Surgeon educator perspectives of implementing a national undergraduate curriculum in otolaryngology

OBJECTIVE

The General Medical Council will be implementing a national medical licensing assessment for all UK medical students by 2024-25. Surgeon educator perceptions on a national undergraduate curriculum in otolaryngology were reviewed accordingly.

METHOD

A mixed methods study was undertaken within a UK school of surgery assessing ENT surgeon educators. Perspectives on teaching content, quality and student experience were assessed with degree of agreement assessed (Likert scoring). Associated qualitative focus group sessions underwent detailed thematic analysis according to grounded theory.

RESULTS

A response rate of 50 per cent was achieved involving 21 participants working across 14 hospitals. These showed strong agreement that implementation of a national curriculum would improve the standard of teaching delivered at a personal, institutional and national level. Further themes were identified relating to the personal, institutional and specialty related factors influencing practical delivery.

CONCLUSION

A series of practical recommendations are made to potentially assist the implementation of a national ENT curriculum.

Mutations in LAMB2 Are Associated With Albuminuria and Optic Nerve Hypoplasia With Hypopituitarism

CONTEXT

Mutations in LAMB2, encoding the basement membrane protein, laminin β2, are associated with an autosomal recessive disorder characterized by congenital nephrotic syndrome, ocular abnormalities, and neurodevelopmental delay (Pierson syndrome).

CASE DESCRIPTION

This report describes a 12-year-old boy with short stature, visual impairment, and developmental delay who presented with macroscopic hematuria and albuminuria. He had isolated growth hormone deficiency, optic nerve hypoplasia, and a small anterior pituitary with corpus callosum dysgenesis on his cranial magnetic resonance imaging, thereby supporting a diagnosis of optic nerve hypoplasia syndrome. Renal histopathology revealed focal segmental glomerulosclerosis. Using next-generation sequencing on a targeted gene panel for steroid-resistant nephrotic syndrome, compound heterozygous missense mutations were identified in LAMB2 (c.737G>A p.Arg246Gln, c.3982G>C p.Gly1328Arg). Immunohistochemical analysis revealed reduced glomerular laminin β2 expression compared to control kidney and a thin basement membrane on electron microscopy. Laminin β2 is expressed during pituitary development and Lamb2-/- mice exhibit stunted growth, abnormal neural retinae, and here we show, abnormal parenchyma of the anterior pituitary gland.

CONCLUSION

We propose that patients with genetically undefined optic nerve hypoplasia syndrome should be screened for albuminuria and, if present, screened for mutations in LAMB2.

Dynamics of Japanese encephalitis virus transmission among pigs in Northwest Bangladesh and the potential impact of pig vaccination

Background

Japanese encephalitis (JE) virus infection can cause severe disease in humans, resulting in death or permanent neurologic deficits among survivors. Studies indicate that the incidence of JE is high in northwestern Bangladesh. Pigs are amplifying hosts for JE virus (JEV) and a potentially important source of virus in the environment. The objectives of this study were to describe the transmission dynamics of JEV among pigs in northwestern Bangladesh and estimate the potential impact of vaccination to reduce incidence among pigs.

Methodology/Principal Findings

We conducted a comprehensive census of pigs in three JE endemic districts and tested a sample of them for evidence of previous JEV infection. We built a compartmental model to describe JEV transmission dynamics in this region and to estimate the potential impact of pig vaccination. We identified 11,364 pigs in the study area. Previous JEV infection was identified in 30% of pigs with no spatial differences in the proportion of pigs that were seropositive across the study area. We estimated that JEV infects 20% of susceptible pigs each year and the basic reproductive number among pigs was 1.2. The model suggest that vaccinating 50% of pigs each year resulted in an estimated 82% reduction in annual incidence in pigs.

Conclusions/Significance

The widespread distribution of historic JEV infection in pigs suggests they may play an important role in virus transmission in this area. Future studies are required to understand the contribution of pig infections to JE risk in humans and the potential impact of pig vaccination on human disease.

Japanese encephalitis (JE) virus infection can cause severe neurological disease in man. More JE cases are seen in northwestern districts in Bangladesh. Pigs are the most common amplifying host of the virus and can act as a potential environmental source. We conducted a comprehensive census of pigs in three JE endemic districts and tested a sample of them for evidence of previous JEV infection. We built a compartmental model to describe JEV transmission dynamics in this region and to estimate the potential impact of pig vaccination. We identified 11,364 pigs in our study area, mostly raised in backyards. About 30% of the pigs had evidence of previous JE virus infection. Our model suggests that vaccinating 50% of pigs each year resulted in an estimated 82% reduction in annual incidence in pigs. Pigs in northwestern Bangladesh may play a significant role in JE virus transmission. JE incidence may be substantially reduced through reasonable pig vaccination coverage.

Clinical Profile of Acute Respiratory Infection (ARI) in Children

Bangladesh Journal of Medical Science Vol.1(4) 1994 pp.6-14

First Report of Powdery Mildew of Pumpkin Caused by Golovinomyces cichoracearum in Neelum Valley, Azad Kashmir

During July 2011, a severe powdery mildew outbreak was recorded in pumpkin (Cucurbita moschata Duch.) fields in economically poor areas in the Neelum Valley (Leswa, Mir Pura, Jura, Kundal Shahi, and Bela). Disease symptoms included grayish white circular to irregular patches consisting of epiphytic mycelia and conidia on both surfaces of the leaves of infected vines. Fungal mycelia and conidiophores were also visible in white powdery patches on the main stems, leaves, and petioles of affected plants. Leaves became necrotic with age. Powdery mildew symptoms were more severe on pumpkin vines located in the shade, and severely affected vines collapsed. A voucher specimen (IR00027) has been deposited in First Fungal Culture Bank of the Pakistan (FCBP), Institute of Agriculture Sciences, University of the Punjab, Lahore, Pakistan. For morphological observation, a clear tape strip was used to remove fungal tissue from infected leaves. The tape was mounted on microscope slides with water and examined with a light microscope (2). Conidiophores were unbranched, cylindrical, erect and arose singly on hyphal cells, 110 to 200 × 6 to 12 μm, composed of a foot cell and three to eight barrel-shaped conidia formed in chains with a sinuate edge, followed with a basal septum at the branching point or slightly displaced from the mycelium. Foot cells were 50 to 80 × 6 to 12 μm, and slightly swollen with constriction at the base. Conidia were cylindrical to doliiform, 30 to 50 × 14 to 20 μm and produced in chains. The length/breadth ratio of the conidia was 1.8 to 2.6. Fibrosin bodies were absent in both conidiophores and conidia. No cleistothecia were observed. Identification of the causal agent as Golovinomyces cichoracearum (DC.) V.P. Heluta (synonym Erysiphe cichoracearum) was based on morphology (1). Pathogenicity was determined using field-infected plant leaves transported to a greenhouse. Fresh conidia of field isolates of G. cichoracearum were transferred by a sterile brush from the affected leaves to fully expanded four to five healthy leaves of three 40-day-old vines. For the control, three vines were stroked with a clean sterile brush and control plants were placed 100 m away from the inoculated plants. For disease development 20°C and 80% relative humidity was maintained in the greenhouse. A plastic sheet was placed around each vine for a week and removed later. Inoculated vines developed visible white spots of powdery mildew on the leaves after 10 days in the greenhouse, whereas control plants remained asymptomatic. Fungal colony and conidial morphology on the leaves of inoculated plants were as described above. Previously, G. cichoracearum has been reported on other cucurbits (3) in the plains of Pakistan. To our knowledge, this is the first report of occurrence of G. cichoracearum as a causal agent of powdery mildew on pumpkin in Neelum Valley, Azad Kashmir. References: (1) U. Braun. Beih. Nova Hedwigia 89:1, 1987. (2) J. C. Correll et al. Plant Dis. 71:248, 1987. (3) A. Wahid et al. Pak. J. Agric. Res. 9:209, 1988.

MRSA and cataract surgery - reflections for practice

INTRODUCTION

Postoperative bacterial endophthalmitis is a devastating complication of cataract surgery. Methicillin-resistant Staphylococcus aureus (MRSA) endophthalmitis is rare. Recent debate over MRSA screening in United Kingdom (UK) National Health Service (NHS) hospital services has implications for cataract patients and ophthalmology services.

AIMS

To discuss issues for clinical practice as based on reflective experience at a UK district general NHS hospital in relation to care of MRSA-positive cataract patients.

METHODS

Retrospective case series and reflective practice.

RESULTS

Three cases presented highlight practice points around cataract patients colonized with MRSA. Known or determined MRSA-colonized patients should be treated with anti-microbial agents at time of cataract surgery known to be active against MRSA. Preventative treatment with intracameral vancomycin or intravenous teicoplanin alongside appropriate topical treatments may be of merit. Importantly fluoroquinolones, often prescribed by cataract surgeons, may have a selective effect favoring the proliferation of MRSA.

CONCLUSION

MRSA screening may cause unnecessary delays in cataract care and may represent a patient safety concern in its own right. Patients colonized with MRSA may safely undergo cataract surgery provided there is no evidence of periorbital infection and provided appropriate infection control and antibiotic prophylaxis measures are used. The well-prepared cataract surgeon needs to be aware of developments in infection control and should liaise with local clinical microbiology colleagues in relation to bacterial resistance to antibiotics.

Association of oral candidal carriage with dental caries in children

INTRODUCTION

Oral candidiasis is one of the most common opportunistic oral fungal infections. Oral candidal carriage in schoolchildren is a subject of increasing interest worldwide and has recently been associated with increased caries incidence in children.

AIMS

This study was carried out to identify association between oral candidal carriage in children and dental caries.

SUBJECTS AND METHODS

One hundred subjects with an age range between 6 and 12 years were included in this study. The subjects were distributed equally into two groups, i.e., study (caries-positive) and control (caries-free) groups. Oral hygiene index and DMFT/dmft scores were recorded for each subject. Sampling for Candida was carried out using intraoral swabs and concentrated oral rinse. Sabouraud dextrose agar containing 0.1 mg/ml of chloramphenicol was used as the primary culture medium. Candida was identified by employing API-20C AUX and germ tube formation tests.

RESULTS

The subjects in the caries-positive group showed a high frequency of oral candidal carriage compared to the caries-free subjects and the results were statistically very significant (p < 0.01). The odds ratio was 67.37, implying a high caries risk with positive oral candidal carriage (95% CI 14-323).

DISCUSSION

The findings of this study underscore the possible association of Candida with dental caries.

CONCLUSIONS

The occurrence of dental caries in children with mixed dentition is positively correlated with the frequency of oral candidal carriage.

The challenge of embracing a smoke-free lifestyle: a neglected area in smoking cessation programs

Relapse prevention theory and practice has focussed on teaching coping skills to deal with withdrawal and temptations to relapse with the result that treatments appear to be effective in reducing relapse over the short term, but not over the longer term. Once cravings subside ex-smokers face a further task of adjusting to a smoke-free lifestyle that involves learning to think and act like a non-smoker. To highlight this task, we operationalized a new conceptual framework that describes three tasks of quitting (the 3Ts): (i) making a quit attempt; (ii) learning to effectively deal with cravings and withdrawal; and (iii) adapting to a smoke-free lifestyle. This was introduced to the Quitline service in Victoria, Australia, in preparation for a randomized controlled trial aimed at testing whether a program of four to six extra callbacks could help ex-smokers with the third task and as a result reduce rates of relapse compared with Quitline's standard callback program. This paper describes the conceptual framework (focussing on the third task) and initial reactions to it from both Quitline advisors and callers. The conceptual framework is now integrated in the service and appears to have changed the way Quitline operates and the apparent expectations of its clients.

FENS 2000--Federation of European Neuroscience Societies. 24-28 June 2000, Brighton, UK

This meeting of the Federation of European Neuroscience Societies (FENS), hosted by the British Neuroscience Association (BNA), included a diverse range of neuroscience presentations including many of pharmacological relevance. The pharmacological characterization and mode of action of numerous drugs was presented, including IL-1ra, ARL-17477, zVAD-fmk, L-790984, CEP-1347, gacyclidine, NBI-30775, AWD-131-138, flumazenil, ondansetron, LY-367385, MPEP, and NBI-34060.

Helicobacter pylori: isolation from gastric biopsy specimens

Forty-two gastric biopsies, in two transport media, were homogenized and cultured on three media under micro-aerophilic conditions. Brain-heart infusion agar with a commercial antibiotic supplement (giving 10 mg vancomycin, 5 mg trimethoprim and 2500 i.u. polymixin per litre) yielded the best results. Ordinary chocolate (heated) human blood agar could be used in laboratories with limited resources. Growth was obtained in 4-6 days at 37 degrees C. All isolates were sensitive to metronidazole. The resistance to nalidixic acid and rapid urease production of Helicobacter pylori could be used to differentiate this species from Campylobacter spp. Indicator medium (brain-heart infusion broth with 7% human blood and 40 mg 2,3,5-triphenyletetrazolium chloride agar/litre) also proved useful in identification.

Subcutaneous phaeohyphomycosis

We report the case of a 13-year-old boy who presented with multiple swellings all over the body. His condition remained undiagnosed for over 3 years. Exophiala spinifera was recovered from pus drained from the swellings. We discuss the difficulties in the initial diagnosis and the ease of correct diagnosis once we had used special fungal stains.

Effects of oral pantoprazole on 24-hour intragastric acidity and plasma gastrin profiles

Pantoprazole selectively blocks gastric parietal cell H+,K(+)-ATPase. To define a dosage regimen for clinical trials we compared the effect of pantoprazole 40 and 60 mg daily on 24-h intragastric acidity and plasma gastrin concentrations using a double-blind, randomized, cross-over design. Eleven men took each of the three regimens (placebo, 40, 60 mg) for 5 days. On Day 5, 24-h pHmetry and plasma gastrin profile were performed. A consistent decrease in intragastric acidity with each dosage regimen was shown by a rise in 24-h median pH from 1.4 (1.2-1.8, IQR) on placebo to 2.3 (1.8-4.4, P = 0.0022) during pantoprazole 40 mg and to 3.5 (2.6-4.9, P = 0.0017) during 60 mg. Pantoprazole 40 and 60 mg maintained the intragastric pH above 3 for 33% and 58% of time, respectively, compared with 15% time with placebo. Twenty-four-hour integrated plasma gastrin concentration rose from 478 to 1798 and 1962 pmol.h/L, respectively. The drug was well tolerated. The decrease of acidity was dose related and should result in clinical efficacy similar to other antisecretory drugs. It is not known whether higher doses might abolish acid secretion. The optimal dose of pantoprazole is yet to be established.

Comparative in vitro activity of enoxacin and other fluoroquinolones against multi-resistant strains of Salmonella typhi

The in vitro activities of enoxacin, lomefloxacin, norfloxacin, ofloxacin, and pefloxacin against 274 strains of Salmonella typhi isolated from suspected typhoid fever patients (137 multi-resistant strains and 137 strains sensitive to chloramphenicol, ampicillin and/or co-trimoxazole) were determined using disk diffusion and agar dilution techniques. In vitro, enoxacin was active against all tested strains with a MIC90 and inhibition zone size against multi-resistant strains of 0.12 mg/l and 34 mm diameter, respectively. Similar results were found with the other fluoroquinolones. Enoxacin and other fluoroquinolones may be the therapy of choice in cases of typhoid fever caused by organisms resistant to the standard therapy, chloramphenicol.

HLA frequencies in Pakistani population

HLA frequencies on 1231 subjects from within the country, using methods employed by National Institute of Health, USA is reported. Pakistani population appears to be a mixture of an indigenous population with others particularly Orientals and Negroids. Relationship with Caucasians is not convincing.

Use of automatic computerised pump to maintain constant intragastric pH

We used continuous variable rate infusions of famotidine in eight normal volunteers under fasting conditions to raise intragastric pH to 5.0. An intragastric glass electrode continuously monitored acidity and this information was automatically computed to regulate an intravenous infusion system (GastroJet). The computer was programmed to aim for pH 6.0, increasing and lowering infusion rates accordingly. Two regimens were compared with placebo (10 mg bolus followed by infusion or infusion of famotidine alone). Volunteers were admitted to an investigation ward and each study was preceded by a standard normal meal. Hydration was maintained with intravenous fluids. During placebo treatment the median pH was 1.5 and the pH was less than 5.0 for 98% of the time. All volunteers responded to famotidine but dosage requirements varied (range 41 mg to 126 mg). The median pH rose to 6.5 when infusions of famotidine followed boluses and to 6.6 when infusions alone were used - the pH was less than 5.0 for 20% and 16% of the time respectively (p less than 0.05 Wilcoxon compared with placebo). Mean drug use was greater with boluses (98 mg v 87 mg p = 0.03: paired Student's t test) and onset was not apparently faster. Blood famotidine concentrations followed infusion rate changes. Famotidine infused by GastroJet maintains a high fasting intragastric pH and priming boluses are probably unnecessary.

In vitro activity of ofloxacin against 210 clinical isolates of typhoid salmonellae

210 clinical isolates of typhoid salmonellae, cultivated from blood of patients with typhoid fever (108 strains of Salmonella typhi, 99 strains of Salmonella paratyphi A and three strains of Salmonella paratyphi B) as well as 266 random clinical isolates of Escherichia coli (n = 152), Klebsiella spp. (n = 51) and Proteus spp. (n = 63) were tested for susceptibility to ofloxacin, using an agar dilution method. All the typhoid salmonellae were found to be highly sensitive to ofloxacin with MICs ranging from 0.03 mg/l to 0.12 mg/l. The sensitivity pattern of enterobacteriaceae was comparable to data published internationally.

Clinical Profile and Outcome of Acute Post-Streptococcal Glomerulonephritis in Children

DOI: http://dx.doi.org/10.3329/bjms.v1i1.7848 Bangladesh Journal of Medical Science Vol.1(1) 1994 pp.22-27