Novices' learning curve in single-port surgery using three surgical training programs.

BACKGROUND: The objective of this study was to evaluate the novices' learning curves and proficiency level reached in laparoendoscopic single-site (LESS) surgery using three surgical training programs. MATERIAL AND METHODS: Participants were randomly divided into three groups, who trained in a specific practice regimen for 12 days using a laparoscopic box simulator and three tasks. Group A trained in three stages using conventional laparoscopic surgery (CLS) with straight instruments, and LESS with straight and articulating instruments for four days each. Group B trained in two stages in LESS with straight and articulating instruments for six days each. Group C trained only in LESS with articulating instruments exclusively for all 12 days. Performance was registered daily during the 12 days to evaluate the participants' progress. RESULTS: Pre- and post-training analysis of the three groups showed significant differences in performance, denoting the significant improvement in their LESS skills, with no difference between the groups. Group C reached a high level of technical competence with their specific training program in LESS, obtaining a lower asymptote and slow learning rate. CONCLUSION: Specific training programs in LESS settings using articulated instruments showed a slower learning rate than the other programs but better proficiency in the technique with the best surgical performance.

Face, content, and construct validity of the virtual immersive operating room simulator for training laparoscopic procedures.

BACKGROUND: The aim of this work is to present the face, content, and construct validation of the virtual immersive operating room simulator (VIORS) for procedural training of surgeons' laparoscopic psychomotor skills and evaluate the immersive training experience. METHODS: The VIORS simulator consists of an HMD Oculus Rift 2016 with a visor on a 1080 × 1200 pixel OLED screen, two positioning sensors with two adapted controls to simulate laparoscopic instruments, and an acrylic base to simulate the conventional laparoscopic setup. The immersion consists of a 360° virtual operating room environment, based on the EndoSuite at Hospital Infantil de Mexico Federico Gomez, which reproduces a configuration of equipment, instruments, and common distractions in the operating room during a laparoscopic cholecystectomy procedure. Forty-five surgeons, residents, and medicine students participated in this study: 27 novices, 13 intermediates, and 5 experts. They completed a questionnaire on the realism and operating room immersion, as well as their capabilities for laparoscopic procedural training, scored in the 5-point Likert scale. The data of instrument movement were recorded and analyzed using 13 movement analysis parameters (MAPs). The experience during training with VIORS was evaluated through NASA-TLX. RESULTS: The participants were enthusiastic about the immersion and sensation levels of the VIORS simulator, with positive scores on the realism and its capabilities for procedural training using VIORS. The results proved that the VIORS simulator was able to differentiate between surgeons with different skill levels. Statistically significant differences were found in nine MAPs, demonstrating their construct validity for the objective assessment of the procedural laparoscopic performance. At cognitive level, the inversion experience proves a moderate mental workload when the laparoscopic procedure is carried out. CONCLUSION: The VIORS simulator has been successfully presented and validated. The VIORS simulator is a useful and effective device for the training of procedural laparoscopic psychomotor skills.

Steerable Surgical Instrument for Conventional and Single-Site Minimally Invasive Surgery.

Background. This article aims to present an innovative design of a steerable surgical instrument for conventional and single-site minimally invasive surgery (MIS), which improves the dexterity and maneuverability of the surgeon while offering a solution to the limitations of current tools. Methods. The steerable MIS instrument consists of a deflection structure with a curved sliding joints design that articulates the distal tip in two additional degrees of freedom (DoFs), relative to the instrument shaft, using transmission by cables. A passive ball-joint mechanism articulates the handle relative to the instrument shaft, improves wrist posture, and prevents collision of instrument handles during single-site MIS procedures. The two additional DoFs of the articulating tip are activated by a thumb-controlled device, using a joystick design mounted on the handle. This steerable MIS instrument was developed by additive manufacturing in a 3D printer using PLA polymer. Results. Prototype testing showed a maximum tip deflection of 60° in the left and right directions, with a total deflection of 120°. With the passive ball-joint fully offset, the steerable tip achieved a deflection of 90° for the right and 40° for the left direction, with a total deflection of 130°. Furthermore, the passive ball-joint mechanism in the handle obtained a maximum range of motion of 60°. Conclusions. This steerable MIS instrument concept offers an alternative to enhance the application fields of conventional and single-site MIS, increasing manual dexterity of the surgeon and the ability to reach narrow anatomies from other directions.

Construct validity of the SurgForce system for objective assessment of laparoscopic suturing skills.

BACKGROUND: Laparoscopic surgery requires a new set of skill to be learned by the surgeons, of which the most relevant is tissue manipulation. Excessive forces applied to the tissue can cause rupture during manipulation or ischemia when confronting both sides of the tissue. The aim of this study is to establish the construct validity of the SurgForce system for objective assessment of advanced laparoscopic skills, based on the force signal generated during suture tasks, and the development of force parameters for evaluating tissue handling interaction. METHODS: The SurgForce system, a tissue handling training device that measures dynamic force, was used to capture the force generated by surgeons with different levels of laparoscopic experience. For construct validity, 37 participants were enrolled in this study: 19 medical students, 12 residents of surgical specialties and 6 expert surgeons. All participants performed an intracorporeal knotting suture task over a synthetic tissue pad with a laparoscopic box-trainer. The force performance of the participants was analyzed using 11 force-based parameters with the application of the SurgForce system. Statistical analysis was performed between novice, intermediate, and expert groups using a Kruskal-Wallis test, and between the pairs of groups using a Mann-Whitney U-test. RESULTS: Overall, 9 of the 11 force-related parameters showed significant differences between the three study groups. Results between the pairs of groups presented significant differences in 5 force parameters proposed. Construct validity results demonstrated that the SurgForce system was able to differentiate force performance between surgeons with different levels of laparoscopic experience. CONCLUSION: The SurgForce system was successfully validated. This force system showed its potential to measure the force exerted on tissue for objective assessment of tissue handling skills in suturing tasks. Furthermore, its compact design allows the use of this device in conventional laparoscopic box-trainers.

Design of a Dynamic Force Measurement System for Training and Evaluation of Suture Surgical Skills.

The aim of this study is to present the SurgeForce system, a tissue handling training device for analysis of dynamic force applied to the tissue and objective assessment of basic surgical skills during the suture process. The SurgeForce system consists of a mechanical base formed by two platforms joint with three stainless steel springs and a three axial digital accelerometer attached to the upper platform, which detects the dynamic force caused by a surgeon when performing a suture task over a synthetic tissue pad. Accelerometer data is sent to a control unit where preprocessing to transform the raw data into a force signal is done, and then, the force signal is sent to a computer application, which register the force exerted over the synthetic tissue pad. For validation, 17 participants (6 surgeons and 11 medical students) performed three simple interrupted sutures with knot tying using the SurgeForce system. Ten force-based metrics were proposed to evaluate their performance during the suturing task. Results of the validation showed statistical differences in 8 of 10 force-based parameters for assessment of basic surgical skills during the suture task. The SurgeForce system demonstrated its capacity to differentiate force-based performance of surgeons and medical students. The SurgeForce system has been successfully validated. This system was able to distinguish force performance between experts and novices, showing its potential to distinguish surgeons with basic suture skills from those who are not yet prepared.

Mycobacterium abscessus infections in lung transplant recipients: 15-year experience from a single institution.

PURPOSE: To evaluate our institutional experience with Mycobacterium abscessus infections occurring in lung transplant recipients (LTR). METHODS: We retrospectively reviewed our prospectively collected institutional adult lung transplant database from 2001 to 2015 to identify patients with M. abscessus or Mycobacterium chelonae/abscessus infection before or after transplantation. Untreated, colonized patients were excluded from the study. Electronic health records of nine out of 516 lung recipients (1.74%) with clinical infection were reviewed to determine outcomes. RESULTS: Seven patients acquired the infection after transplantation. Indications for transplantation were: idiopathic pulmonary fibrosis (in 6), chronic obstructive pulmonary disease (in 2), and cystic fibrosis (in 1). Five patients (55.5%) underwent bilateral lung transplantation; one patient required bilateral re-transplantation for complications from infection. M. abscessus was isolated from the respiratory tract with a median time of 7.5 months (range: 3 days to 13 months) from transplantation. All patients were treated using a multidrug regimen, with durations ranging from 3 days to 12 months. Complications from infection included death in one patient, bronchial anastomotic dehiscence in one patient, delayed bronchial occlusions in two patients, and osteomyelitis of the knee in one patient. Median survival time from transplantation was 39 months (range: 11-96 months) and from the date of first positive culture was 58 months (range: 3-91 months). Five patients (55.5%) were cured but two had re-infections >1 year later. CONCLUSIONS: Mycobacterium abscessus infection in LTR is rare and can lead to severe complications. Eradication is difficult and usually requires prolonged combination antibiotic therapy and occasionally surgical management.

Nontuberculous Mycobacterial Infections of the Upper Extremity: 15-Year Experience at a Tertiary Care Medical Center.

PURPOSE: To present our experience with culture-positive, nontuberculous mycobacterial infections (NTMI) of the upper extremity and to compare the clinical features and outcomes of treatment among immunocompetent and immunocompromised patients. METHODS: All patients at our medical center diagnosed with NTMI of the upper extremity from December 1, 2000, through December 31, 2015, were included. We performed a retrospective analysis of patient demographic characteristics, delay to diagnosis, risk factors, clinical presentation, specific location, diagnostic testing, treatment regimens, and outcomes. These variables were compared between immunocompetent and immunocompromised patients. RESULTS: Forty-four patients were identified with culture-positive NTMI of the upper extremity. Of the patients, 27 (61%) were men (median age, 59 years [range, 23-83 years]). Twenty (45%) patients were immunocompromised. Immunocompromised patients had fewer known inoculation injuries compared with immunocompetent patients (45% vs 92%). A significant difference existed in the treatment regimens selected for immunocompetent versus immunocompromised patients: immunocompetent patients were more often treated with both antibiotics and surgery (88% vs 50%), whereas immunocompromised patients were more often treated with antibiotics alone (45% vs 4%). Overall, 24% experienced treatment failure and 9% died. Outcomes were relatively similar between immunocompetent and immunocompromised patients. A shorter delay to diagnosis was associated with a lower failure rate. CONCLUSIONS: Diagnosis of upper-extremity NTMI is often delayed because of indolent presentation and lack of clinical suspicion. The clinical presentation, diagnostic delay, and diagnostic testing results are similar between immunocompetent and immunocompromised patients. Although treatment varied significantly between patient groups, outcomes were similar. Timely diagnosis has the greatest impact on patient outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Enantioselective synthesis of an octahydroindolizine (indolizidine) alcohol using an enzymatic resolution.

A homo-chiral synthesis of (7R,8aS)-octahydro-5,5-dimethylindolizin-7-amine 8 and (7S, 8aS)-octahydro-5,5-dimethylindolizin-7-ol 9, amine building blocks which have found applications within the pharmaceutical industry, is presented. The approach uses a Novozym 435-mediated kinetic resolution of racemic octahydroindolizine (indolizidine) alcohol 13 as a key step (up to 100 g scale).

Clinical and Radiological Characterization of Central Nervous System Involvement in Nocardiosis: A 20-Year Experience.

Background This study aimed to present the clinical and radiological characteristics and the outcomes of patients with Nocardia infection of the central nervous system (CNS). Methodology We conducted a retrospective review of patients aged 18 and older admitted between August 1998 and November 2018 with culture-proven nocardiosis and CNS involvement. Results Out of 110 patients with nocardiosis, 14 (12.7%) patients had CNS involvement. The median age was 54.5 (27, 86) years, and 12 (85.7%) patients were male. Overall, 12 (85.7%) patients were immunosuppressed on high doses of glucocorticoids; seven (50%) patients were solid organ transplant recipients. Only eight (57.1%) patients had neurological symptoms at presentation, and the rest were diagnosed with CNS involvement after imaging surveillance. Three distinct radiologic patterns were identified, namely, single or multiple abscesses, focal cerebritis, and small, septic embolic infarcts. All isolates of Nocardia were susceptible to trimethoprim/sulfamethoxazole and amikacin, with susceptibility to linezolid and carbapenems being 90.9% and 79.5%, respectively. Despite receiving antibiotic therapy, six (42.8%) patients died, most of them within weeks of initial admission. All surviving patients underwent prolonged antimicrobial therapy until the resolution of MRI abnormalities. All solid organ transplant recipients recovered. Conclusions Nocardia CNS infection was a rare condition, even among a large, immunosuppressed patient population. CNS imaging surveillance is paramount for immunosuppressed patients with nocardiosis, as CNS involvement influences the choice and duration of therapy. Nocardia antibiotic susceptibility varied widely between strains and the empiric therapy should consist of multiple classes of antimicrobials with CNS penetration. Mortality was high, but all solid organ transplant recipients recovered.

Effect of three training programs on surgical performance in single-port laparoscopic surgery.

OBJECTIVE: The aim of this study was to evaluate the effect of three training methodologies on the acquisition of psychomotor skills for laparoendoscopic single-site surgery (LESS), using straight and articulating instruments. METHODS: A prospective study was conducted with subjects randomly divided into three groups, who performed a specific training for 12 days using three laparoscopic tasks in a laparoscopic simulator. Group-A trained in conventional laparoscopy setting using straight instruments and in LESS setting using both straight and articulating instruments. Group-B trained in LESS setting using straight and articulating instruments, whereas Group-C trained in LESS setting using articulating instruments. Participants' performance was recorded with a video-tracking system and evaluated with 12 motion analysis parameters (MAPs). RESULTS: All groups obtained significant differences in their performance in most of the MAPs. Group-C showed an improvement in nine MAPs, with a high level of technical competence. Group-A presented a marked improvement in bimanual dexterity skills. CONCLUSIONS: Training in LESS surgery using articulating laparoscopic instruments improves the quality of skills and allows smoother learning curves.

OBJETIVO: Evaluar el efecto de tres métodos de entrenamiento en la adquisición de habilidades psicomotrices para la cirugía laparoendoscópica por puerto único (LESS, laparoendoscopic single-site surgery) utilizando instrumental recto y articulado. MÉTODO: Se realizó un estudio prospectivo con sujetos divididos aleatoriamente en tres grupos, quienes realizaron un entrenamiento específico durante 12 días utilizando tres tareas laparoscópicas en un simulador laparoscópico. El grupo A entrenó en el entorno laparoscópico convencional con instrumentos rectos, y en el entorno LESS con instrumentos rectos y articulados. El grupo B entrenó en el entorno LESS con instrumentos rectos y articulados. El Grupo C entrenó en el entorno LESS con instrumentos articulados. El desempeño de los participantes se registró con un sistema de seguimiento en video y fue evaluado con 12 parámetros de análisis de movimiento (MAP, motion analysis parameters). RESULTADOS: Todos los grupos obtuvieron diferencias significativas en su desempeño para la mayoría de los MAP. El grupo C mostró una mejora en nueve MAP, con un alto nivel de competencia técnica. El grupo A mostró una marcada mejora en la habilidad de destreza bimanual. CONCLUSIONES: El entrenamiento en cirugía LESS con instrumentos articulados mejora la calidad de las habilidades adquiridas y permite curvas de aprendizaje más suaves.

Invasive Nocardiosis Versus Colonization at a Tertiary Care Center: Clinical and Radiological Characteristics.

Objective: To describe the clinical and radiographic findings in a large cohort of patients with positive cultures for Nocardia emphasizing the differences between invasive disease and colonization. Patients and Methods: We conducted a single-center, retrospective cohort study of 133 patients with a positive Nocardia isolate between August 1, 1998, and November 30, 2018, and a computed tomography (CT) of the chest within 30 days before or after the bacteria isolation date. Results: Patients with colonization were older (71 vs 65 years; P=.004), frequently with chronic obstructive pulmonary disease (56.8% vs 16.9%; P<.001) and coronary artery disease (47.7% vs 27%, P=.021), and had Nocardia isolated exclusively from lung specimens (100% vs 83.1%; P=.003). On CT of the chest, they had frequent airway disease (84.1% vs 51.7%; P<.001). Patients with invasive nocardiosis had significantly (P<.05) more diabetes, chronic kidney disease, solid organ transplant, use of corticosteroids, antirejection drugs, and prophylactic sulfa. They had more fever (25.8% vs 2.3%; P<.001), cutaneous lesions (14.6% vs 0%; P=.005), fatigue (18% vs 0%; P=.001), pulmonary nodules (52.8% vs 27.3%; P=.006), and free-flowing pleural fluid (63.6% vs 29.4%; P=.024). The patterns of nodule distribution were different-diffuse for invasive nocardiosis and peribronchiolar for Nocardia colonization. Conclusion: The isolation of Nocardia in sputum from a patient with respiratory symptoms does not equal active infection. Only by combining clinical and chest CT findings, one could better differentiate between invasive nocardiosis and Nocardia colonization.

Global TravEpiNet: a national consortium of clinics providing care to international travelers--analysis of demographic characteristics, travel destinations, and pretravel healthcare of high-risk US international travelers, 2009-2011.

BACKGROUND: International travel poses a risk of destination-specific illness and may contribute to the global spread of infectious diseases. Despite this, little is known about the health characteristics and pretravel healthcare of US international travelers, particularly those at higher risk of travel-associated illness. METHODS: We formed a national consortium (Global TravEpiNet) of 18 US clinics registered to administer yellow fever vaccination. We collected data regarding demographic and health characteristics, destinations, purpose of travel, and pretravel healthcare from 13235 international travelers who sought pretravel consultation at these sites from January 2009 through January 2011. RESULTS: The destinations and itineraries of Global TravEpiNet travelers differed from those of the overall population of US international travelers. The majority of Global TravEpiNet travelers were visiting low- or lower-middle-income countries, and Africa was the most frequently visited region. Seventy-five percent of travelers were visiting malaria-endemic countries, and 38% were visiting countries endemic for yellow fever. Fifty-nine percent of travelers reported ≥1 medical condition. Atovaquone/proguanil was the most commonly prescribed antimalarial drug, and most travelers received an antibiotic for self-treatment of travelers' diarrhea. Hepatitis A and typhoid were the most frequently administered vaccines. CONCLUSIONS: Data from Global TravEpiNet provide insight into the characteristics and pretravel healthcare of US international travelers who are at increased risk of travel-associated illness due to itinerary, purpose of travel, or existing medical conditions. Improved understanding of this epidemiologically significant population may help target risk-reduction strategies and interventions to limit the spread of infections related to global travel.

Outcomes of atherothrombotic transient ischemic attack and minor stroke in an emergency department: results of an outpatient management program.

STUDY OBJECTIVE: Management of patients with transient ischemic attack varies widely. The aim of this study is to analyze the outcomes of patients with transient ischemic attacks or minor stroke managed in the emergency department (ED) on an outpatient basis and to identify risk factors associated with stroke recurrence. METHODS: We prospectively analyzed 97 patients with transient ischemic attack or minor stroke who were treated with a standard diagnostic and therapeutic protocol in the ED by emergency physicians. Factors in previous reports were analyzed in relation with a new neurologic event at 90 days or the presence of a severe extracranial carotid stenosis. RESULTS: Incidence of recurrent transient ischemic attack or stroke was 7.2% at 24 hours, 9.3 % at 1 week, and 23.7 % at 3 months. Overall incidence of moderate to severe stroke was 0%, 1%, and 5% at the same points, and in outpatients was 0%, 0%, and 4.2%. ABCD2 scoring in these patients predicted stroke rates of 6% at 7 days and 9.9% at 90 days. CONCLUSION: Patients with transient ischemic attack of atherothrombotic origin can be safely treated at the ED with an exhaustive diagnostic and therapeutic protocol. The rates of stroke recurrence obtained in our study are comparable with those in previous studies that show low recurrence risk.

Invasive Nocardiosis in Transplant and Nontransplant Patients: 20-Year Experience in a Tertiary Care Center.

OBJECTIVE: To present the clinical characteristics and outcome of transplant and nontransplant patients with invasive nocardiosis. PATIENTS AND METHODS: We conducted a retrospective chart review of 110 patients 18 years and older diagnosed with culture-proven invasive nocardiosis (defined as the presence of clinical signs and/or radiographic abnormalities) between August 1, 1998, and November 30, 2018. Information on demographic, clinical, radiographic, and microbiological characteristics as well as mortality was collected. RESULTS: One hundred ten individuals with invasive nocardiosis were identified, of whom 54 (49%) were transplant and 56 nontransplant (51%) patients. Most transplant patients were kidney and lung recipients. The overall mean age was 64.9 years, and transplant patients had a higher prevalence of diabetes and chronic kidney disease. A substantial proportion of nontransplant patients were receiving corticosteroids (39%), immunosuppressive medications (16%), and chemotherapy (9%) and had chronic obstructive pulmonary disease (20%), rheumatologic conditions (18%), and malignant neoplasia (18%). A higher proportion of transplant patients (28%) than nontransplant patients (4%) received trimethoprim-sulfamethoxazole prophylaxis. In both groups, the lung was the most common site of infection. Seventy percent of all Nocardia species isolated were present in almost equal proportion: N brasiliensis (16%), N farcinica (16%), N nova (15%), N cyriacigeorgia (13%), and N asteroides (11%). More than 90% of isolates were susceptible to trimethoprim-sulfamethoxazole, linezolid, and amikacin. There was no significant difference in mortality between the 2 groups at 1, 6, and 12 months after the initial diagnosis. CONCLUSION: The frequency of invasive Nocardia infection was similar in transplant and nontransplant patients and mortality at 1, 6, and 12 months was similar in both groups. Trimethoprim-sulfamethoxazole prophylaxis failed to prevent Nocardia infection.

Diabetes, Active Disease, and Afternoon Serum Cortisol Levels Predict Cushing's Disease Mortality: A Cohort Study.

CONTEXT: Cushing's disease (CD) is a life-threating disease, with increased mortality in comparison with the general population. OBJECTIVE: This study aimed to evaluate standardized mortality ratios (SMRs) in CD patients. We also analyzed independent risk factors related to increased mortality. DESIGN: We conducted a longitudinal cohort study in a 3rd level specialty center, from 1979 to 2018, in patients with CD. RESULTS: From 1375 cases with a pathology diagnosis of pituitary adenoma, 191 cases had the confirmed diagnosis of CD (14%). A total of 172 patients completed follow-up, with a mean age at diagnosis of 33 ±â€…11 years, female predominance (n = 154, 89.5%), majority of them with microadenoma (n = 136, 79%), and a median follow-up of 7.5 years (2.4-15). Eighteen patients (10.5%) died, 8 of them (44%) were with active CD, 8 (44%) were under remission, and 2 (11%) were under disease control. Estimated all-cause SMR = 3.1, 95% confidence interval (CI) 1.9-4.8, P < 0.001. Cardiovascular disease was the main cause of death (SMR = 4.2, 1.5-9.3, P = 0.01). Multivariate Cox regression models adjusted for potential cofounders showed that diabetes (HR = 5.2, IC 95% 1.8-15.4, P = 0.002), high cortisol levels after 1600 hours at diagnosis (3.4, 2.3-7.0, P = 0.02), and active CD (7.5, 3.8-17.3, P = 0.003) significantly increased the risk of mortality. CONCLUSIONS: Main cause of CD mortality was cardiovascular disease. Main risk factors for mortality were uncontrolled diabetes, persistently high cortisol levels after 1600 hours at diagnosis, and active disease at last follow-up.

Tuberculous peritonitis masquerading as carcinomatosis.

Tuberculous peritonitis may debut with unspecific symptoms that can pose a diagnostic challenge for clinicians. We present a patient with tuberculous peritonitis masquerading as carcinomatosis. High clinical suspicion, appropriate identification of bacterial isolates of the Mycobacterium tuberculosis complex, and susceptibility testing are crucial to select target therapy.

Coccidioides in lung transplant: case report.

A middle-aged woman was hospitalised for generalised, painful skin lesions 6 weeks after a successful double-lung transplant. She had end-stage lung disease associated with chronic obstructive pulmonary disease due to alpha-1 antitrypsin deficiency, and she had been treated with itraconazole for 16 months because of lung infection associated with Malbranchea spp. Results of a skin biopsy of the initial lesion on her arm showed non-specific dermal inflammation, presumably due to reactivation of the Malbranchea spp infection. Follow-up cervical lymph node biopsy and culture showed Coccidioides posadasii/C. immitis A detailed review of her travel history showed a 4-month stay in Arizona as a teenager that she barely remembered. Coccidioides spp were likely misidentified as Malbranchea spp owing to similar morphological characteristics. Dosages of immunosuppressive medications were reduced, and antifungal therapy was changed to posaconazole. Her skin lesions resolved.

Neurobrucellosis associated with feral swine hunting in the southern United States.

Although uncommon, Brucella infection can occur outside the areas of high endemicity, such as the USA. In the southern USA, hunters of wild swine are at risk for brucellosis. We present a case of a patient with fever, headache and constitutional symptoms that were ongoing for 11 months. He was diagnosed with neurobrucellosis. The patient was treated successfully with intravenous ceftriaxone, oral doxycycline and oral rifampin therapy. He had persistent neurological sequelae after completing treatment. This case illustrates the high index of suspicion needed to diagnose neurobrucellosis in a non-endemic country because initial symptoms can be subtle. The disease can be treated successfully, but long-lasting neurological sequelae are common.

Proximal tubular dysfunction associated with tenofovir and didanosine causing Fanconi syndrome and diabetes insipidus: a report of 3 cases.

We report 3 cases of patients with HIV/AIDS in whom Fanconi syndrome and nephrogenic diabetes insipidus developed secondary to use of an antiretroviral regimen containing tenofovir disoproxil fumarate and didanosine. These patients presented with a history of polydipsia, polyuria, weight loss, anorexia, and wasting. Interestingly, 1 patient was not taking protease inhibitors. This response is a well-documented yet uncommon complication of tenofovir use in the HIV population. We recommend continued monitoring for renal toxicity when using NRTI combination of tenofovir and didanosine.