Controversies in tuberculosis

Tuberculous infection among children continues to be a significant cause of morbidity. The symptom complex are so variable among children that the final diagnosis often rests on the laboratory tests. Proper interpretation of the tests, specially tuberculin test and radiographic studies, are necessary for establishing correct diagnosis. The usefulness of tuberculin test in both unimmunized and BCG vaccinated children is highlighted. BCG accelerated response as a test should be reserved for identifying serious form of pulmonary disease or CNS tuberculosis when the tuberculin test is negative. Radiographic assessment may be sensitive in some instances but not always specific and hence needs cautious interpretation. Tuberculosis among BCG vaccinated children though not uncommon, needs proper documentation. Current trends in the management of tuberculosis including CNS forms are briefly outlined.     

Conversion of temporary hemodialysis catheters to permanent hemodialysis catheters: a retrospective study of catheter exchange versus classic de novo placement

Many clinicians believe that de novo access is required when converting temporary hemodialysis (HD) catheters to long-term or permanent catheters. However, since vascular access sites are at a premium in the dialysis patient, it is important to preserve existing central venous catheters and conserve future access sites. In this retrospective study, data from 94 patients referred to interventional radiology for placement of long-term, tunneled HD catheters between July 2001 and September 2002 were reviewed. The study group consisted of 42 patients in whom the temporary catheter was exchanged for a peel-away sheath and a tunneled catheter inserted using the existing venous access site. The control group included 52 patients who received traditional de novo placement of permanent catheters. Based on available follow-up data, we report a 100% technical success rate, with 72% patency at 30 days in the study group (n = 32; mean age 58 years). By comparison, de novo catheter placement (n = 35; mean age 59 years) yielded a 100% technical success rate, with 83% patency at 30 days. The overall infection rate was 0.30 per 100 catheter-days (total 3036 catheter-days) and 0.36 per 100 catheter-days (total 3295 catheter-days), respectively (chi2 = 0.64, p > or = 0.05). There was no incidence of exit site infection, tunnel infection, or florid sepsis in either group. Likewise, no stenosis or bleeding complication was noted. Thus conversion of a temporary HD catheter to a tunneled catheter using the same venous insertion site is safe, does not increase the risk of infection, and allows conservation of other central venous access sites.     

Conversion of temporary hemodialysis catheters to tunneled hemodialysis catheters

PURPOSE: To determine the feasibility and clinical outcomes of conversion of temporary to tunneled hemodialysis catheters using the same venous insertion site. METHODS: Data from 42 patients with existing temporary hemodialysis catheters referred for placement of tunneled hemodialysis catheters were retrospectively reviewed. In these patients, the temporary catheter was exchanged for a peel-away sheath, and a tunneled catheter was inserted using the existing venous access site. Technical success, procedural complications, and clinical outcomes were evaluated. Hemodialysis records were reviewed to assess catheter patency during a 30-day follow-up period. RESULTS: The study group consisted of 20 males and 22 females (mean age: 58 years). All 42 temporary catheters were successfully converted to tunneled hemodialysis catheters without immediate procedure-related complications. Follow-up data were available for 32 patients (total: 3038; median 71 catheter days). Nine catheters were removed for infection, yielding a catheter infection rate of 0.30/100 catheter days; three catheters were removed for blood flow <200 ml/min. 13 patients had catheters removed when catheters were no longer needed. Three patients died with working catheters. The patency rate was 72% at 30 days, with four catheters functioning at the end of the study period. CONCLUSION: Conversion of a temporary hemodialysis catheter to a tunneled hemodialysis catheter using the same venous insertion site is a safe procedure that avoids complications associated with venotomy and allows conservation of other central venous access sites. Patency and infection rates in these catheters are comparable to several studies of catheter exchange and de novo placement of tunneled hemodialysis catheters.     

Use of a "small-bubble technique" to increase the success of Anwar's "big-bubble technique" for deep lamellar keratoplasty with complete baring of Descemet's membrane

PURPOSE: To describe a quick and simple "small-bubble" technique to immediately determine the success of attaining complete Descemet's membrane (DM) separation from corneal stroma through Anwar's "big-bubble" technique of deep anterior lamellar keratoplasty (DALK) for complete stromal removal. METHODS: A partial trephination was followed by a lamellar dissection of the anterior stroma. Deep stromal air injection was then attempted to achieve the big bubble to help separate the stroma from the DM. To confirm that a big bubble had been achieved, a small air bubble was injected into the anterior chamber (AC) through a limbal paracentesis. If the small bubble is then seen at the corneal periphery, it confirms that the big-bubble separation of DM was successful because the convex nature of the bubble will cause it to protrude posteriorly, forcing the small AC bubble to the periphery. If the small AC bubble is not seen in the corneal periphery, this means that it is present in the centre, beneath the opaque corneal stroma, and therefore the big bubble has not been achieved. RESULTS: We used the small-bubble technique to confirm the presence of the big bubble in three (one keratoconus, one interstitial keratitis and one dense corneal scar) out of 41 patients who underwent DALK. The small-bubble technique confirmed that the big bubble was achieved in the eye of all three patients. Complete stromal removal with baring of the DM was achieved, and postoperatively all three eyes achieved best corrected vision of 6/6. CONCLUSION: The small-bubble technique can be a useful surgical tool for corneal surgeons attempting lamellar keratoplasty using the big-bubble technique. It helps in confirming the separation of DM from the deep stroma, which is important in achieving total stromal replacement. It will help to make the transition to lamellar keratoplasty smoother, enhance corneal graft success and improve visual outcomes in patients.     

Embracing Technology for Capacity Building in Mental Health: New Path,Newer Challenges

Psychiatric Quarterly - Technology driven capacity building initiatives are the way to break the barrier of shortage of mental health human resources in India. This new path, while is a welcome...