Efficacy and Safety of Percutaneous Radiological Gastrostomy (PRG) as a Rescue Measure for Enteral Feeding in Patients with Advanced Head, Neck, and Upper Digestive Malignancies

Background Percutaneous radiologic gastrostomy is an established mode of enteral feeding for nutritional support for patients with dysphagia from upper digestive tract malignancy. Its role as a rescue measure in patients with advanced malignancy, presenting with absolute dysphagia and failure of nasogastric tube insertion has not been well established.

Purpose This study was performed to assess technical success and long-term outcomes of percutaneous radiologic gastrostomy (push type) for nutritional support for patients with absolute dysphagia as a last ditch nonsurgical rescue effort for enteral access.

Materials and Methods This was a prospective observational study of 31 patients who underwent push-type percutaneous radiologic gastrostomy over a period of 2 years (March 2017–March 2019). The study was a part of a larger trial approved by the institutional ethics committee. Patients were followed till the removal of tube, death, or 1 year, whichever was earlier. Gastrostomy tube-related problems and complications were documented. Descriptive summary statistics were employed to analyze the success rate and complications.

Results Thirty-one patients with mean age 56 years (26–78 years) including 18 males and 13 females with head and neck squamous cell cancer and esophageal cancer presenting with absolute dysphagia or significant dysphagia with failed nasogastric or endoscopic enteral access were included. Overall technical success was 93.5% (29/31), achieved in 26/31 patients with just fluoroscopy guidance and 3/5 patients with computed tomography guidance. One major (3.3%) and two minor (6.5%) complications were encountered. Five out of 29 gastrostomy tubes had to be exchanged, after a mean of 44 days (1–128 days) after insertion.

Conclusion Percutaneous radiologic gastrostomy is a safe and effective intervention even as a rescue measure in patients with absolute dysphagia from advanced upper digestive tract malignancies.

Pancreatic hemorrhage contributes to late mortality in patients with acute necrotizing pancreatitis

OBJECTIVES

The frequency, risk factors, and impact on survival of hemorrhage into (peri)pancreatic collections in patients with acute pancreatitis (AP) has not been well studied. The study was designed to evaluate the risk factors for hemorrhage, successful hemostasis and its effect on in-hospital mortality.

METHODS

In a prospective cohort study for prediction of severity of AP, the incidence, risk factors, and outcomes of pancreatic hemorrhage were analyzed. Patients with significant hemorrhage were managed according to a predefined protocol including endovascular intervention.

RESULTS

Out of 363 patients hospitalized during the study-period, 33(9%) patients developed hemorrhage. Median time from onset of AP to hemorrhage was 59(45-68) days. The cause of hemorrhage was arterial in 19(57.5%) patients and unlocalized in 14(42.5%) patients. Hemorrhage was managed by conservative approach in 7 (21.2%), radiographic angioembolisation in 16 (48.5%), radiographic angioembolisation followed by surgery in 3 (9.1%), and surgery in 7 (21.2%) patients. Persistent organ failure [aHR 2.3 (1.1-5.1), p = 0.03], use of large bore (>20 Fr) catheter for initial drainage [aHR 3.9 (1.7-9.1), p = 0.001] and extensive (>50%) necrosis [aHR 3.1 (1.4-6.9), p = 0.005] were significant risk factors for hemorrhage. Hemorrhage was an independent predictor of mortality [aHR 2.0 (1.2-3.4), p = 0.008] in addition to persistent organ failure (aHR 12.1 (5.7-25.8), p < 0.001). In-hospital mortality in patients with hemorrhage was 22/33 (66.7%) vs. 81/330 (25%) in no hemorrhage group [p <0.001].

CONCLUSION

Pancreatic hemorrhage occurs later in the course of acute pancreatitis in relatively sicker group of patients with organ failure and extensive necrosis, and is independently associated with a higher risk of in-hospital mortality.

The spectrum of manifestations of primary hyperparathyroidism in children and adolescents

INTRODUCTION

Primary hyperparathyroidism (PHPT) is a rare disease in children and adolescents. Early recognition of this disease is important to prevent significant morbidity and mortality.

MATERIAL AND METHODS

We included 10 consecutive patients with PHPT aged 14 to 19 years of age and followed-up prospectively upto one year after parathyroidectomy.

RESULTS

Our cohort included 6 females and 4 males. The mean age of the patients was 16.7 ±1.8 years. The symptoms at presentation were musculoskeletal pain (90%), bone deformity (50%), fracture (30%), proximal myopathy (40%), renal stones (50%), reflux symptoms (40%), and pancreatitis (30%). The mean serum calcium was 3.1 ±0.5 mmol/l, mean serum inorganic phosphorus was 0.9 ±0.3 mmol/l and median serum alkaline phosphatase (ALP) was 1911.5 IU/l (IQR: 522.7-5702.3). The median serum intact parathyroid hormone was 133.5 pmol/l (IQR: 69.5 -178.7) while serum 25(OH)D was 47.7 nmol/l (IQR: 23.7-72.7). Hypercalciuria was observed in 7 patients. Hungry bone syndrome was observed in 4 (40%) patients after surgery. Typical parathyroid adenoma was found in 9 (90%) patients while one patient had atypical adenoma with high mitotic index. After one year of surgery, all patients had significant improvement in clinical and biochemical parameters with persistence of residual bone deformities.

CONCLUSIONS

Our study showed the spectrum of manifestations of PHPT in children and adolescents and outcomes of parathyroidectomy till one year. Long-term follow-up studies with bigger cohorts are required to understand the true nature of the disease in children and adolescents.

Differentiating tubercular from pyogenic causes of spine involvement on Magnetic Resonance Imaging

Introduction

Based on clinical parameters alone, it is difficult to differentiate between tubercular (TB) and pyogenic spondylodiscitis. Therefore, this study aimed to identify imaging features that can help to differentiate these two entities.

Methodology

This retrospective observational study included microbiologically confirmed cases of TB and pyogenic spondylitis over three years. Magnetic resonance imaging of included cases was reviewed for a predefined set of imaging findings. A multivariable logistic regression analysis was done to compare the radiological features of both groups. A scoring system was created using the features that were significant in univariate and multivariable analysis.

Results

Of the 90 included cases, 44 were TB and 46 were pyogenic. Involvement of the thoracic vertebra, paravertebral abscess, epidural abscess, posterior element involvement, loss of height, spine deformity, nerve compression, destruction of the disc and larger abscess size were more common in patients with TB. Involvement of the thoracic spine, posterior element involvement and spine deformity were independent predictors of diagnosing TB spine. At a score of 7 (out of 11) or above, the scoring system had a sensitivity and specificity of 86% and 94%, respectively, in diagnosing the TB spine.

Conclusion

In the presence of relevant clinical findings, specific MRI findings can help to differentiate TB from pyogenic spondylitis.

No-Touch Radio Frequency Ablation for a Subcapsular Hepatocellular Carcinoma: A Case Report and Review of Literature

Radiofrequency Ablation of subcapsular lesions poses a challenge due to the risks of tumour seeding along the track, hemorrhage and lower efficacy. “No touch ablation” is a relatively novel technique used in the ablation of subcapsular HCC with good results. This technique avoids direct puncture of the tumour by inserting more than one electrodes adjacent to and outside the tumor and activating them sequentially to perform ablation. The risk of track site seeding and haemorrhage is significantly reduced. We describe a case of a subcapsular HCC in a 65-year-old female patient which was successfully treated with this novel technique.

Utility of first order MRI-Texture analysis parameters in the prediction of histologic grade and muscle invasion in urinary bladder cancer: a preliminary study

OBJECTIVE

To explore the utility of first-order MRI-texture analysis (TA) parameters in predicting histologic grade and muscle invasion in urinary bladder cancer (UBC).

METHODS

After ethical clearance, 40 patients with UBC, who were imaged on a 3.0-Tesla scanner, were retrospectively included. Using the TexRAD^TM platform, two readers placed freehand ROI on the sections demonstrating the largest dimension of the tumor, evaluating only one tumor per patient. Interobserver reproducibility was assessed using the intraclass correlation coefficient (ICC). Mann-Whitney U test and ROC curve analysis were used to identify statistical significance and select parameters with high class separation capacity (AUC >0.8), respectively. Pearson's test was used to identify redundancy in the results.

RESULTS

All texture parameters showed excellent ICC. The best parameters in differentiating high and low-grade tumors were mean/ mean of positive pixels (MPP) at SSF 0 (AUC: 0.897) and kurtosis at SSF 5 (AUC: 0.828) on the ADC images. In differentiating muscle invasive from non-muscle invasive tumors, mean/ MPP at SSF 0 on the ADC images showed AUC >0.8; however, this finding resulted from the confounding effect of high-grade histology on the ADC values of muscle invasive tumors.

CONCLUSION

MRI-TA generated few parameters which were reproducible and useful in predicting histologic grade. No independent parameters predicted muscle invasion.

ADVANCES IN KNOWLEDGE

There is lacuna in the literature concerning the role of MRI-TA in the prediction of histologic grade and muscle invasion in UBC. Our study generated a few first-order parameters which were useful in predicting high-grade histology.

Radiology of the neuroendocrine neoplasms of the gastrointestinal tract: a comprehensive review

Neuroendocrine neoplasms (NENs) are a group of neoplasms arising from the diffuse endocrine system (DES). The gastrointestinal tract (GIT) is the most common site of NEN. The WHO classification divides NEN into three broad categories viz. well-differentiated NENs, poorly differentiated NENs, and mixed neuroendocrine-non-neuroendocrine neoplasms. All GIT NEN have the potential to synthesize and secrete various bioactive substances which may lead to various clinical syndromes. The NEN may occur anywhere in the GIT and exhibit varying clinical presentation, prognosis, and metastatic potential. Further, some tumors show association with familial syndromes like multiple endocrine neoplasia type 1 and neurofibromatosis type 1. Ultrasonography, computed tomography (CT), magnetic resonance imaging, and positron emission tomography-CT are the imaging modalities useful in the diagnosis, localization, and staging of GIT NEN. Management depends on the site, size, grade, and stage of the tumor with interventional radiology playing a significant role in some cases. This imaging review describes the role of a radiologist in the management of GIT NEN.

Multilocular Thymic Cyst in a Patient with Diffuse Infiltrative Lymphocytosis Syndrome

Diffuse Infiltrative Lymphocytosis Syndrome (DILS) is a multisystem disorder characterised by bilateral salivary gland enlargement and/or xerostomia in patients with Human Immunodeficiency Virus (HIV) infection. A 16 year old young male patient, presented with bilateral painless parotid swelling for five years. On evaluation, he was found to have oral thrush and bilateral cervical lymphadenopathy. He turned out to be positive for HIV with a cluster of differentiation 4 (CD4) count of 237/mcl. On Positron Emission Tomography- Contrast Tomography (PET-CT), a multiloculated thymic cyst (13×9×6 cm) was noted. He was diagnosed to have DILS with a large multiloculated thymic cyst. The patient was managed with tenofovir, lamivudine and efavirenz along with cotrimoxazole prophylaxis and fluconazole and was followed uptil nine months for the regress of the conditions. The case highlights the rare association between DILS and thymic cyst.

Unusual Primary Neoplasms of the Adult Liver: Review of Imaging Appearances and Differential Diagnosis

The radiological appearance of common primary hepatic tumors such as hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) is widely recognized. Hepatic masses with unusual histology are occasionally encountered, but seldom suspected on imaging. However, many possess characteristic imaging findings, which when assessed along with the clinical and demographic background and serum tumor markers, may enable a prospective diagnosis. This review attempts to familiarize the reader with the clinicopathological characteristics, imaging manifestations, and differential diagnosis of these unusual liver tumors in adults. Biphenotypic primary liver carcinoma is suspected in masses showing distinct areas of HCC and CCA-type enhancement pattern in cirrhotic livers. Fibrolamellar carcinoma occurs in young individuals without underlying chronic liver disease and shows a characteristic T2-hypointense scar frequently showing calcification. Perivascular epithelioid cell tumors are differentials for any arterial hyperenhancing mass in the noncirrhotic liver, particularly in patients with tuberous sclerosis. Multifocal subcapsular tumors showing target-like morphology, capsular retraction and "lollipop" sign are suspicious for epithelioid hemangioendothelioma. On the other hand, multiple hemorrhagic lesions showing patchy areas of bizarre-shaped arterial phase hyperenhancement are suspicious for angiosarcoma. Primary hepatic lymphoma (PHL) is suspected when patients with immunosuppression present with solitary or multifocal masses that insinuate around vessels and bile ducts without causing luminal narrowing. Intense diffusion restriction and low-level homogeneous or target-like enhancement are also ancillary features of PHL. Primary hepatic neuroendocrine tumor shows uptake on Ga-68 DOTANOC PET/CT. Although a straightforward diagnosis may be difficult in these cases, awareness of the characteristic imaging appearances is helpful in suspecting the diagnosis.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Brain abscess in patients with chronic kidney disease: A case-based approach to management in resource-limited settings

The management of patients with brain abscess poses a significant challenge to clinicians in patients with chronic kidney disease. Obtaining a biopsy sample from the affected area is the mainstay in the diagnosis, but it is often unavailable. In most cases, therapy is guided by clinical findings and imaging alone. We discuss three cases of brain abscess- each with a different scenario and discuss the issues faced in management. The first case was a 32-year-old post-renal transplant male patient with a brain abscess due to dematiaceous fungi and was treated with amphotericin. The second case was a 42-year-old female patient with stage 5 chronic kidney disease on maintenance hemodialysis who presented with a brain abscess due to suspected fungal infection based on imaging findings and was managed with antibiotics and voriconazole. The third case was a 42-year-old post-renal transplant male patient who presented with a brain abscess due to nocardiosis and was managed with cotrimoxazole, meropenem and linezolid. We also summarize the approach to the management of brain abscess in resource-limited settings.

Nontuberculous mycobacteria: A report of eighteen cases from a tertiary care center in India

Context

Nontuberculous mycobacteria (NTM) are ubiquitous mycobacteria present in environment and generally affect patients with either structural lung disease or immunosuppression and commonly involve lungs, lymph node, or skin.

Materials and Methods

Between July 2016 and February 2019, 18 cases of NTM were diagnosed and their relevant clinical, diagnostic, and treatment details were recorded after taking informed consent.

Results

We report 18 cases of NTM involving lungs (n = 11), skin and soft tissue (n = 3), joint (n = 2), genitourinary (n = 1), and central nervous system (n = 1). History of immunosuppression was present in two patients, whereas history of some form of intervention was seen in six patients. Mycobacterium fortuitum group (n = 5) was the most commonly isolated organism, followed by Mycobacterium avium complex (n = 4), Mycobacterium abscessus (n = 3), Mycobacterium kansasii (n = 2), and Mycobacterium chelonae (n = 1). In two patients, M. chelonae and M. abscessus were isolated in succession. Of these 18 patients, clinical response was present in 15 of the patients. Diagnosis and treatment of NTM in resource limited settings is extremely challenging.

Conclusion

Most of the patients with NTM are misdiagnosed and are treated as tuberculosis in India, sometimes with a multidrug resistance regimen, which results in significant morbidity and mortality. We present these cases to shed some light on the epidemiology of NTM in this part of India.

Infectious versus non-infectious causes of oligoarticular inflammatory arthritis: A prospective study from a tertiary care hospital in north India

Oligoarticular arthritis (inflammation of upto 4 joints) has a wide range of infectious and non-infectious etiologies. The aim of our study was to identify the features which could help in the differentiation of infectious from non-infectious arthritis. The study was prospective and observational, and included 100 patients with oligoarticular inflammatory arthritis. The final diagnosis was made using standard diagnostic criteria and the patients were categorized into infectious and non-infectious groups. Among the 100 patients who were recruited, the following final diagnosis were made: peripheral spondyloarthritis (n = 37), axial spondyloarthritis (n = 11), tuberculosis (n = 19), brucellosis (n = 6), septic arthritis (n = 6), gouty arthritis (n = 5), early rheumatoid arthritis (n = 5), non-tubercular mycobacteria (n = 2), SLE (n = 2), post-chikungunya arthritis (n = 2), acute lymphocytic leukaemia (n = 1), pachydermoperiostosis (n = 1), sarcoidosis (n = 1) and juvenile idiopathoic arthritis (n = 1). The patients were categorized into two groups: infectious (33) and non-infectious (60). The presence of monoarthritis, clinically-significant weight loss, hepatomegaly, splenomegaly and erosive arthritis were significantly more common in the infectious group as compared to the non-infectious group.

Multi-drug Resistant Tuberculous Osteomyelitis of the First Carpometacarpal Joint Presenting as Unmasking Immune Reconstitution Inflammatory Syndrome

Tuberculosis (TB) is an important cause of significant morbidity and mortality, particularly in patients living with human immunodeficiency virus (HIV ) infections. The co-infection of TB and HIV coinfection is further complicated by a relatively higher frequency of extra-pulmonary TB and upsurge of drug resistance. Musculoskeletal TB is a relatively less common form of extrapulmonary TB; involvement of carpometacarpal joint as an initial manifestation is even rarer. We herein present a retro positive patient who presented with low-grade fever, constitutional features and swelling of the base of the left thumb. On evaluation, he was found to have axillary and inguinal lymphadenopathy with lytic destruction of carpometacarpal joint as well as D10-D11 vertebrae. Fine needle aspiration (FNA) of synovial fluid was negative for tuberculosis but geneXpert from FNA of axillary node revealed Mycobacterium tuberculosis with rifampicin resistance. This case highlights the rarity of carpometacarpal joint involvement in TB as the initial manifestation and the importance of meticulous search of alternative sites for sampling in difficult situations such as osteoarticular TB. It also highlights the rising prevalence of drug-resistant TB and a definitive need for microbiological diagnosis wherever feasible.

Endovascular Management of a Rare Cause of Bleeding Per Vaginam: A Hole in the Mole

Uterine artery aneurysm is a rare cause of bleeding per vaginam. Uterine artery pseudoaneurysms are rare but potentially life-threatening causes of persistent or delayed bleeding post-uterine curettage or any uterine surgery. Color Doppler ultrasonography is very useful for emergent diagnosis of these conditions and subsequent follow-up post-embolization. Computed tomography scan and magnetic resonance imaging play an important role in confirming the diagnosis. Transcatheter arterial embolization is the therapy of choice for such cases. Our case highlights the presentation, imaging appearance, and endovascular management of a case of uterine artery pseudoaneurysm.

Pull-Type Radiologically Inserted Gastrostomy: An Improvised Technique Using a Frugal Innovation

Purpose To describe a new technique for “pull type” radiologically inserted gastrostomy (RIG) and prospectively compare it with conventional (described) technique in terms of technical ease (fluoroscopy time, radiation dose) and safety profile.

Materials and Methods Adult patients with head injury with Glasgow coma scale (GCS) (M score) < 5, one week after decompression or those requiring nutritional support for > 4 weeks, or patients with recurrent aspiration pneumonitis on nasogastric feeding were included. Hemodynamically unstable patients or those with uncorrectable coagulopathy were excluded. Patients underwent pull-type RIG with alternate patient getting allocated to groups A (conventional technique) and B (new technique). The authors compared the technical success, complication rate, fluoroscopy time, radiation dose, and cost of hardware in these two groups.

Results The average fluoroscopy time for group A (9 patients) was 498.7 ± 145.3 seconds, whereas for group B (16 patients), it was 302.8 ± 54.1 seconds with p-value = 0.06. The mean radiation dose of group A was 74.7 ± 15.7 mGy, whereas for group B, it was 56.7 ± 14.1 mGy (p-value = 0.004). The minor complication rates were 11.1% in both the groups.

Conclusion The authors’ innovative technique using a customized snare has the potential to increase the technical ease of pull-type RIG with reduced fluoroscopy time, radiation dose, and cost with a similar safety profile.

Mucor menace in an immunocompetent young male after dental manipulation

Fungal rhino-orbital sinusitis due to mucormycetes is a rapidly progressive condition with high mortality, rarely seen in immunocompetent individuals. A 26-year-old immunocompetent male presented with rhino-orbital mucormycosis after a history of dental manipulation. The patient was successfully managed with a combination of surgery, amphotericin B, and posaconazole. Here, we highlight the delay in diagnosis and challenges faced in the management.

First things first: Importance of eosinophil count in diagnosing occult parasites

Tropical pulmonary eosinophilia (TPE) is a rare allergic manifestation to the filarial nematode. A 38-year old male and a 15-year old female presented with cough and breathlessness. Their complete blood count showed eosinophilia. This finding was overshadowed by the radiological findings suggestive of tuberculosis. The diagnosis of TPE was confirmed by filarial antigen detection test and both the patients were successfully treated with diethylcarbamazine. TPE presents with cough and breathlessness and can be often confused with tuberculosis, especially in endemic settings. An important clue in differentiating the two entities is the presence of eosinophilia in the former.

The clinical significance of CA19-9 in ovarian mature cystic teratoma

OBJECTIVE

To evaluate the clinical significance of CA19-9 in patients with ovarian mature cystic teratoma (MCT).

MATERIALS AND METHODS

A retrospective study was performed on 65 patients with pathologically-confirmed MCT and 80 patients with benign epithelial ovarian tumors. Serum tumor markers for all patients and tissue CA19-9 for MCTs were measured. The relationships between clinical characteris- tics of MCTs and CA19-9, as well as the correlation between serum and tissue level of CA19-9 in MCTs, were evaluated.

RESULTS

The mean serum level of CA19-9 in MCTs was significantly higher than that in benign ovarian epithelial tumors (49.9 ± 73.4 IU/ml vs. 17.08 ± 24.8 IU/ml). CA19-9 was the only tumor marker with a mean serum level above the cut-off value and the elevation rate was 30.76% in MCTs. The positive tissue expression rate of CA19-9 in MCT patients were 50.9% and were higher than that of preoperative serum levels (50.9% vs. 32.7%).

CONCLUSION

Serum CA19-9 has the highest positivity rate among other tumor markers in MCT. Elevated serum CA19-9 is not an uncommon finding MCT and could be used as a marker in the differential diagnosis of MCT in patients with pelvic mass.

Evaluation of the reasons for nonacceptance of kidneys retrieved or offered in Rio Grande do Sul and Pais Vasco

In Rio Grande do Sul (RS), as in Pais Vasco (PV), some kidneys are retrieved or offered and not accepted for transplantation. This study aimed to evaluate the profile of the available kidneys and the reasons for them not being accepted in the 2 regions, and to compare the characteristics of the organs and reasons for refusal. All of the kidneys retrieved or offered in RS in December 2012 and in PV from September to December 2012 were evaluated. Data were collected from each local donation registry. There were 61 kidneys available in RS and 61 in PV in the study period. Of these, 16 kidneys (26%) in RS and 27 (44%) in PV were not implanted. The age of the donors was higher in PV (59 years) than in RS (45 years; P = .000), as was the age of the donors of accepted kidneys (62 and 41 years old, respectively; P = .000). The proportion of donors considered to be "extended criteria" was higher in PV (78%) than in RS (47%; P = .001), and the refusal rate of the kidneys from these donors was the same in the 2 regions. The reasons for not using the kidneys in RS and in PV were similar and absolute. It is concluded that there is no organ waste in the 2 regions, but that the offer of kidneys can be expanded in RS by considering elderly donors for evaluation, even if this means a higher number of refused organs.

Current fluoroquinolone susceptibility criteria for Salmonella needs re-evaluation

BACKGROUND

Disc diffusion technique is the routine susceptibility testing procedure for isolates of enteric fever, the most common clinical diagnosis among febrile patients in Nepal.

OBJECTIVE

To evaluated the current fluoroquinolones (FQs) susceptibility criteria and nalidixic acid screening test in Salmonella enterica serovar Typhi and Paratyphi A.

METHODS

S. Typhi and Paratyphi A strains isolated from 443 suspected enteric fever patients visiting National Public Health Laboratory (NPHL) during April through October 2008 were analyzed. All isolates were confirmed by standard microbiological procedures including serotyping. Antibiotic susceptibility testing was performed by using Kirby Bauer disc diffusion method and Clinical and Laboratory Standards Institute (CLSI) approved interpretive criteria. Agar dilution method was used to determine Minimum Inhibitory Concentration (MIC) of ciprofloxacin, ofloxacin and nalidixic acid.

RESULT

Out of 41 Salmonella isolates, 80.49% were nalidixic acid resistant, with S. Paratyphi A showing higher resistance rate (88.23%) compared to S. Typhi (75%). The difference in both MIC and zone diameter in nalidixic acid susceptible and nalidixic acid resistant isolates was found to be significant (P < 0.001) and decreased susceptibility to FQs was strongly correlated (sensitivity and specificity of 100%) with resistance to nalidixic acid. Regression analysis of MIC against zone diameter based on the current CLSI recommended guidelines suggests that accommodation of current susceptible and resistant MIC requires increase in the zone diameter of ciprofloxacin and ofloxacin.

CONCLUSION

Before using these drugs for management of enteric fever, appropriate identification of Salmonella isolates with reduced susceptibility to FQs is essential to limit the possible treatment failure and development of highly resistant strains. The current FQs susceptibility break point criteria for Salmonella need re-evaluation.

Laparoscopic Cholecystectomy at Shree Birendra Hospital

Introduction: Since its introduction in Shree Birendra Hospital, laparoscopic cholecystectomy has gradually replaced its open counterpart. Along with its superior results, surgeons had to deal with the difficult challenges of managing bile duct injuries. Methods: A prospective study of all laparoscopic cholecystectomies performed in the General surgical unit of Shree Birendra Hospital from January 2003 to December 2010 was carried out from case records in a separate register kept for laparoscopic surgeries. Results: Out of the total number of 786 patients who underwent laparoscopic cholecystectomy during the study period, 21 (2.67%) required conversion to open procedure with the most common indication being unclear anatomy at Calot’s triangle. There were 14 major post operative complications (1.78%) with bile duct injuries occurring in 7 patients (0.89%). Among these injuries, 3 injuries were recognized during the primary operation. Laparotomy with t tube placement for 6 weeks was the mode of treatment in 2 patients with Strasberg type D injuries detected post operatively. Delayed repair after 3 months were carried out in 2 injuries- one hepaticojejunostomy (Type E2) and the other required anastamosis to the left hepatic duct (Type E3). In follow up, these patients have remained aniciteric and comfortable so far. Conclusion: Bile duct injuries continue to remain a major morbidity factor in laparoscopic cholecystectomy and its management a challenge to the surgeon. Though repair in a specialized hepatobiliary center is recommended, in the absence of such center in our country, it is being done in SBH with good results. DOI: http://dx.doi.org/10.3126/mjsbh.v10i1.6444 Medical Journal of Shree Birendra Hospital Jan-June 2011 10(1) 15-19

GIST of Mesocolon: A Case Report

Gastrointestinal Stromal Tumor (GIST) is a rare soft tissue tumor and a GIST arising from the mesocolon is even rarer and sparsely reported in the world literature. Herein we report one such case that we encountered in our clinical practice and review the literature on the management of such a rare case. DOI: http://dx.doi.org/10.3126/mjsbh.v10i1.6448 Medical Journal of Shree Birendra Hospital Jan-June 2011 10(1) 37-39

Values of Lymphocyte Subsets in Nepalese Healthy Adult Population

Introduction: CD4 T lymphocyte is the most commonly used cellular marker in tracking Human Immunodeficiency Virus (HIV) infection progression and monitoring effect of antiretroviral therapy (ART). Due to lack of local reference values of CD4 and other T lymphocytes in Nepal, most clinical decisions are based on the reference renges of western countries.  Methods: This study was conducted at three major hospitals/laboratory of central, eastern and western Nepal during November 2008 through July 2009. Using the predefined criteria, 602 (200, 202 and 200 from central, eastern and western regions respectively) healthy adult volunteers of age range 18-60 years were recruited wiht equal representation from each age group and sex. Blood specimens were screened for HIV following standard algorithm using ELISA and two rapid test kits based on different principles. Samples with discordant test-results were excluded. HIV sero-negative specimens were further analyzed for CD4, CD8 and CD4:CD8 ratio, and absolute lymphocyte count (ALC) by FACS count (Becton Dickinson, USA) and automated cell counter (BC-3000 Plus, Shenzhen Mindray Biomedical Electronics, Germany) respectively. Results: The average value (mean± standard deviation) of CD4, CD8, CD4/CD8 ratio and ALC of Nepalese adult population were found to be 786 ± 248, 567±230, 1.52 ± 0.59 and 2712 ± 836 respectively. All four parameters but CD8 were significantly different with sex and females had relatively higher values. However, none of these parameters reported significant difference with age except the ALC. Conclusions: Nepalese healthy adult populations have significantly different T lymphocyte subsets compared to other countries. The present reference ranges of CD4 and other T lymphocytes may be used for any clinical purposes including classifying and monitoring disease status in HIV infected individuals, immune status evaluation, monitoring ART and accordingly making amendment in national HIV treatment guidelines in Nepal. Keywords:Absolute lymphocyte count, CD4, CD8, human immunodeficiency virus, T lymphocytes.

Values of lymphocyte subsets in Nepalese healthy adult population

INTRODUCTION

CD4 T lymphocyte is the most commonly used cellular marker in tracking Human Immunodeficiency Virus (HIV) infection progression and monitoring effect of antiretroviral therapy (ART). Due to lack of local reference values of CD4 and other T lymphocytes in Nepal, most clinical decisions are based on the reference ranges of western countries.

METHODS

This study was conducted at three major hospitals/laboratory of central, eastern and western Nepal during November 2008 through July 2009. Using the predefined criteria, 602 (200, 202 and 200 from central, eastern and western regions respectively) healthy adult volunteers of age range 18-60 years were recruited with equal representation from each age group and sex. Blood specimens were screened for HIV following standard algorithm using ELISA and two rapid test kits based on different principles. Samples with discordant test-results were excluded. HIV sero-negative specimens were further analyzed for CD4, CD8, and CD4:CD8 ratio, and absolute lymphocyte count (ALC) by FACS count (Becton Dickinson, USA) and automated cell counter (BC-3000 Plus, Shenzhen Mindray Biomedical Electronics, Germany) respectively.

RESULTS

The average value (mean± standard deviation) of CD4, CD8, CD4/CD8 ratio and ALC of Nepalese adult population were found to be 786 ± 248, 567±230, 1.52 ± 0.59 and 2712 ± 836 respectively. All four parameters but CD8 were significantly different with sex and females had relatively higher values. However, none of these parameters reported significant difference with age except the ALC.

CONCLUSIONS

Nepalese healthy adult populations have significantly different T lymphocyte subsets compared to other countries. The present reference ranges of CD4 and other T lymphocytes may be used for any clinical purposes including classifying and monitoring disease status in HIV infected individuals, immune status evaluation, monitoring ART and accordingly making amendment in national HIV treatment guidelines in Nepal.

Diagnostic dilemma of the single screening test used in the diagnosis of syphilis in Nepal

Syphilis screening by the nontreponemal rapid plasma reagin (RPR) test is not usually followed up by specific treponemal tests in most of the resource poor healthcare settings of Nepal. We analyzed serum specimens of 504 suspected syphilis cases at the immunology department of the national reference laboratory in Nepal during 2007-2009 using RPR test and Treponema pallidum hemagglutination assay (TPHA). In overall, 35.7% were positive by both methods (combination) while 13.1% were RPR positive and TPHA negative, 8.7% were positive by TPHA only and 42.5% were negative by both methods. Among the RPR reactive (n = 246), 73.2% were positive by TPHA. Non-specific agglutination in RPR testing was relatively higher (26.8%) compared to TPHA (19.6%). Although TPHA was found more specific than RPR test, either of the single tests produced inaccurate diagnosis. Since the single RPR testing for syphilis may yield false positive results, specific treponemal test should be routinely used as confirmatory test to rule out false RPR positive cases. More attention needs to be paid on formulation of strict policy on the implementation of the existing guidelines throughout the country to prevent misdiagnosis in syphilis with the use of single RPR test.

Salmonella enterica serovar Paratyphi A: an emerging cause of febrile illness in Nepal

With an aim to evaluate the isolation rate and antibiotic susceptibility pattern in Salmonella enterica serovar Typhi and S. Paratyphi A, 656 blood samples collected from clinically diagnosed enteric fever patients at National Public Health Laboratory, Nepal during January through December 2008 were processed. Isolates were identified by standard microbiological procedures including serotyping. Antibiotic susceptibility testing was performed by disc diffusion method and minimum inhibitory concentration (MIC) to ciprofloxacin, ofloxacin and nalidixic acid was determined by agar dilution method following CLSI guidelines. Altogether 59 isolates of S. Typhi (49.15%) and S. Paratyphi A (50.85%) were recovered. A total of 80% isolates were resistant to nalidixic acid with S. Paratyphi A (93%) showing significantly higher resistance (P < 0.05) compared to S. Typhi (66%). The nalidixic acid resistant S. Paratyphi A strains required significantly higher MICs (P < 0.001) to quinolone (MIC expressed as mean +/- SD for nalidixic acid 477.87 +/- 87.02 microg/mL, ofloxacin 1.8 +/- 0.63 microg/mL, ciprofloxacin 0.62 +/- 0.3 microg/mL) compared with that of S. Typhi (nalidixic acid 173.18 +/- 72.03 microg/mL, ofloxacin 0.43 +/- 0.11 microg/mL, ciprofloxacin 0.25 microg/mL). Increased MIC of fluoroquinolone (FQ) is of particular concern in emerging strains of S. Paratyphi A as exposure to these drugs fuels up further development of full FQ resistant populations. Use of FQs as the first-line drugs for empirical therapy and management of enteric fever in areas where these strains are prevalent is questionable and requires an urgent review.

Resistotypes of Vibrio cholerae 01 Ogawa Biotype El Tor in Kathmandu, Nepal

Cholera continued to be a major diarrheal illness in Nepal and antibiotic resistance has appeared as a serious problem in cholera management. The study aimed at analyzing the distribution pattern of the resistotypes (R-types) of Vibrio cholerae in the Kathmandu valley, Nepal. During June 2008 to January 2009, 210 diarrheal specimens received at National Public Health Laboratory from suspected cholera patients were subjected to standard bacteriological investigation including biotyping and serotyping. Antimicrobial susceptibility pattern of V. cholerae isolates was determined by Kirby Bauer disc diffusion method following CLSI guidelines. A total of 57 (27%) V. cholerae isolated were recovered, all of which belonged to 01 Ogawa Biotype EL Tor. Based on antibiogram, V. cholerae isolates in our study revealed three distinct R-types: R-type I, R-type II and R-type III. All three R types showed resistance to furazolidone, nalidixic acid and cotrimoxazole while sensitive to ciprofloxacin and tetracycline. Additional resistance to ampicillin and erythromycin was observed respectively in R-type II and III. Different R-types showed unique month wise variations (P < 0.05). Differentiation of V. cholerae strains into R-types is an important tool. In addition to direct patient management, it may have implication in identifying the source and spread of infection, and understanding the distribution pattern in a particular geographical region.

Antibiotic Susceptibility Patterns of Vibrio cholerae isolates

INTRODUCTION: Cholera is one of the most common diarrhoeal diseases in Nepal. Etiological agent of cholera is Vibrio cholerae which removes essential body fluids, salts and vital nutrients, which are necessary for life causing dehydration and malnutrition. Emerging antimicrobial resistant is common. The aim of the present study was to determine the antibiotic susceptibility pattern of cholera patients in Nepal. METHODS: All the laboratory works were conducted in the bacteriology section of National Public Health Laboratory, Teku from March to September 2005. During this period a total of 340 stool samples from diarrhoeal patients were collected and processed according to the standard laboratory methods. Each patient suffering from diarrhoea was directly interviewed for his or her clinical history during sample collection. RESULTS: A total of 340 stool samples were processed and studied from both sex including all ages of patients. Among the processed sample 53 Vibrio cholerae cases were found. All isolated Vibrio cholerae O1 were El Tor, Inaba. All isolated (100%) Vibrio cholerae O1 were sensitive to Ampicillin, Ciprofloxacin, Erythromycin and Tetracycline whereas all were resistant to Nalidixic acid and Cotrimoxazole. Only 15.1% cases were sensitive to Furazolidone whereas 84.9% were resistant. CONCLUSION: All V. cholerae strains isolated in this study were found resistant to Multi Drug Resistant (resistant to at least two antibiotics of different group). Ampicillin, Ciprofloxacin, Erythromycin and Tetracycline were found still more potent antibiotics against Vibrio cholerae isolated during the study. Keywords: antibiotics, susceptibility, Vibrio cholera.

Antibiotic susceptibility patterns of Vibrio cholerae isolates

INTRODUCTION

Cholera is one of the most common diarrhoeal diseases in Nepal. Etiological agent of cholera is Vibrio cholerae which removes essential body fluids, salts and vital nutrients, which are necessary for life causing dehydration and malnutrition. Emerging antimicrobial resistant is common. The aim of the present study was to determine the antibiotic susceptibility pattern of cholera patients in Nepal.

METHODS

All the laboratory works were conducted in the bacteriology section of National Public Health Laboratory, Teku from March to September 2005. During this period a total of 340 stool samples from diarrhoeal patients were collected and processed according to the standard laboratory methods. Each patient suffering from diarrhoea was directly interviewed for his or her clinical history during sample collection.

RESULTS

A total of 340 stool samples were processed and studied from both sex including all ages of patients. Among the processed sample 53 Vibrio cholerae cases were found. All isolated Vibrio cholerae O1 were El Tor, Inaba. All isolated (100%) Vibrio cholerae O1 were sensitive to Ampicillin, Ciprofloxacin, Erythromycin and Tetracycline whereas all were resistant to Nalidixic acid and Cotrimoxazole. Only 15.1% cases were sensitive to Furazolidone whereas 84.9% were resistant.

CONCLUSION

All V. cholerae strains isolated in this study were found resistant to Multi Drug Resistant (resistant to at least two antibiotics of different group). Ampicillin, Ciprofloxacin, Erythromycin and Tetracycline were found still more potent antibiotics against Vibrio cholerae isolated during the study.

Therapeutic Drug Monitoring of Antiepileptic Drugs

Commonly used conventional antiepileptic drugs for pharmacotherapy in epilepsy are phenytoin, carbamazepine and valproic acid. These drugs have complex pharmacokinetic properties leading to fluctuation in their plasma level at given same therapeutic dose. The present study was done to monitor their plasma levels. A prospective observational study was conducted at Natoinal Public Health Laboratory. After taking detail history, blood samples were taken from epileptic patients of all age groups and both gender who were on usual therapeutic dose of one or two combined antiepileptic drugs. Plasma level of these drugs were analyzed by using Fluorescence Polarization Immuno Assay (FPIA) technique. Out of total 417 testing, 81were tested for phenytoin , 241 for carbamazepine and 95 for valproic acid. Their levels were further analyzed to find therapeutic, subtherapeutic and toxic levels. Out of total 81 blood samples tested for phenytoin, 38.8% had plasma drug at therapeutic level, 38.8% at subtherapeutic level and 28.4% had toxic level. Carbamazepine was tested in 241 samples and 79.3% cases had at therapeutic drug level, 15.8% had subtherapeutic drug level and 4.9% had toxic level. Out of 95 samples tested for valproic acid, 62% had therapeutic level and 20% had subtherapeutic and 18% had toxic level of drug. Therapeutic drug monitoring of phenytoin showed wide fluctuation in its plasma level. Its toxic and subtherapeutic levels were quite high. It is suggested that the dose of phenytoin should be adjusted after regular plasma level monitoring only. Monitoring of carbamazepine and valproic acid were also helpful when their toxicity and efficacy are doubtful.JNMA J Nepal Med Assoc. 2008 Jul-Sep;47(171):94-97.

Therapeutic drug monitoring of antiepileptic drugs

Commonly used conventional antiepileptic drugs for pharmacotherapy in epilepsy are phenytoin, carbamazepine and valproic acid. These drugs have complex pharmacokinetic properties leading to fluctuation in their plasma level at given same therapeutic dose. The present study was done to monitor their plasma levels. A prospective observational study was conducted at National Public Health Laboratory. After taking detail history, blood samples were taken from epileptic patients of all age groups and both gender who were on usual therapeutic dose of one or two combined antiepileptic drugs. Plasma level of these drugs were analyzed by using Fluorescence Polarization Immuno Assay (FPIA) technique. Out of total 417 testing, 81 were tested for phenytoin , 241 for carbamazepine and 95 for valproic acid. Their levels were further analyzed to find therapeutic, subtherapeutic and toxic levels. Out of total 81 blood samples tested for phenytoin, 38.8% had plasma drug at therapeutic level, 38.8% at subtherapeutic level and 28.4% had toxic level. Carbamazepine was tested in 241 samples and 79.3% cases had at therapeutic drug level, 15.8% had subtherapeutic drug level and 4.9% had toxic level. Out of 95 samples tested for valproic acid, 62% had therapeutic level and 20% had subtherapeutic and 18% had toxic level of drug. Therapeutic drug monitoring of phenytoin showed wide fluctuation in its plasma level. Its toxic and subtherapeutic levels were quite high. It is suggested that the dose of phenytoin should be adjusted after regular plasma level monitoring only. Monitoring of carbamazepine and valproic acid were also helpful when their toxicity and efficacy are doubtful.

Study on CD4 cell responses in HIV infected subjects in Nepal

HIV infection is characterized by gradual deterioration of immune function mainly the CD4 cells. This study was conducted with the objectives to evaluate the kinetics of CD4 cell depletion and duration of HIV infection and the role of ART in improving CD4 cell levels specifically in Nepalese HIV patients. During April 2005 to March 2006, all together 220 blood samples collected from 110 HIV patients visiting National Public Health Laboratory (NPHL), Kathmandu, were analyzed for CD4 cell count using standard protocol. CD4 cell count before and after starting of anti-retro viral therapy showed significant association (P<0.05). The results of this study clearly indicated that antiretroviral therapy has been playing a role in maintenance CD4 cell counts in HIV infected patients.

Shigella isolates of Nepal: changes in the incidence of shigella subgroups and trends of antimicrobial susceptibility pattern

OBJECTIVES

Shigellosis is an important cause of bloody diarrhoea in all age groups, especially in children. A retrospective study was done to analyse the pattern of shigella isolates and the antimicrobial susceptibility trend of these shigella isolated at different hospitals of Nepal from Jan, 2003- Dec, 2005.

MATERIALS AND METHODS

A total of 118 Shigella species isolated at nine different hospital laboratories of Nepal were reported to National Public Health Laboratory during January, 2003- December 2005 .The isolates were tested for the confirmation of identification and antimicrobial susceptibility pattern by standard bacteriological techniques.

RESULTS

Of the 118 Shigella isolates reported, Shigella flexneri 51 (43.22%) was the predominant of the four species followed by Shigella dysenteriae 49(41.52 %) , Shigella boydii (7.62%) and Shigella sonnei (7.62%).But the yearly distribution of the Shigella isolates in 2003 and 2004 showed that Shigella dysenteriae was the most common of the four species. In 2005, a shift in the species was noted as Sh flexneri replaced Sh dysenteriae and became the most prevalent species. The percentage of Shigella dysenteriae type-1 among all Shigella dysenteriae were 66.66 % in 2003, 44.44 % in 2004 and 60 % in 2005. Individual or multiple resistances to Ampicillin, Nalidixic acid, and/or Cotrimoxazole was seen in all the four species of Shigella. 33% of the total Shigella isolates reported were multi drug resistant (showing resistance to 3 or more antibiotics at a time). Shigella dysenteriae type-1(Sd 1) isolates resistant to ciprofloxacin were also encountered in the present study .Of the total 25 Shigella dysenteriae type 1 isolates reported, 18(72%) were ciprofloxacin resistant . All the Shigella isolates were however sensitive to Ceftriaxone and Azithromycin.

CONCLUSION

Distribution of different species of Shigella and their antibiotic susceptibility profile may vary from one geographical location to another and may also change with time. Systematic monitoring of the species and serotypes of Shigellae and their antimicrobial susceptibility can help to guide therapy and reveal periodic epidemics due to Sd 1, which may have acquired resistance to antibiotics that have previously been effective. Key words: Dysentery, Shigella, Shigella dysenteriae type-1, Antimicrobial resistance.