SMaRT-PCR: sampling using masks and RT-PCR, a non-invasive diagnostic tool for paediatric pulmonary TB

BACKGROUND

Key challenges in paediatric TB diagnosis are invasive sampling and poor sensitivity of standard methods. This study demonstrates the diagnostic potential of non-invasive sampling of bioaerosols from children using SMaRT-PCR, comprising mask sampling combined with reverse transcriptase-polymerase chain reaction (RT-PCR) for TB.

METHODS

Exhaled bioaerosols were captured on modified N-95 masks in a 10-min talk-cough-breathe process from 51 children (30 with TB confirmed using standard sampling methods and 21 without TB) aged 2-15 years. All mask samples were tested using in-house RT-PCR for 16s and rpoB RNA transcripts. Additional mask samples from children with TB were tested using Xpert® MTB/RIF (n = 3) and Xpert® MTB/RIF Ultra (n = 27).

RESULTS

SMaRT-PCR sensitivity for detecting TB among treatment-naïve children was 96% if 16s or rpoB was present, and 75% if both genes were present, comparable to standard methods (71%) in the same cohort. Specificity was better for both genes, at 95%, than 85% for a single gene detection. Mask sampling with Xpert MTB/RIF or Ultra had a sensitivity of only 13%.

CONCLUSION

This is the first study to provide evidence for testing bioaerosols as a promising alternative for detecting paediatric TB. Sampling is non-invasive and simple, with the potential for point-of-care applications. This pilot study also suggests that RNA transcript-based detection may improve TB diagnostic sensitivity in children; however, further investigation is required to establish its adaptability in clinical settings..

THE STUDY OF VDR FOKI RS2228570 SNP IN AUTOIMMUNE THYROIDITIS

Autoimmune thyroid disease (AITD) is a common organ-specific autoimmune disease. A strong influence of genetic and epigenetic modifications has been demonstrated to take part in the development and progression of autoimmune thyroid diseases. The linkage between the Vitamin D receptor (VDR) polymorphism and several autoimmune disorders, including the AITD. In this article, we aim to investigate the Frequency of VDR Fokl (rs2228570) genotypes (CC, CT, TT) and alleles (C,T) in autoimmune thyroiditis. The investigation of VDR Fokl (rs2228570) was conducted on 150 samples (control (75 healthy women) and diseased women (75 diseased with autoimmune thyroiditis)) patients from the Adjara (Georgia) Population. It also examined some clinical and laboratory characteristics of the study population. Autoimmune thyroiditis's disease was diagnosed by measuring blood antibodies, determining the level of thyroperoxidase, and conducting an ultrasound examination. Anti-TPO and TSH were studied using the ELISA method. The genomic DNA was extracted from the peripheral blood. The polymerase chain reaction was evaluated to examine the VDR Fokl rs2228570 SNP polymorphism. According to VDR Fokl (rs2228570) genotypes (CC; CT, TT) frequency, in the control group, the Frequency of CC-genotype is 48%, CT-heterozygous genotype is 29.33%, and TT-genotype is 22.67%; in the diseased population, the Frequency of CC-genotype is 57.33%, CT-genotype is 34.67%, and TT-genotype is 8%. According to VDR Fokl (rs2228570) alleles (C, T), the Frequency of the C-allele is high, and the Frequency of the T-allele is low in both populations. The Frequency of the CC and CT genotypes of VDR Fokl (rs2228570) is high in the population with autoimmune thyroiditis compared to the control group; the TT genotype is relatively low in the population suffering from autoimmune thyroiditis; According to VDR Fokl (rs2228570) alleles (C, T), the Frequency of C-allele is high both population.

Robot assisted radical prostatectomy in fit older patients compared to a standard population: Clinical characteristics, surgical, oncological and functional outcomes

INTRODUCTION

To compare robotic assisted radical prostatectomy (RARP) in well-selected older patients with clinically localized prostate cancer, compared to a younger population. Primary endpoint was perioperative outcomes comparison and secondary endpoint were oncological and functional outcomes comparison to a younger population.

METHODS

Single tertiary center cohort of consecutive patients treated with RARP (2017-2020) with retrospective analysis. Patients were classified by age in two groups: <75: control group (CG) and ≥75: study group (SG). Patients aged ≥75 had a comprehensive geriatric assessment (CGA) and only patients classified Balducci ≤2 were admitted to surgery.

RESULTS

Two hundred and sixty-nine patients were included, 56 in SG and 213 in CG. Median follow-up was 9.8 months. Univariate analysis showed no statistically significant (SS) difference between the groups for patients' characteristics (PSA, digital rectal examination -DRE- and biopsy Gleason Score), perioperative data (operative time, hospitalization length, transfusions rate, immediate complications, Clavien-Dindo complications, 30-days re-interventions and 30-days re-hospitalisation), oncological (TNM, margins, extraprostatic extension, postoperative PSA, BCR, metastases, overall survival -OS- and cancer specific survival -CSS-) and functional outcomes. Median perioperative blood loss was lower in the SG: 200.00 cc IQR [100.00, 300.00] vs 200.00cc IQR [100.00, 400.00] in the CG (P<0.05). A multivariate regression considering age>75, DRE, GS, PSA, cardiovascular history and diabetes showed none of variables associated with early BCR. Limitations are retrospective design, small number of patients and short follow-up.

CONCLUSIONS

RARP shows similar perioperative, oncologic and functional outcomes for older patients selected by a CGA when compared to younger patients. The SG shows a minor perioperative bleeding.

LEVEL OF EVIDENCE

IV.

Do health care physician need to risk their own lives? Time to change our own attitude towards recommended physical activity

Background

Cardiovascular diseases are the leading cause of death around the world,South Asian population are at higher risk of atherosclerotic coronary artery diseases (CAD) comparatively. There is a recommended physical activity level to prevent atherosclerotic cardiovascular disease (ASCVD). Health care professionals especially doctors are main advisors to prescribe the exercise protocols among general population. Hence we conducted a survey among doctors of Pakistan to identify their physical activity as well as their knowledge and attitude toward recommended physical activity.

Methodology

An online questionnaire was shared with doctors of various specialties working in private and public healthcare system of the Pakistan. It consisted of consent for participation,followed by information regarding demographic profile, preexisting co-morbid conditions, opinion regarding importance of physical activity to prevent ASCVD (5 point scale), perceived physical activity level (4 point scale), knowledge regarding ACC recommended physical activity level for primary prevention of ASCVD, lifestyle, and barriers in following recommended physical activity level. Collected data were entered and analyzed using SPSS version 21.0, participants were categorized into two groups as “cardiologists” and “non-cardiologists” and results were compared between the two groups.

Results

A total of 159 doctors participated in the survey, out of whom 97 (61%) were cardiologist and remaining 62 (39%) were affiliated with other specialties. Male participants (72.3%) were predominant and mean age was 30.44±23.16 years. More than 60% (61.6%) of the participants were free of preexisting co-morbid condition, most common ASCVD risk factor was positive family history (26.4%) followed by smoking (7.5%) and hypertension (6.3%). According to BMI, 21.4% (34) were obese and 40.3% (64) were overweight. A total of 74.8% (119) of the participants claimed to know about ACC recommended physical activity level but 65.5% (78) were actually aware of recommended 150 min of moderate-intensity or 75 min of vigorous-intensity aerobic activity level. According to the lifestyle activities only 26.4% (42) of the participants were found to follow the ACC recommended physical activity level per week, this proportion was same between cardiologists and non-cardiologists, 25.8% vs. 27.4% respectively. Lack of time from daily routine (71.7%) was found to be most commonly stated reason for physical in activeness followed by overburden/over stress at workplace (33.3%) and lack of resources (14.5%).

Conclusion

Knowledge and adherence to the ACC recommended physical actively level was poor among both cardiologists and non-cardiologists even after considering it important for the primary prevention of ASCVD. Majority of doctors were overweight and obese.Lake of time and resources and over stressed work life of doctors are the key barriers in following recommended physical activity level.

Funding Acknowledgement

Type of funding sources: None.

[Outcomes following the triage of patients for urological cancer and non-cancer surgery during Covid-19 pandemic peak]

INTRODUCTION

Faced with the first wave of Covid-19 pandemic, guidelines for surgical triage were developed to free up healthcare resources. The aim of our study was to assess clinical characteristics and surgical outcomes of triaged patients during the first Covid-19 crisis.

METHOD

We conducted a cohort-controlled, non-randomized, study in a University Hospital of south-eastern France. Data were collected prospectively from consecutive patients after triage during the period from March 15th to May 1st and compared with control data from outside pandemic period. Primary endpoint was intensive care unit (ICU) admissions for surgery-related complications. Rates of surgery-specific death, postponed operations, positive PCR testing and Clavien-Dindo complications and data from cancer and non- cancer subgroups were assessed.

RESULTS

After triage, 96 of 142 elective surgeries were postponed. Altogether, 71 patients, median age 68 y.o (IQR: 56-75 y.o), sex ratio M/F of 4/1, had surgery, among whom, 48 (68%) had uro-oncological surgery. No patients developed Covid-19 pneumonia in the post-surgery period. Three (4%) were admitted to the ICU, one of whom died from multi-organ failure due to septic shock caused by klebsiella pneumonia following a delay in treatment. Three Covid-19 RT-PCR were done and all were negative. There was no difference in mortality rates or ICU admission rates between control and Covid- era patients.

CONCLUSIONS

Surgery after triage during the first Covid-19 pandemic was not associated with worse short-term outcomes. Urological cancers could be operated on safely in our context but delays in care for aggressive genitourinary diseases could be life threatening.

LEVEL OF EVIDENCE

3.

Évaluation médico-economique de l’impact de mesures d’adaptation au virage de la chirurgie robot-assistée en urologie

INTRODUCTION

The development of robot-assisted urological surgery is held back by the lack of robust medico-economic analyses and their heterogeneity. We conducted a medico-economic study to evaluate the implementation of measures to optimize the transition to robotic surgery.

METHOD

We carried out a single-center, controlled study from the point of view of the public healthcare establishment for 4 years. Economic data collection was based on a micro-costing method and revenues from stay-related groups. Clinical data corresponded to mean lengths of stay, operating duration, complications and stays in intensive care. The measures to optimize the transition to robotic, implemented mid-study period, enabled before/after comparison.

RESULTS

Altogether, 668 patients undergoing robotic surgery were included. Robotic activity increased significantly from periods 1 to 2 to 256% (P=<0.001) as did the overall proportion of robotic by 45% to 85% (P=<0.001). The mean lengths of stay fell significantly, 6.8 d vs. 5.1 d (P<0.001). Costs and revenues increased significantly, resulting in a persistent deficit for the activity €226K vs. €382K (P=<0.001). With increased volume of activity, the deficit per operation and the cost per minute of robotic operating room fell significantly, €3,284 vs. €1,474/procedure (P=<0.001) and €27 vs €24/min (P=<0.029), tending towards a break-even point (=zero deficit) at 430 operations per year.

CONCLUSIONS

Robotic-assisted surgery can be significantly optimized by implementing measures for the robotic turn to reach a break-even point at 430 operations per year. A better multidisciplinary case mix could lower the break-even volume of activity in short term.

LEVEL OF EVIDENCE

3.

QT interval in patients receiving HCQ in SARS-CoV-2- A study on risk factors and correlation of baseline QTc with delta QTc in Pakistani population

Funding Acknowledgements

Type of funding sources: None.

Introduction

Hydroxychloroquine(HCQ) use alone or in combination with Azithromycin (AZM) in SARS-CoV-2 infection is associated with QTc prolongation and risk of arrhythmias.

Objectives

To determine changes in QTc interval and factors predictive of extreme QTc prolongation in patients receiving HCQ alone or in azithromycin combination in Pakistani patients.

Methodology

Retrospective review of records of hospitalized patients with SARS-Cov2 RT-PCR positive result who received HCQ or HCQ/Azithromycin in combination from March-May 2020. Baseline ECGs as well as post drug use ECGs data was recorded. Tisdale score was calculated for predicting risk of QTc prolongation,QTc interval was calculated using Bazett formula. Data entry and analysis was done in SPSS version 23. 

Results

A total of 134 patients were included in the study.  82.1%(110) were males and 17.9%(24) were females, mean age was 54.9 ± 13.7 years. 61.2% (82) had severe disease and 38.8 %(52) had non-severe disease. 14.2%(19) had history of cardiac disease, 35.8%(48) had hypertension and 35.1%(47) had diabetes mellitus. 70.1% (94) patients had received HCQ, AZM, or HCQ/AZM in combination. 40(29.9%) patients had not received any drug. Median baseline QTc among controls and non-control group was 383.5 (IQR 342.25-413.75)msec  and 379(IQR 358-402)msec respectively. HCQ alone was administered to 26.9%(36) and HCQ/AZM to 33.6%(45) patients. 55.6% (45/81) developed QTc prolongation(QTc> 480 msec) or delta QTc increase > 60 msec. 6.2%(5/81) had absolute QTc > 500 msec post-drug administration. 55.6%(25/45) and  30.6%(11/36) (p-value 0.024) developed QTc prolongation in combination and HCQ alone groups respectively. Delta QTc increased to >60msec in 42.0% (34/81); 53.3%(24/45) in  combination group and in 27.8%(10/36) of those receiving HCQ alone( p-value 0.021). Median delta change was 63( IQR 25-81) and 48.5(IQR 26.25-66.75) msec; Median Day 2 QTc  was 413.5 msec (IQR 377.5-436) and 413 msec (IQR361-447); and median maximum QTc was 447(IQR391-471) and 429.8(IQR401.5-45.75) msec in those receiving HCQ/AZM combination and HCQ alone respectively. 9%(12/134) had arrhythmias during hospital stay, in  8.9% (4) and 5.6%(2) patients of those receiving HCQ/AZM combination and HCQ alone respectively, no patient developed torsade de pointes, one patient had non-sustained VT. There was no statistically significant association of QTc prolongation  with mortality, acute kidney injury, myocardial injury or severity of disease. Diuretic use was found to be statistically significant association with QTc prolongation(p-value 0.038). There was a weak correlation of baseline QTc with Δ QTc(r = 0.207 and p-value 0.017)

Conclusion

QTc prolongation was observed in a significant population of patients receiving HCQ and HCQ/AZM combination, however, no significant life threating arrhythmias occurred.

A systematic review of immune checkpoint inhibitor-related neurological adverse events and association with anti-neuronal autoantibodies

Introduction: Immune checkpoint inhibitors (ICI) therapy has led to a paradigm shift in cancer drug development and in the clinical evaluation of approaches to combination cancer treatment. Dysregulation of the immune system by ICI therapy may also elicit autoimmune phenomena and consequently manifest clinically as immune-related adverse events (irAEs) including neurological irAEs. Areas Covered: The purpose of this review is to explore the role of autoantibodies in the diagnosis and prediction of neurological irAEs and to evaluate their pathogenicity. We searched Pubmed and Embase for neurological irAEs and associated autoantibodies and found 28 patients with central and peripheral neurological irAEs. Of these patients, up to 40% had encephalitis, 34.4% with myasthenia gravis and 22% of patients with peripheral neuropathy and Guillain-Barre Syndrome had autoantibodies. Expert Opinion: Overall, our survey suggested a causal relationship between neurological irAEs and autoantibodies. Detection of autoantibodies may help to diagnose neurological irAEs and inform their clinical management.

Biodegradable dendritic Boltorn™ nanoconstructs: A promising avenue for cancer theranostics

The family of Boltorn™ H40 dendrimers is an imperative subclass of hyperbranched biodegradable polymers (HBPs), which has received mounting attention as a result of its inimitable chemical, physical and biodegradable properties. These properties embrace three-dimensional dendrimeric nanoarchitecture to avert tanglement between polymer branches, adequate spatial cavities for increased encapsulation of guest molecules, good solubility as well as low viscosity to improve processability, and a huge number of surface functional groups for chemical manipulations. Similarly, low toxicity, non-immunogenicity, and natural biodegradation are significant and critical advantages in therapeutic applications as compared to other dendritic polymers. All these characteristics of Boltorn™ H40 are of pronounced importance for planning and developing advanced targeted cargo delivery carriers for cancer therapy. The present review highlights the applications of Boltorn™ H40 HBPs for the transport of chemotherapeutic agents to manage various types of cancers.

P81 Intraoperative MEP recordings from a urethral sphincter electrode for spinal conus tumour surgery and its importance

Objectives

To emphasise the importance of motor evoked potential (MEP) recordings from a simple urethral sphincter electrode along with routine use of bulbocavernosus reflex recordings, anal sphincter and other lower limb muscle free running and stimulated EMG and MEP’s, and SEP techniques for sphincter preservation.

Design

Case report.

Subjects

Patients with conus or other spinal lesions at risk of postoperative sphincter disturbance.

Methods

Transcranial ‘train of 5’ stimulation (5 pulses, interstimulus interval 4msec, 200 µsec pulse width) was applied, with recordings from the urethral sphincter (small electrode taped to Foley catheter to lie just inside the urethra, referred to nearby needle anteriorly in mons pubis) and anal sphincter (paired needle electrodes in both left and right sides of external sphincter).

Results

Intraoperative stimuli of structures during dissection at one point gave a motor response confined to the urethral sphincter suggesting that these fibres may have been considered non-functional and cut had these not been assessed separately. Urethral sphincter MEP’s during the dissection confirmed that these motor fibres remained in continuity throughout.. The patient was intact after tumour removal.

Conclusions

This is an avant-garde technique by which we managed to save the nerve supply to the urethral sphincter and eventually urinary continence which would have been compromised if separate urethral monitoring was not attempted along with usual intraoperative nerve monitoring. We believe its first in the UK.

Improving Metastatic Breast Cancer Care in Kenya Using Information Technology

Background and context: In Africa, up to two thirds of breast cancer patients have been reported to present with an advanced stage of III or IV at diagnosis leading to a disproportionately higher mortality. In Kenya, breast cancer is the most common cancer in females in terms of diagnosis and mortality. Metastatic breast cancer (MBC) patients are an ignored part of the breast cancer community as they are marginalized in many of the breast cancer related initiatives. MBC suffer from clinical depression, anxiety and four out of five of these women do not receive any services, referral or guidance to help them with their emotional distress. Preferred evidence based methods of support desired by women with MBC, include online support. International resources are not always applicable to the local context thus making them unattractive for people from diverse cultures and background, such as those from Africa. Kenya has a high percentage of literate females and highest Internet usage in the area. This provides a unique opportunity in an otherwise limited resource country to reach out to a significant population of MBC patients. The patients voices are a valuable and trustworthy assessment of their actual needs. They have been used frequently in the area of cancer as a first step in designing needs-tailored interventions. We propose to develop a virtual online forum with the aim of providing patients with MBC, and their caregivers an interactive forum for psycho social support, addressing stigmas, seek relevant clinical advice, find links to the nearest healthcare facilities, download helpful information, participate in support group activities and receive links to other important helpful sites that are locally relevant. We also propose that such forum should also reflect the needs of our patients as described by themselves. Aim: Primary aim of this project is developing a virtual online interactive support forum where MBC patients and their caregivers can access information on social, psychological, spiritual, religious and clinical needs. The purpose is to be partly achieved by assessing the patient needs by needs assessment survey and to evaluate the impact of such intervention on patient knowledge and satisfaction with care. Strategy/Tactics: Web site development is the key component of the project. Patients would be asked to fill out the Supportive Care Needs Survey/The Knowledge Assessment Tool. The surveys will take place at four major cancer treatment hospitals in Kenya. Postlaunch promotion and awareness about Web site will be made and, usage data and knowledge tool to be used to assess the impact and acceptability. Web site updated regularly to address issues identified. Program/Policy process: Information gathered would be made part of policy on national cancer strategy, recommendations to factor in identified patient needs in policy. What was learned: Ongoing process.

Prevention of chemotherapy toxicity by agents that neutralize or degrade cell-free chromatin

Background

Toxicity associated with chemotherapy is a major therapeutic challenge and is caused by chemotherapy-induced DNA damage and inflammation. We have recently reported that cell-free chromatin (cfCh) fragments released from dying cells can readily enter into healthy cells of the body to integrate into their genomes and induce DNA double-strand breaks, apoptosis and inflammation in them. We hypothesized that much of the toxicity of chemotherapy might be due to release of large quantities of cfCh from dying cells that could trigger an exaggerated DNA damage, apoptotic and inflammatory response in healthy cells over and above that caused by the drugs themselves.

Methods

We tested this hypothesis by administering cfCh neutralizing/degrading agents namely, anti-histone antibody complexed nanoparticles, DNase I and a novel DNA degrading agent-Resveratrol-Cu concurrently with five different chemotherapeutic agents to examine if chemotherapy-induced toxicity could be minimized.

Results

We observed (i) significant reduction in chemotherapy-induced surge of cfCh in blood; (ii) significant reduction in chemotherapy-induced surge of inflammatory cytokines CRP, IL-6, IFNγ and TNFα in blood; (iii) abolition of chemotherapy-induced tissue DNA damage (γH2AX), apoptosis (active caspase-3) and inflammation (NFκB and IL-6) in multiple organs and peripheral blood mononuclear cells; (iv) prevention of prolonged neutropenia following a single injection of adriamycin and (v) significant reduction in death following a lethal dose of adriamycin.

Conclusion

Our results suggest that toxicity of chemotherapy is caused to a large extent by cfCh released from dying cells and can be prevented by concurrent treatment with cfCh neutralizing/degrading agents.

The Tulip GT® airway versus the facemask and Guedel airway: a randomised, controlled, cross-over study by Basic Life Support-trained airway providers in anaesthetised patients

We performed a randomised, controlled, cross-over study of lung ventilation by Basic Life Support-trained providers using either the Tulip GT® airway or a facemask with a Guedel airway in 60 anaesthetised patients. Successful ventilation was achieved if the provider produced an end-tidal CO2 > 3.5 kPa and a tidal volume > 250 ml in two of the first three breaths, within 60 sec and within two attempts. Fifty-seven (95%) providers achieved successful ventilation using the Tulip GT compared with 35 (58%) using the facemask (p < 0.0001). Comparing the Tulip GT and facemask, the mean (SD) end-tidal CO2 was 5.0 (0.7) kPa vs 2.5 (1.5) kPa, tidal volume was 494 (175) ml vs 286 (186) ml and peak inspiratory pressure was 18.3 (3.4) cmH2 O vs 13.6 (7) cmH2 O respectively (all p < 0.0001). Forty-seven (78%) users favoured the Tulip GT airway. These results are similar to a previous manikin study using the same protocol, suggesting a close correlation between human and manikin studies for this airway device. We conclude that the Tulip GT should be considered as an adjunct to airway management both within and outside hospitals when ventilation is being undertaken by Basic Life Support-trained airway providers.