Fungal Planet description sheets: 558-624.

Novel species of fungi described in this study include those from various countries as follows: Australia: Banksiophoma australiensis (incl. Banksiophoma gen. nov.) on Banksia coccinea, Davidiellomycesaustraliensis (incl. Davidiellomyces gen. nov.) on Cyperaceae, Didymocyrtis banksiae on Banksia sessilis var. cygnorum, Disculoides calophyllae on Corymbia calophylla, Harknessia banksiae on Banksia sessilis, Harknessia banksiae-repens on Banksia repens, Harknessia banksiigena on Banksia sessilis var. cygnorum, Harknessia communis on Podocarpus sp., Harknessia platyphyllae on Eucalyptus platyphylla, Myrtacremonium eucalypti (incl. Myrtacremonium gen. nov.) on Eucalyptus globulus, Myrtapenidiella balenae on Eucalyptus sp., Myrtapenidiella eucalyptigena on Eucalyptus sp., Myrtapenidiella pleurocarpae on Eucalyptuspleurocarpa, Paraconiothyrium hakeae on Hakea sp., Paraphaeosphaeria xanthorrhoeae on Xanthorrhoea sp., Parateratosphaeria stirlingiae on Stirlingia sp., Perthomyces podocarpi (incl. Perthomyces gen. nov.) on Podocarpus sp., Readeriella ellipsoidea on Eucalyptus sp., Rosellinia australiensis on Banksia grandis, Tiarosporella corymbiae on Corymbia calophylla, Verrucoconiothyriumeucalyptigenum on Eucalyptus sp., Zasmidium commune on Xanthorrhoea sp., and Zasmidium podocarpi on Podocarpus sp. Brazil: Cyathus aurantogriseocarpus on decaying wood, Perenniporia brasiliensis on decayed wood, Perenniporia paraguyanensis on decayed wood, and Pseudocercospora leandrae-fragilis on Leandrafragilis.Chile: Phialocephala cladophialophoroides on human toe nail. Costa Rica: Psathyrella striatoannulata from soil. Czech Republic: Myotisia cremea (incl. Myotisia gen. nov.) on bat droppings. Ecuador: Humidicutis dictiocephala from soil, Hygrocybe macrosiparia from soil, Hygrocybe sangayensis from soil, and Polycephalomyces onorei on stem of Etlingera sp. France: Westerdykella centenaria from soil. Hungary: Tuber magentipunctatum from soil. India: Ganoderma mizoramense on decaying wood, Hodophilus indicus from soil, Keratinophyton turgidum in soil, and Russula arunii on Pterigota alata.Italy: Rhodocybe matesina from soil. Malaysia: Apoharknessia eucalyptorum, Harknessia malayensis, Harknessia pellitae, and Peyronellaea eucalypti on Eucalyptus pellita, Lectera capsici on Capsicum annuum, and Wallrothiella gmelinae on Gmelina arborea.Morocco: Neocordana musigena on Musa sp. New Zealand: Candida rongomai-pounamu on agaric mushroom surface, Candida vespimorsuum on cup fungus surface, Cylindrocladiella vitis on Vitis vinifera, Foliocryphia eucalyptorum on Eucalyptus sp., Ramularia vacciniicola on Vaccinium sp., and Rhodotorula ngohengohe on bird feather surface. Poland: Tolypocladium fumosum on a caterpillar case of unidentified Lepidoptera.Russia: Pholiotina longistipitata among moss. Spain: Coprinopsis pseudomarcescibilis from soil, Eremiomyces innocentii from soil, Gyroporus pseudocyanescens in humus, Inocybe parvicystis in humus, and Penicillium parvofructum from soil. Unknown origin: Paraphoma rhaphiolepidis on Rhaphiolepsis indica.USA: Acidiella americana from wall of a cooling tower, Neodactylaria obpyriformis (incl. Neodactylaria gen. nov.) from human bronchoalveolar lavage, and Saksenaea loutrophoriformis from human eye. Vietnam: Phytophthora mekongensis from Citrus grandis, and Phytophthora prodigiosa from Citrus grandis. Morphological and culture characteristics along with DNA barcodes are provided.

Drug-aggravated Bullous Pemphigoid in a 47-year-old Asian Woman - A Case Report.

INTRODUCTION: Bullous pemphigoid is the most common chronic recurrent autoimmune subepidermal blistering disorder most prevalent in the geriatric population. It varies widely in clinical presentation ranging from tense bullae to intense generalized pruritus. It is immunologic in origin with the presence of IgG antibodies. CASE REPORT: A 47-year-old female presented to the hospital with complaints of blisters in the lower limbs, which she self managed with neem oil, after which the blisters occurred over the body. The patient also experienced blisters over both upper and lower limbs, gluteal region, painful generalized ulcers, necrotic patches, multiple erythematous blisters, ulcer erosions over bilateral legs and upper limbs with few lesions, which were foul-smelling and oozing. On the second day of admission, the patient's CRP and ESR levels were tested and the levels were 33.5 and 35 mm/hr, respectively. The patient was treated with an injection of meropenem 1 g three times daily, dexamethasone 4 mg once daily, and ofloxacin 400 mg once daily. On the third day of admission, the patient complained of leg swelling, and subsequently, D-Dimer levels were checked, which showed a value of 5,740 and was treated with an injection of enoxaparin 40 mg for the same throughout the course of the hospital stay A skin biopsy confirmed the diagnosis of bullous pemphigoid. The culture test showed the growth of Klebsiella pneumonia and Acinetobacter baumani, which were resistant to most of the antibiotics. The patient was managed appropriately with modalities including antibiotics, anti-inflammatory agents, immunosuppressants, multivitamins, fluids, and albumin. The patient responded well to the treatment without new lesions or fever spikes. There was the presence of necrotic patches of old lesions alone at the time of discharge. CONCLUSION: This case report was done with the purpose of presenting an exemplary case of bullous pemphigoid aggravated by the application of neem oil and emphasizing the inappropriate use of folk medicine in an autoimmune disease like bullous pemphigoid.

Nocardia nova mycetoma over forehead in a lepromatous leprosy patient.

We present a case of a 31-year-old male, a known patient with lepromatous leprosy with a type 2 lepra reaction, who presented with a slowly growing asymptomatic swelling with multiple discharging sinuses over the forehead that developed over 6 months. Smears of the serosanguinous discharge on Gram staining showed Gram-positive branching filamentous bacilli, which on culture on blood agar showed chalky-white colonies. Histology of the lesion showed suppurative granulomas with polymorphs surrounding characteristic grains. The isolate was identified as Nocardia nova by gene sequencing and the patient was started on combined antibiotic therapy that resulted in complete resolution of the infection in six months. To the best of our knowledge, this is the first report of mycetoma related to Nocardia nova in association with leprosy.

Sudden vision loss caused by rhino-orbital zygomycosis in diabetic patients: case series.

Rhino-orbital zygomycosis is a life-threatening fungal infection generally occurring in patients with an underlying disorder, such as diabetes mellitus with ketoacidosis or with immunocompromising factors, although it may rarely appear in healthy individuals. The study has been undertaken to discuss the clinical presentation, pathogenesis, diagnostic work up and management of this rapidly progressive disease. Four male patients having uncontrolled diabetes and presenting with signs and symptoms of rhino-orbital zygomycosis were studied to illustrate the serious nature of the disease. All the four patients had rapidly deteriorating vision loss either unilateral or bilateral along with other nasal and orbital signs and symptoms. All the patients were put on liposomal amphotericin B and underwent orbital exenteration and pansinusectomy. One patient died, while the other three were successfully treated. Early diagnosis is critical in the prevention of morbidity and mortality associated with the disease. There is need for a high index of clinical suspicion in immunocompromised patients. Timely medical-surgical treatment proves extremely important for prognosis.

Subcutaneous phaeohyphomycotic cyst caused by Pyrenochaeta romeroi.

Pyrenochaeta romeroi is a rare agent of chronic, suppurative subcutaneous infections which ultimately lead to mycetoma. It has only rarely been reported from deep, non-mycetomatous infections. We describe a case of a subcutaneous phaeohyphomycotic cyst in a 45-year-old Indian female who suffered from verrucous plaque and a swelling (30 mm in diameter) on the right forearm that gradually increased in size over a period of 3 months. Direct microscopic examination with 10% KOH and histopathological investigation of exudates revealed septate hyphae without granules, the hallmark of mycetoma. The lesion appeared to be a subcutaneous phaeohyphomycotic cyst caused by P. romeroi. The suspected agent was recovered in culture, identified on the basis of morphologic features and its identification confirmed by sequencing of the internal transcribed spacer regions of rDNA. Treatment consisted of surgical excising of the cyst without any antifungal therapy. There was no relapse during a one-year follow-up and the patient was successfully cured. In vitro antifungal susceptibility tests demonstrated that itraconazole (0.5 microg/ml), isavuconazole (0.125 microg/ml) and posaconazole (0.5 microg/ml) had potent activity against this isolate of P. romeroi. High MICs were found with amphotericin B (4 microg/ml), fluconazole (>64 microg/ ml), voriconazole (4 microg/ml) and caspofungin (8 microg/ml). However, their clinical effectiveness in the treatment of P. romeroi infections remains to be evaluated.

Primary cutaneous zygomycosis from a tertiary care centre in north-west India.

BACKGROUND & OBJECTIVES: Zygomycosis is highly invasive fungal infection, with high mortality rate. In most of patients, diabetes mellitus is an underlying factor but in primary cutaneous zygomycosis, presentation may be different. Here we present the description of clinical presentation, fungi isolated and management of cases with cutaneous zygomycosis seen in a tertiary care hospital in north India during 2001-2007. METHODS: All patients diagnosed with primary cutaneous zygomycosis between November 2001 and September 2007 presenting with clinical diagnosis of necrotizing fasciitis were included. Detailed history of each patient was taken, clinical presentation, site of involvement, underlying illness and risk factor, if any were noted. The diagnosis was established by direct microscopic evidence of broad, aseptate or sparsely septate ribbon-like hyphae with right angle branching in KOH wet mount and histopathological examination of stained sections. Cultures were put up for fungal isolation and species identification. Outcome of the therapy was analysed. RESULTS: Of the nine patients reviewed, only one had diabetes mellitus. Commonest risk factor was injection abscess (33.3%). Apophysomyces elegans was isolated in four cases, Saksenaea vasiformis and Absidia corymbifera in one each. The fungal culture was sterile in three cases. Mortality rate was high with only four patients responded well to surgical and/or medical therapy. INTERPRETATION & CONCLUSION: Primary cutaneous zygomycosis appears to be on rise in India that calls for high index of clinical suspicion and an early biopsy of the affected area for timely diagnosis. The standard treatment is a combination of amphotericin B therapy, surgical debridement, and reversal of the underlying disease or immunosuppression.

Inducible clindamycin resistance in Staphylococcus aureus: a study from North India.

BACKGROUND: The resistance to antimicrobial agents among Staphylococci is an increasing problem. The resistance to macrolide can be mediated by msr A gene coding for efflux mechanism or via erm gene encoding for enzymes that confer inducible or constitutive resistance to macrolide, lincosamide and Type B streptogramin. AIM: The present study was aimed to find out the percentage of Staphylococcus aureus having inducible clindamycin resistance (iMLS(B)) in our geographic area using D-test. Also, we tried to ascertain the relationship between Methicillin-resistant Staphylococcus aureus (MRSA) and inducible clindamycin resistance, association of these iMLS(B) isolates with community or nosocomial setting and treatment options for these iMLS(B) isolates. SETTINGS AND DESIGN: A total of 200 non-duplicate Staphylococcus aureus isolates from various clinical samples from both outdoor and indoor patients were studied. MATERIALS AND METHODS: Susceptibility to routine antimicrobial agents was carried out using Kirby Bauer method. Methicillin resistance was detected by oxacillin disc on Mueller Hinton agar (MHA) supplemented with 2% NaCl. D-test was performed on all erythromycin-resistant and clindamycin-sensitive Staphylococcus aureus strains to detect inducible clindamycin resistance. RESULTS: Among 200 Staphylococcus aureus strains, 50 (25%) were found to be MRSA and 36 were D-test positive. Also, MRSA isolates showed both higher inducible resistance and constitutive resistance to clindamycin as compared to Methicillin-sensitive Staphylococcus aureus (MSSA). Out of 36 isolates of Staphylococcus aureus showing inducible clindamycin resistance, 24 were from the outpatient department and 12 were recovered from indoor patients. All isolates of Staphylococcus aureus showed 100% sensitivity to vancomycin and linezolid. CONCLUSIONS: Clindamycin is kept as a reserve drug and is usually advocated in severe MRSA infections depending upon the antimicrobial susceptibility results. We have reported a higher incidence of iMLS(B) from both community (66.67%) as well as hospital (33.33%) setup. Therefore clinical microbiology laboratory should report inducible clindamycin resistance routinely.

Prevalence of allergic bronchopulmonary aspergillosis among patients with severe bronchial asthma in a tertiary care hospital in Northern India.

INTRODUCTION: The link between fungi and asthma has been known for centuries. About one-third to one-half of severe asthmatics has history of atopic sensitization to filamentous fungi, most predominantly to Aspergillus fumigatus. Allergic bronchopulmonary aspergillosis (ABPA) is the one of the most documented fungal presentations among patients with asthma. This study was done on 50 patients with severe asthma who were consecutively enrolled from January 2016 to June 2017 to look for prevalence of ABPA. MATERIALS AND METHODS: Blood samples were collected from 50 patients with severe asthma, and serum was separated to test for absolute eosinophil count, total IgE, and Aspergillus fumigates-specific IgE. RESULTS: The prevalence of ABPA was found to be 70% (35/50). Of these, ABPA-B (ABPA with bronchiectasis) was less 31.4% (11/35) when compared with 68.5% (24/35) of patients with serological ABPA. Out of these 35 patients, there were 18 females and 17 were males. The mean age of the patients was 41.3 years. CONCLUSION: ABPA prevalence is high in patients with severe asthma, and there is a need to look for and evaluate this association further.

Usability of donor corneas harvested from the deceased having septicaemia or malignancy.

CONTEXT: There is a wide gap between supply and demand in relation to healthy corneal grafts. Specific contraindications like infection and malignancy lead to non-usage of many grafts, despite the fact that deeming graft unhealthyness for these two contraindications is debatable. AIMS: This study was conceptualized to assess if corneas donated from the deceased with septicaemia or malignancy can be deemed fit for implantation. SETTINGS AND DESIGN: Retrospective histopathological and microbiological analysis of cadaveric donor corneas. METHODS: A total of 76 donor corneas from 38 patients rejected for corneal transplantation in view of patient having septicaemia or malignancy were analysed for pathological and microbiological workup, to look for dissemination of disease within corneal tissue. Pathology workup included gross and microscopic histopathological evaluation of tissue. Microbiology workup included Grams stain and KOH with calcofluor mount, culture in blood agar, chocolate agar, Sabourauds dextrose agar and Mc Conkeys broth. RESULTS: A total of 46 donor corneas of 23 septicaemia patients when evaluated showed presence of culture positive infection in 18 patients (78.2%). Histopathological examination done for 30 donor corneas from 15 cancer patients did not reveal presence of tumour cells in the specimen. Corneas of two of cancer patients having septicaemia revealed growth on cultures. CONCLUSIONS: Corneal tissues harvested from septicaemia donors showed significantly higher incidence of corneal contamination, confirming their unsuitability for usage. However, there was no incidence of tumour transmission in corneal tissues of the patients with malignancies, suggesting that they can be considered for ophthalmic purpose.

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair under epidural anesthesia: a detailed evaluation.

BACKGROUND: Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is as efficacious as the open Lichtenstein procedure, can be learned with proper training, and causes less postoperative pain, better cosmesis, and earlier return to work. The one major factor preventing the widespread acceptance of TEP is the requirement for general anesthesia (GA). In contrast, open hernia is performed using local or regional anesthesia, thereby having the advantage of quicker recovery, decreased postoperative nausea and vomiting (PONV), fewer hemodyanamic changes, reduced metabolic responses to surgical stress, and better muscle relaxation. This study attempted to evaluate whether laparoscopic TEP can be performed under less invasive anesthesia, such as regional anesthesia, and to determine its feasibility and limitations METHODS: All total of 22 male patients were studied between January 2002 and March 2003 in a tertiary care referral hospital. Epidural anesthesia with 2% lignocaine with adrenaline (Adr) was given via a lumbar epidural catheter, achieving a sensory level of T6. The standard technique for TEP was followed, using three midline infraumbilical ports. RESULTS: Twenty-two patients (20 unilateral, 2 bilateral) underwent operation. The mean operating time was 67.8 +/- 18 (range, 40-110) min. All 22 cases were started with epidural anesthesia, 7 of which (31.9%) were converted to GA; the other 15 (68.1%) were completed under epidural anesthesia. All cases were successfully completed laparoscopically, and there were no conversions. There were no intraoperative complications. There was no significant difference between the cases conducted under epidural anesthesia (67.6 +/- 23 min) and those converted to GA (69.3 +/- 7.3 min). There was no statistically significant difference between the conversion rates of smaller versus larger hernias in this study (p value 0.22). A significant association of success of the procedure was seen with a sensory level of T6 and above (2/15 conversions to GA; i.e., 13.3%) and cases with a sensory level below T6 (5/7 converted; i.e., 71.4%) and adequate epidural catheter length (p = 0.015). Prevention and management of pneumoperitoneum and subsequent shoulder-tip pain was the key to preventing conversions (6 of 9 converted to GA; i.e., 67%; p = 0.006). There were no significant postoperative complications, and no recurrences were noted during a mean follow-up period of 29 months (range, 20-36 months). CONCLUSIONS: From the present study it is clear that TEP is possible under epidural anesthesia provided a minimal sensory level of T6 is achieved. To achieve that level, an appropriate higher site for catheter insertion and/or adequate intraepidural catheter length needs specific attention. Pneumoperitoneum, shoulder-tip pain, intraoperative straining, and inadequate preperitoneal space are factors whose interplay leads to conversion to GA. The size of the hernia is not related to pneumoperitoneum or conversion to GA.

Assessment of current prescribing practices using World Health Organization core drug use and complementary indicators in selected rural community pharmacies in Southern India.

BACKGROUND: Due to the lack of clear, comprehensive, and rational drug policy, the production of pharmaceutical preparations in India is distorted for the most part. Indian markets are flooded with more than 70,000 formulations, compared to approximately 350 formulations listed in the World Health Organization (WHO) Essential Drug List. Studies have indicated that majority of prescriptions in India are of drugs of "doubtful efficacy." To promote rational drug use in developing countries, assessment of drug use patterns with the WHO drug use indicators is becoming increasingly necessary. The aim of this study was to assess the patterns of drug use by using WHO core drug use and complementary indicators. METHODS: One thousand fifty-two patients were prospectively interviewed and their prescriptions analyzed according to WHO guideline five randomly selected busy community pharmacies in northern district of the State of Tamil Nadu, South India to analyze the WHO core drug use and complementary indicators using an investigator-administered data collection form. The main outcome measured is patterns of drug use measured using WHO core drug use and complementary indicators. RESULTS: The data obtained showed that, out of total drugs prescribed (3936), only 2.5 % (100) drugs were prescribed by generic name. Mean number of drugs per encounter was 3.7. Use of antibiotics was 22 %, percentage of encounters with an injection was 7.2 %, and the percentage of drugs prescribed from formulary was 99.8 %. CONCLUSIONS: Brand name prescribing is dominated even in rural India. There is a need to improve the availability of essential guidelines and key drugs in the stock in rural areas of India. Prescriptions studied were conforming to most indicators of WHO except the number of drugs prescribed & generic name prescription practice, which deviated. In India the healthcare is dominated by private practitioners at the primary level. Prescription practices of the individual community-based clinician needs consistent monitoring with respect to generic name prescribing habits as well as the number of drugs prescribed. The WHO drug use indicator guidelines need to be promoted amidst the primary care clinicians and should not be just limited to hospitals having a formulary. The data collected by this study can be used by policymakers to monitor and improve the prescribing and consumption of pharmaceutical products in Southern India.

Incidence, risk factors, microbiology of venous catheter associated bloodstream infections--a prospective study from a tertiary care hospital.

PURPOSE: Central venous catheters (CVCs) though indispensable in current medical and intensive care treatment, also puts patients at risk of catheter related infection (CRI) resulting in increased morbidity and mortality. We analysed the incidence, risk factors, bacteriological profile and antimicrobial susceptibility pattern of the isolates in central venous catheter associated bloodstream infection (CVC-BSI) in the intensive care unit (ICU) patients and studied the formation of biofilm in CVCs. MATERIALS AND METHODS: The following case control study included 115 patients with CVC in situ. Quantitative blood cultures (QBC) and catheter tip cultures were performed for the diagnoses. Direct catheter staining was done for an early diagnosis by acridine orange (AO) and Gram staining methods. Biofilm production in catheters was detected by 'tissue culture plate' (TCP) method. The results were analysed using the computer-based program statistical package for the social sciences (SPSS). RESULTS: In 25/115 patients, definite diagnosis of CVC-BSI was made. The mean age was 48.44 ± 17.34 years (cases) vs 40.10 ± 18.24 years (controls) and the mean duration of catheterisation was 25.72 ± 8.73 days (cases) vs 11.89 ± 6.38 days (controls). Local signs of infection (erythema, tenderness and oozing) were found more significantly in CVC-BSI cases. The AO staining was more sensitive and Gram staining of catheters showed higher specificity. Staphylococcus aureus followed by Pseudomonas aeruginosa and non-albicans Candida were common CVC-BSI pathogens. Multidrug-resistant (MDR) strains were isolated in bacterial agents of CVC-BSI. Non-albicans Candida and Enterococcus faecalis showed strong biofilm production. CONCLUSION: The incidence of CVC-BSI was 21.73% and the rate was 14.59 per 1000 catheter days. Prolonged ICU stay and longer catheterisation were major risk factors. S. aureus was isolated most commonly in CVC-BSI cases. The menace of multidrug resistance and biofilm formation in CVCs is associated with CVC-BSI.

gamma-Glutamyl transpeptidase: a novel biochemical marker in inflammation.

gamma-Glutamyl transpeptidase (gamma-GT) plays an important role in the turnover of glutathione and protein biosynthesis. Because in inflammation both catabolic and anabolic steps are activated together with migration of cells, an alteration in gamma-GT activity was postulated to occur at the site of inflammation with the development of the inflammatory process. We discovered that gamma-GT activity was increased markedly at sites of inflammation produced in several ways in rats. A significant increase in enzyme activity appeared soon after the induction of inflammation. In carrageenin-induced acute inflammation, the paw tissue attained a 3- to 4-fold increase in enzyme activity within 4 hr; in established adjuvant arthritis, a 20- to 24-fold increase over its basal activity occurred in the rat paw tissue. The specific enzyme activity was 20-22 nmoles/min/mg protein in the cellular sediment of carrageenin-induced pleural exudate. In cotton granulomatous tissue it was 5- to 6-fold higher compared to the enzyme activity of the skeletal muscles. The in vivo increase in gamma-GT activity was prevented from occurring in proportion to the anti-inflammatory potencies of the test drugs given orally. The prevention of enzyme activity was observed with indomethacin in carrageenin-induced edematous paw tissue and with phenylbutazone in both adjuvant arthritis and carrageenin-induced pleural exudate. Prednisolone was observed to be the most potent drug against cotton granuloma. Nonsteroidal anti-inflammatory drugs (NSAIDs) were not found to affect enzyme activity in vitro when incubated with cellular infiltrate from a cotton pellet granuloma. Differences in certain physico-chemical characteristics, viz. stability at 50 degrees, pH dependency and effects of solvents, were not discernible in between the enzyme activities of the untreated and edematous paw tissues. The studies thus suggest that measurement of gamma-GT in inflammation may prove to be a valuable biochemical marker for the assessment of anti-inflammatory activity of drugs in vivo.

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair: overcoming the learning curve.

BACKGROUND: Total extraperitoneal (TEP) laparoscopic inguinal hernia repair is preferred to the transabdominal preperitoneal (TAPP) repair since it preserves peritoneal integrity. However, in general it is considered to be more difficult than the latter because of the peculiarity of anatomy and limitation of working space. Therefore it has been assigned with a "steep learning curve" that the surgeon needs to climb steadily and slowly. This paper offers a working protocol, which is aimed at reducing the steep limb of this curve. METHODS: A total of 61 patients were studied between April 2000 and September 2002. Of these, five patients had a open unilateral Stoppa's preperitoneal operation to learn the detailed anatomy of the extraperitoneal space. Thereafter, laparoscopic TEP procedure was started in the following 56 cases by P.L. In case of difficulty, the procedure was to be converted to the open preperitoneal operation only. Of the first 10 cases, five were converted to unilateral Stoppa's preperitoneal operation for various reasons, and one case was converted after 30 cases. Thus a total of 11 cases were completed by open unilateral Stoppa's preperitoneal operation and 50 cases were completed laparoscopically. The first 30 cases started initially as laparoscopic operations were analyzed in groups of 10 each and compared to another study from Netherlands (evaluating four surgeons) wherein the initial laparoscopic procedures were started with the assistance of a surgeon well experienced in laparoscopic TEP operation. RESULTS: The comparison of our first 30 cases with the Netherlands group showed that while the conversions (five cases) to open operation were higher in the first 10 cases, there were no conversions in the next 20 cases. Also, there were no complications or recurrences in the present study, in striking contrast to three recurrences and 10 complications in the comparative study. The following 26 cases were associated with no recurrence or major complication. CONCLUSION: In this study we performed a total of 11 open unilateral Stoppa's preperitoneal procedures in our attempt to learn the anatomy of this extraperitoneal space better, and in the absence of any surgeon experienced in laparoscopic TEP procedure. We were able to place a large mesh in each and every case and also recognize double hernias in six cases, thus preventing recurrences and complications. We strongly recommend a minimum of 10 open Stoppa's preperitoneal procedures, to enable a trained laparoscopic surgeon to start laparoscopic TEP operation independently and in the absence of another trained laparoscopic hernia surgeon, whose presence may not prevent complications and recurrences.

Randomized controlled study of laparoscopic total extraperitoneal versus open Lichtenstein inguinal hernia repair.

BACKGROUND: Whereas open anterior inguinal herniorrhaphy is a time-tested, safe, and well-understood operation with a high success rate, laparoscopic techniques of inguinal hernia repair are fairly recent. Consequently, short- and long-term outcomes are still being evaluated. Few studies have compared laparoscopic extraperitoneal inguinal hernia repair with tension-free open hernia repair. The current study was conducted to compare complications, operative time, postoperative pain, length of hospital stay, and return to work between open tension-free mesh Lichtenstein (open) repair and laparoscopic total extraperitoneal (TEP) repair. METHODS: In a prospective randomized study, open hernia repair was performed in one group (n = 25), and TEP repair using a large mesh was performed in another (n = 25). Then intraoperative and postoperative complications and results were compared. RESULTS: The mean operative time in the TEP group was 75.72 +/- 31.6 min, which was significantly longer than the mean operative time in the open group (54 +/- 15) min (p <0.001). The mean pain scores in the TEP group were 2.64 +/- 1.4 at 12 h and 1.76 +/- 1.4 at 24 h. These scores were significantly lower than the corresponding scores of 3.52 +/- 1.7 (p <0.04) and 2.74 +/- 1.5 (p <0.01) in the open repair group. The mean postoperative analgesic dose was 2.6 +/- 2.3 in the TEP group, which was significantly lower than in the open group 5.76 +/- 3.5 (p <0.001). There was no major complication in either group. The time until return to work was significantly lower in the TEP group (12.8 +/- 7.1) days versus 19.3 +/- 4.3 days; than in the open group (p <0.001). In terms of cosmetics, all 25 patients (100%) in TEP group rated themselves as "highly satisfied," as compared with 7 patients (28%) in the open group (p <0.001). After a mean follow-up period of 13 months (range, 9-18 months), no recurrence was seen in either of the two groups. CONCLUSION: In terms of complications and short-term recurrence, TEP repair is comparable with open repair. Moreover, TEP is significantly less painful in the early postoperative period, leading to earlier ambulation than open repair. Additionally, TEP results in significantly earlier return to work and better cosmetic results. Currently, TEP seems to be a better alternative than the existing open repair, provided the long-term recurrence rates are comparable. Despite the fact that TEP was a new procedure for the surgeon and the study was conducted during the learning phase, the results are comparable with those in the world literature.

A new radiopharmaceutical for gallbladder studies: 99mTc-Sn-LIDA complex.

A simple method for the preparation of 99mTc-Sn-LIDA complex is described. Organ distribution and blood clearance studies in animals are reported. This complex has also been used successfully in more than 50 patients for assessing gallbladder function.

Outbreak of Salmonella worthington meningitis & septicaemia in a hospital at Chandigarh (north India).

During August 1988 an outbreak of hospital acquired infection due to S. worthington has been reported at the Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh. A total of seven neonates presented with the clinical features of meningitis and septicaemia during this outbreak and six babies died. S. worthington was isolated from blood and cerebrospinal fluid respectively. The same strains were isolated from the baby warmer mattress, baby cot, suction machine bottle and wall of the fridge. Samples from doctors, nurses and apparently healthy babies born during this period did not grow the above organism. This appears to be the first report on S. worthington in human beings from India. The outbreak was controlled by thorough cleaning and fumigation. The organisms were also mostly sensitive to antibiotics used, in contrast to the multiple drug resistant pattern reported from elsewhere.

Erythrocytic glucose-6-phosphate dehydrogenase deficiency in the Bania community of Punjab.

Five hundred members belonging to the Bania community of Punjab were screened for erythrocytic glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. The incidence of enzyme deficiency in males was 2.84 per cent and in females 2.75 per cent, with an overall incidence of 2.80 per cent. No correlation between age and G-6-PD deficiency was found. The mean values for haemoglobin and haematocrit did not differ significantly in the normal and deficient subjects. Study of the deficiency pattern amongst family members of the enzyme deficient subjects confirmed the X-linked inheritance of G-6-PD deficiency.

Evaluation of status of tuberculin skin sensitivity test among medical students.

The status of tuberculin skin sensitivity tests was evaluated in 87 medical students. It was found that Mantoux test has less significant role to play in the vaccinated individuals and in the population at high risk of exposure. Hence this test is to be supplemented with clinical manifestations and other investigations to establish the final diagnosis of tuberculosis.