Prevention of vaccine-matched and mismatched influenza in children aged 6-35 months: a multinational randomised trial across five influenza seasons

BACKGROUND

Despite the importance of vaccinating children younger than 5 years, few studies evaluating vaccine prevention of influenza have been reported in this age group. We evaluated efficacy of an inactivated quadrivalent influenza vaccine (IIV4) in children aged 6-35 months.

METHODS

In this phase 3, observer-blinded, multinational trial, healthy children from 13 countries in Europe, Central America, and Asia were recruited in five independent cohorts, each in a different influenza season. Participants were randomly assigned (1:1) to either IIV4 (15 μg haemagglutinin antigen per strain per 0·5 mL dose; a single dose on day 0 for vaccine-primed children, and two doses, on days 0 and 28, for vaccine-unprimed children) or to one or two doses of a non-influenza control vaccine. Primary endpoints were moderate-to-severe influenza or all influenza (irrespective of disease severity) confirmed by RT-PCR on nasal swabs. Cultured isolates were further characterised as antigenically matched or mismatched to vaccine strains. Efficacy was assessed in the per-protocol cohort and total vaccinated cohort (time-to-event analysis), and safety was assessed in the total vaccinated cohort.

FINDINGS

Between Oct 1, 2011, and Dec 31, 2014, 12 018 children were recruited into the total vaccinated cohort (6006 children in the IIV4 group and 6012 children in the control group). 356 (6%) children in the IIV4 group and 693 (12%) children in the control group had at least one case of RT-PCR-confirmed influenza. Of these 1049 influenza strains, 138 (13%) were A/H1N1, 529 (50%) were A/H3N2, 69 (7%) were B/Victoria, and 316 (30%) were B/Yamagata. Overall, 539 (64%) of 848 antigenically characterised isolates were vaccine-mismatched (16 [15%] of 105 for A/H1N1; 368 [97%] of 378 for A/H3N2; 54 [86%] of 63 for B/Victoria; 101 [33%] of 302 for B/Yamagata). Vaccine efficacy was 63% (97·5% CI 52-72) against moderate-to-severe influenza and 50% (42-57) against all influenza in the per-protocol cohort, and 64% (53-73) against moderate-to-severe influenza and 50% (42-57) against all influenza in the total vaccinated cohort. There were no clinically meaningful safety differences between IIV4 and control.

INTERPRETATION

IIV4 prevented influenza A and B in children aged 6-35 months despite high levels of vaccine mismatch. Vaccine efficacy was highest against moderate-to-severe disease, which is the most clinically important endpoint associated with greatest burden.

FUNDING

GlaxoSmithKline Biologicals SA.

Low Seroprevalence of Torque Teno Virus in HCV positive patients and phylogenetic analysis from Pakistani isolates

The torque teno virus (TTV) has a heterogeneous genome and its role in hepatitis C (HCV) infection is still controversial, therefore the purpose of the present study was to determine if there is any association between Hepatitis C and TTV co-infection and to determine the phylogenetic relationship between existing types in the Pakistani population. A total of 500 individuals (250 HCV positive patients and 250 healthy controls) were selected. DNA was extracted from serum samples and polymerase chain reaction (PCR) of the open reading frame 1 (ORF1) region of TTV was performed. Out of 500 samples 9 HCV positive index cases (3.6%) and 8 healthy samples (3.2%) were found to be positive for TTV. A comparison was made between TTV sequences reported from all over the world with the ones obtained in the present study by sequencing of TTV positive samples followed by phylogenetic analysis using maximum parsimony (MP) method. Our results indicated that the virus was undergoing divergent evolution as very high sequence diversity was found in the ORF1 gene. The study also shows that association between HCV and TTV was not found. Because the virus was found to be affecting both healthy individuals and HCV infected population with almost same frequency. Therefore a thorough screening of TTV virus at the population level is required in order to draw a comprehensive inference.

Cassava flour slurry as a low-cost alternative to commercially available gel for obstetrical ultrasound: a blinded non-inferiority trial comparison of image quality

OBJECTIVE

To evaluate the quality of ultrasound images obtained with cassava flour slurry (CFS) compared with conventional gel in order to determine objectively whether CFS could be a true low-cost alternative.

DESIGN

Blinded non-inferiority trial.

SETTING

Obstetrical ultrasound unit in an academic medical centre.

POPULATION OR SAMPLE

Women with a singleton pregnancy, undergoing anatomy ultrasounds.

METHODS

Thirty pregnant women had standard biometry measures obtained with CFS and conventional gel. Images were compared side-by-side in random order by two blinded sonologists and rated for image resolution, detail and total image quality using a 10-cm visual analogue scale. Ratings were compared using paired t-tests. Participant and sonographer experience was measured using five-point Likert scales.

MAIN OUTCOME MEASURES

Image resolution, detail, and total image quality. Participant experience of gel regarding irritation, messiness, and ease of removal.

RESULTS

We found no significant difference between perceived image quality obtained with CFS (mean = 6.2, SD = 1.2) and commercial gel (mean = 6.4, SD = 1.2) [t (28) = -1.1; P = 0.3]. Images were not rated significantly differently for either reviewer in any measure, any standardized image or any view of a specific anatomic structure. All five sonographers rated CFS as easy to obtain clear images and easy for patient and machine cleanup. Only one participant reported itching with CFS.

CONCLUSIONS

CFS produces comparable image quality to commercial ultrasound gel. The dissemination of these results and the simple CFS recipe could significantly increase access to ultrasound for screening, monitoring and diagnostic purposes in resource-limited settings.

FUNDING

This study was internally funded by our department.

TWEETABLE ABSTRACT

Low-cost homemade cassava flour slurry creates images equal to commercial ultrasound gel, improving access.

Biodegradation of benzo[a]pyrene by bacterial consortium isolated from mangrove sediment

Benzo[a]pyrene is a high-molecular-weight polycyclic aromatic hydrocarbon highly recalcitrant in nature and thus harms the ecosystem and/or human health. Therefore, its removal from the marine environment is crucial. This research focuses on benzo[a]pyrene degradation by using enriched bacterial isolates in consortium under saline conditions. Bacterial isolates capable of using benzo[a]pyrene as sole source of carbon and energy were isolated from enriched mangrove sediment. These isolates were identified as Ochrobactrum anthropi, Stenotrophomonas acidaminiphila, and Aeromonas salmonicida ss salmonicida. Isolated O. anthropi and S. acidaminiphila degraded 26% and 20%, respectively, of an initial benzo[a]pyrene concentration of 20 mg/L after 8 days of incubation in seawater (28 ppm of NaCl). Meanwhile, the bacterial consortium decomposed 41% of an initial 50 mg/L benzo[a]pyrene concentration after 8 days of incubation in seawater (28 ppm of NaCl). The degradation efficiency of benzo[a]pyrene increased to 54%, when phenanthrene was supplemented as a co-metabolic substrate. The order of biodegradation rate by temperature was 30°C > 25°C > 35°C. Our results suggest that co-metabolism by the consortium could be a promising biodegradation strategy for benzo[a]pyrene in seawater.

Immunologic non-inferiority and safety of the investigational pneumococcal non-typeable Haemophilus influenzae protein D-conjugate vaccine (PHiD-CV) 4-dose vial presentation compared to the licensed PHiD-CV 1-dose vial presentation in infants: A phase III randomized study

BACKGROUND

To support vaccination programs in developing countries, a 4-dose vial presentation of pneumococcal non-typeable Haemophilus influenzae protein D-conjugate vaccine (PHiD-CV) was developed. This study assessed immunologic non-inferiority and safety of the investigational PHiD-CV 4-dose versus licensed 1-dose vial presentation in infants.

METHODS

In this phase III, mono-center, observer-blind study in Bangladesh, 6-10-week-old infants were randomized 1:1 to receive PHiD-CV primary vaccination (at ages 6, 10, 18 weeks) and a booster dose (at age 9 months) with a 4-dose vial (with preservative, 4DV group) or 1-dose vial (preservative-free, 1DV group). DTPw-HBV/Hib was (co)-administered per study protocol and polio, measles and rubella vaccines as part of the national immunization program. Non-inferiority of PHiD-CV 4-dose versus 1-dose vial for each vaccine pneumococcal serotype (VT) and vaccine-related serotype 19A in terms of antibody geometric mean concentration (GMC) was assessed (criterion: upper limit of 2-sided 95% confidence interval of antibody GMC ratios [1DV/4DV] <2-fold). Immune responses were measured. Solicited, unsolicited and serious adverse events (AEs) were evaluated.

RESULTS

Of 320 infants (160 per group) vaccinated during the primary vaccination phase, 297 received a booster. Non-inferiority was demonstrated for each VT and 19A. One month post-primary vaccination, for most VT, ≥97.9% of infants in each group had antibody concentrations ≥0.2 μg/mL; for 19A ≥ 80.1% reached this threshold. Pneumococcal antibody responses and opsonophagocytic activity for each VT and 19A were within similar ranges between groups after primary and booster vaccination, as were anti-protein D responses. Booster immune responses were observed in both groups. Reported AEs were within similar ranges for both presentations.

CONCLUSION

Immunologic non-inferiority of PHiD-CV 4-dose vial (with preservative) versus PHiD-CV 1-dose vial (preservative-free) was demonstrated. Immune responses and reactogenicity following primary/booster vaccination were within similar ranges for both presentations. PHiD-CV 4-dose vial would help improve access and coverage in resource-limited countries. Clinical Trial Registry: NCT02447432.

[Renal cell carcinomas in childhood]

BACKGROUND

Renal cell carcinoma is a rare childhood disease. However, it should be considered in the differential diagnosis in the detection of a renal mass.

OBJECTIVES

Incidence and mortality of renal cell carcinomas in childhood. Presentation of clinical symptoms, diagnostics, histology, therapy and course of the disease.

PATIENTS AND METHODS

Evaluation of our own prospective data of a small patient population of 8 patients, as well as discussion of the current literature on this tumor entity.

RESULTS

The average follow-up period was 27 months. Preoperative staging studies showed no metastases. The histologically primary predominant subtype was papillary renal cell carcinoma. Tumor stage and lymph node status were the most important prognostic factors in our study.

CONCLUSIONS

Renal cell carcinoma in childhood is a rare disease whose treatment is challenging and should be performed in an interdisciplinary team. Typical clinical symptoms, as in adults, are absent. The partial nephrectomy should be, if practicable, the surgical treatment of choice. The most important risk factors for survival are tumor stage and lymph node status. Data on adjuvant target therapy for metastatic disease in childhood are lacking. Further prospective, multicenter studies are necessary to generate more information on the biology and course of this disease and to obtain adjuvant treatment options in locally advanced disease.

[Epidemiology and clinical characteristics of primary congenital glaucoma]

INTRODUCTION

Primary congenital glaucoma (PCG) is a rare and sight threatening condition. Few large epidemiological studies are available in the literature concerning this condition. The purpose of the study was to evaluate the epidemiological and clinical characteristics of children affected by PCG.

PATIENTS AND METHOD

Children affected by PCG, from 1 day to 3 years old at the time of diagnosis were retrospectively included between 1999 and 2014. The analysis concerned the pregnancy, family history, initial referral, clinical presentation with description of the classic findings in this condition, mean age at first consultation, duration of follow-up and presence of a delay in treatment, defined as a delay of over one month from the appearance of clinical signs until diagnosis. Two groups were defined according to age at appearance of the clinical signs: "early" group prior to 2 months old and "late" group beyond 2 months up until 3 years old.

RESULTS

One hundred and forty-one eyes of 71 children were included, with 49.3% girls (n=35 children) and 50.7% boys (n=36 children) for a male:female ratio of 1.02. The "early" group included 50 children i.e. 70.3% of the population; the "late" group 21 children or 29.7% of the population. A first-degree family history of congenital glaucoma existed in 28% of cases (n=19). The average age at first consultation was 13.1 months for the entire population, and the mean duration of follow-up was 56.6 months. Involvement was bilateral in 99.3% of cases (n=70 children) and the most frequent clinical sign was buphthalmos in 64.5% of eyes (n=91 eyes). Treatment was delayed in 35.3% of cases (n=25 children).

DISCUSSION AND CONCLUSION

This study is of particular relevance because it was performed over a long period and on a large population, considering the rare prevalence of the pathology, and has found epidemiological and clinical data comparable with those available in the literature for similar populations.

[Corneal neovascularisation treatments compared: Subconjunctival bevacizumab injections and/or photodynamic therapy]

PURPOSE

To evaluate and compare the efficacy of subconjunctival bevacizumab injections alone, photodynamic therapy alone and combined treatments for reduction of corneal neovascularization.

METHODS

This study was conducted as a prospective case series. A total of seven eyes of 7 patients with corneal neovascularization caused by ocular surface disorders including fungal infectious keratitis and penetrating keratoplasty were included in the study. Patients were randomized into the three following groups: patients in group A received a single subconjunctival injection of 10mg (0.4mL) of bevacizumab, patients in group B were treated with photodynamic therapy with verteporfin (6mg/m(2)) to the neovascularized area and those in group C received a subconjunctival injection of bevacizumab and photodynamic therapy 7 days later. Morphological changes in neovascularization were evaluated over 6 months using slit-lamp biomicroscopy and digital corneal photography. A computer-assisted semi-automatic analysis of the area of corneal neovascularization was performed with Image J software.

RESULTS

Recession of corneal vessels was observed in all eyes at 1 month post-treatment. The neovascularized surface area in all groups combined showed a decrease in the first month after treatment and this decrease continued up to the 6th month. The surface area of corneal neovascularization decreased by 34.05±8.28% in group A (subconjunctival injection of bevacizumab), by 42.06±28.36% in group B (photodynamic therapy with verteporfin) and by 51.67±18.93% in group C (combined subconjunctival injection of bevacizumab and photodynamic therapy). A combined treatment consisting of a subconjunctival injection followed by a PDT session 7 days later might be more effective for the treatment of corneal neovascularisation. No serious local or systemic adverse events were observed.

CONCLUSIONS

Our medium-term results suggest that combined subconjunctival injection of bevacizumab and photodynamic therapy with verteporfin might be used safely and effectively to reduce corneal neovascularization surface. This combined therapy may show a tendency toward greater efficacy than the individual monotherapies. Controlled prospective randomized multicentric trials with a larger sample size are necessary to assess long-term efficacy and to confirm these results.

[Long-term efficacy of Fadenoperation associated to conventional surgery in the treatment of esotropia with distance-near incomitance: About 55 cases]

OBJECTIVE

The purpose of this study is to evaluate the short-, medium- and long-term efficacy of posterior fixation sutures with conventional surgery in controlling strabismus in the case of esotropia with distance-near incomitance.

MATERIALS AND METHODS

This is a retrospective study of consecutive patients with partially accommodative and non-accommodative esotropia associated with distance-near incomitance who underwent posterior fixation sutures along with conventional surgery. The preoperative and postoperative distance and near deviation measurements and the distance-near incomitance were evaluated at 1, 6 and 12 years. Surgical success was defined as a postoperative distance angle and a distance-near incomitance less than 10 prism diopters (PD).

RESULTS

In total, 55 patients were included. Preoperatively, the mean distance deviation, near deviation and distance-near incomitance were 15.9 (± 3.4), 29.7 (± 5.8) and 13.8 (± 3.1) PD, respectively. Postoperatively, the mean distance deviation was 1.6 (± 0.8) PD (P < 0.001) at 1 year, 2.8 (± 1.6) PD (P< 0.005) at 6 years and 5.6 (± 2.4) PD (P < 0.05) at 12 years. The mean near deviation was 7.8 (± 2.3) PD (P < 0.001) at 1 year, 10.5 (± 3.7) PD (P < 0.005) at 6 years and 15.2 (± 4.4) PD (P < 0.05) at 12 years. The mean distance-near incomitance was 5.2 (± 1.8) PD (P < 0.01) at 1 year, 7.7 (± 2.8) PD (P < 0.05) at 6 years and 9.6 (± 3.2) PD (P > 0.05) at 12 years. The success rate was 91, 78 and 58% at 1, 6 and 12 years, respectively.

CONCLUSION

Distance-near incomitance is a source of amblyopia. It needs to be corrected while treating an esotropia. This study seems to confirm the short- and medium-term efficacy of posterior fixation sutures along with conventional surgery in the treatment of this problem. It also seems to show progressive, albeit partial, loss of its long-term efficacy.

Disseminated intravascular coagulation in acute promyelocytic leukaemia and its impact on the induction failure: a single centre study

Life-threatening coagulopathy associated with acute promyelocytic leukemia (APL) has been the defining clinical characteristic and is an important risk factor for fatal haemorrhage and early death. Pathogenesis of coagulopathy in APL is complex and mainly includes disseminated intravascular coagulation (DIC). The study was done to see the status of DIC and its impact on the outcome of APL in our setting. Among the total 60 patients, induction mortality rate was 30% and remission rate was 70%. The main cause of induction mortality was bleeding that accounts for 66.7% of mortality. DIC was present among 32 out of 60 patients (53.33%). Induction mortality has significant relationship to DIC as the induction mortality rate is 47% in patients with DIC and 11% in patient without DIC (P value 0.0009). Induction motality rate in low, intermediate and high risk group is 6.70%, 24% and 58% respectively (p value < 0.0001). Finally, risk group subclassification revealed presence of DIC in high risk group has the highest early mortality rate.

A novel and robust technique for determining lymph node status in colorectal cancer

483

Background: Currently, techniques that determine lymph node positivity (prior to resection) have poor sensitivity and specificity. The ability to determine lymph node status, based on preoperative biopsies, would greatly assist in planning treatment in colorectal cancer. This is particularly relevant in polyp-detected cancers. This study aims to harness the potential of public gene expression repositories, to develop gene expression profiles that could accurately determine nodal status in colorectal cancer. Methods: Public gene expression repositories were screened for experiments comparing metastatic and non-metastatic colorectal cancer. A customized graphic user interface was developed to extract genes dysregulated across the majority of identified studies (i.e., consensus profiles or “CP”). The utility of CP was tested by determining if classifiers could be derived that determined nodal positivity or negativity. CP-derived classifiers were tested on separate Affymetrix and Illumina–based experiments and collated outputs compiled in summary-receiver operator curve characteristic format. The association between classification and oncologic outcome was determined using an additional, independent data set. Results: Four consensus profiles were generated from which classifiers were derived that accurately determined node positive and negative status (pooled AUC were 0.79 ± 0.04 and 0.8 ± 0.03 for nodal positivity and negativity respectively). Overall AUC ranged from 0.73 to 0.86 demonstrating high accuracy across consensus profile type, classification technique and array platform used. As CP enabled classification of nodal status, survival outcomes could be compared for those predicted node negative or positive. Patterns of disease-free and overall survival were identical to those observed for standard histopathologic nodal status. Genes contained within consensus profiles were strongly linked to the metastatic process and included FYN, WNT5A, COL8A1 and BMP. Conclusions: Microarray expression data available in public gene expression repositories can be harnessed to generate consensus profiles. The latter are a source of classifiers that have prognostic and predictive properties.

Somatic CALR mutations in myeloproliferative neoplasms with nonmutated JAK2

BACKGROUND

Somatic mutations in the Janus kinase 2 gene (JAK2) occur in many myeloproliferative neoplasms, but the molecular pathogenesis of myeloproliferative neoplasms with nonmutated JAK2 is obscure, and the diagnosis of these neoplasms remains a challenge.

METHODS

We performed exome sequencing of samples obtained from 151 patients with myeloproliferative neoplasms. The mutation status of the gene encoding calreticulin (CALR) was assessed in an additional 1345 hematologic cancers, 1517 other cancers, and 550 controls. We established phylogenetic trees using hematopoietic colonies. We assessed calreticulin subcellular localization using immunofluorescence and flow cytometry.

RESULTS

Exome sequencing identified 1498 mutations in 151 patients, with medians of 6.5, 6.5, and 13.0 mutations per patient in samples of polycythemia vera, essential thrombocythemia, and myelofibrosis, respectively. Somatic CALR mutations were found in 70 to 84% of samples of myeloproliferative neoplasms with nonmutated JAK2, in 8% of myelodysplasia samples, in occasional samples of other myeloid cancers, and in none of the other cancers. A total of 148 CALR mutations were identified with 19 distinct variants. Mutations were located in exon 9 and generated a +1 base-pair frameshift, which would result in a mutant protein with a novel C-terminal. Mutant calreticulin was observed in the endoplasmic reticulum without increased cell-surface or Golgi accumulation. Patients with myeloproliferative neoplasms carrying CALR mutations presented with higher platelet counts and lower hemoglobin levels than patients with mutated JAK2. Mutation of CALR was detected in hematopoietic stem and progenitor cells. Clonal analyses showed CALR mutations in the earliest phylogenetic node, a finding consistent with its role as an initiating mutation in some patients.

CONCLUSIONS

Somatic mutations in the endoplasmic reticulum chaperone CALR were found in a majority of patients with myeloproliferative neoplasms with nonmutated JAK2. (Funded by the Kay Kendall Leukaemia Fund and others.).

In vitro study of cypermethrin on human spermatozoa and the possible protective role of vitamins C and E

Cypermethrin, a type II synthetic pyrethroid pesticide, is widely used in pest control programmes in agriculture and public health. This study aimed to assess the potential effect of cypermethrin on human spermatozoa and the possible ameliorative effects of vitamins C and E. Semen samples of 20 healthy normozoospermic men were divided into six aliquots at room temperature. The first aliquot served as control not exposed to treatments, and the second was incubated with 20 mm vit. C and 2 mm vit. E where the third one was exposed to 10 μm cypermethrin for 6 h. The other three aliquots were incubated with vit. C, vit. E and both vitamins for 30 min before cypermethrin exposure. Semen aliquots were analysed for sperm motility, sperm viability, hypo-osmotic swelling test and modified alkaline comet assay. The results demonstrated a significant decrease in sperm motion, sperm function and increased sperm DNA damage in the cypermethrin group. Addition of vitamins C and E alone/combined led to significant improvement in sperm motion, sperm function and DNA damage, being maximal with both vitamins together. It is concluded that in vitro cypermethrin can alter sperm function and induce DNA damage in spermatozoa, which is improved after using vitamins C and E.

Signal-dependent fra-2 regulation in skeletal muscle reserve and satellite cells

Activator protein-1 (AP-1) is a ubiquitous transcription factor that paradoxically also has some tissue-specific functions. In skeletal muscle cells, we document that the AP-1 subunit, Fra-2, is expressed in the resident stem cells (Pax7-positive satellite cells) and also in the analogous undifferentiated ‘reserve' cell population in myogenic cultures, but not in differentiated myofiber nuclei. Silencing of Fra-2 expression enhances the expression of differentiation markers such as muscle creatine kinase and myosin heavy chain, indicating a possible role of Fra-2 in undifferentiated myogenic progenitor cells. We observed that Fra-2 is a target of cytokine-mediated extracellular signal-regulated kinase-1/2 signaling in cultured muscle cells, and extensive mass spectrometry and mutational analysis identified S320 and T322 as regulators of Fra-2 protein stability. Interestingly, Fra-2 S320 phosphorylation occurs transiently in activated satellite cells and is extinguished in myogenin-positive differentiating cells. Thus, cytokine-mediated Fra-2 expression and stabilization is linked to regulation of myogenic progenitor cells having implications for the molecular regulation of adult muscle stem cells and skeletal muscle regeneration.

Oncological outcome of primary versus secondary muscle-invasive bladder cancer is comparable after radical cystectomy

BACKGROUND

High-risk non-muscle-invasive bladder cancer (NMIBC) progressing to muscle-invasive bladder cancer (MIBC) is associated with adverse tumour biology. It is unclear, however, whether outcome of NMIBC progressing to MIBC is adverse compared to primary MIBC and whether NMIBC of higher risk of progression to MIBC is adverse compared to NMIBC of lower risk.

OBJECTIVE

Our objective was to assess cancer-specific survival (CSS) following radical cystectomy (RC) for primary MIBC and for NMIBC progressing to MIBC in dependence of EORTC risk score.

MATERIALS AND METHODS

Clinical and histopathological characteristics and CSS of 150 patients were assessed. Secondary MIBCs were stratified by EORTC risk score at the last transurethral resection of bladder tumour for NMIBC.

RESULTS

CSS did not differ significantly between primary and secondary MIBC (p = 0.521). Secondary MIBC with high EORTC score had significantly shorter CSS compared to secondary MIBC with intermediate EORTC score (p = 0.029). In multivariable analysis, pathological tumour stage (HR = 3.77; p = 0.020) and lymph node stage (HR = 2.34; p = 0.022) were significantly correlated with CSS.

CONCLUSION

While the outcome of secondary MIBC is not generally adverse compared to primary MIBC, the EORTC risk score not only reflects high risk of progression of NMIBC to MIBC, but also worse outcome following RC for secondary MIBC. Timely RC should thus be debated in high-risk NMIBC.

A descriptive cost analysis study of cases of right iliac fossa pain

Patients with suspected appendicitis comprise a large proportion of general surgical workload. The resulting healthcare burden is significant when one considers that investigations, observation and surgical procedures are often needed. As no previous study has examined the cost of managing patients with suspected appendicitis, we performed a cost analysis study of management of cases of right iliac fossa (RIF) pain in University Hospital Limerick. Patients who were admitted with right iliac fossa pain from 1st April 2011 to 4th May 2011 were identified prospectively. After discharge, patients' medical records were reviewed. Costing data collected comprised details on length of stay, number and type of radiological investigations, number and type of blood investigations, medications administered and operations performed. Costs for radiological investigations were obtained from casemix data. Blood investigation costs were obtained from relevant laboratories. Medication costs were obtained from the pharmacy department. Operation costs were based on the cost of equipment combined with cost relating to operating theatre time and recovery unit time. Due to unavailability of data on Irish public hospital bed-day cost, a private hospital provided cost details on this aspect. 94 patients (M = 33, F = 61) were admitted with RIF pain during this time period. 62 underwent surgery. There were 53 appendicectomies performed with 42 (79%) positive for appendicitis on histological analysis. Blood test, radiology, pharmacy, operative and bed-day costs were €1857, €6252, €3517, €184,191 and €152,706 respectively. The total estimated cost was €348,525 (€3708 average per patient). There is a high cost associated with managing suspected appendicitis in Ireland. Strategies to reduce cost include reducing unnecessary admissions and unnecessary operations. Reducing LOS may be another potentially valuable cost saving method. It is imperative that resources are channelled into the provision of accurate costing structures.

Back pain: an unusual presentation of Castleman's diseases

DOI: http://dx.doi.org/10.3329/bmrcb.v38i1.10452 Bangladesh Med Res Counc Bull 2012; 38: 40-41