Collaborative approach to paediatric chronic non-bacterial osteomyelitis of the mandible: Great Ormond Street Hospital case series

This paper outlines a 10-patient case series of chronic non-bacterial osteomyelitis (CNO) of the mandible at a tertiary paediatric hospital in the UK. Our findings highlight the homogeneous presenting signs and symptoms of an intermittently painful, swollen angle and ramus of the mandible. We present the typical laboratory investigative findings (normal inflammatory markers) and imaging appearances (sclerosis and periosteal oedema). Our paper outlines an investigation protocol, including recommendations for extraoral bone biopsies and systemic magnetic resonance imaging (MRI). We explain the importance of multidisciplinary care, with combined care by rheumatologists and infectious disease specialists. Finally we demonstrate the efficacy of our treatment algorithm for oral non-steroidal anti-inflammatory drugs (NSAIDs), and in those cases refractory to NSAIDS, intravenous pamidronate. This paper provides a useful addition to the literature by informing OMF surgeons of this rare condition and given the clinical equipoise in treatments, it can hopefully guide clinicians in an investigation pathway and management protocol.

HAEMATOSPERMIA: CAUSES AND ASSOCIATED CHANGES IN SEMEN ANALYSIS IN NORTH OF IRAQ

Haematospermia is the medical term used to describe the presence of blood in semen. It can occur due to a variety of reasons and can be a benign or serious condition. The present study aimed to identify the prevalence and characterization of haematospermia in patients visiting hospital clinics. To do so, a total of 44 patients were recruited and characterized regarding their demographic variation, symptoms, severity, associated diseases, and measured prostate-specific-antigen (PSA). Results confirmed that patients were middle-aged (around 40 years) and the duration (days) of haematospermia is around 16±12. Only a few of these patients have shown an association with chronic diseases such as hypertension and diabetes or other vascular diseases. Less than 50% of these patients have shown past-surgical history and few of them were using anticoagulants 16±12. The majority of patients had painless haematospermia while only (13.6%) had painful haematospermia, irritative urinary symptoms were found in (13.6%) while obstructive urinary symptoms in (4.5%). Ultrasound (US) examination of the abdomen, pelvis, and scrotum was normal in more than 50% of them while others have shown prostatic involvement. Few of these patients experienced pus on laboratory examination. To sum up, haematospermia is represented as an inconvenient disease in our sample leading to interference with daily quality of life, with no clear understanding aetiology of the disease and its progression.

Predictive risk factors for persistent pain following total prosthetic temporomandibular joint replacement

The aim of this study was to determine the rate of persistent pain following total TMJ replacement and to identify potential predictive risk factors. A retrospective review of case notes treated by a single surgeon in a tertiary unit was performed. For each patient a number of variables were recorded including visual analogue pain scores (0 to 10) and opioid usage pre surgery and at 12 months or last follow up beyond 12 months. Persistent pain scores of 5 to 7 were regarded as moderate and 8 to 10 as severe. The mean pain score at last follow-up was significantly lower than preoperatively (2.1 vs. 6.3, p < 0.001) with a mean follow-up time of 40.1 months (range 12-44). 16.4% of the patients reported moderate to severe pain and 13.7% were still on regular opioids at the last follow-up. Therefore 15 patients (20.5%) suffered from chronic postoperative pain after TMJ replacement surgery. Patients reporting severe preoperative pain scores (p = 0.04), regular opioid use (p = 0.001) or multiple previous open TMJ surgeries (p = 0.03) were more likely to suffer from chronic persistent pain and these should be regarded as predictive risk factors. The identification of these factors allows for better risk stratification of patients, informed consent and the agreement of expected outcomes. Patients with true articular disease and a single failed surgery should be considered for early total TMJ replacement to minimise multifactorial persistent pain.

Patients with NSTEMI have fewer symptoms and higher quality of life three months after admission for acute chest pain

Background

A substantial proportion of patients admitted for possible non-ST elevation acute coronary syndrome (NSTE-ACS) who are not diagnosed with non-ST elevation myocardial infarction (NSTEMI) suffer from conditions (e.g. chronic myocardial injury [CMI]) that may imply serious cardiac risk and impaired quality of life. It is unknown what predicts quality of life and recurrence of symptoms in chest pain patients.

Purpose

To investigate which demographic and clinical characteristics, including discharge diagnosis, that predict recurrent symptoms and quality of life three months after hospitalization for acute chest pain.

Methods

A total of 1506 patients ≥18 years admitted with suspected NSTE-ACS at Haukeland University Hospital, Bergen, Norway, were included in the WESTCOR study. The final diagnosis was adjudicated by two independent cardiologists based on all clinical data including routine cTnT (5th gen, Roche Diagnostics). Three months after discharge patients received questionnaires assessing general health (SF-12v1), angina-related health (SAQ-7) and dyspnea (Rose Dyspnea Scale). In all, 774 (51.3%) patients responded and were included in the analyses. Univariable and multivariable regression models were applied to identify predictors of symptoms and quality of life scores after adjusting for a subset of candidate predictors. A subgroup analysis was undertaken in patients with stable troponin concentrations (N=658).

Results

Based on the discharge diagnosis the patients were grouped as NSTEMI (14.2%), unstable angina pectoris (UAP) (16.9%), non-coronary cardiac disease (6.6%), non-cardiac disease (6.3%) and non-cardiac chest pain (NCCP) (56.0%). After three months the NSTEMI patients had the highest quality of life scores and the lowest prevalence of symptoms (angina and dyspnea), while the inverse was true for the UAP patients (Fig 1). Revascularized patients had a better quality of life compared to those treated conservatively (P&lt;0.001). Adjusted multivariable analysis also demonstrated that revascularization (β=0.19, P=0.002) and a diagnosis of UAP (β=−0.18, P=0.007) succeeded to predict angina frequency. Additionally, current smoking and hypertension were also associated with worse quality of life outcomes (Table 1). NCCP patients had high median prevalence of symptoms after three months, with 50% of the group reporting chest pain in the last four weeks, and 33% reporting dyspnea. In the subgroup analysis, current smoking predicted worse quality of life in all domains (all P&lt;0.05) except SAQ7-Angina frequency.

Conclusions

Three months after hospitalization for chest pain revascularized patients had better quality of life and less symptoms compared to other patient groups. A diagnosis of UAP predicted recurrent symptoms and impaired quality of life in patients, suggesting that closer monitoring should be considered in order to minimize re-hospitalization.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The study is funded by grants from the Western Norway Regional Health Authority, Haukeland and Stavanger University hospitals. Figure 1Table 1

1527 A Rare Case of Facial Skin Necrosis Following Subdermal Poly-L-Lactic Acid Injection

Introduction

Non-surgical / minimally invasive aesthetic procedures are a growing trend in the UK. A range of devices are available for soft tissue augmentation, including injectable Poly-L-Lactic acid (PLLA). PLLA is used for soft tissue augmentation and is thought effective for the correction of contour deficiencies, facial wrinkles and in restoring subcutaneous volume in patients with HIV-associated lipoatrophy.

Method

In this case report, we present a rare but serious complication of subdermal injection of Poly-L-Lactic acid. A 45-year-old lady presented to our service approximately 24 hours after administration of self-sourced poly-L-Lactic acid.

Results

A 4cm ovaloid patch of full thickness skin necrosis over the zygomatic region was evident on presentation, with reactive/inflammatory changes in the adjacent skin. Vascular compromise is deemed the most likely cause, with loss of the transverse facial artery mapping to the area of necrosis. This patient was managed conservatively, with dressings and a prophylactic course of antibiotics.

Conclusions

Vascular compromise is a recognised and rare complication of subdermal injectable devices for facial soft tissue augmentation. The transverse facial artery branches from the superficial temporal artery within the substance of the parotid gland. Cadaveric and imaging studies alike demonstrate that the most common anatomical variant is a single TFA (70%), originating at the level of the temporofacial trunk of the facial nerve. It typically has a 5cm course, giving off on average 1.9 cutaneous perforators. This case highlights the importance of a detailed understanding of facial anatomy to ensure safe and effective placement of dermal fillers/devices.

Biodiversity of orb-web spiders (family: araneidae) of buner valley, Pakistan

The present research was carried out to explore the spider fauna of Buner valley with taxonomic study from February 2018 to January 2019. For this purpose samples were collected, four times at each month from 4 tehsils: Daggar, Gagra, Mandan and Totalai. Two methods were used, hand picking and sweep net for collection of samples. During day and night, three habitats, arid area, agriculture land and building area were search for collection. A total of 534 samples of spider were collected from four sampling sites, in which 379 were belonging to family Araniedae. After confirmation, the identified species were belonging to 8 genera (Neoscona, Argiope, Cyclosa, Araneus, Cyrtophora, Larinia, Erivoxia and Poltys) and 19 species. 18 of them were identified to specie level while a single specie to its generic level. The genus Neoscona was the dominant genus 26.31% having 5 species while the genus Argiope 21.05% is the second dominant having 4 species followed by Cyclosa 15.78% having 3 species followed by Cyrtophora and Araneus 10.52% having two species both. The Poltys and Larinia 5.26% are the rarest genera represent single-single specie both. Statistical analysis show that specie richness (D) = 5.77, Simpson index (1-D) = 0.87, Shannon index (H) = 2.33. Diversity of spiders was evenly distributed and calculated Evenness value was H/InS = 0.5408. There is also few atypical species and Fisher alpha estimate high value (Fisher α) = 4.42. Chao-1 estimated we have reported 22 species.

Systematic analysis of leisler's bat Nyctalus leisleri (Kuhl, 1817) captured from FATA region, Pakistan

Extensive field surveys were carried out to explore the distribution of Leisler's Bat Nyctalus leisleri (Kuhl, 1819) in selected area of FATA regions, Pakistan. Specimens of Leisler's Bat Nyctalus leisleri (Kuhl, 1819) (n5) were collected from Kurram Agency (Shublan) (N33.8229788 E70.1634414) at elevation 1427m and Khyber Agency (Landi Kotel) (N34.0909899 E71.1457517) at elevation 1091m for two years survey extending from May 2013 through August 2015. The mean head and body length, hind foot length, ear length and tail length the Nyctalus leisleri specimens captured from the study area was 65.08 ± 1.58 mm, 44.06 ± 0.52 mm, 8.38 ± 0.60 mm, 13.20 ± 0.99 mm and 39.46 ± 1.46 mm, respectively. For molecular analysis the sequences of COI gene were obtained and analyzed. The mean intraspecific divergences of Nyctalus leisleri was 0.04%. The mean interspecific divergences of Nyctalus noctula and Nyctalus leisleri was 0.2%. The mean concentration of each nucleotides was A = (26.3%), T = (32.8%), G = (15.9%) and C = (25.0%). The mean A+T contents were 59.2%and C+G were 40.9%. In the phylogenetic tree Nyctalus leisleri and Nyctalus noctula clustered with significant bootstrap support value.

Molecular detection of carbapenem resistance genes in rectal swabs from patients in Gulf Cooperation Council hospitals

BACKGROUND

Gram-negative organisms harbouring carbapenem resistance genes (CRGs) are spreading globally, including in Gulf Cooperation Council (GCC) countries. However, relatively few data are available about carriage of CRGs in hospitalized patients in this region.

AIM

To determine prevalence of CRG carriage and risk factors for colonization among patients in GCC hospitals.

METHODS

Rectal swabs were obtained from ∼50 intensive care unit (ICU) patients from each of 11 hospitals in five GCC countries between March and November 2019. The swabs were tested for the presence of bla_KPC, bla_NDM, bla_VIM, bla_IMP, and bla_OXA-48 CRG using a commercial polymerase chain reaction test. Data on risk factors for colonization were collected and analysed.

FINDINGS

Of 529 specimens screened, 138 (26.1%) were positive for one or more CRGs. The positivity rates among the hospitals ranged from 8.0% to 67.3%; ∼20% of the positive specimens harboured ≥2 CRGs. The most common CRG detected was bla_OXA-48, which was present in 82 specimens (15.5%). Additional CRGs included bla_NDM, bla_VIM, bla_KPC, and bla_IMP either alone or in combination. Overall, 31.1% of patients on antibiotics on admission to the ICU were positive for CRGs compared to 16.5% not on antibiotic therapy (P < 0.001). CRG detection was also more common among patients aged >65 years (P = 0.027) and increased with hospital length of stay (P = 0.025).

CONCLUSION

The rate of CRGs detected in hospitalized patients in GCC countries varied considerably. Prior antibiotic exposure, increasing age, and prolonged length of stay were associated with CRG detection.

Trend of bacterial meningitis in Bahrain from 1990 to 2013 and effect of introduction of new vaccines

Meningitis is among the 10 commonest infectious causes of death worldwide. This retrospective analysis of reported cases of meningitis in Bahrain aimed to assess the trend in the incidence of bacterial meningitis from 1990 to 2013, before and after the introduction of new vaccines. Of 1455 reported cases of meningitis during the study period 73.1% were viral and 26.9% were bacterial etiology (tuberculous meningitis 8.3%; Streptococcus pneumoniae 4.9%, Haemophilus influenzae 3.6% and Neisseria meningitidis 1.7%). There was a peak of meningitis cases in 1995-1996. The incidence of meningitis due to H. influenzae and N. meningitidis showed a marked reduction after the introduction of the corresponding vaccines in 1998 and 2001 respectively, and S. pneumoniae became the predominant organism after Mycobacterium tuberculosis. The changing trend in the etiology of bacterial meningitis points to the need to study vaccination programme modifications, such as pneumococcal vaccine for the adult population, especially high-risk groups.

Invasive candidiasis in Pakistan: clinical characteristics, species distribution and antifungal susceptibility

This study reports for the first time, to our knowledge, descriptive epidemiological data for 188 invasive Candida isolates from Pakistan, including species identification and antifungal susceptibility against fluconazole, itraconazole, voriconazole, caspofungin, micafungin, anidulafungin and amphotericin. Risk factors for invasive candidiasis (IC) were determined for 96 patients from Karachi, Pakistan. In adults and neonates, Candida tropicalis (38 and 36 %, respectively) was the most common species, followed in adults by Candida parapsilosis (17.8 %), Candida glabrata (15.9 %) and Candida albicans (12.3 %). C. albicans (21 %) was the second most common in neonates. In children, C. albicans (31.9 %), C. tropicalis (26.4 %) and C. parapsilosis (19.4 %) were the most common. C. albicans IC was significantly associated with paediatric age [crude odds ratio (COR) 3.46, 95 % confidence interval (CI) 1.63-7.32]. Rare species made up 17.5 % of the total isolates studied. Resistance to fluconazole was seen in C. glabrata (15 .0%) and Candida krusei (100 .0%). Only one isolate (C. glabrata) was resistant to all three echinocandins. Low MICs of fluconazole for 98 % (184/188) of isolates tested support its continued use as an empiric therapy for IC. Non-C. albicans IC was associated with the use of β-lactam inhibitor combinations (COR 3.16, 95 % CI 1.05-9.57). Use of healthcare devices was documented in 85.4 % of IC patients, whilst 75 .0% had been admitted to special care units. Surprisingly, 66.7 % of patients with IC were not obviously immunosuppressed. The high frequency of modifiable risk factors in this population indicates that candidaemia can be reduced with stringent antibiotic and infection control measures. These data will be useful for empiric selection of antifungals in Karachi, and contribute to global assessments of antifungal resistance.

Genetic analysis of NaCl tolerance in tomato

We attempted to find the suitable parents for the development of tomato hybrids for high salt soils by exploiting combining ability, gene action and heterosis. Six salt-tolerant and three salt-intolerant genotypes, along with their 18 F1 crosses, were evaluated at seedling stage under 10 and 15 dS/m (NaCl) salinity stress, compared to the control level of salinity. The experiment was laid out based on a two-way complete randomized design factorial arrangement with two replications; data on root and shoot length, fresh and dry weights, leaf area, plant length, Na(+), K(+) and K(+)/Na(+) concentrations were recorded. There was significant variation within genotypes, lines, testers, crosses, and line × tester interaction for all plant characters studied under normal and two salinity levels. Estimates of combining ability indicated that under low (10 dS/m) and high (15 dS/m) salinities, line BL1176 and tester LO2875 showed significant GCA effects for most of the traits studied. The cross-combinations 6233 × LO2875, CLN2498A x LO2875 and BL1176 × 17902 showed highest SCA values for most of the characters under 10 and 15 dS/m, respectively. Potence ratio showed that under low and high salinities, all the traits showed over dominant type of gene action except leaf area and K(+) concentration (in 10 dS/m) and shoot length, and leaf area (in 15 dS/m). The highest heterosis for most of the parameters was observed in cross-combinations BL1176 × LO2875 and CLN2498A x LO2875.

Genetic variability of NaCl tolerance in tomato

Cultivation of crops in soils with high salt (NaCl) content can affect plant development. We examined the morphological and physiological mechanisms of salt tolerance in tomato. The responses of 72 accessions of tomato (Solanum lycopersicum) to salinity were compared by measuring shoot and root lengths, and fresh shoot and root weights relative to those of controls (plants grown in normal salt levels). All traits were reduced at the seedling stage when salinity levels were increased. The accession x salinity interaction was significant for all traits. Root length had higher heritability than other traits and was used as a selection criterion to identify salt-tolerant and -non-tolerant accessions. On the basis of root length, accessions LA2661, CLN2498A, CLN1621L, BL1176, 6233, and 17870 were considered to be more tolerant than accessions 17902, LO2875 and LO4360. The degree of salt tolerance was checked by analyzing K+ and Na+ concentrations and K+/Na+ ratio in tissues of plants treated with 10 and 15 dS/m salinity levels. Tolerance of these accessions to salinity was most associated with low accumulation of Na+ and higher K+/Na+ ratios.

Applications of multi-nuclear magnetic resonance spectroscopy at 7T

AIM: To discuss the advantages of ultra-high field (7T) for ¹H and ¹³C magnetic resonance spectroscopy (MRS) studies of metabolism.

METHODS: Measurements of brain metabolites were made at both 3 and 7T using ¹H MRS. Measurements of glycogen and lipids in muscle were measured using ¹³C and ¹H MRS respectively.

RESULTS: In the brain, increased signal-to-noise ratio (SNR) and dispersion allows spectral separation of the amino-acids glutamate, glutamine and γ-aminobutyric acid (GABA), without the need for sophisticated editing sequences. Improved quantification of these metabolites is demonstrated at 7T relative to 3T. SNR was 36% higher, and measurement repeatability (% coefficients of variation) was 4%, 10% and 10% at 7T, vs 8%, 29% and 21% at 3T for glutamate, glutamine and GABA respectively. Measurements at 7T were used to compare metabolite levels in the anterior cingulate cortex (ACC) and insula. Creatine and glutamate levels were found to be significantly higher in the insula compared to the ACC (P < 0.05). In muscle, the increased SNR and spectral resolution at 7T enables interleaved studies of glycogen (¹³C) and intra-myocellular lipid (IMCL) and extra-myocellular lipid (EMCL) (¹H) following exercise and re-feeding. Glycogen levels were significantly decreased following exercise (-28% at 50% VO₂ max; -58% at 75% VO₂ max). Interestingly, levels of glycogen in the hamstrings followed those in the quadriceps, despite reduce exercise loading. No changes in IMCL and EMCL were found in the study.

CONCLUSION: The demonstrated improvements in brain and muscle MRS measurements at 7T will increase the potential for use in investigating human metabolism and changes due to pathologies.