Pathogenic infection caused by coagulase negative multiple drug resistant Staphylococcus

Staphylococcus epidermidis is becoming increasingly important as a cause of clinical illness. In the past, its presence in the wound, blood and urine culture was generally dismissed as contamination and went undocumented. However, more recently its pathogenic role is being recognized notably in bacterial endocarditis, postcardiotomy endocarditis, bacteraemia secondary to colonised prosthetic heart valves, postsurgical wound infection and urinary tract infection. The ability of the organism to cause local sepsis in superficial tissues is a matter of debate. A case of pyogenic infection due to multidrug resistant coagulase negative staphylococci is reported here.     

Dopa-responsive parkinsonism secondary to right temporal lobe haemorrahage.

A 46-year-old man developed a symmetrical parkinsonian syndrome 7 weeks after large right temporal intracerebral haemorrhage resulting from a ruptured arteriovenous malformation. His signs included bradykinesia, rigidity, start hesitation, and poor postural reflexes, without a resting tremor. He also had signs of a Parinaud's syndrome. Computed tomography and magnetic resonance imaging of the brain demonstrated changes in the right temporal lobe associated with the haemorrhage but no abnormality of the basal ganglia or midbrain. Levodopa therapy produced a dramatic improvement within a few days of commencement. We postulate that the parkinsonism resulted from midbrain compression secondary to transtentorial herniation. Although parkinsonism is a rare complication of lobar intracerebral haemorrhage, it is important to recognise as it may be potentially treatable.     

Use of carbidopa levodopa in a patient with hydrocephalus and frozen movement

While movement disorders are frequently encountered after brain injuries, and may create a host of complicated problems for the clinician, only a few cases of Parkinsonism associated with hydrocephalus have ever been described in the literature. Parkinsonism like syndrome complicating hydrocephalus is a rare disorder, especially when associated with nontumoral aqueductal stenosis. Yet as this case report discusses, hdyrocephalus induced Parkinsonism may be responsive to levodopa-carbidopa administra tion. This report describes a perplexing case of persistent akinesis following corrective surgery for aqueductal stenosis and the subsequent response to levodopa carbidopa administration. We present the case of a 28 year old male with a history of non tumoral aqueductal stenosis diagnosed at age 12. As a child, he underwent a ventriculo peritoneal shunt placement for obstructive hydrocephalus followed by multiple shunt revisions over the next several years. Sixteen years after his initial shunt placement, the patient presented with a decline in mental status. A third ventriculocisternostomy was performed rather than another shunt revision. Following surgery, the patient remained obtunded, and displayed profound hypokinesis, best described as freezing in movement. Upon admission to a rehabiliation unit 2 weeks later, he had made only minimal progress. A SPECT single photon emission computed tomography brain scan revealed decreased basal ganglia perfusion. Levodopa carbidopa therapy was initiated and within 2 weeks, the patient showed improvement in speed of movement, facial expres sion and verbal output. Eight weeks later, the patient could independently complete his basic activities of daily living and demonstrated little, if any, disordered movement. This report illustrates how dopaminergic agents may be useful in cases of hypokinesis following corrective surgery for aqueductal stenosis. SPECT may further aid in the diagnosis and management of Parkinsonism like syndromes in brain injuries.     

Corpectomy for multi-level cervical spondylosis and ossification of the posterior longitudinal ligament

The choice of a surgical approach for multi-level cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL) is still a controversial issue. While most of the surgeons are still performing decompression by laminectomy some are doing multi-level anterior decompression. Few neurosurgeons are performing decompression by corpectomy. We have treated 26 patients by median cervical corpectomy during the last 4 years. These patients were followed up for a mean period of 25 months. Twenty one (80%) patients had a good outcome, 2 patients remained unchanged and 3 expired. Review of the literature and our experience indicates that patients with CSM and OPLL should be operated by median cervical corpectomy (anterior approach).     

Preemptive analgesia for postoperative pain relief in lumbosacral spine surgeries: a randomized controlled trial.

BACKGROUND CONTEXT: Administration of analgesic medication, before the actual onset of painful stimulus, is more effective than that after the onset of painful stimulus. This is the principle of preemptive analgesia. Although it is often considered superior to other forms of analgesia, its role in postoperative pain relief after lumbosacral spinal surgery has not been fully investigated. PURPOSE: To analyze the efficacy of preemptive analgesia with a single caudal epidural injection for patients undergoing surgeries on the lumbosacral spine by the posterior approach. STUDY DESIGN/SETTING: Randomized, double-blinded and controlled clinical trial. PATIENT SAMPLE: Eighty-two patients who underwent discectomy in the lumbosacral spine by the posterior approach, with or without instrumentation, were randomized to the control group (n=40) and to the study group (n=42). METHODS: Patients in control group received a single caudal epidural injection of 20 ml of normal saline. Patients in study group received a single caudal epidural injection of 20 ml containing bupivacaine and tramadol as the active agents. The time interval between this injection and the surgical incision was never less than 20 minutes in either of the groups. This facilitated enough time for the drug to get fixed to the nerve roots, leading to effective preemptive analgesia. OUTCOME MEASURES: Patients were monitored for postoperative pain immediately after surgery when they had completely recovered and regained consciousness from general anesthesia, and subsequently 4, 8, 12 and 24 hours thereafter. Pain was quantified using the visual analog scale (VAS) and the verbal rating scale (VRS). The time at which supplemental analgesic medication was first demanded in the postoperative period by the patient was also noted. RESULTS: The two groups were comparable for age, sex, body weight and the type of surgery they underwent. Because the data did not have a normal Gaussian distribution, the one-tailed Mann-Whitney test, being a nonparametric test, was adopted for statistical analysis. Accordingly, VAS and VRS values at all time intervals were significantly lower (p<.0001) in the study group as compared with the control group. This indicated significantly better pain relief in the study group. There was also a significant delay (p=.0041) in the first demand for supplemental analgesic medication in the postoperative period in the study group. No complication specific to the procedure was noted except for the development of postoperative urinary retention, which was transient and appropriately managed with urinary catheterization. CONCLUSIONS: Preemptive analgesia with a single caudal epidural injection of bupivacaine and tramadol is a safe, simple and effective method for postoperative pain relief.     

Preoperative methicillin‐resistant Staphylococcus aureus (MRSA) screening: An effective method to control MRSA infections on elective orthopaedics wards

Background: Methicillin‐resistant Staphylococcus aureus (MRSA) infections continue to increase in UK hospitals despite the introduction of various control measures. These infections have serious clinical and economic implications, particularly in relation to elective orthopaedic surgery. Methods: A prospective study was performed from August 2003 to July 2004 to assess the effect of preadmission screening and ‘ring fencing’ of beds on the incidence of infection in an elective orthopaedics unit. Results: The preoperative incidence of MRSA colonization was 2.25% and 53% of these patients had at least one risk factor. There were no postoperative MRSA infections in the ring‐fenced orthopaedic unit. Conclusions: Preoperative screening and ring fencing reduced the MRSA incidence to zero in the operated patients. Mechanisms need to be developed where screening and isolation of MRSA cases can be performed in most, if not all, hospital admissions.     

Prevalence of metabolic syndrome in adolescents from a north Indian population.

AIMS: To estimate the prevalence and distribution of the metabolic syndrome (MS) in adolescents attending school in the north Indian city of Chandigarh. RESEARCH DESIGN AND METHODS: At total of 1083 adolescents attending school (aged 12-17 years) participated in a community-based cross-sectional survey. Anthropometric examination included height, weight, body mass index, waist circumference, hip circumference, waist-hip ratio and blood pressure measurement. A fasting blood sample was taken for measurement of glucose, insulin and lipid profile. Socio-demographic characteristics were investigated using a questionnaire. The metabolic syndrome was determined by the National Cholesterol Education Program Adult Treatment Panel III definition modified for age. RESULTS: The overall prevalence of MS in adolescents was 4.2%. However, the prevalence rose to 5.8% when the fasting plasma glucose cut-off was lowered to 5.5 mmol/l. There was no gender difference in the distribution of MS. When stratified by body mass index (BMI), 5.5% adolescents were overweight (BMI > or = 95th percentile), while 4% were at risk for overweight (BMI between 85th and 95th percentile). Of the overweight adolescents, 36.6% met the criteria for MS, while 11.5% at risk for overweight and only 1.9% of the normal population had MS (P < 0.0001). Low high-density lipoprotein was the most common and abdominal obesity the least common constituent of MS. There was a significant difference (P < 0.0001) between the prevalence of MS adolescents from low to high socio-economic strata. CONCLUSIONS: A substantial number (4.2%) of north Indian adolescents and 36.6% of overweight adolescents had MS. This poses a serious threat to the current and future health of these young people.     

Cerebral hemodynamic and metabolic profiles in fulminant hepatic failure: relationship to outcome.

The purpose of this retrospective study was to examine the potential role of cerebral hemodynamic and metabolic factors in the outcome of patients with fulminant hepatic failure (FHF). Based on the literature, a hypothetical model was proposed in which physiologic changes progress sequentially in five phases, as defined by intracranial pressure (ICP) and cerebral blood flow (CBF) measurements. Seventy-six cerebral physiologic profiles were obtained in 26 patients (2 to 5 studies each) within 6 days of FHF diagnosis. ICP was continuously measured by an extradural fiber optic monitor. Global CBF estimates were obtained by xenon clearance techniques. Jugular venous and peripheral artery catheters permitted calculation of cerebral arteriovenous oxygen differences (AVDO2), from which cerebral metabolic rate for oxygen (CMRO2) was derived. A depressed CMRO2 was found in all patients. There was no evidence of cerebral ischemia as indicated by elevated AVDO2s. Instead, over 65% of the patients revealed cerebral hyperemia. Eight of the 26 patients underwent orthotopic liver transplantation-all recovered neurologically, including 6 with elevated ICPs. Of the 18 patients receiving medical treatment only, all 7 with increased ICP died in contrast to 9 survivors whose ICP remained normal (P < 0.004). Hyperemia, per se, was not related to outcome, although it occurred more frequently at the time of ICP elevations. Six patients were studied during brain death. All 6 revealed malignant intracranial hypertension, preceded by hyperemia. In conclusion, the above findings are consistent with the hypothetical model proposed. Prospective longitudinal studies are recommended to determine the precise evolution of the pathophysiologic changes.     

Identification of skills common to renal and iliac endovascular procedures performed on a virtual reality simulator.

INTRODUCTION: There is a learning curve in the acquisition of endovascular skills for the treatment of vascular disease. Integration of Virtual reality (VR) simulator based training into the educational training curriculum offers a potential solution to overcome this learning curve. However evidence-based training curricula that define which tasks, how often and in which order they should be performed have yet to be developed. The aim of this study was to determine the nature of skills acquisition on the renal and iliac modules of a commercially-available VR simulator. METHOD: 20 surgical trainees without endovascular experience were randomised to complete eight sessions on a VR iliac (group A) or renal (group B) training module. To determine skills transferability across the two procedures, all subjects performed two further VR cases of the other procedure. Performance was recorded by the simulator for parameters such as time taken, contrast fluid usage and stent placement accuracy. RESULTS: During training, both groups demonstrated statistically significant VR learning curves: group A for procedure time (p<0.001) and stent placement accuracy (p=0.013) group B for procedure time (p<0.001), fluoroscopy time (p=0.003) and volume of contrast fluid used (p<0.001). At crossover, subjects in group B (renal trained) performed to the same level of skill on the simulated iliac task as group A. However, those in group A (iliac trained) had a significantly higher fluoroscopy time (median 118 vs 72 secs, p=0.020) when performing their first simulated renal task than for group B. CONCLUSION: Novice endovascular surgeons can significantly improve their performance of simulated procedures through repeated practice on VR simulators. Skills transfer between tasks was demonstrated but complex task training, such as selective arterial cannulation in simulators and possibly in the real world appears to involve a separate skill. It is thus suggested that a stepwise and hierarchical training curriculum is developed for acquisition of endovascular skill using VR simulation to supplement training on patients.