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Ventriculoperitoneal (VP) shunt insertion is the commonest form of treatment for hydrocephalus. Shoulder tip pain after VP shunt insertion is unusual and has only recently been reported. We present a case of excruciating shoulder tip pain due to diaphragmatic irritation after VP shunt insertion.

Introduction:Ventriculostomy-related infection (VRI) from external ventricular drain (EVD) insertion is a common complication and carries a high mortality rate. Choice of empiric antibiotics depends on the institutions common causative organisms and their susceptibility. We determined risk factors for mortality in patients with VRI, the common organisms causing VRI, and the rate of EVD-related VRI at our institution.Methods:Medical records and operative data of patients with cerebrospinal fluid positive cultures with an EVD inserted from 2012 to 2015 were traced. Forty-five patients with EVD-related VRI were included in the study.Results:The overall rate of VRI was 6.3%, and the overall mortality rate due to VRI was 48.9%. Acinetobacter baumannii was the most common organism causing VRI (14 patients, 29.2%) with a mortality rate of 64.3%. Only 14.3% of A. baumannii are sensitive to meropenem and imipenem. We found that patients that had a decompressive craniectomy (DC) had a lower mortality rate (P = 0.042) and patients with a longer duration of the EVD being in place before the diagnosis of VRI had poor outcome (P = 0.040). Multivariate logistic regression was performed and we found that the use of steroid (P = 0.014), Pseudomonas aeruginosa infection (P = 0.010), multiple organism infection (P = 0.017), lower Glasgow Coma Scale (P = 0.043), and a longer duration the EVD was in place before the diagnosis of VRI (P = 0.008) were related with higher mortality.Conclusion:VRI mortality rate is high with an alarming resistance pattern seen in Acinetobacter VRI. EVDs should be removed as soon as feasible, and DC may be offered to patients with severe ventriculitis or meningitis.

Introduction: Many people living with human immunodeficiency virus (HIV) do not enter healthcare until late in their infection course. We analysed the trends in baseline CD4 count among HIV patients in Sungai Buloh Hospital, Malaysia. Material and methods: A retrospective cohort study was conducted from the Malaysian AIDS Treatment Cohort (MATCH) database of HIV-positive patients registered in our HIV clinic between 2007 and 2016. Results: Out of 8757 patients, 84.5% were male. Heterosexual (38.2%) and homosexual (36.4%) contacts were the predominant HIV risk factors. Approximately 44% of patients presented late to care (CD4 < 200 cells/µl). The overall median baseline CD4 cell count was 235 cells/µl. The yearly median baseline CD4 cell count increased steadily from 176 cells/µl in 1997 to a peak of 271 cells/µl in 2015 (p for trend < 0.001). By HIV exposure risks, homosexual risk group consistently had the highest median baseline CD4 cell count, followed by heterosexual and intravenous drug use (IVDU) risk groups. The proportion of late presenters significantly decreased over time from 57.0% in 2007 to 44.0% in 2016 (p for trend < 0.001). Conclusions: The trends in baseline CD4 cell counts are improving, but the proportion of late presenters is still significant. Innovative strategies are imperative to identify HIV infected individuals early and link them promptly to HIV care.

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