During the last couple of decades, with standardization and progress in surgical techniques, immunosuppression and post liver transplantation patient care, the outcome of liver transplantation has been optimized. However, the principal limitation of transplantation remains access to an allograft. The number of patients who could derive benefit from liver transplantation markedly exceeds the number of available deceased donors. The large gap between the growing list of patients waiting for liver transplantation and the scarcity of donor organs has fueled efforts to maximize existing donor pool and identify new avenues. This article reviews the changing pattern of donor for liver transplantation using grafts from extended criteria donors (elderly donors, steatotic donors, donors with malignancies, donors with viral hepatitis), donation after cardiac death, use of partial grafts (split liver grafts) and other suboptimal donors (hypernatremia, infections, hypotension and inotropic support). ( J CLIN EXP HEPATOL 2013;3:337-346)

Although the incidence of early graft dysfunction is statistically more with increase in number of donor risk factors, the overall survival and outcome in extended criteria liver donors are similar to that of an ideal donor. With the supply demand gap widening, extended criteria for selection of deceased donors will definitely expand the donor pool without adversely affecting the outcome of liver transplantation.

Similarly, studies have shown that increase in nalidixic acid resistant S. Typhi (NARST) strains is associated with a consistent increase in the minimum inhibitory concentration (MIC) levels of ciprofloxacin. This reflected the need to redefine fluoroquinolone breakpoints for S. Typhi. [4] In the past decade, strains of the organism that show decreased ciprofloxacin susceptibility (DCS) have emerged in Asia. DCS is defined as ciprofloxacin MIC of 0.12-1 μg/mL. [5] Patients infected with DCS S. Typhi have neither responded to fluoroquinolone therapy as effectively as before nor have they cleared the organisms in stool cultures. [5] In view of the poor response to ciprofloxacin therapy for S. Typhi, Clinical and Laboratory Standards Institute (CLSI) published evidence-based revision of the ciprofloxacin MIC and the disc diffusion interpretative criteria in 2012. The revised criteria are as follows: Ciprofloxacin cut-off for susceptibility using disk diffusion was raised from 21 to 31 mm and the MIC value lowered from 1 to 0.06 μg/mL. Subsequently, in 2013, levofloxacin and ofloxacin disc diffusion zone diameter interpretative criteria for S. Typhi has been removed and MIC interpretative criteria has been revised. The cut-off for levofloxacin and ofloxacin MIC for S. Typhi has been lowered to ≤0.12 μg/mL susceptible, 0.25-1 μg/mL intermediate and ≥2 μg/mL resistant. It is noteworthy that ciprofloxacin, levofloxacin and ofloxacin disc diffusion and MIC breakpoints have been changed/deleted only for typhoidal Salmonella in the Enterobacteriaceae family. [6] Ciprofloxacin MIC was determined using E-test (Epsilometer test, bioMérieux, France) for 488 clinical isolates between 2010 and 2012. The E-test results were interpreted using both the current as well as the previous CLSI guidelines [Table 1]. As per the earlier (2011) guidelines, 466 isolates (95%) were susceptible. When re-evaluated as per the revised (2012) guidelines, only 14 isolates (3%) remained susceptible, while the majority (88%) fell in the intermediate or moderately susceptible zone. The MIC 50 and MIC 90 for ciprofloxacin were 0.25 AbstractThe rise of multidrug resistant strains of Salmonella Typhi in the last decade of the previous century led to the use of fluoroquinolones as the drug of choice. However, over the past few years fluoroquinolone resistance has been increasingly reported. In accordance with the revised Clinical and Laboratory Standards Institute (CLSI) breakpoints, only 3% of the isolates were susceptible to ciprofloxacin in comparison to 95% as per the earlier guidelines when 488 isolates collected between 2010 and 2012 were re-interpreted. Interestingly, re-emergence of strains susceptible to chloramphenicol, ampicillin and cotrimoxazole is being seen. Amidst the changing susceptibility profile, azithromycin remains a promising alternative.

Four antigenically different dengue virus serotypes (DENV-1, DENV-2, DENV-3 and DENV-4) are known to cause infections in humans. Some of these are known to cause more severe disease than the others. Chances for developing Dengue hemorrhagic fever-dengue shock syndrome (DHF-DSS) increases significantly with history of previous infection with one of the four serotypes. Therefore, early diagnosis, serotyping and providing early warning of dengue fever epidemics to concerned authorities becomes very important for better patient outcome and to curb the rapid spread in the community. During the 2014 outbreak, a total of 100 samples from suspected cases of dengue were collected. NS1 antigen based rapid test was used for serological diagnosis. Dengue complex one step reverse transcription-polymerase chain reaction was performed to look for presence of viral RNA. Single tube multiplex RT-PCR was also performed to look for infecting serotype. CDC Dengue Multiplex Real Time PCR assay was performed for rapid diagnosis and simultaneous serotyping of the dengue virus. Out of the 100 samples screened, 69 were found to be positive by NS1Ag Rapid test. 34 samples were found positive by dengue consensus RT-PCR assay. 22 samples were found to be positive by single tube Dengue multiplex RT-PCR assay. Serotype DEN-2 was present in maximum numbers followed by DEN-3. 44 samples were found positive by DENV CDC Multiplex Real time PCR assay. DEN-2 was found in maximum numbers followed by DEN-1. Dengue remains to be an important health problem in India and across the globe. Few serotypes of dengue are more dangerous than the others. Rapid diagnosis and serotyping remains the key for better patient management and prevention of disease spreading in the community. Highly sensitive, specific and rapid CDC real time RT-PCR assay was found to be most promising tool among all available molecular diagnostic methods. This will serve a rapid and reliable simultaneous dengue virus detection as well serotyping assay in near future for rapid identification of dengue suspected sample screening.

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EGFR mutations and ALK gene rearrangement was found to be mutually exclusive. Incidence of EGFR mutations (35.5%) is much higher in Indian population than in Caucasians (13%) and is close to the incidence in East Asian countries. The 7.6% incidence of ALK fusion oncogene in Indian patients establishes the importance of molecular studies to give maximum benefit of targeted therapy to the patients.

A 10-week-old female infant suffering from complete balanced atrioventricular canal defect with severe hyperkinetic pulmonary arterial hypertension was transferred to our institute from a nearby private health care center with respiratory distress. She was being managed as a case of congestive cardiac failure with mechanical ventilation, broad spectrum antibiotics (injectable cefotaxime), antifailure medications and supportive measures over past two weeks without much improvement. Multiple attempts to wean her off from the ventilatory support were unsuccessful. Clinical examination on arrival at our facility showed irritable child with tachycardia (146/ min), tachypnoea (36/min), raised rectal temperature (38.9°C) and oxygen saturation (SpO 2 ) of 94%. Laboratory investigations revealed microcytic anaemia (Hb = 8.9 gm/dL), polymorphonuclear leukocytosis (WBC = 12 x 10 3 cells/µl with neutrophils = 76%), and raised acute-phase reactants (C-reactive protein = 20 mg/dL). Chest radiograph also showed new asymmetric bilateral pulmonary infiltrates suggestive of pneumonic consolidation in addition to features of congestive cardiac failure.Blood, urine, Cerebrospinal Fluid (CSF) and endotracheal aspirate were sent to microbiology laboratory for bacteriological culture and she was continued on the same management. In view of ventilator dependency and refractory cardiac failure, emergency surgery for total surgical correction of the cardiac anomaly was performed on the second day of admission. During postoperative period, her ventilator and inotropic requirements were high and total leukocyte count increased further (WBC = 18.4 x 10 3 cells/ µl) with predominance of neutrophils (82%). Meanwhile, the Gram stained smears from thick endotracheal aspirate revealed Gramnegative bacilli with numerous polymorphonuclear leucocytes in the background. Endotracheal aspirate culture on blood agar grew yellow pigmented colonies on aerobic incubation at 37°C for 24 hours [Table/ Fig-1]. These colonies were non-lactose fermenting on MacConkey and triple sugar iron agar. The organism was non-motile, positive for cytochrome oxidase activity and indole production. The isolate was identified as Chryseobacterium indologenes by VITEK 2 ID-AST (bio Merieux, France) fully automated bacterial identification system. Antibiotic susceptibility testing was also performed by VITEK 2 system and susceptibility breakpoints were interpreted based on Clinical and Laboratory Standards Institute (CLSI) recommendations for other non-Enterobacteriaceae [1]. The isolate was susceptible to ciprofloxacin, trimethoprim/sulfamethoxazole (TMP/SMX) and cefepime. Tigecycline showed intermediate susceptibility. The details of minimum inhibitory concentration for various antimicrobial agents are shown in [Table /Fig-2].

Linear acantholytic dermatoses are a spectrum of cutaneous disorders that form a subset of linear dermatoses with distinct clinical features and histopathologically show acantholysis. The lesions may be zosteriform or follow the lines of Blaschko. This report describes a four-year-old boy who, on a follow up of two years, exhibited a relapsing acantholytic dermatosis along the lines of Blaschko. Histopathology of a representative lesion revealed epidermal acantholysis with multiple acantholytic keratinocytes with in the prickle cell layer and an absence of corp ronds and grains, consistent with features of Hailey-Hailey disease. This, to our knowledge, is the third case of relapsing linear acantholytic dermatosis reported.