Meeting the Consultation Surge: A Nationwide Survey of Consult Volume and Mitigation Strategies in Infectious Diseases Fellowship Programs

High patient volume in fellowship programs can affect learning, wellness, and patient outcomes. Training programs must find ways to mitigate high consultation volume to protect the learning environment. This survey describes average new consults and average censuses for infectious diseases training programs and strategies implemented to mitigate high volume.

Lung and sinus fungal infection imaging in immunocompromised patients

BACKGROUND

Imaging is a key diagnostic modality for suspected invasive pulmonary or sinus fungal disease and may help to direct testing and treatment. Fungal diagnostic guidelines have been developed and emphasize the role of imaging in this setting. We review and summarize evidence regarding imaging for fungal pulmonary and sinus disease (in particular invasive aspergillosis, mucormycosis and pneumocystosis) in immunocompromised patients.

OBJECTIVES

We reviewed data on imaging modalities and findings used for diagnosis of invasive fungal pulmonary and sinus disease.

SOURCES

References for this review were identified by searches of PubMed, Google Scholar, Embase and Web of Science through 1 April 1 2023.

CONTENT

Computed tomography imaging is the method of choice for the evaluation of suspected lung or sinus fungal disease. Although no computed tomography radiologic pattern is pathognomonic of pulmonary invasive fungal disease (IFD) the halo sign firstly suggests an angio-invasive pulmonary aspergillosis while the Reversed Halo Sign is more suggestive of pulmonary mucormycosis in an appropriate clinical setting. The air crescent sign is uncommon, occurring in the later stages of invasive aspergillosis in neutropenic patients. In contrast, new cavitary lesions should suggest IFD in moderately immunocompromised patients. Regarding sinus site, bony erosion, peri-antral fat or septal ulceration are reasonably predictive of IFD.

IMPLICATIONS

Imaging assessment of the lung and sinuses is an important component of the diagnostic work-up and management of IFD in immunocompromised patients. However, radiological features signs have sensitivity and specificity that often vary according to underlying disease states. Periodic review of imaging studies and diagnostic guidelines characterizing imaging findings may help clinicians to consider fungal infections in clinical care thereby leading to an earlier confirmation and treatment of IFD.

Donor call simulation: A novel medical education tool to evaluate trainees' clinical decision-making in transplant infectious disease

BACKGROUND

Evaluating organ suitability for transplantation based on infection risk is a core competency in transplant infectious disease (TID). It is unclear if trainees have opportunities to practice during training. We created a simulation curriculum to develop and evaluate this skill among infectious disease (ID) trainees.

METHODS

We created six simulation questions about organ suitability for transplant based on infection risk. During trainees' TID rotations, faculty texted or paged the simulation cases posing as the transplant coordinator. Trainees had 15 min to ask questions before deciding the suitability of the organ and explained their clinical reasoning in a survey. Trainees completed a post-simulation survey to evaluate its effectiveness.

RESULTS

ID trainees, including residents and fellows on rotation, from seven centers participated. Eighty-seven percent (13/15) of trainees felt the simulation was effective in teaching them this concept, and 80% (12/15) felt prepared for clinical practice. The proportion of correct responses was generally high among the six different cases (43%-100%); correct responses increased for some cases in the post-activity survey. Of the 100 clinical reasoning decisions made during the activity, 19% were discordant, where the trainee correctly identified suitable organs for incorrect reasons.

CONCLUSION

Our simulation was effective in teaching when to accept or reject an organ for transplant and was a valuable educational tool. By evaluating clinical reasoning for decisions our simulation provides educators with nuanced insight and allows for targeted coaching. This study demonstrates a critical need for further educational tools in TID.

1298. Donor Call Simulation: A Novel Medical Education Tool to Evaluate Trainees’ Clinical Decision-Making in Transplant Infectious Disease

Background

Simulation is a useful education tool for high-stakes clinical skills and decision-making. Recommending whether to accept or reject an organ for transplantation based on infection risk is a critical core competency in Transplant Infectious Disease (ID), however there are no published data that learners have opportunities to practice this during training. We created a novel simulation to expose learners to this real-life clinical scenario and evaluated their clinical decision-making in these situations.

Methods

We created 6 simulations with common ID consult questions about whether to accept or reject an organ for transplant based on infection risk (Table 1). During learners’ Transplant ID rotations, faculty periodically texted or paged them with the simulation cases as though they were the transplant coordinator. Learners had 15 minutes to ask follow up questions before deciding to accept or reject the organ and explain their decision-making process in a survey. Learners completed a survey 1 month after the simulation experience to evaluate its effectiveness.

Results

Between October 2021 and April 2022, 16 learners from 7 medical centers participated in the simulation (Table 2) and 94% (15/16) completed the follow up survey. Eighty-seven percent (13/15) of ID learners reported that the simulation was effective in teaching them when to accept or reject organs and 80% (12/15) felt more prepared to make these decisions in practice. Most learners correctly identified acceptable organs for transplant during the simulations (Figure 1). Of the 100 clinical reasoning decisions made during the activity, 19% were discordant, where the learner correctly decided to accept or decline the organ but with incorrect or incomplete reasoning for this decision (Figure 2).

Conclusion

ID learners perceived our transplant ID simulation as an effective educational tool to learn when to accept or reject an organ for transplant. By evaluating the clinical reasoning behind these decisions our simulation provides ID educators with nuanced insight into their learners' thought process and allows for targeted coaching to correct deficits in reasoning.

Disclosures

Rebecca Kumar, MD, Gilead: Grant/Research Support|Regeneron: Grant/Research Support Jonathan Hand, MD, GlaxoSmithKline: Grant/Research Support|Janssen: Grant/Research Support|Pfizer: Grant/Research Support Roderick Go, DO, Aptose Biosciences: Stocks/Bonds|Bristol Meyers Squibb: Stocks/Bonds|Cytodyn Inc.: Stocks/Bonds|Scynexis: Grant/Research Support Erica J. Stohs, MD, MPH, bioMerieux: Grant/Research Support.

New updates in the world of hepatitis C virus infected organ transplantation

PURPOSE OF REVIEW

With the advent of direct acting antiviral (DAA) therapy, the use of organs from hepatitis C virus infected (HCV+) donors is gaining more traction. In this review, we aim to: provide an overview of recent literature that supports the use of HCV+ organs, outline ongoing challenges to the use of these organs, and highlight the areas within this field where active investigation is ongoing.

RECENT FINDINGS

The present review describes clinical outcomes related to the transplantation of both HCV+ nonviremic and viremic organs and the distinction between hepatic and nonhepatic transplants. It also discusses the current debate pertaining to the ideal treatment strategy for donor-derived HCV infection, that is pre-emptive therapy versus prophylaxis therapy.

SUMMARY

Data suggest that the use of HCV+ organs is an effective and relatively well tolerated strategy to combat the organ scarcity. However, clinicians must be vigilant to a signal of increased inflammation as HCV+ organ transplantation becomes more universal. Recent studies suggest that shorter courses of DAA may sufficiently treat donor-derived HCV infection, however the best treatment approach to minimize risk, cost, and toxicity is still under investigation.

Local and regional variability in utilization and allocation of hepatitis C virus-infected hearts for transplantation

With the advent of direct-acting antiviral agents, there has been a rapid rise in hepatitis C virus-infected (HCV+) heart transplantation. We aimed to understand local and regional differences in utilization and allocation of HCV+ hearts. Using United Network for Organ Sharing (UNOS) de-identified data from January 1, 2016 to September 30, 2019 we compared trends in the utilization rates (hearts transplanted/donors recovered) of HCV-uninfected (HCV-) to those of HCV+ nonviremic (HCV-NV) and viremic (HCV-V) hearts nationally and by UNOS region. We also evaluated allocation rates (hearts successfully allocated/donors recovered) by organ procurement organization (OPO). We found that (1) in 2019, national utilization rates for HCV-NV and HCV-V hearts were the same as HCV- hearts (27.6% for HCV-NV, 30.9 for HCV-V, and 31.7% for HCV-, P = .277); (2) utilization rates of HCV-NV hearts were low in regions 3 and 4 and of HCV-V hearts in regions 3, 4, and 8 even in the contemporary period since 2018; and (3) there was marked variability in allocation of HCV+ hearts at the OPO level even within the same UNOS region. We conclude that despite national strides in the utilization of HCV+ hearts for transplantation, more aggressive allocation of HCV+ hearts at the OPO level may still significantly affect the organ shortage.

Post-transplant survey to assess patient experiences with donor-derived HCV infection

BACKGROUND

Despite increased utilization of hepatitis C virus-infected (HCV+) organs for transplantation into HCV-uninfected recipients, there is lack of standardization in HCV-related patient education/consent and limited data on financial and social impact on patients.

METHODS

We conducted a survey on patients with donor-derived HCV infection at our center transplanted between 4/1/2017 and 11/1/2019 to assess: why patients chose to accept HCV+ organ(s), the adequacy of their pre-transplant HCV education and informed consent process, financial issues related to copays after discharge, and social challenges they faced.

RESULTS

Among 49 patients surveyed, transplanted organs included heart (n = 19), lung (n = 9), kidney (n = 11), liver (n = 4), heart/kidney (n = 4), and liver/kidney (n = 2). Many recipients accepted an HCV-viremic (HCV-V) organ due to perceived reduction in waitlist time (n = 33) and/or trust in their physician's recommendation (n = 29). Almost all (n = 47) felt that pre-transplant education and consent was appropriate. Thirty patients had no copay for direct-acting antivirals (DAA) for HCV, including 21 with household income <$20 000; seven had copays of <$100 and one had a copay >$1000. Two patients reported feeling isolated due to HCV infection and eight reported higher than anticipated medication costs. Patients' biggest concern was potential HCV transmission to partners (n = 18) and family/friends (n = 15). Overall almost all (n = 47) patients reported a positive experience with HCV-V organ transplantation.

CONCLUSION

We demonstrate that real-world patient experiences surrounding HCV-V organ transplantation have been favorable. Almost all patients report comprehensive HCV-related pre-transplant consent and education. Additionally, medication costs and social isolation/exclusion were not barriers to the use of these organs.

A case report of disseminated histoplasmosis and concurrent cryptococcal meningitis in a patient treated with ruxolitinib

Background

Ruxolitinib is a highly potent janus kinase inhibitor that places its users at risk for various bacterial infections and viral reactivation. However new reports are also emerging that suggest greater immunosuppression and risk for fungal disease.

Case presentation

We report the case of a 51 year-old veteran from Guam, treated with ruxolitinib for polycythemia vera, who developed disseminated histoplasmosis and concurrent cryptococcal meningitis.

Conclusion

This case draws attention to the degree of immunosuppression that may be seen with this drug and the need for heightened vigilance for opportunistic infections in those treated with inhibitors of janus kinase/signal transducers and activators of transcription (JAK/STAT) such as ruxolitinib.

1493. Effect of HIV Status on Early Syphilis Treatment Response in the Era of Combination Antiretroviral Therapy

Background

Rates of incident early syphilis are increasing and HIV-coinfection is common. Syphilis treatment for HIV-positive individuals does not differ from that of the general population, although data published prior to combination antiretroviral therapy (cART) suggest that HIV-infected persons may be less likely to achieve expected serologic responses to treatment (SRT).

Methods

We conducted a cohort study of early syphilis diagnosed in a large HIV clinic and a public sexually transmitted diseases (STD) clinic in San Diego. SRT was defined as a fourfold or greater decline in rapid plasma reagin (RPR) titer following syphilis treatment. We compared SRT at 6 and 12 months post-treatment between HIV-infected and HIV-uninfected persons.

Results

Of 1,239 early syphilis cases reviewed, 742 (61%) were included in the analysis. Reasons for exclusion included lack of follow-up RPR (n = 454), nonreactive RPR at syphilis diagnosis (n = 33), and incomplete data (n = 10). Of those analyzed, 533 (72%) were HIV-positive; 168 (23%) HIV-negative; HIV status was unknown for 41 (5%). Overall, 449 (60%) and 657 (89%) of analyzed cases achieved SRT 6 and 12 months after treatment, respectively. HIV-positive cases were less likely to achieve SRT at 12 months than HIV-negative cases (464/533 [87%] vs. 160/168 [95%], P = 0.003, Figure 1), as were early latent syphilis cases (285/348 [82%]) vs. primary (102/117 [92%]) and secondary syphilis (264/277 [94%]) (Table 1).

Conclusion

In this cohort of early syphilis cases, most achieved SRT within 12 months of treatment, but only 60% achieved SRT within 6 months. Significantly lower 12-month SRT responses were seen in HIV-positive compared with HIV-negative persons and in early latent compared with primary and secondary syphilis. The impact of cART use, viral suppression, and treatment choice on outcomes is being analyzed.

Disclosures

All authors: No reported disclosures.

Serial perioperative cell-free DNA levels in donors and recipients undergoing living donor liver transplantation

BACKGROUND

Effect of anaesthesia and surgery on cell-free DNA (cfDNA) is not known. Given that surgical stress augments inflammation and injury, we hypothesized that levels of cfDNA will fluctuate during perioperative period. Therefore, in this study serial perioperative cfDNA concentration was measured in donors and recipients undergoing living donor liver transplantation (LDLT).

METHODS

Baseline, post-induction, intraoperative and post-operative plasma cfDNA levels were evaluated in 21 donors and recipients each, by Sytox green method. In addition, qPCR was performed in a subset of samples.

RESULTS

Baseline cfDNA levels were higher in recipients (37.62 ng/ml) than in donors (25.49 ng/ml). A decrease in cfDNA was observed following anaesthesia induction in both recipients (11.90 ng/ml) and donors (10.75 ng/ml). When the kinetics of the cfDNA was monitored further, an increase was noted intraoperatively in donors (46.18 ng/ml) and recipients (anhepatic phase: 56.25 ng/ml, reperfusion phase: 54.36 ng/ml). cfDNA levels remained high post-operatively. One recipient who developed post-operative sepsis had the highest cfDNA level (94.72 ng/ml).

CONCLUSION

Plasma cfDNA levels are high in recipients indicative of liver injury. Lower cfDNA levels following induction may be attributed to the subduing effect of anaesthetic agents on cell death. High cfDNA levels seen in intra- and post-operative phases reflect cellular trauma and inflammation. This similar pattern of fluctuation of cfDNA level in donors and recipients is suggestive of its possible utility as a surgical stress marker. In addition, comparable cfDNA levels in anhepatic and reperfusion phase reflect less ischemia reperfusion injury during LDLT.

Phytoplankton species diversity indices in Anjanapura reservoir, Western Ghat region, India

A qualitative study on species composition and diversity of phytoplankton flora was carried out in the Anjanapura reservoir. Water samples were collected monthly at four sites from November 2005 to October 2007 for plankton analysis. A total of 152 phytoplankton species belonging to 59 genera were recorded. The species belonging to genera Crucigenia, Pediastrum, Scenedesmus, Tetraedron, Cyclotella, Gyrosigma, Melosira, Navicula, Fragillaria, pinnularia, Synedra, Closterium, Cosmarium, Euastrum, Staurastrum, Gleocapsa, Merismopedia, Microcystis, Oscillatoria, Euglena and Phacus were found dominant. Phytoplankton density was recorded in the range of 222-1467 Org l(-1) for chlorococcales, 267-1467 Org I (-1) for diatoms, 44-889 Org l(-1) for desmids, 44-889 Org l(-1) for blue-greens and 22-1667 Org l(-1) for euglenoids. Seasonal density Shannon-Weiner diversity index (1.60-1.88) indicate that reservoir exhibited rich phytoplankton and Nygaard tropic status indices for myxophycean (1.0-1.50), chlorophycean (1.62-2.16), diatoms (0.10-0.14), euglenophycean (0.18-0.19) and compound quotient(3.25-4.66) showed that reservoir was moderately polluted. From the observed data, it could be concluded that the presence of more diverse group of phytoplankton indicate the productivity of the reservoir.

Ileal ganglioneuromatosis with adenocarcinoma in a patient with multiple neurofibromatosis

Von Recklinghausen's disease or type 1 neurofibromatosis is an autosomal dominant disease characterized by mucocutaneous neurofibromas, café-au-lait spots and involves many organs including gastrointestinal tract. Gastrointestinal involvement in neurofibromatosis is uncommon and is seen 25% patients and nearly 5% of them are only symptomatic (Shekitka and Sobin, Am J Surg Pathol 18:250-257, 1994; Tomita et al., Int J Colorectal Dis 21: 89-91, 2006).

Hypolipidemic Effect of Celastrus paniculatus in Experimentally Induced Hypercholesterolemic Wistar Rats

The objective of the present study was to evaluate hypolipidemic effect of methanolic extract of Celastrus paniculatus in experimentally induced hypercholesterolemic rats. Hypercholesterolemia was induced by feeding the animals with high fat diet. Oral administration of methanolic seed extract (50%) of Celastrus paniculatus at the optimized dose of 65 mg/kg body weight, substantially reduced the plasma total cholesterol, triglycerides and LDL cholesterol in comparison with induced hypercholesterolemic animal group and the results were comparable with the standard hypocholesterolemic drug and almost similar to the control group. Atherogenic index and liver weight of treated animals also showed significant decrease compared to the hypercholesterolemic animals. It substantially increased the HDL cholesterol level as compared to control group. A significant increase in the activities of lipoprotein lipase and plasma LCAT enhanced hepatic bile acid synthesis and thereby, increased degradation of cholesterol to neutral sterols. Furthermore, the activities of HMG-CoA reductase, glucose 6-phosphate dehydrogenase and malate dehydrogenase were significantly reduced. Histological studies showed less cholesterol deposits in the aorta of animals fed with seed extract of C. paniculatus compared to the induced hypercholesterolemic animals not given C. paniculatus supplement.

Corneal changes in type II diabetes mellitus in Malaysia

AIM

To compare corneal endothelial structure and central corneal thickness (CCT) between type II diabetics and non-diabetic control patients. To look for correlations between diabetic status and corneal findings.

METHODS

Hospital-based, observational study. 200 eyes (from 100 type II diabetic patients and 100 controls) were included. Specular microscopy and pachymetry were used to measure endothelial cell density, size, coefficient of variation in cell area, hexagonality as well as corneal thickness. Independent t-tests were used to compare variables between diabetics and controls. Pearson correlation tests were used to evaluate correlations between corneal findings and diabetic status such as duration of diabetes, haemoglobin A1c (HbA1c) level and severity of diabetic retinopathy.

RESULTS

Endothelial cell density in the diabetic group (2541.6±516.4 cells/mm(2)) was significantly lower than that in the control group (2660.1±515.5 cells/mm(2), P<0.05). The average size of endothelial cells, standard deviation (SD) of cell size and coefficient of variation (CV) of cell area were all significantly higher in diabetics. Hexagonality was significantly lower in diabetics (41.1%±19.6%) compared to non-diabetics (45.2%±20.6%). CCT was higher in diabetics but not significant (P>0.05). Duration of diabetes, HbA1c level and severity of diabetic retinopathy were not significantly correlated with corneal endothelial findings.

CONCLUSION

Type II diabetes causes a significant alteration in the state of the cornea including reduction in endothelial cell density and increased pleomorphism and polymegathism. Central corneal thickness is unaffected.

Plant metabolites: an alternative and sustainable approach towards post harvest pest management in pulses

Grain legumes are an important source of proteins in vegetarian diet besides their role in biological nitrogen fixation. They are prone to heavy pest infestation both on and off the field. Pest associated losses are an important contributing factor towards declining per capita availability of grain legumes. Synthetic chemical pesticides have played an important role in crop preservation, however their incessant use has posed several environmental and human health concerns. Methyl bromide and phosphine are commonly used for the post harvest preservation of grain legumes. However, the former has to be phased out by 2015 as per the Montreal protocol whereas the latter is showing development of resistance to it by the insects. In the light of this, alternative, safer and sustainable strategies are needed for crop protection. Plants can serve as a rich source of bioactive chemicals for this purpose. Both primary as well as secondary metabolites can be evaluated against the target pests. The paper reviews the status of research in the area of use of plant metabolites in post harvest pest management of grain legumes.

Socioeconomic background in relation to stage at diagnosis, treatment and survival in women with breast cancer

In a large population-based series of invasive breast cancer patients, we investigated socioeconomic background (SEB) in relation to (a) stage at diagnosis; (b) treatment pattern; and (c) 5-year survival. Women diagnosed during 1998–2000 and resident in the Northern and Yorkshire regions of England were identified from the cancer registry database (N=12 768). Logistic regression and Cox proportional hazards analyses were used to estimate associations between SEB (defined using the Townsend Index for area of residence) and tumour stage, treatment pattern, and survival. Living in a more deprived area was associated with increased likelihood of being diagnosed with stage III or IV disease (age-adjusted odds ratio (OR) 1.13; 95% confidence interval (CI) 1.08–1.18 per quartile increase in Townsend score), and, after adjustment for age and stage, reduced odds of having surgery (OR 0.85; 95% CI 0.80–0.91), and receiving radiotherapy (OR 0.91; 95% CI 0.88–0.94). Amongst patients receiving surgery, those living in more deprived areas had decreased odds of having breast conserving surgery (age plus stage-adjusted OR 0.92; 95% CI 0.89–0.95). Living in a more deprived area was also associated with increased mortality (age- plus stage-adjusted hazard ratio 1.08; 95% CI 1.05–1.11). These effects may operate through several pathways, such as later presentation leading to advanced disease.

Bilateral corneal perforation in a sexually active adult male with gonococcal conjunctivitis

A 41 year-old Malay man had been treated by general practitioners for bilateral red eyes with profuse discharge of three weeks' duration with no improvement. He then presented to an ophthalmologist who noted profuse purulent discharge, bilateral corneal perforation, lid swelling and chemosis. Culture of the ocular discharge grew Neisseria gonorrhoeae. Treatment with systemic and topical antibiotics prevented microperforations in the right eye from progressing to overt perforation and was able to control disease in the left eye.

Prevalence of blindness and cataract surgery in Gandaki Zone, Nepal

BACKGROUND/AIM

Himalaya Eye Hospital (HEH), established in 1993, is rendering eye care services in the Gandaki and Dhaulagiri zones. The hospital has extensive community outreach activities along with services for outpatients, emergencies, and subspecialties such as vitreoretinal, paediatric, and low vision. The operation theatre is well equipped to match the surgical needs including phaco surgery for cataract. The hospital has performed more than 14 000 cataract surgeries and 250 000 treatment services during this period. The aim of this study was to estimate the prevalence of blindness, visual impairment, and cataract surgical coverage among the older adult population of three districts of Gandaki Zone, where 80% of the hospital's service recipients reside.

METHODS

People aged 45 years and older were enrolled in the study using a stratified cluster design. Subjects in 25 randomly selected clusters from the listed 806 were recruited through door to door visits. Each recruited subject had visual acuity (VA) and clinical examination conducted by an ophthalmologist. The survey was preceded by pre-pilot and pilot studies to refine the operational method. To assess quality assurance the interobserver variation in VA measurement was also carried out in five different clusters.

RESULTS

Out of 5863 selected subjects 85.3% were examined. Blindness defined as presenting VA <6/60 in both eyes was found in 2.6% (95% confidence interval (CI): 2.2 to 3.9), whereas 16.8% individuals examined had vision <6/19 in one or both eyes. Cataract was the principal cause of blindness in 60.5%, and refractive error was the dominant cause of vision impairment (<6/19) 83.3%. Cataract surgical coverage was 59.5% among the cataract blind and associated with younger age, literacy, and male sex.

CONCLUSION

The finding suggests a positive impact of the HEH programme on the prevalence of blindness and cataract surgical services in the survey area. Strategies to further improve access and utilisation of facilities and increase cataract surgical coverage need to be developed.

Postoperative seizures after extratemporal resections and hemispherectomy in pediatric epilepsy

Objectives: To estimate frequency and risk factors for acute postoperative seizures (APOS) within the first week after extratemporal cortical resection (ETR) and hemispherectomy (HS) in children and to assess the predictive value of APOS on long-term seizure outcome in this group.

Methods: The authors conducted a retrospective analysis of children (<18 years), who underwent ETR or HS for intractable epilepsy between 1995 and 2002. APOS features and seizure outcome after ETR or HS were obtained at 6, 12, and 24 months. Univariate logistic regression was used for risk factors of APOS and life table analysis and log rank tests for seizure outcome at 0 to 6, 6 to 12, and 12 to 24 months.

Results: Of 132 patients, 34 (26%) had APOS. APOS were more frequent after ETR (26/71) than HS (8/61) (p < 0.01). APOS, irrespective of their timing, number, semiology, or other perioperative complications, were an independent predictor of poor postoperative seizure outcome at 2 years (p < 0.001). The estimated odds of postoperative Engel class I outcome in the APOS vs non-APOS categories was 0.27 (73% less likely) for 0- to 6-month, 0.22 (78% less likely) for 6- to 12-month, and 0.13 (87% less likely) for the 12- to 24-month intervals.

Conclusions: Acute postoperative seizures (APOS) occur in 26% children, and the risk is higher after extratemporal cortical resection than hemispherectomy. APOS predict a poor postoperative seizure outcome at 6, 12, and 24 months. This study is useful for counseling families after epilepsy surgery. It also suggests that APOS may not be discounted as “benign” in research studies that evaluate seizure outcomes after epilepsy surgery.

Changes in astigmatism in children with congenital nystagmus

BACKGROUND

Astigmatism is commonly reported in children with and without nystagmus. In children less than 4 years of age the astigmatism changes from against the rule (ATR) to with the rule (WTR) astigmatism in children without nystagmus. However, little is known about children with congenital nystagmus. We compared astigmatism in children with congenital nystagmus below 4 years and above 4 years of age.

MATERIAL AND METHODS

Three hundred and fifty-six eyes in 178 children who satisfied the study criteria were included. The children were divided into those below 4 years of age (n of eyes = 192) and those above (n of eyes = 164). Cycloplegic refraction (with manual retinoscopy) carried out at presentation and at the last follow-up were recorded and compared. Cycloplegia was achieved using cyclopentolate eye drops. Outcome of eyes with no astigmatism at initial presentation was compared with the final refraction in both the age groups. The visual acuity at the first presentation was compared with the visual acuity at the last presentation.

RESULTS

Average follow-up duration was 3.36+/-1.59 years. On presentation, 176 (49.44%) eyes did not have any astigmatism. We found that 26 (25.2%) out of the 103 children below 4 years of age who did not have any astigmatism on presentation developed WTR astigmatism after a mean follow-up of 3.5+/-1.5 years. (p= 0.042). In children >or=4 years of age only 7 (9.6%) children out of 73 developed WTR after a mean follow-up of 3.4+/-1.4 years. The visual acuity change was not found to be significant in the two groups. The majority (90.3%) improved or had same visual acuity in group A and 88.9% improved or had the same visual acuity in group B at the last follow-up (p= 0.77).

DISCUSSION

Our incidence of WTR astigmatism in children with congenital nystagmus is similar to those previously reported series. Our data suggest that there is a significant chance that children under 4 years with congenital nystagmus may develop WTR astigmatism compared with children above 4 years of age.

CONCLUSION

With the rule (WTR) astigmatism is common in children with nystagmus. Children under 4 years of age presenting with no astigmatism may acquire WTR astigmatism as they grow. The amount of astigmatism increases with age in children with nystagmus. Visual acuity, however, remains stable as the age advances.

Multidisciplinary approach in the long-term management of intrahepatic stones: Indian experience

BACKGROUND

Intrahepatic stones, though common in East Asia, are uncommon in India. There is paucity of data from India regarding the treatment and long-term outcome of patients with intrahepatic stones.

METHODS

We retrospectively analyzed medical records of 35 patients with intrahepatic stones who had been treated surgically. Endoscopic biliary drainage had been used in patients who presented with acute cholangitis. Intraoperative stone clearance was confirmed by choledochoscopy and intraoperative cholangiography. Outcome of surgery, frequency and subsequent management of recurrent intrahepatic stones, and factors associated with stone recurrence and cholangitis were analyzed.

RESULTS

Twenty-one (60%) patients had bilobar disease. Eight patients underwent hepatectomy and 16 hepatico-jejunostomy with access loop; 12 of these were jejuno-duodenal anastomoses. Postoperative morbidity was observed in 10 patients (29%). Recurrence of stones occurred in 12 patients (34%) and cholangitis in 9 patients (26%). Presence of bilobar disease and associated biliary strictures were associated with recurrent cholangitis (p< 0.05). Two patients (6%) required re-operation for recurrent cholangitis. Complete removal of recurrent stones using conventional endoscope was possible through jejuno-duodenostomy in all 5 cases who had this type of access loop construction.

CONCLUSION

Surgical treatment for intrahepatic stones depends on the site of involvement. Construction of a jejuno-duodenal access loop in patients with bilobar disease and intrahepatic strictures is helpful in facilitating postoperative stone clearance. A multidisciplinary approach is beneficial especially when the disease is bilobar and recurrent in type.

Are some cases of infected pancreatic necrosis treatable without intervention?

BACKGROUND

Infected pancreatic necrosis is considered an absolute indication for interventional management such as percutaneous drainage or surgery. The presence of retroperitoneal air is a sign of anaerobic sepsis.

METHOD

A retrospective review of case records of patients presenting with severe acute pancreatitis and pancreatic necrosis was performed to identify cases in whom conservative treatment was followed by a satisfactory outcome.

RESULTS

Four patients were identified over a 3-year period who had pancreatic necrosis and retroperitoneal air; they were treated with antibiotics and intensive care, and they improved without any interventional treatment.

CONCLUSIONS

Some patients with infected pancreatic necrosis are treatable medically. The clinical status of the patients may well be a more important factor governing the choice of the treatment approach than bacteriological findings of infection alone.

Port-site tuberculosis after laparoscopy: report of eight cases

In light of the explosive increase in laparoscopic surgery, there is concern about the effectiveness of sterilizing reusable laparoscopic instruments by immersion in 2% glutaraldehyde. This article describes the clinical features of eight patients who presented with biopsy-proven tuberculosis at the port-site unassociated with other clinical features of tuberculosis. Three of the eight patients had positive cultures for Mycobacterium tuberculosis. The port-site sinuses healed with antituberculous chemotherapy. There is conflicting information in the literature regarding the effectiveness of a 20-min instrument soak in 2% glutaraldehyde to clear M. tuberculosis. In light of the preceding information, the current practice of glutaraldehyde disinfection for reusable laparoscopes needs to be reexamined.

Laparoscopic cholecystectomy in acute cholecystitis

BACKGROUND

In the light of laparoscopic cholecystectomy increasingly applied to all forms of cholecystitis, this study aimed at evaluating the safety of laparoscopic cholecystectomy applied to all cases of acute cholecystitis, and at determining factors associated with the risk of conversion to open cholecystectomy.

METHODS

The clinical, biochemical, radiologic, and operative data from 124 consecutive cases of acute cholecystitis were analyzed retrospectively to determine the complications and morbidity after operation. The data were analyzed further by univariate and multivariate analysis to identify factors associated with conversion.

RESULTS

No major bile duct injury or mortality occurred. Bile leak from the stump of the cystic duct developed in four patients. These were managed successfully by endoscopic biliary stent placement. The mean duration of hospital stay was 3.8 days in the laparoscopic group and 8.2 days in the open group. Of the 124 patients (18.5%), 23 underwent conversion to open cholecystectomy. Univariate analysis identified the following factors as associated with conversion: common duct dilation greater than 7 mm observed on ultrasound, (p < 0.05), pericholecystic collection seen on ultrasound (p < 0.0001), emphysematous cholecystitis (p < 0.01), endoscopic retrograde cholangiopancreatographic evidence of Mirizzi syndrome (p < 0.05), and pericholecystic collection at operation (p < 0.0001). On multivariate analysis, only pericholecystic collection (p < 0.015) and gallbladder wall thickness greater than 5 mm (p < 0.013) were statistically significant.

CONCLUSIONS

Laparoscopic cholecystectomy for acute cholecystitis can be applied safely to all comers, offering the advantage of a shortened hospital stay. Pericholecystic collection, as observed on ultrasound, is associated with a high risk of conversion to open cholecystectomy.