Pleurodesis for effusions in pediatric oncology patients at end of life

Background Pleurodesis for end-of-life care has been used in adults for decades, but little is known about the usefulness of this technique in improving the quality of care for pediatric patients. Objective To assess whether intractable pleural effusions in pediatric oncology patients at end of life could be sufficiently relieved by pleurodesis. Material and methods Eleven pleurodeses were performed with doxycycline in seven pediatric cancer patients (age 3–21 years) with intractable pleural effusions at the end of life. Five patients had unilateral pleurodeses and two had a unilateral followed by bilateral pleurodeses. Results Respiratory rates decreased in all seven patients (P = 0.016) and aeration improved significantly after chest tube placement (P = 0.033). The chest tubes were placed a median of 1 day before pleurodesis. Eight of nine chest tubes (89%) were removed before discharge at a median of 3 days after pleurodesis. Pain secondary to the pleurodesis lasted 1 day or less. Improvement in the respiratory rate remained after pleurodesis and chest tube removal (P = 0.031). Five of seven patients (70%) were able to leave the hospital to return home. The five patients discharged lived 10 to 49 days (median 19 days) after discharge. Conclusion Pediatric oncology patients with intractable effusions at end of life can have respiratory benefit from pleurodeses and, as a result, are more likely to return home for terminal care.     

Laparoscopic partial nephrectomy in obese patients: a systematic review and meta‐analysis

What's known on the subject? and What does the study add? The literature yielded only four studies on the subject; however, no clear outcome can be taken from individual studies. This review adds a meta‐analysis of these four studies to make the patient cohort larger and to allow for a greater understanding of the procedure in this select group of patients.

• ? To compare the safety and efficacy of laparoscopic partial nephrectomy (LPN) in obese and non‐obese patients.
• ? We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to November 2011), EMBASE (1980 to November 2011), CINAHL, Clinicaltrials.gov, Google Scholar, reference lists of articles and abstracts from conference proceedings without language restriction for studies comparing LPN in obese and non‐obese patients.
• ? Four observational cohort studies were included for 256 obese patients compared with 403 non‐obese patients who underwent LPN.
• ? There was no difference in operative duration (mean difference [MD] 5.64, 95% confidence interval [CI]–3.80 to 15.09), warm ischaemic time (MD –1.04, 95% CI –2.68 to 0.59), estimated blood loss (MD 53.73, 95% CI 0.72–106.74) or hospital stay (MD –0.04, 95% CI –0.30 to 0.22).
• ? There was no difference in complications in total (odds ratio [OR] 1.02, 95% CI 0.70–1.49), intraoperative complications (OR 0.68, 95% CI 0.30–1.53), or postoperative complications (OR 1.15, 95% CI 0.75–1.77).
• ? The obese group had significantly more Clavien grade III complications (OR 3.95, 95% CI 1.36–11.42), despite the low absolute incidence, with 4.3% (11/256) in the obese group vs 1.5% (6/403) in the non‐obese group.
• ? Experienced laparoscopic surgeons can safely and efficiently perform PN for obese patients with comparable results to those of non‐obese patients.
• ? The likelihood of major (Clavien Classification ≥ III) complications is higher for the obese patient.

     

Pythium insidiosum keratitis - A review

Pythium insidiosum is an oomycete and is also called “parafungus” as it closely mimics fungal keratitis. The last decade saw an unprecedented surge in Pythium keratitis cases, especially from Asia and India, probably due to growing research on the microorganism and improved diagnostic and treatment modalities. The clinical features such as subepithelial infiltrate, cotton wool-like fluffy stromal infiltrate, satellite lesions, corneal perforation, endoexudates, and anterior chamber hypopyon closely resemble fungus. The classical clinical features of Pythium that distinguish it from other microorganisms are reticular dots, tentacular projections, peripheral furrowing, and early limbal spread, which require a high index of clinical suspicion. Pythium also exhibits morphological and microbiological resemblance to fungus on routine smearing, revealing perpendicular or obtuse septate or aseptate branching hyphae. Culture on blood agar or any other nutritional agar is the gold standard for diagnosis. It grows as cream-colored white colonies with zoospores formation, further confirmed using the leaf incarnation method. Due to limited laboratory diagnostic modalities and delayed growth on culture, there was a recent shift toward various molecular diagnostic modalities such as polymerase chain reaction, confocal microscopy, ELISA, and immunodiffusion. As corneal scraping (10% KOH, Gram) reveals fungal hyphae, antifungals are started before the culture results are available. Recent in vitro molecular studies have suggested antibacterials as the first-line drugs in the form of 0.2% linezolid and 1% azithromycin. Early therapeutic keratoplasty is warranted in nonresolving cases. This review aims to describe the epidemiology, clinical features, laboratory and molecular diagnosis, and treatment of Pythium insidiosum keratitis.     

Interocular transfer of orientation-specific fMRI adaptation reveals amblyopia-related deficits in humans

We devised an experimental strategy for assessing the cortical cross-talk between ocular subsystems. For this purpose we measured the interocular transfer of adaptation (IOTA) at different levels in the human brain, using orientation-selective fMRI adaptation. We tested 10 normally sighted and 10 stereoblind or stereodeficient amblyopic observers by adapting monocularly to phase-reversing, oblique sinusoidal gratings. Following monocular adaptation, cortical activations evoked by the same (monoptic) or the other eye (interocular) were measured for the same and for the orthogonal orientation in a two by two factorial design. In both experimental groups, we obtained significant orientation-selective monocular adaptation in area V1 and in extrastriate regions on the dorsal and ventral visual pathways. In the normally-sighted subjects we found in addition interocular adaptation in V1 and extrastriate visual areas. This interocular adaptation indicates that fMRI adaptation transfers from the adapted ocular subsystem to the non-adapted ocular subsystem, and thus provides a measure of binocular interaction in normally-sighted subjects. In the amblyopic subjects, no interocular adaptation was seen at any of the investigated cortical levels, regardless of which eye was adapted. We suggest that the abnormal pattern of interocular transfer of fMRI adaptation is related to the disturbed integration of binocular signals in amblyopia.     

Fascicular multiple ocular motor nerve paresis as first presentation of anaplastic astrocytoma

A case of spontaneous, painless partial III (pupil-sparing) and IV fascicular nerve paresis as the first presentation of anaplastic astrocytoma is reported. The other ocular, neurological and systemic examination was within normal limits. The literature and possible anatomical location of this atypical presentation is reviewed.     

Isolation and antimicrobial susceptibility pattern of Nocardia among people with culture-proven ocular infections attending a tertiary care eye hospital in Tamilnadu, South India

AIMS: To evaluate the epidemiology, microbiological features, as well as antibiotic susceptibility patterns of Nocardiafrom cases with ocular nocardial infections seen over a period of 8 years in a tertiary eye care hospital. METHODS: Microbiology records of 164 cases of culture-proven ocular nocardial infection diagnosed between March 1997 and February 2005 were reviewed retrospectively. The outcome data included isolation rate, predisposing factors, demography (age and sex), and category of infection, utility of conventional diagnostic methods, microbiological profile, and antibiogram-resistogram patterns. Results: A total of 164 (3.1%) Nocardiaspecies were identified among 5378 culture-proven cases. Ninety-six (58.5%) isolates were from corneal scrapings followed by vitreous biopsy (17.0%). Most (58.0%) of the cases were between 51 and 80 age groups. Male preponderance was obvious. All the 164 (100%) nocardial infections were identified by culture. Of 125 ocular specimens subjected to Gram's staining, nocaridal filaments were identified in 70 (56%) specimens. In addition to KOH mounting, modified AFB staining was also found to be helpful. Upon in vitrosusceptibility testing, 98.7 and 90.2% of nocardial isolates showed sensitivity towards amikacin and ciprofloxacin, respectively. Conclusions: Ocular nocardiosis is relatively rare among ocular infections. Amikacin and ciprofloxacin are highly effective in treating ocular nocardiasis. Prompt and accurate microbiological diagnosis and early administration of these antibiotics may have a positive effect on the ocular outcome as well as in controlling nocardial prevalence.     

Achieving asepsis of banana leaves for the management of toxic epidermal necrolysis

BACKGROUND: Banana leaf is used in many centers in India during the care of patients with toxic epidermal necrolysis (TEN) and other extensive blistering disorders. Sepsis is an important cause of death in TEN patients and use of banana leaf may be a source of such infection. AIMS: We conducted this study to detect the bacterial flora of the banana leaf and to examine various methods of rendering the leaf aseptic. METHODS: Five pieces of banana leaf, 2 x 2 cm in size, were cultured separately in blood agar as follows: One piece was heated over a flame and one was soaked in boiling water and one was autoclaved. Methylated spirit was applied over one piece and ignited. One piece was placed on the media, 'as is.' The Petri dishes were incubated examined after 48 h. RESULTS: All the pieces except the autoclaved specimen of the leaf grew coagulase-negative staphylococci (CONS) when aseptic precautions were not maintained and aerobic spore bearers when all aseptic measures were subsequently instituted during the procedure. CONCLUSION: We recommend measures to prevent possible transmission of bacterial infection by the leaf. Autoclaved and aseptically handled banana leaves may be used to reduce chance of infection in the treatment of TEN.