Biomedical subjects
Publications and source records attributed to N Shetty.
This report provides the first videotape example of a patient with permanent cerebellar ataxia from high dose cytosine arabinoside. This case was unusual in that the patient was young, the effects are seemingly permanent and severe, and corticospinal tract damage also occurred. Early recognition to stop drug administration remains the only method to reduce risk.
Tuberculosis of the craniocervical junction is rare even where the condition is endemic. It poses problems in both diagnosis and management. We describe 25 cases followed over a period of 12 years, and relate the presentation, diagnosis and management. Of our 25 patients 16 were managed conservatively and nine by surgery. In order to diagnose this condition a high index of suspicion and advanced imaging techniques are necessary. Early diagnosis and adequate treatment led to good results without fatal complications.
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Sitafloxacin is a new quinolone active against multi-resistant Gram-positive pathogens. An open study was conducted in patients with serious systemic infections with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococcus (VRE). Patients with MRSA were recruited if treatment with glycopeptides had failed. Of 11 patients with MRSA infection, four were cured, six failed treatment and one was indeterminate. Of nine patients with VRE infection (one patient had both pathogens), five were cured and four failed. Fifteen adverse events in 12 patients were potentially related to the study drug. Sitafloxacin was effective in VRE and some recalcitrant MRSA infections.
AIMS: To evaluate the clinical usefulness and the costs of using a rapid, commercial ligase chain reaction test (LCx) to detect Mycobacterium tuberculosis directly from clinical samples. METHODS: A prospective study of 2120 routine clinical specimens from 1161 patients over a 13 month period. Investigations for mycobacterial disease by microscopy, culture, and the Abbott LCx assay were performed. Sequential LCx assays were monitored in a cohort of patients undergoing treatment. The costs of the assay were calculated using the WELCAN system. Sensitivity, specificity, and positive and negative predictive values of the LCx assay were compared with conventional tests. The performance of the assay in patients undergoing treatment and cost in terms of WELCAN units converted to pounds/annum was studied. RESULTS: The assay was 85%/88% sensitive and 98%/100% specific in culture confirmed/clinically confirmed cases of tuberculosis, respectively. The assay was not useful for the measurement of treatment outcomes. The test cost approximately 42,500 Pounds/annum. CONCLUSIONS: The assay is a rapid, sensitive, and specific adjunct to clinical diagnosis, especially in differentiating non-tuberculous mycobacteria. However, it does not differentiate old and treated tuberculosis from reactivated disease, it is not useful to monitor adherence to treatment, and it is expensive.
In our practice sequestration of the shafts of long bones in children because of acute osteomyelitis continues to be a problem. Conventional procedures for bone grafting are likely to fail. Vascularised grafts with microvascular anastomosis are technically demanding with a high rate of failure. Transfer of the rib on its vascular pedicle to achieve anterior fusion in the thoracic spine is now well established and the length of the pedicle available is adequate to allow grafting of a diaphyseal defect in the humerus. We describe the successful use of this procedure in two patients.
Cefadroxil is a semi-synthetic first generation oral cephalosporin with advantages of almost 100% excretion in the urine within six hours and low cost. It was freely available in the formulary and we undertook an audit of its usage, the indications cited, underlying clinical conditions and relevant microbiology in 106 cases. Following the audit, cefadroxil was restricted, available only on the advice of a microbiologist. Subsequently, another survey was carried out to document the reasons for requesting cefadroxil by clinical staff and the alternatives suggested in each case. The first survey revealed that in 91% cases, cefadroxil had been used inappropriately. The second suggested that the reasons for requesting it were based upon misunderstanding by clinicians as to its value. The only useful indication identified was the treatment of susceptible bacteruria in pregnancy. A suitable oral alternative could be identified for all other cases where an antibiotic was indicated. We believe that first generation cephalosporins such as cefadroxil have little role in hospital practice and should therefore be restricted.
The microbicidal activity of a new disinfectant Sterilox, a super-oxidized water, containing a mixture of oxidizing substances, was tested against Clostridium difficile spores, Helicobacter pylori, vancomycin resistant Enterococcus species, Candida albicans and several Mycobacterium species using membrane filters. All tests were performed in duplicate with and without added horse serum at 1% and 5% v/v. Distilled water, 0.35% peracetic acid (Nu-Cidex) and 2% glutaraldehyde were included as controls. Sterilox: spore suspension (9:1 v/v) achieved log10 kill of > 5 with 5% horse serum in 2 min against H. pylori, vancomycin resistant Enterococcus species, C. albicans and four atypical Mycobacterium species: M. avium, M. chelonei, M. xenopi and M. smegmatis. Sporicidal activity of Sterilox against Clostridium difficile was markedly diminished in the presence of 5% horse serum. Sterilox may be an effective alternative in endoscopy units, as it is a potent microbicidal agent and the manufacturer claims it is not corrosive to metal and is nontoxic to biological tissues.
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Automated and semiautomated technology in microbiology has seen great advances in recent years. The choice of automated equipment for the identification and susceptibility testing of bacteria in a routine diagnostic laboratory depends on speed, accuracy, ease of use, and cost factors. The Vitek analyser (bioMerieux, UK) was installed in a busy diagnostic teaching hospital laboratory in London. This report describes one year's experience. Changes to work practice as a result of incorporating the equipment into the laboratory, and the advantages and disadvantages of automation in key areas are described in detail, together with possible solutions to problems. The Vitek analyser was found to be valuable for the speed and accuracy with which results were available for the common bacterial pathogens. Results of susceptibility testing were standardised according to NCCLS guidelines and used breakpoint MICs to ascertain susceptibility and resistance; they were an improvement on disc testing. This equipment is not a reference facility for difficult to identify organisms and many manual techniques, including some disc susceptibility testing, will have to be retained by the laboratory.
Surgical reconstruction of the trachea is a relatively complex procedure. We had 20 cases of tracheal stenosis. We have a modest experience of 16 tracheal reconstructions for acquired tracheal stenosis. Two patients underwent laser treatment while another two died before any intervention. The majority of these cases were a result of prolonged ventilation (14 cases), following organophosphorous poisoning (11 cases), Guillain-Barré syndrome, bullet injury, fat embolism and surprisingly only one tumor, a case of mucoepidermoid carcinoma, who had a very unusual presentation. There were 12 males and 4 females in this series, age ranging from 12-35 years. The duration of ventilation ranged from 1-21 days and the interval from decannulation to development of stridor was between 5-34 days. Six of them were approached by the cervical route, 5 by thoracotomy and cervical approach, 2 via median sternotomy and 3 by thoracotomy alone. Five of them required an additional laryngeal drop and 1 required pericardiotomy and release of pulmonary veins to gain additional length. The excised segments of trachea measured 3 to 5 cms in length. All were end to end anastomosis with interrupted Vicryl sutures. We have had no experience with stents or prosthetic tubes. Three patients developed anastomotic leaks which were controlled conservatively. Almost all of them required postoperative tracheo-bronchial suctioning with fibreoptic bronchoscope. We had one death in this series due to sepsis.
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Exit site infection is a major risk factor for the development of peritonitis in continuous ambulatory peritoneal dialysis. The frequency of infection can be reduced by scrupulous exit site care with or without topical antiseptics. A randomized trial was performed of 149 catheters in 130 patients to assess any additional benefits conferred by the use of povidine iodine dry powder spray at dressing changes over an existing strict protocol of exit care. Exit infections occurred in 14 (18%) of 77 patients using spray and in 15 (21%) of 72 patients not using spray. The risk of peritonitis was also similar in each group. The proportion of infections caused by Staphylococcus aureus was reduced in the spray group, but those caused by Pseudomonas aeruginosa were increased. Rash occurred in 6% of those using the spray. The use of the spray did not therefore seem justified.
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We report a rare case of left ventricular myxoma with embolization to the right coronary artery, presenting as an acute myocardial infarction. The tumor was excised from the left ventricle, and the tumor embolus was removed from the right coronary artery. Saphenous vein bypass grafting was also performed successfully.
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