Babesiosis: An unusual cause of sepsis after kidney transplantation and review of the literature

We report a unique case of babesiosis presenting as sepsis after kidney transplantation. A 70‐year‐old female kidney transplant recipient presented with fever, hemolytic anemia, and acute kidney injury, and met three of four systemic inflammatory response syndrome criteria. Serology was positive for Babesia microti, confirmed by polymerase chain reaction. The patient was treated with atovaquone and azithromycin and made a full recovery. Reports of babesiosis after solid organ transplantation are rare, with only four prior cases reported in the literature. We report the first case of babesiosis, to our knowledge, presenting as sepsis that was successfully treated after solid organ transplantation.     

Use of tissue expansion to facilitate liver and small bowel transplant in young children with contracted abdominal cavities

Liver and small bowel transplant is an established treatment for infants with IFALD. Despite organ reduction techniques, mortality on the waiting list remains high due to shortage of size‐matched pediatric donors. Small abdominal cavity volume due to previous intestinal resection poses a significant challenge to achieve abdominal closure post‐transplant. Seven children underwent tissue expansion of abdominal skin prior to multiorgan transplant. In total, 17 tissue expanders were placed subcutaneously in seven children. All seven subjects underwent re‐exploration to deal with complications: hematoma, extrusion, infection, or port related. Three expanders had to be removed. Four children went on to have successful combined liver and small bowel transplant. Two children died on the waiting list of causes not related to the expander and one child died from sepsis attributed to an infected expander. Tissue expansion can generate skin to facilitate closure of abdomen post‐transplant, thus allowing infants with small abdominal volumes to be considered for transplant surgery. Tissue expansion in children with end‐stage liver disease and portal hypertension is associated with a very high complication rate and needs to be closely monitored during the expansion process.     

Lot quality assurance sampling (LQAS) for monitoring leprosy elimination in an endemic district in Tamilnadu

This paper examines whether the health administration can use lot quality assurance sampling (LQAS) for identifying high prevalence areas for leprosy for initiating necessary corrective measures. The null hypothesis was that leprosy prevalence in the district was at or above ten per 10,000 and the alternative hypothesis was that it was at or below five per 10,000. A total of 25,500 individuals were to be examined with 17 as an acceptable maximum number of cases (critical value). Two-stage cluster sample design was adopted. The sample size need not be escalated as the estimated design effect was 1. During the first phase, the survey covered a population of 4,837 individuals out of whom 4,329 (89.5%) were examined. Thirty-five cases were detected and this number far exceeded the critical value. It was concluded that leprosy prevalence in the district should be regarded as having prevalence of more than ten per 10,000 and further examination of the population in the sample was discontinued. LQAS may be used as a tool by which one can identify high prevalence districts and target them for necessary strengthening of the programme. It may also be considered for certifying elimination achievement for a given area.     

Risk Factors for Severe Retinopathy of Prematurity in Preterm Low Birth Weight Neonates

Objective  

To evaluate the risk factors predisposing to severe retinopathy of prematurity (ROP) in a level III neonatal unit. This retrospective study was conducted in a tertiary care neonatal and ophthalmic center.     

Formalin-induced cataract in goat eyes as a surgical training model for phacoemulsification

We compared 2 techniques of inducing cataract in enucleated goat eyes as a training model for phacoemulsification. The cataract was induced using 0.2 to 0.5 mL of formalin 20%. In 10 eyes, formalin was injected through a clear corneal side port into the nucleus after capsulorhexis and in 10 eyes, through the pars plana before capsulorhexis. The pars plana technique achieved a cataract of different grades of nuclear hardness with the added advantage of anterior capsule elasticity closely simulating that of senile cataract but without compromising corneal clarity.     

Determination of a reference interval in a population

The reference interval is the most widely used medical decision-making tool that separates healthy from diseased individuals. We briefly discuss the methods used to determine reference interval and its limitations.     

Improved outcome of referrals for intestinal transplantation in the UK

Aim

To describe the outcome of children with intestinal failure referred to Birmingham Children''s Hospital (BCH) for consideration of intestinal transplantation (ITx), to determine factors for an adverse outcome and to analyse the impact of post‐1998 strategies on survival.

Subjects and methods

A retrospective analysis was performed of children referred for ITx assessment from January 1989 to December 2003. Children were assessed by a multidisciplinary team and categorised into: (a) stable on parenteral nutrition; (b) unsuitable for transplantation (Tx); and (c) recommended for Tx. To analyse the impact of the post‐1998 strategies on survival, a comparison was made between the two eras (pre‐1998 and post‐1998).

Results

152 children with chronic intestinal failure were identified (63M:89F, median age 10 months (range 1–170)). After assessment, 69 children were considered stable on parenteral nutrition (5‐year survival 95%); 28 children were unsuitable for Tx (5‐year survival 4%); and 55 children were recommended for Tx (5‐year survival 35%, which includes 14 children who died waiting for size‐matched organs). Twenty three ITx and nine isolated liver transplants (iLTx) were performed. In a multivariate analysis, the following factors in combination had an adverse effect on survival: the presence of a primary mucosal disorder (p = 0.007, OR ratio 3.16, 95% CI 1.37 to 7.31); absence of involvement of a nutritional care team at the referring hospital (p = 0.001, OR ratio 2.55, 95% CI 1.44 to 4.52); and a serum bilirubin>100 µmol/l (p = 0.001, OR ratio 3.70, 95% CI 1.84 to 7.47). Earlier referral (median serum bilirubin 78 µmol/l in the post‐1998 era compared with 237 µmol/l in the pre‐1998 era, p = 0.001) may be a contributory factor to improved survival. The strategies of combined en bloc reduced liver/small bowel transplantation and iLTx resulted in fewer deaths on the waiting list in the post‐1998 era (2 deaths in post‐1998 era v 12 deaths in pre‐1998 era). The overall 3‐year survival in the post‐1998 era (69%) has improved compared with the pre‐1998 era (31%; p<0.001)

Conclusion

The changing characteristics at the time of referral, including earlier referral and innovative surgical strategies have resulted in improved long‐term survival of children referred for ITx.Intestinal failure is defined as a condition in which intestinal nutrient absorption is inadequate to sustain life and to support growth without intravenous nutritional supplementation.¹ The prevalence has increased from 2–3 per million to 5–6 per million of the population, as a result of improved survival in the newborn period.² There are three main causes of long‐term intestinal failure: (1) short bowel syndrome (SBS), usually occurring after extensive neonatal surgical resection for necrotising enterocolitis, small bowel atresia and gastroschisis; (2) motility disorders, for example Hirschprung''s disease, pseudo‐obstruction; and (3) primary mucosal disorders, for example microvillous inclusion disease, tufting enteropathy.From the 1970s successful developments in parenteral nutrition and in central venous catheter placement made it possible to maintain children with intestinal failure in a satisfactory nutritional state for many years.^3,4 However, the long‐term use of parenteral nutrition is associated with life‐threatening complications: liver disease, recurrent septicaemia, and thromboses resulting in difficult venous access.⁴ Intestinal transplantation has evolved from an innovative procedure in the late 1980s to a technically feasible option in the late 1990s⁵ and around 1300 intestinal transplants have now been performed worldwide.⁶ Moreover, non‐transplant surgery (for example, bowel lengthening or plication procedures) may be a treatment option in selected patients.⁷ In patients with SBS who develop severe liver disease, isolated liver transplantation may be an option if there is a realistic likelihood of eventual successful intestinal adaptation and recovery from intestinal failure.⁸ Thus, there are various possible treatment options for children with intestinal failure and choosing the best strategy for individual cases poses a major clinical challenge.Children who have developed complications associated with intestinal failure in the UK have been referred to the intestinal transplant program at Birmingham Children''s Hospital (BCH) since 1989, and the first intestinal transplant was performed in 1993. This centre was officially designated as the sole UK centre for paediatric small bowel transplantation in 1997. An earlier analysis of our experience between 1989 and 1997 indicated a poor survival rate (31%). At that time many referred patients were already seriously ill and many died awaiting transplantation (69%). For this reason, several new treatment strategies were implemented in 1998: combined reduced en bloc liver and small bowel transplantation; isolated liver transplantation for selected patients for short bowel syndrome; and non‐transplant surgery for selected patients of short bowel syndrome with dilated dysmotile loops of bowel. The aim of this study was to describe the outcome of children with intestinal failure referred to our centre, to determine risk factors for adverse outcome and analyse the impact of the new strategies implemented since 1998 onwards.     

Sexually transmitted infections and sexual practices in injection drug users and their regular sex partners in Chennai, India

OBJECTIVE: Measuring sexually transmitted infections (STIs) and sexual practices in injection drug users (IDUs) and their regular sex partners. GOAL: Informing HIV intervention programs. DESIGN: Cross-sectional. RESULTS: One percent IDUs and 2% of their regular female sex partners were syphilis infected; 40% (84/211) and 38% respectively (81/211) were infected with HSV-2. 30% IDUs and 5% of their female regular sex partners were HIV positive. Serodiscordant results for syphilis and HSV-2 were noticed. Women having first sex at ageor=38 years had seven times the odds of having any non-HIV-STI. CONCLUSION: Reaching out to IDUs and their female regular sex partners with modified STI management guideline and promoting women-controlled safer sex measures are needed harm-reduction measures.