and there is a need to look for and evaluate this association further.

Fungal Planet description sheets: 558-624

Novel species of fungi described in this study include those from various countries as follows: Australia: Banksiophoma australiensis (incl. Banksiophoma gen. nov.) on Banksia coccinea, Davidiellomycesaustraliensis (incl. Davidiellomyces gen. nov.) on Cyperaceae, Didymocyrtis banksiae on Banksia sessilis var. cygnorum, Disculoides calophyllae on Corymbia calophylla, Harknessia banksiae on Banksia sessilis, Harknessia banksiae-repens on Banksia repens, Harknessia banksiigena on Banksia sessilis var. cygnorum, Harknessia communis on Podocarpus sp., Harknessia platyphyllae on Eucalyptus platyphylla, Myrtacremonium eucalypti (incl. Myrtacremonium gen. nov.) on Eucalyptus globulus, Myrtapenidiella balenae on Eucalyptus sp., Myrtapenidiella eucalyptigena on Eucalyptus sp., Myrtapenidiella pleurocarpae on Eucalyptuspleurocarpa, Paraconiothyrium hakeae on Hakea sp., Paraphaeosphaeria xanthorrhoeae on Xanthorrhoea sp., Parateratosphaeria stirlingiae on Stirlingia sp., Perthomyces podocarpi (incl. Perthomyces gen. nov.) on Podocarpus sp., Readeriella ellipsoidea on Eucalyptus sp., Rosellinia australiensis on Banksia grandis, Tiarosporella corymbiae on Corymbia calophylla, Verrucoconiothyriumeucalyptigenum on Eucalyptus sp., Zasmidium commune on Xanthorrhoea sp., and Zasmidium podocarpi on Podocarpus sp. Brazil: Cyathus aurantogriseocarpus on decaying wood, Perenniporia brasiliensis on decayed wood, Perenniporia paraguyanensis on decayed wood, and Pseudocercospora leandrae-fragilis on Leandrafragilis.Chile: Phialocephala cladophialophoroides on human toe nail. Costa Rica: Psathyrella striatoannulata from soil. Czech Republic: Myotisia cremea (incl. Myotisia gen. nov.) on bat droppings. Ecuador: Humidicutis dictiocephala from soil, Hygrocybe macrosiparia from soil, Hygrocybe sangayensis from soil, and Polycephalomyces onorei on stem of Etlingera sp. France: Westerdykella centenaria from soil. Hungary: Tuber magentipunctatum from soil. India: Ganoderma mizoramense on decaying wood, Hodophilus indicus from soil, Keratinophyton turgidum in soil, and Russula arunii on Pterigota alata.Italy: Rhodocybe matesina from soil. Malaysia: Apoharknessia eucalyptorum, Harknessia malayensis, Harknessia pellitae, and Peyronellaea eucalypti on Eucalyptus pellita, Lectera capsici on Capsicum annuum, and Wallrothiella gmelinae on Gmelina arborea.Morocco: Neocordana musigena on Musa sp. New Zealand: Candida rongomai-pounamu on agaric mushroom surface, Candida vespimorsuum on cup fungus surface, Cylindrocladiella vitis on Vitis vinifera, Foliocryphia eucalyptorum on Eucalyptus sp., Ramularia vacciniicola on Vaccinium sp., and Rhodotorula ngohengohe on bird feather surface. Poland: Tolypocladium fumosum on a caterpillar case of unidentified Lepidoptera.Russia: Pholiotina longistipitata among moss. Spain: Coprinopsis pseudomarcescibilis from soil, Eremiomyces innocentii from soil, Gyroporus pseudocyanescens in humus, Inocybe parvicystis in humus, and Penicillium parvofructum from soil. Unknown origin: Paraphoma rhaphiolepidis on Rhaphiolepsis indica.USA: Acidiella americana from wall of a cooling tower, Neodactylaria obpyriformis (incl. Neodactylaria gen. nov.) from human bronchoalveolar lavage, and Saksenaea loutrophoriformis from human eye. Vietnam: Phytophthora mekongensis from Citrus grandis, and Phytophthora prodigiosa from Citrus grandis. Morphological and culture characteristics along with DNA barcodes are provided.

Incidence, risk factors, microbiology of venous catheter associated bloodstream infections--a prospective study from a tertiary care hospital

PURPOSE

Central venous catheters (CVCs) though indispensable in current medical and intensive care treatment, also puts patients at risk of catheter related infection (CRI) resulting in increased morbidity and mortality. We analysed the incidence, risk factors, bacteriological profile and antimicrobial susceptibility pattern of the isolates in central venous catheter associated bloodstream infection (CVC-BSI) in the intensive care unit (ICU) patients and studied the formation of biofilm in CVCs.

MATERIALS AND METHODS

The following case control study included 115 patients with CVC in situ. Quantitative blood cultures (QBC) and catheter tip cultures were performed for the diagnoses. Direct catheter staining was done for an early diagnosis by acridine orange (AO) and Gram staining methods. Biofilm production in catheters was detected by 'tissue culture plate' (TCP) method. The results were analysed using the computer-based program statistical package for the social sciences (SPSS).

RESULTS

In 25/115 patients, definite diagnosis of CVC-BSI was made. The mean age was 48.44 ± 17.34 years (cases) vs 40.10 ± 18.24 years (controls) and the mean duration of catheterisation was 25.72 ± 8.73 days (cases) vs 11.89 ± 6.38 days (controls). Local signs of infection (erythema, tenderness and oozing) were found more significantly in CVC-BSI cases. The AO staining was more sensitive and Gram staining of catheters showed higher specificity. Staphylococcus aureus followed by Pseudomonas aeruginosa and non-albicans Candida were common CVC-BSI pathogens. Multidrug-resistant (MDR) strains were isolated in bacterial agents of CVC-BSI. Non-albicans Candida and Enterococcus faecalis showed strong biofilm production.

CONCLUSION

The incidence of CVC-BSI was 21.73% and the rate was 14.59 per 1000 catheter days. Prolonged ICU stay and longer catheterisation were major risk factors. S. aureus was isolated most commonly in CVC-BSI cases. The menace of multidrug resistance and biofilm formation in CVCs is associated with CVC-BSI.

Coexistence of Extended Spectrum Beta-Lactamases, AmpC Beta-Lactamases and Metallo-Beta-Lactamases in Acinetobacter baumannii from burns patients: a report from a tertiary care centre of India

Multidrug-resistant Acinetobacter baumanii is a major pathogen encountered in pyogenic infections, especially from burns patients in hospital settings. Often there is also coexistence of multiple beta-lactamase enzymes responsible for beta-lactam resistance in a single isolate, which further complicates treatment options. We conducted a study on burn wound pus samples obtained from the burns unit of our hospital. Phenotypic tests were used to determine the Extended Spectrum Beta-Lactamase, AmpC Beta-Lactamase and Metallo-Beta-Lactamase producing status of the isolates. Almost half of the samples from the burn wounds yielded Acinetobacter baumanii as the predominant pathogen (54.05%). Coexistence of the three resistance mechanisms was seen in 25 of the 100 (25%) isolates of Acinetobacter baumanii. This study emphasizes the need for the detection of isolates that produce these enzymes to avoid therapeutic failures and nosocomial outbreaks.

Abstract P4-02-02: Comparison of 18F-FDG PET-CT and 11C-MET PET-CT for assessment of response to neoadjuvant chemotherapy in locally advanced breast carcinoma

INTRODUCTION: Neo-adjuvant chemotherapy plays an important role in treatment of breast cancer by decreasing the tumor load & it offers an opportunity to evaluate response of primary tumor to chemotherapy. This makes response monitoring crucial in the management of breast carcinoma. Standard anatomical imaging modalities are unable to accurately reflect the response to chemotherapy until several cycles of drug treatment have been completed. Metabolic imaging using tracers like 18F-fluorodeoxyglucose (FDG) as a marker of glucose metabolism or amino acid tracers like L-methyl-11C methionine (MET) have potential role for the measurement of treatment response in breast cancer.

AIMS AND OBJECTIVES: To compare FDG PET-CT with MET PET-CT for assessment of response to neoadjuvant chemotherapy, in locally advanced breast carcinoma and to correlate it with clinico-pathological response.

METHODS: In our prospective study, 20 patients with histology proven locally advanced breast carcinoma were enrolled. All patients underwent clinical assessment and PET-CT imaging using FDG and MET before and after 3 cycles of neoadjuvant chemotherapy (CAF regimen). Thereafter, all patients were taken for modified radical mastectomy and the resected breast with dissected axillary nodes was sent for histo-pathological analysis. Tumor response to the neoadjuvant chemotherapy was evaluated clinically using WHO criteria and by PET-CT imaging using PERCIST criteria. Responses calculated were compared for statistical significance using paired t- test.

RESULTS: Mean SUV in FDG-PET for primary tumor (p < 0.001) and axilla (p = 0.001) were significantly higher than in MET-PET. After three cycles of chemotherapy, clinical size of the primary tumor decreased by 55.76%, mean SUVmax of the primary lesion decreased by 47.21% in FDG-PET (p = 0.16) and by 45.5% in MET-PET (p = 0.167).

Nocardia nova mycetoma over forehead in a lepromatous leprosy patient

We present a case of a 31-year-old male, a known patient with lepromatous leprosy with a type 2 lepra reaction, who presented with a slowly growing asymptomatic swelling with multiple discharging sinuses over the forehead that developed over 6 months. Smears of the serosanguinous discharge on Gram staining showed Gram-positive branching filamentous bacilli, which on culture on blood agar showed chalky-white colonies. Histology of the lesion showed suppurative granulomas with polymorphs surrounding characteristic grains. The isolate was identified as Nocardia nova by gene sequencing and the patient was started on combined antibiotic therapy that resulted in complete resolution of the infection in six months. To the best of our knowledge, this is the first report of mycetoma related to Nocardia nova in association with leprosy.

Primary cutaneous zygomycosis from a tertiary care centre in north-west India

BACKGROUND & OBJECTIVES

Zygomycosis is highly invasive fungal infection, with high mortality rate. In most of patients, diabetes mellitus is an underlying factor but in primary cutaneous zygomycosis, presentation may be different. Here we present the description of clinical presentation, fungi isolated and management of cases with cutaneous zygomycosis seen in a tertiary care hospital in north India during 2001-2007.

METHODS

All patients diagnosed with primary cutaneous zygomycosis between November 2001 and September 2007 presenting with clinical diagnosis of necrotizing fasciitis were included. Detailed history of each patient was taken, clinical presentation, site of involvement, underlying illness and risk factor, if any were noted. The diagnosis was established by direct microscopic evidence of broad, aseptate or sparsely septate ribbon-like hyphae with right angle branching in KOH wet mount and histopathological examination of stained sections. Cultures were put up for fungal isolation and species identification. Outcome of the therapy was analysed.

RESULTS

Of the nine patients reviewed, only one had diabetes mellitus. Commonest risk factor was injection abscess (33.3%). Apophysomyces elegans was isolated in four cases, Saksenaea vasiformis and Absidia corymbifera in one each. The fungal culture was sterile in three cases. Mortality rate was high with only four patients responded well to surgical and/or medical therapy.

INTERPRETATION & CONCLUSION

Primary cutaneous zygomycosis appears to be on rise in India that calls for high index of clinical suspicion and an early biopsy of the affected area for timely diagnosis. The standard treatment is a combination of amphotericin B therapy, surgical debridement, and reversal of the underlying disease or immunosuppression.

Sudden vision loss caused by rhino-orbital zygomycosis in diabetic patients: case series

Rhino-orbital zygomycosis is a life-threatening fungal infection generally occurring in patients with an underlying disorder, such as diabetes mellitus with ketoacidosis or with immunocompromising factors, although it may rarely appear in healthy individuals. The study has been undertaken to discuss the clinical presentation, pathogenesis, diagnostic work up and management of this rapidly progressive disease. Four male patients having uncontrolled diabetes and presenting with signs and symptoms of rhino-orbital zygomycosis were studied to illustrate the serious nature of the disease. All the four patients had rapidly deteriorating vision loss either unilateral or bilateral along with other nasal and orbital signs and symptoms. All the patients were put on liposomal amphotericin B and underwent orbital exenteration and pansinusectomy. One patient died, while the other three were successfully treated. Early diagnosis is critical in the prevention of morbidity and mortality associated with the disease. There is need for a high index of clinical suspicion in immunocompromised patients. Timely medical-surgical treatment proves extremely important for prognosis.

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair under epidural anesthesia: a detailed evaluation

BACKGROUND

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is as efficacious as the open Lichtenstein procedure, can be learned with proper training, and causes less postoperative pain, better cosmesis, and earlier return to work. The one major factor preventing the widespread acceptance of TEP is the requirement for general anesthesia (GA). In contrast, open hernia is performed using local or regional anesthesia, thereby having the advantage of quicker recovery, decreased postoperative nausea and vomiting (PONV), fewer hemodyanamic changes, reduced metabolic responses to surgical stress, and better muscle relaxation. This study attempted to evaluate whether laparoscopic TEP can be performed under less invasive anesthesia, such as regional anesthesia, and to determine its feasibility and limitations

METHODS

All total of 22 male patients were studied between January 2002 and March 2003 in a tertiary care referral hospital. Epidural anesthesia with 2% lignocaine with adrenaline (Adr) was given via a lumbar epidural catheter, achieving a sensory level of T6. The standard technique for TEP was followed, using three midline infraumbilical ports.

RESULTS

Twenty-two patients (20 unilateral, 2 bilateral) underwent operation. The mean operating time was 67.8 +/- 18 (range, 40-110) min. All 22 cases were started with epidural anesthesia, 7 of which (31.9%) were converted to GA; the other 15 (68.1%) were completed under epidural anesthesia. All cases were successfully completed laparoscopically, and there were no conversions. There were no intraoperative complications. There was no significant difference between the cases conducted under epidural anesthesia (67.6 +/- 23 min) and those converted to GA (69.3 +/- 7.3 min). There was no statistically significant difference between the conversion rates of smaller versus larger hernias in this study (p value 0.22). A significant association of success of the procedure was seen with a sensory level of T6 and above (2/15 conversions to GA; i.e., 13.3%) and cases with a sensory level below T6 (5/7 converted; i.e., 71.4%) and adequate epidural catheter length (p = 0.015). Prevention and management of pneumoperitoneum and subsequent shoulder-tip pain was the key to preventing conversions (6 of 9 converted to GA; i.e., 67%; p = 0.006). There were no significant postoperative complications, and no recurrences were noted during a mean follow-up period of 29 months (range, 20-36 months).

CONCLUSIONS

From the present study it is clear that TEP is possible under epidural anesthesia provided a minimal sensory level of T6 is achieved. To achieve that level, an appropriate higher site for catheter insertion and/or adequate intraepidural catheter length needs specific attention. Pneumoperitoneum, shoulder-tip pain, intraoperative straining, and inadequate preperitoneal space are factors whose interplay leads to conversion to GA. The size of the hernia is not related to pneumoperitoneum or conversion to GA.

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair: overcoming the learning curve

BACKGROUND

Total extraperitoneal (TEP) laparoscopic inguinal hernia repair is preferred to the transabdominal preperitoneal (TAPP) repair since it preserves peritoneal integrity. However, in general it is considered to be more difficult than the latter because of the peculiarity of anatomy and limitation of working space. Therefore it has been assigned with a "steep learning curve" that the surgeon needs to climb steadily and slowly. This paper offers a working protocol, which is aimed at reducing the steep limb of this curve.

METHODS

A total of 61 patients were studied between April 2000 and September 2002. Of these, five patients had a open unilateral Stoppa's preperitoneal operation to learn the detailed anatomy of the extraperitoneal space. Thereafter, laparoscopic TEP procedure was started in the following 56 cases by P.L. In case of difficulty, the procedure was to be converted to the open preperitoneal operation only. Of the first 10 cases, five were converted to unilateral Stoppa's preperitoneal operation for various reasons, and one case was converted after 30 cases. Thus a total of 11 cases were completed by open unilateral Stoppa's preperitoneal operation and 50 cases were completed laparoscopically. The first 30 cases started initially as laparoscopic operations were analyzed in groups of 10 each and compared to another study from Netherlands (evaluating four surgeons) wherein the initial laparoscopic procedures were started with the assistance of a surgeon well experienced in laparoscopic TEP operation.

RESULTS

The comparison of our first 30 cases with the Netherlands group showed that while the conversions (five cases) to open operation were higher in the first 10 cases, there were no conversions in the next 20 cases. Also, there were no complications or recurrences in the present study, in striking contrast to three recurrences and 10 complications in the comparative study. The following 26 cases were associated with no recurrence or major complication.

CONCLUSION

In this study we performed a total of 11 open unilateral Stoppa's preperitoneal procedures in our attempt to learn the anatomy of this extraperitoneal space better, and in the absence of any surgeon experienced in laparoscopic TEP procedure. We were able to place a large mesh in each and every case and also recognize double hernias in six cases, thus preventing recurrences and complications. We strongly recommend a minimum of 10 open Stoppa's preperitoneal procedures, to enable a trained laparoscopic surgeon to start laparoscopic TEP operation independently and in the absence of another trained laparoscopic hernia surgeon, whose presence may not prevent complications and recurrences.

Transurethral resection of the prostate as catheter-free day-care surgery

OBJECTIVE

To evaluate the feasibility of transurethral resection of the prostate (TURP) as catheter-free day-care surgery.

PATIENTS AND METHODS

The study comprised 64 patients (mean age 62.4 years) with a mean (range) American Urological Association symptom score of 21.4 (9-31) and prostate volume (by ultrasonography) of 32.8 (17-50) mL, and with no significant comorbidity. The patients were admitted on the morning of the surgery and, under brief spinal anaesthesia, underwent standard TURP. After surgery the urethral catheter was removed as soon as the effluent was clear. The patients were discharged after they could pass urine freely and with a good stream.

RESULTS

The mean duration of catheterization after TURP was 7.15 h; 59 patients (92%) had their catheter removed within 10 h (mean duration 6.42 h). There were no major complications during or after TURP. After removing the catheter, no patients required its reinsertion for failure to void or for clot retention. The mean hospital stay after TURP was 10.7 h and 98% of patients were discharged within 23 h of surgery.

CONCLUSION

TURP can be conducted safely in a day surgery setting in patients with mild to moderate benign prostatic enlargement and no coexisting medical illness.

Randomized controlled study of laparoscopic total extraperitoneal versus open Lichtenstein inguinal hernia repair

BACKGROUND

Whereas open anterior inguinal herniorrhaphy is a time-tested, safe, and well-understood operation with a high success rate, laparoscopic techniques of inguinal hernia repair are fairly recent. Consequently, short- and long-term outcomes are still being evaluated. Few studies have compared laparoscopic extraperitoneal inguinal hernia repair with tension-free open hernia repair. The current study was conducted to compare complications, operative time, postoperative pain, length of hospital stay, and return to work between open tension-free mesh Lichtenstein (open) repair and laparoscopic total extraperitoneal (TEP) repair.

METHODS

In a prospective randomized study, open hernia repair was performed in one group (n = 25), and TEP repair using a large mesh was performed in another (n = 25). Then intraoperative and postoperative complications and results were compared.

RESULTS

The mean operative time in the TEP group was 75.72 +/- 31.6 min, which was significantly longer than the mean operative time in the open group (54 +/- 15) min (p <0.001). The mean pain scores in the TEP group were 2.64 +/- 1.4 at 12 h and 1.76 +/- 1.4 at 24 h. These scores were significantly lower than the corresponding scores of 3.52 +/- 1.7 (p <0.04) and 2.74 +/- 1.5 (p <0.01) in the open repair group. The mean postoperative analgesic dose was 2.6 +/- 2.3 in the TEP group, which was significantly lower than in the open group 5.76 +/- 3.5 (p <0.001). There was no major complication in either group. The time until return to work was significantly lower in the TEP group (12.8 +/- 7.1) days versus 19.3 +/- 4.3 days; than in the open group (p <0.001). In terms of cosmetics, all 25 patients (100%) in TEP group rated themselves as "highly satisfied," as compared with 7 patients (28%) in the open group (p <0.001). After a mean follow-up period of 13 months (range, 9-18 months), no recurrence was seen in either of the two groups.

CONCLUSION

In terms of complications and short-term recurrence, TEP repair is comparable with open repair. Moreover, TEP is significantly less painful in the early postoperative period, leading to earlier ambulation than open repair. Additionally, TEP results in significantly earlier return to work and better cosmetic results. Currently, TEP seems to be a better alternative than the existing open repair, provided the long-term recurrence rates are comparable. Despite the fact that TEP was a new procedure for the surgeon and the study was conducted during the learning phase, the results are comparable with those in the world literature.

Post-surgical zygomycotic necrotizing subcutaneous infection caused by Absidia corymbifera

Necrotizing infections of the skin and subcutaneous tissue are usually bacterial in origin. Rarely, fungi of the class Zygomycetes, which cause deep mycoses, may be responsible for acute necrotizing infections of these areas. Several local and systemic predisposing factors have been associated with such acute necrotizing infections. Surgical debridement and amphotericin B remain the mainstay of treatment. In this report we describe a patient with post-surgical necrotizing subcutaneous infection caused by Absidia corymbifera, 2 weeks following appendectomy. Successful management with surgical debridement, topical amphotericin B and oral potassium iodide is reported.

Footprints of a giant

The chemical accident at the Union Carbide factory in Bhopal, India in 1984 has killed 16,000 people so far and tens of thousands of others are still seriously ill. A physician reviews some of their ailments and comments on the lack of medical services available to them and of knowledge about long-term health effects of the exposures. Documenting observed effects also is underway, aiming to define the symptoms, propose effective management, and help direct research efforts. Information may be provided to relief and rehabilitation efforts and may even be helpful in the ongoing criminal suit against Union Carbide. The Indian government, meanwhile, suspended its research efforts in 1994, even though many health effects may not develop for years.

Safety and efficacy of transurethral resection of the prostate under sedoanalgesia

OBJECTIVE

To assess the safety and efficacy of sedoanalgesia (local anaesthesia with sedation) in patients with benign prostatic hyperplasia (BPH) undergoing transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

The study comprised 50 patients with BPH, two-thirds of whom were graded III-IV using the American Society of Anesthesiologists system. All patients had a topical instillation of lignocaine jelly 2% into their urethra, combined with 1% lignocaine (100-200 mg) with 1 : 400 000 adrenaline infiltration of the prostate via the perineal route. Sedation and anxiolysis were obtained with the intramuscular pethidine (0.5 mg/kg) and promethazine (1 mg/kg). Standard TURP was then carried out, with pain monitored during surgery using a visual analogue scale (VAS, maximum 10 points) and the amount of analgesic required after TURP recorded. The amount of prostatic tissue excised, duration of surgery, blood requirement, catheter interval, complications and hospital stay were recorded. The effectiveness of TURP was assessed by comparing symptom scores, uroflowmetry and postvoid residual volume before and after surgery.

RESULTS

The mean intraoperative VAS was < or = 1 at any time during or after surgery; no patient required any postoperative analgesics. Only two patients complained of discomfort during the procedure and even they were comfortable after a supplemental dose of pethidine (12.5 mg). There were no conversions to general or regional anaesthesia. No blood transfusion was required in any patient. All patients began a normal diet 30 min after surgery and all were discharged within 48 h of surgery. There were no deaths; one patient had transient urinary incontinence and three had mild urinary tract infection.

CONCLUSION

Sedoanalgesia was an effective, safe and simple alternative to general or regional anaesthesia for TURP in patients with BPH.

Clinicomicrobiologic evaluation of active tubotympanic type chronic suppurative otitis media

OBJECTIVES

This prospective study was conducted to determine the spectrum of micro-organisms encountered in patients with active-stage chronic suppurative otitis media (CSOM) (tubotympanic type) and to see whether prescribing an antibiotic after culture sensitivity was more beneficial as compared to initial treatment without cultures.

DESIGN

Prospective randomized study of 110 patients of active CSOM (tubotympanic type) divided into two groups of 55 cases each.

SETTING

Departments of Ear, Nose and Throat and Microbiology of a tertiary care hospital.

METHODS

The patients in group A were prescribed an antibiotic according to the culture and sensitivity, whereas in group B, culture was not done at the first visit, and a broad-spectrum antimicrobial, namely, co-trimoxazole, was prescribed blindly for a maximum period of 2 weeks. The cases that still had ear discharge were then subjected to culture and sensitivity and the antibiotic was prescribed accordingly.

MAIN OUTCOME MEASURES

All patients in group A were subjected to bacterial culture and sensitivity and fungal culture. Only failed cases in group B were subjected to the same.

RESULTS

In group A, 47 patients (85.50%) had positive bacterial culture and 20 patients had positive fungal culture. Pseudomonas aeruginosa was the most common bacterial isolate. All of these 47 patients had a dry ear with a maximum 2 weeks of antibiotic therapy. Among the remaining 8 patients who had negative bacterial culture, 5 patients (9.0%) showed fungal isolates on culture and responded to topical antifungal treatment. The remaining 3 failed cases (5.5%) responded to daily dry mopping alone. In group B, 41 patients (74.54%) attained a dry ear. Bacterial culture and sensitivity were done in the remaining 14 (25.46%) failed cases. The culture was positive in 11 patients (20.0%) and sterile in 3 patients (5.5%). In the latter group, only 1 patient had fungus on culture and the remaining 2 patients responded to daily dry mopping alone, which was done at a maximum for a week only. The most common fungal pathogen isolated was Aspergillus flavus.

CONCLUSIONS

Pseudomonas aeruginosa was the most common bacteria and Aspergillus flavus the most common fungus isolated in this study. In group A patients, the failed cases were less as compared to the control group B, but the p value was .2. Hence, there is no definite role of culture and sensitivity in the initial management plan of all cases of CSOM. Ideally, every such case should be prescribed a broad-spectrum antibiotic and only in failed cases should culture and sensitivity be done.

Evaluation of status of tuberculin skin sensitivity test among medical students

The status of tuberculin skin sensitivity tests was evaluated in 87 medical students. It was found that Mantoux test has less significant role to play in the vaccinated individuals and in the population at high risk of exposure. Hence this test is to be supplemented with clinical manifestations and other investigations to establish the final diagnosis of tuberculosis.

Sensitivity of EIA in the diagnosis of tuberculosis using 38-kDa antigen

Patients, who reported to Government Medical College Hospital, Chandigarh with suspected signs and symptoms of pulmonary tuberculosis, were examined. Their sputum was investigated for the presence of acid-fast bacilli, using the routine Ziehl-Neelsen staining, for 3 consecutive days. The positive cases were referred for treatment and the rest were referred for supplementary tests like x-ray, Mantoux test, FNAC and the presence of IgG antibodies in their serum against recombinant 38-kDa antigen derived from Mycobacterium tuberculosis, using micro-ELISA plates. It was found that 37.8% of the cases who were negative for acid-fast bacilli found to be positive for the presence of antimycobacterial IgG antibodies with an antibody titre greater than the cut off value in addition to one of the above mentioned positive supplementary finding. Hence, EIA for tuberculosis is more sensitive as compared to the routine acid-fast bacilli staining.

Otomycosis--a clinico-mycological study and efficacy of mercurochrome in its treatment

A total of 110 patients of symptomatic otomycosis was investigated, prospectively. Aural swabs were collected on 1st, 7th and 14th day and examined by direct microscopy and culture for fungi. Of these, 80 patients found to be having pure fungal infection, were taken up for mycological and therapeutic study. Fungi belonging to genus Aspergillus were isolated in 76 (95.0%) patients of which Aspergillus niger was the commonest isolate in 46 (57.5%), followed by A. flavus in 27 (33.7%), A. fumigatus in 3 (3.7%), Candida species in 3 (3.7%) and Mucor in 1 (1.2%). The patients were of all age groups but majority were between 21 and 30 years and the male-female ratio was equal. Of the total of 40 male patients, twenty-one were Sikhs using turban. Before developing the symptoms, forty five patients used oil, mixture of oil and garlic juice, antibiotics, steroids, antiseptics or wax solvent as ear drops. Only two patients were diabetic. No patient had fungal infection elsewhere in the body. The patients were called for regular follow-up for three weeks. In forty cases mercurochrome was applied as the antifungal agent after cleaning the external auditory canal, in twenty-three clotrimazole and in rest of the seventeen patients miconazole was used. On 7th day, only 11 (13.7%) patients grew different fungi in culture. They became symptom-free on 14th day and no fungal material could be seen on otoscopy, direct microscopy or culture. Mercurochrome was found to be most effective in these patients.

Association of hypersensitivity and carriage of dermatophytes in clinically normal sites in patients with Tinea cruris

Forty nine patients with mycologically confirmed Tinea cruris were investigated for the association of hypersensitivity to trichophytin and the isolation of dermatophytes from clinically normal sites with chronicity and recurrence of infection. At the end of six months following specific therapy, 24 patients returned for follow up and they were similarly studied. Dermatophytes were isolated from clinically asymptomatic sites in 46% patients before treatment and in 21% of the patients on follow up. Immediate weal reaction and increased concentration of IgE antibodies were seen in 73% and 80% of the patients respectively. However, the delayed hypersensitivity reaction was more associated with patients having lesions for more than 6 months (48%) in comparison with patients with a short history (17%). On follow up after 6 months, the different hypersensitivity reactions and IgE antibody concentration maintained more or less the same association. Therefore in persistent or recurrent Tinea cruris infection, besides potential carriage in clinically normal sites, hypersensitivity to antigens of dermatophytes possibly plays an important role in pathogenicity.

Rhinosporidiosis in India: a case report and review of literature

A 21-year-old male from Kerala, south India, who had been living in Chandigarh for the last 4 years presented with a nasal polyp in the left nasal cavity. On histopathological examination, it was found to be due to rhinosporidiosis. This disease is not uncommon in south India, but few case reports have been documented from north India. This paper presents a case report of rhinosporidiosis from the Government Medical College and Hospital, Chandigarh, and a review of literature of the disease.

Prevalence of fungal corneal ulcers in northern India

Fungal corneal ulcer is common in India due to the tropical climate and a large agrarian population that is at risk. Various factors such as trauma, the injudicious use of topical antibiotics and corticosteroids are involved. Many of the age and sex-related risk factors also play a minor role. This 6-year study from Northern India revealed that fungi were detected in 61 (8.4%) out of 730 patients investigated. Direct microscopy was positive in 51 (7%) and culture in 53 (7.3%) patients. Aspergillus spp. were the most common causative agents accounting for 25 (40.1%) of the isolates, followed by Fusarium sp. with ten (16.4%), Curvularia sp. with five (8.2%), Candida albicans with five (8.2%), Acremonium sp. with four (6.6%), Paecilomyces sp. with three (4.9%), Penicillium sp. with two (3.3%), Alternaria sp. with two (3.3%), Fonsecaea pedrosoi var. cladosporium with two isolates (3.3%) and Pseudallescheria boydii, Drechslera sp. and Aureobasidium pullulans with one isolate (1.6%) each. The prevalence of fungal ulcers in males was three times higher than in females. The affected individuals had a rural background and were in the 51-60 year age group.

Incidence of cryptococcosis in and around Chandigarh, India, during the period 1982-91

The incidence of cryptococcosis was evaluated in and around Chandigarh, India over a period of 10 years (1982-91). Different species of Cryptococcus were isolated from 38 patients. Cryptococcus neoformans was the predominant isolate (26 = 68%) followed by Cr. albidus (2), Cr. laurentii (1) and not precisely identified Cryptococcus species (9 = 24%). Serotyping of the 18 isolates of Cr. neoformans revealed that 13 (72%) were serotype A, two (11%) were serotype AD and three (17%) were serotype B (Cr. neoformans var. gattii). Cryptococcus species were found to produce infection in 24 patients and were possibly transient colonizers in another 14 patients. In addition, in 11 patients no Cryptococcus species was isolated from any site but the latex agglutination test for antigen (Crypto-LA) was positive in serum and/or cerebrospinal fluid. Response to various antifungal drugs was also studied in these patients.

Evaluation of Calcofluor staining in the diagnosis of fungal corneal ulcer

For laboratory diagnosis of mycotic keratitis, demonstration of fungal pathogens on direct microscopy and their isolation by culture is essential. The addition of Calcofluor white (CFW) stain to the diagnostic armamentarium has significantly increased the sensitivity of smear examination on direct microscopy. During a period of 1 year, 143 consecutive patients with corneal ulcers were investigated by direct microscopy with potassium hydroxide (KOH) wet mount, Calcofluor white stain and routine cultures of corneal scrapings. Fungi were detected as aetiological agents in 21 (15%) patients. Different species of the genera Aspergillus (35%), Fusarium (23%), Acremonium (12%), Paecilomyces (12%), Cladosporium (6%), Alternaria (6%) and Pseudallescheria (6%) were the common isolates. Calcofluor white stain on direct microscopy detected fungi in 20 (95.2%) patients in comparison with 15 (71.4%) patients by both KOH wet mount examination and culture. Calcofluor white stain was significantly more sensitive than KOH wet mount in demonstrating fungal pathogens.