Gyan Chand

Changing microbiological profile of pathogenic bacteria in diabetic foot infections: time for a rethink on which empirical therapy to choose?

Aims/hypothesisWe studied the bacterial aetiology and antibiotic sensitivity pattern of diabetic foot ulcers in India.MethodsRecords of 447 hospitalised patients between 1991 and 2008 were retrospectively analysed between two time periods (before and after 1999) to compare bacterial aetiology and antimicrobial sensitivity patterns. The first three consecutive cultures from the same wound during treatment were evaluated.ResultsOf 1,632 cultures, 66% were polymicrobial, 23% monomicrobial and 11% sterile. In the monomicrobial group, 14% (n = 228) of cultures were Gram-negative, whereas 9% (n = 147) were Gram-positive. The most common pathogens in the first culture were Pseudomonas aeruginosa (20.1%), Staphylococcus aureus (17.2%) and Escherichia coli (16.3%). Results for the third cultures showed persistence of P. aeruginosa (15.3%) and E. coli (14.2%). Gram-negative isolates dominated over Gram-positive ones (25.3% vs 15.1%, p < 0.05). Antibiotic sensitivity patterns before and after 1999 were: piperacillin–tazobactam 74% vs 66% (p < 0.005), imipenem 77% vs 85% (NS), cefoperazone–sulbactam 47% vs 44% (p < 0.005), amikacin 62% vs 78% (NS), ceftriaxone 41% vs 36% (p < 0.005), amoxicillin–clavulanate 51% vs 43% (p < 0.05) and clindamycin 43% vs 36% (p < 0.005), respectively.Conclusions/interpretationUnlike in the West, in India Gram-negative bacteria were found to have always been dominant in the wounds of patients with diabetic foot infections. Infection with polymicrobial multidrug-resistant Gram-negative bacilli is common. The policy of empirical antimicrobial therapy at tertiary care needs to be changed.

Cardiovascular dysfunction and catecholamine cardiomyopathy in pheochromocytoma patients and their reversal following surgical cure: results of a prospective case-control study.

BACKGROUND Cardiovascular (CV) dysfunction and cardiomyopathy can cause perioperative morbidity in pheochromocytoma patients, but have not been studied systematically. This prospective, case-control study evaluated nature and extent of CV dysfunctions and their reversal following curative pheochromocytoma surgery. METHODS Thirty-five pheochromocytoma patients, 9 normotensive nonpheochromocytoma adrenal tumors and 10 essential hypertensives were evaluated with 2-dimensional echocardiography, tissue Doppler, and serum N-terminal pro-brain natriuretic peptide (s-NTpro-BNP, a sensitive myocardial damage biomarker) serially before and after treatment. RESULTS Pheochromocytoma patients had systolic and diastolic dysfunction, reduced left ventricular (LV) ejection fraction (EF), increased LV end-diastolic and systolic dimensions and volumes, myocardial performance index, and decreased transmitral early/late velocity ratio, which were worse compared with controls. All indices improved significantly with α-blockade and after pheochromocytoma resection, and normalized over 3-6 months. Tissue Doppler early velocity was lower (P = .04) and s-NT-proBNP higher (P = .0001) in pheochromocytoma patients compared with controls. Seven pheochromocytoma patients (20%) had significant LV dysfunction (LVEF <45%; s-NTpro-BNP levels >500 pg/mL) and had more marked postoperative improvement. CONCLUSION Global LV diastolic and systolic dysfunctions specific to pheochromocytoma are common and improve early postoperatively, with sustained improvement upon follow-up. Detailed cardiac evaluation with echocardiography, tissue Doppler, and s-NTpro-BNP may help to reduce perioperative morbidity and monitor recovery in pheochromocytoma patients.

Cardiovascular dysfunction in symptomatic primary hyperparathyroidism and its reversal after curative parathyroidectomy: Results of a prospective case control study

BACKGROUND Cardiovascular mortality in primary hyperparathyroidism (PHPT) is attributed to myocardial and endothelial dysfunction. In this prospective, case-control study we assessed cardiovascular dysfunction in patients with symptomatic PHPT and its reversal after successful parathyroidectomy. METHODS Fifty-six patients with symptomatic PHPT underwent two-dimensional echocardiography, tissue Doppler (diastolic function assessment), serum N-terminal pro-brain natriuretic peptide (s-NTproBNP, a myocardial damage marker), and endothelial- and smooth muscle-dependent vasodilatory response (vascular dysfunction) studies before, 3, and 6 months after parathyroidectomy; 25 age-matched controls were studied similarly. RESULTS Patients had greater left ventricular mass (192 ± 70 vs. 149 ± 44 g; P = .006), interventricular septal thickness (10.8 ± 2.5 vs. 9.0 ± 1.6 mm; P = .001), posterior wall thickness (9.9 ± 2.0 vs. 8.6 ± 2.2 mm; P = .004), and diastolic dysfunction (lower E/A trans-mitral flow velocity ratio [1.0 ± 0.4 vs. 1.3 ± 0.4; P = .01). Patients had greater s-NTproBNP (4,625 ± 1,130 vs. 58 ± 49 pg/mL; P = .002) and lower endothelial-mediated vasodilation (9.3 ± 8.6 vs. 11.7 ± 6.3%; P = .03) and smooth muscle-mediated vasodilation (20.1 ± 17.9 vs. 23.8 ± 11.2%; P = .01). Improvements in left ventricular mass, systolic and diastolic function, and smooth muscle-mediated vasodilation were noted from 3 to 6 months after parathyroidectomy. Endothelial-mediated vasodilation did not improve significantly. S-NTproBNP levels mirrored echocardiographic changes with a substantial, sustained decrease. Results were similar in hypertensive and normotensive patients. CONCLUSION Symptomatic PHPT patients have substantial cardiac and vascular dysfunction, which improve by 6 months after parathyroidectomy. Objective cardiovascular evaluation may improve outcomes in symptomatic PHPT patients.

Primary hyperparathyroidism presenting as hypercalcemic crisis: Twenty-year experience

Context: To study hyperparathyroid-induced hypercalcemic crisis (HIHC). Aims: We see very advanced cases of primary hyperparathyroidism (PHPT) and therefore, we sought to determine the incidence of HIHC in our surgically-treated PHPT patients, clinical presentation, and short- and long-term results with the use of bisphosphonate therapy and expeditious parathyroidectomy over a 20-year period at a single institution. Settings and Design: Retrospective review of PHPT patients at Department of Endocrine Surgery, a tertiary care referral center. Materials and Methods: Retrospective review of 177 patients of advanced PHPT who underwent parathyroidectomy at a single institution from 1989 to 2010. All patients with serum calcium ≥14 mg/dl (≥3.5 mmol/l) were included in HIHC group. Statistical Analysis: Analysis of variance (ANOVA) was used to determine differences between groups. Data is expressed as mean ± standard error of the mean (SEM); P values less than 0.05 were considered significant. Results: We observed a higher incidence of HIHC (n = 37, 21%) with higher incidence of pancreatitis (n = 5, 13.5%). Crisis patients had heavier (6,717 mg) glands. Use of bisphosphonate therapy in seven crisis patients resulted in quicker lowering of serum calcium (mean: 4.5 vs 14.6 days in other crisis patients, P = 0.027) permitting early surgery. The incidence of postoperative hypocalcemia was not higher in these patients. Although the parathyroid adenoma was common pathology in both the groups, the incidence of parathyroid carcinoma was higher in crisis group (10.8%). Outcome with regards to postoperative eucalcemia was similar in both groups. Conclusions: Crisis patients are at risk of developing pancreatitis. Bisphosphonate therapy has the potential to quickly lower the serum calcium permitting early surgery without added risk of postoperative hypocalcemia. Successful and sustained eucalcemia with excellent long-term survival is possible with use of bisphosphonates and semi-emergent, focused parathyroidectmy.

Intra‐operative parathyroid hormone kinetics and influencing factors with high baseline PTH: a prospective study

Intra‐operative parathyroid hormone (IOPTH) kinetics and therefore the efficacy of IOPTH utilization as a predictor of cure are likely to be affected by baseline IOPTH levels, vitamin D deficiency and parathyroid weight.

Posterior Retroperitoneoscopic Adrenalectomy for Clinical and Subclinical Cushing’s Syndrome: Letter

We read with interest the article by Alesina et al. [1] and we congratulate the authors for their contribution to the of management of Cushing’s syndrome, which is frequently encountered by endocrine surgeons. Because of severe obesity and associated co-morbid conditions, surgical excision of tumor by the conventional transperitoneal procedure, via either the open or laparoscopic approach, has always been challenging. A direct approach leading to the tumor has always been desirable. To gain a full understanding of the study of Alesina et al., we would like to know how many of their patients were morbidly obese and what their experience was in the management of such patients [2]. Second, because the chance of malignancy is much higher in patients with adrenal tumors C6 cm [3], and because of limited intraoperative exposure and inability to inspect the liver and peritoneal surfaces, the transperitoneal approach is preferred over the retroperitoneal approach in suspected adrenal malignancy [4, 5], we would like to know how many of their patients had tumors C6 cm on preoperative imaging, and what their strategy was in removing these tumors.

Effect of Preoperative Nerve Block on Postthyroidectomy Headache and Cervical Pain: A Randomized Prospective Study

The aim of the current study was to investigate the efficacy of greater occipital nerve (GON) block and bilateral superficial cervical plexuses (BSCP) blocks in alleviating postoperative occipital headache and posterior neck pain after thyroidectomy. This randomized prospective study consisted of 75 women undergoing total thyroidectomy. Patients were randomized into three groups: Group I (n = 25): patients receiving GON, Group II (n = 25): patients receiving bilateral (BSCP) blocks, and Group III (n = 25): patients receiving no block. Assessment of occipital headache, posterior neck, and incision site pains was made at 12 hours and 24 hours after extubation by Visual Analogue Scale (VAS). In comparison to Group III significantly fewer patients in Groups I and II experienced occipital headache at 12 (p = 0.006) and 24 hours (p = 0.005) and also posterior neck pain at 24 hours (p = 0.003). Mean VAS scores at 12 and 24 hours for occipital headache (p = 0.003 and p = 0.041) and posterior neck pain (p = 0.015 and p = 0.008) were significantly lower in Group I. The differences between Groups II and III were not significant except for the occipital headache at 12 hours. The efficacy of GON block is superior to BSCP blocks in alleviating postthyroidectomy occipital headache and posterior cervical pain.

Role of Telemedicine Technology in Endocrine Surgery Knowledge Sharing

INTRODUCTION This retrospective study was designed to assess the outcome of telemedicine technology supportive of educational collaboration among endocrine surgery peers and its impact on knowledge and skill development. MATERIALS AND METHODS The study was carried out in the Department of Endocrine Surgery in collaboration with School of Telemedicine and Biomedical Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, during October 1999-December 2012. Telemedicine activities were divided into various modules (e.g., case/problem-based learning, clinical grand rounds, postgraduate course/continuing medical education/conference). Endocrine surgeons participating in such sessions were divided into two groups (faculty and residents). A multimodule questionnaire was constructed based on a Likert scale (2-7 points) to test various aspects (e.g., technical performance, role in knowledge exchange, skill development, level of satisfaction, and future recommendations). Responses were expressed in proportions, and the chi-squared test was used to find the differences in opinions of the study groups. RESULTS The questionnaire was sent to 38 surgeons, of whom 36 replied (response rate, 94.74%); of these respondents, 14 were faculty and 22 were residents. More than 80% of participants felt that the technology helped in learning new things and strengthening relations with peers, whereas >90% were of the view that it helped in knowledge exchange and development of skills as well as was helpful in supporting clinical decisions. More than 90% of participants were satisfied and enjoyed using this technology and also were of the opinion that the technology should be integrated into other specialties. Satisfaction with the technology was excellent to good for 94.44% of participants. Both faculty and residents were of the same opinion, and there was no significant difference in their replies. CONCLUSIONS Knowledge sharing in a collaborative environment using telemedicine technology has been found successful in a low-resource setting and is now adopted in the departmental educational program.

Microfilaria in Association with Adrenal Lymphoma Diagnosed on Cytology: An Extremely Rare Case Report Sitoloji ile Tani Konan Adrenal Lenfomayla İlişkili Mikrofilaria: Çok Ender Görülen Bir Olgu Sunumu

ABSTRACT Filariasis is a common public health problem in Asian countries. In this report, the authors have described detection of microfilaria in the cytological specimen of adrenal lymphoma. To the best of our knowledge, this is the first reported case in the literature where microfilaria was seen in an adrenal gland involved by lymphoma. The literature is briefly reviewed. ÖZ Filariasis Asya ülkelerinde sık görülen bir halk sağlığı problemidir. Bu raporda yazarlar adrenal lenfoma sitolojik örneği içinde mikrofilaria saptanmasını tanımlamaktadır. Bildiğimiz kadarıyla bu vaka sunumu literatürde adrenal bezde lenfoma tutulumu ile birlikte görülen ilk mikrofilaria vakasıdır. Literatür kısaca gözden geçirilmektedir.

Effectiveness and Mechanism of Preoperative Lugol Solution for Reducing Thyroid Blood Flow in Patients with Euthyroid Graves’ Disease

To the Editor, We read with interest the article ‘‘Effectiveness and Mechanism of Preoperative Lugol Solution for Reducing Thyroid Blood Flow in Patients with Euthyroid Graves’ Disease’’ authored by Shih-Ming Huang et al. [1]. This prospective study emphasised the role and mechanism of lugol iodine in reducing vascularity of thyroid gland in euthyroid Graves’ disease which resulted in reducing the vascularity of the thyroid gland pre-operatively and thereby enabling safe thyroidectomy, as highly vascular glands with high blood flow are associated with increased operative blood loss and increased incidence of complications [2]. We also congratulate the authors for incorporating the markers VEGF and IL-16 and thereby making it clear with evidence the efficacy of lugol’s iodine. We have few queries which may interest future readers. Did the severity of Graves’ disease in terms of percentage of patients with ophthalmopathy, mean doses of antithyroid drugs required, mean thyroid gland weight affect the reduction in vascularity? Did the authors perform subgroup analysis and did they find whether only a subset require lugol’s iodine? The study has shown that pre-operative treatment with lugol solution reduces blood flow to thyroid, whether it translated into significant difference in intraoperative blood loss between the lugol-administered and lugol not-administered group? Further in the study by Erbil et al., there was a significant reduction in intraoperative blood loss between the two groups [3]. It would be highly appreciative if the authors could mention if there were any complications or untoward incidents due to lugol iodine administration.