Diagnosing tuberculous pericarditis

BACKGROUND

Definitive diagnosis of tuberculous pericarditis requires isolation of the tubercle bacillus from pericardial fluid, but isolating the organism is often difficult.

AIM

To improve diagnostic efficiency for tuberculous pericarditis, using available tests.

DESIGN

Prospective observational study.

METHODS

Consecutive patients (n = 233) presenting with pericardial effusions underwent a predetermined diagnostic work-up. This included (i) clinical examination; (ii) pericardial fluid tests: biochemistry, microbiology, cytology, differential white blood cell (WBC) count, gamma interferon (IFN-gamma), adenosine deaminase (ADA) levels, polymerase chain reaction testing for Mycobacterium tuberculosis; (iii) HIV; (iv) sputum smear and culture; (v) blood biochemistry; and (vi) differential WBC count. A model was developed using 'classification and regression tree' analysis. The cut-off for the total diagnostic index (DI) was optimized using receiver operating characteristic (ROC) curves.

RESULTS

Fever, night sweats, weight loss, serum globulin (>40 g/l) and peripheral blood leukocyte count (<10 x 10(9)/l) were independently predictive. The derived prediction model had 86% sensitivity and 84% specificity when applied to the study population. Pericardial fluid IFN-gamma >or=50 pg/ml, concentration had 92% sensitivity, 100% specificity and a positive predictive value (PPV) of 100% for the diagnosis of tuberculous pericarditis; pericardial fluid ADA >or=40 U/l had 87% sensitivity and 89% specificity. A diagnostic model including pericardial ADA, lymphocyte/neutrophil ratio, peripheral leukocyte count and HIV status had 96% sensitivity and 97% specificity; substituting pericardial IFN-gamma for ADA yielded 98% sensitivity and 100% specificity.

DISCUSSION

Basic clinical and laboratory features can aid the diagnosis of tuberculous pericarditis. If available, pericardial IFN-gamma is the most useful diagnostic test. Otherwise we propose a prediction model that incorporates pericardial ADA and differential WBC counts.

Moulds and yeasts in fruit salads and fruit juices

Thirty-eight fruit salad samples including cantaloupe, citrus fruits, honeydew, pineapple, cut strawberries and mixed fruit salads, and 65 pasteurized fruit juice samples (apple, carrot, grapefruit, grape and orange juices, apple cider, and soy milk) were purchased from local supermarkets in the Washington, DC area and tested for fungal contamination. The majority of fruit salad samples (97%) were contaminated with yeasts at levels ranging from <2.0 to 9.72 log10 of colony forming units per gram (cfu/g). Frequently encountered yeasts were Pichia spp., Candida pulcherrima, C. lambica, C. sake, Rhodotorula spp., and Debaryomyces polymorphus. Low numbers of Penicillium spp. were found in pineapple salads, whereas Cladosporium spp. were present in mixed fruit and cut strawberry salads. Twenty-two per cent of the fruit juice samples tested showed fungal contamination. Yeasts were the predominant contaminants ranging from <1.0 to 6.83 log10 cfu/ml. Yeasts commonly found in fruit juices were C. lambica, C. sake, and Rhodotorula rubra. Geotrichum spp. and low numbers of Penicillium and Fusarium spp. (1.70 and 1.60 log10 cfu/ml, respectively) were present in grapefruit juice.

Biopsy of the prostate guided by transrectal ultrasound: relation between warfarin use and incidence of bleeding complications

AIM

To determine the relation between warfarin use and the frequency of bleeding complications after biopsy of the prostate guided by transrectal ultrasound (TRUS).

METHODS

Overall, 1022 consecutive patients with suspected prostatic disease were followed after biopsy. Warfarin and aspirin use was determined on the day of the procedure. A TRUS-guided biopsy was performed and patients were offered a questionnaire to complete 10 days after the procedure, to determine any immediate or delayed bleeding complications. Follow-up telephone calls were made to those who had not replied within the stipulated period.

RESULTS

Of the 1000 patients who replied, 49 were receiving warfarin, 220 were receiving aspirin and 731 were not receiving any anticoagulant drugs. Of the 49 subjects reporting current use of warfarin, 18 (36.7%) experienced haematuria, compared with 440 (60.2%) of the patients receiving no anti-coagulant drugs who reported haematuria. This was statistically significant (p = 0.001). Of the group receiving warfarin, 4 (8.2%) experienced haematospermia whereas 153 (21%) of the group receiving no anticoagulant medication reported haematospermia. This difference also was statistically significant (p = 0.030). Rectal bleeding was experienced by 7 (14.3%) of the group receiving warfarin compared with 95 (13%) in the group without anticoagulant medication, but this was not statistically significant (p = 0.80). We also demonstrated that there was no statistically significant association between the severity of the bleeding complications and medication with warfarin.

CONCLUSION

None of the group receiving warfarin experienced clinically important bleeding complications. Our results suggest that the frequency and severity of bleeding complications were no worse in the warfarin group than in the control group and that discontinuing anticoagulation medication before prostate biopsy may be unnecessary.

Facilitators and barriers to improving the quality of referrals for potential oral cancer

The quality and content of referral letters are important for prioritisation of patients who may have oral cancer. Referrals letters to the Oral Medicine Clinic at Birmingham Dental Hospital were analysed and practitioners interviewed. Whilst acceptable for general purposes, most letters did not contain sufficient information to allow effective prioritisation. Interviews disclosed a misunderstanding amongst practitioners about the way in which referrals were handled. A number of barriers to increasing the information included in letters were identified. Referral guidelines and a standardised proforma might help improve the ability of the service to operate a fast-track system.

Acute toxicity of chemo-radiotherapy for cervical cancer: the Addenbrooke's experience

AIMS

An audit of acute treatment-related toxicity during chemo-radiotherapy for cervical cancer was carried out to assess its tolerance outside research settings.

MATERIALS AND METHODS

Between May 1999 and April 2003, 74 patients with carcinoma of the cervix were treated with radical radiotherapy given concurrently with weekly cisplatin chemotherapy. Fifty-nine (79.7%) patients received chemo-radiotherapy as primary radical treatment, 10 (13.5%) patients were treated adjuvantly for poor-prognosis features after radical surgery, and the remaining five (6.8%) were given chemo-radiotherapy for pelvic recurrences after previous surgery. Acute treatment-related toxicity was graded prospectively at weekly intervals during chemo-radiotherapy using the National Cancer Institute Common Toxicity Criteria.

RESULTS

The most common adverse effects were diarrhoea (80.6%), malaise (66.7%) and nausea (62.5%). The most common haematological toxicity was anaemia, with 41.7% patients developing grade 1 or 2 toxicity. Only three (4.2%) patients had grade 3 or 4 toxicity. One patient had grade 3 thrombocytopenia, another had grade 4 neutropenia and the third patient had grade 3 diarrhoea. A statistically significant correlation was found between maximum treatment-related toxicity, larger treatment volumes (P = 0.006) and disease stage (P = 0.04). A total of 97.3% of patients completed external beam radiotherapy without any interruptions for treatment-related toxicity. Only two patients (3.4%) experienced a delay in brachytherapy for treatment-related toxicity. Two patients died during external beam radiotherapy, and one patient suffered a fatal pulmonary embolism 1 week after completing brachytherapy treatment. A total of 70.2% patients completed the planned number of chemotherapy cycles, with a further 20.3% receiving at least three cycles. The most common reason for failure to complete chemotherapy as planned was gastrointestinal toxicity. There was no correlation between failure to complete planned chemotherapy and patient age, disease stage, radiotherapy treatment volumes or postoperative treatment.

CONCLUSION

Our study has shown that cisplatin-based chemo-radiotherapy for carcinoma of the cervix is well tolerated when given to a largely unselected population of patients outside research settings. The effectiveness of the treatment should therefore mirror the efficacy obtained in clinical trials.

Does Supervised Exercise Offer Adjuvant Benefit Over Exercise Advice Alone for the Treatment of Intermittent Claudication? A Randomised Trial

OBJECTIVE

Exercise advice is the main treatment for symptom relief in the UK for patients with mild to moderate Intermittent Claudication (IC). Would a weekly exercise and motivation class for 6 months offer adjuvant benefit over written and verbal exercise advice alone?

PATIENTS AND METHODS

Fifty-nine patients attending a regional vascular centre for whom IC was the main factor affecting mobility were randomised to either exercise advice alone (n=30) or exercise advice with a once a week 45 min supervised exercise/motivation class (n=29). The mean age was 68 years. Baseline and 6-month assessment included a Quality of Life Questionnaire--the Short-Form-36, the Charing Cross Symptom Specific Claudication Questionnaire (CCCQ) and treadmill walking distance (3.5 km/h 12%).

RESULTS

At 6-month follow-up the supervised exercise group had improved their treadmill walking by 129% compared to 69% in the advice alone group (p=0.001). This significant improvement was maintained at the subsequent 9 and 12-month follow-up assessments. By the 9-month stage the advice only group CCCQ score had improved 16% from baseline, while the supervised exercise group had a significantly better 43% improvement in base line score (p<0.05). Self reported frequency of walks was higher in the exercise class group being significant for improvement in CCCQ score.

CONCLUSION

A weekly, supervised exercise and motivation class for a 6-month period provides a significant improvement in patients' symptoms, quality of life, and distance walked compared with advice alone and this improvement continues after attendance at class has ceased.

An audit of delays before and during radical radiotherapy for cervical cancer--effect on tumour cure probability

AIM

To evaluate the potential impact of time delay before and during radical radiotherapy for cervical carcinoma at Addenbrooke's Hospital.

MATERIALS AND METHODS

An audit was undertaken which recorded the number of gaps during external beam radiotherapy (EBRT), overall treatment time, and delay between first oncology consultation to start of radiotherapy, for patients receiving primary radical radiotherapy for cervical cancer in 1996, 1998 and 2001. Radiobiological modelling was used to calculate the tumour control probability (TCP). A questionnaire survey of 62 oncology departments in the U.K. was carried out for comparison.

RESULTS

The percentage of patients completing EBRT without any interruptions was 22, 67 and 94% in 1996, 1998, and 2001, respectively (P = 0.0009). The median overall treatment time was 49, 42 and 39 days in 1996, 1998 and 2001, respectively (P = 0.001). However, the median waiting time to start of radiotherapy increased from 14 days in 1996 to 18 days in 1998 and 35 days in 2001 (P = 0.007).

CONCLUSION

The results from the national survey showed that this pattern of improved overall treatment times accompanied by deterioration in waiting times was also seen in most other U.K. centres. Radiobiological modelling showed that any potential gain in TCP resulting from shorter overall treatment times could be offset entirely by the adverse effect of increasing waiting times. The calculations suggest that the tumours most likely to be adversely affected by long waiting times are those with shorter volume doubling times or a medium chance of tumour control at the outset of treatment. A system of patient triage, and prioritization of patients deemed most likely to benefit from a reduced waiting time, may be necessary in the current climate of limited radiotherapy resources.

A reassessment of the fat intake of children from meat and meat products and an estimate of haem iron intakes

BACKGROUND

It is possible that fat intake from red meat has declined as a consequence of changes in animal husbandry and butchery practices. In particular, a study of the intake of vegetarian and meat-eating children concluded that their fat intakes were similar, but the most recent information on the fat content of meat was not available. In addition, iron availability is probably as important as the total amount of iron consumed but estimates of haem iron intake are rarely made.

METHODS

The dietary intake of 50 omnivorous children was reanalysed to produce new estimates of fat and haem iron intakes. Fat intake from meat and meat products only was recalculated using supplements to the food tables not available to the initial survey. Haem iron intake was calculated by discriminating between the different types of meat consumed and estimates of the proportion of iron which is in the haem form.

RESULTS

The recalculated diets had significantly lower energy (8.03-7.50 MJ), fat (79-73 g) and carbohydrate (257-237 g) levels. The proportions of energy from fat (36%) and carbohydrate (51%) were unaffected. Meat supplied 3.2 mg (33%) of the iron intake (9.6 mg) of which 1.3-1.5 mg (13-16% of the total) was estimated to be in the haem form. Children may be relatively unaffected by the changes in the composition of meat as such, if they consume highly processed foods which include, for example, rusk, pastry, breadcrumbs and batter.

CONCLUSIONS

The original estimates of the intake of fat of these omnivorous children from meat and meat products do appear to have been overestimates, but only as the weight of fat consumed not as a percentage of energy. Haem iron was found to supply a substantial proportion of the iron intake of these children and may account for their higher haemoglobin values.

Twelve-lead electrocardiography in tuberculous pericarditis

OBJECTIVES

This study is part of an ongoing initiative started in 1995 to investigate the therapeutic efficacy of adjuvant corticosteroids in the management of tuberculosis (TB) pericarditis. In this retrospective, descriptive study we describe the changes found on the 12-lead electrocardiogram (ECG) in patients with TB pericarditis, with and without cardiac tamponade. We determined the diagnostic accuracy of ECG parameters for cardiac tamponade.

METHODS

All patients referred to our department with echocardiographically confirmed large pericardial effusions underwent a thorough clinical assessment followed by pericardiocentesis and drainage using an indwelling pigtail catheter. The amount of drained effusion was measured, and fluid was sent for diagnostic assessment. Patients were grouped into those with or without cardiac tamponade. The following ECG parameters were assessed: rate, rhythm, microvoltage, electrical alternans, PR segment and ST segment abnormalities.

RESULTS

Of the 157 patients assessed, 88 were diagnosed with TB pericarditis All had abnormal ECGs and 83% had changes of chronic pericarditis. Microvoltage in the extremity and/or precordial leads correlated with the presence of large effusions (> 750 ml). None of the studied parameters correlated with the presence of cardiac tamponade.

CONCLUSIONS

Twelve-lead ECG is of supportive but not diagnostic value in cardiac tamponade. The presence of microvoltage suggests the presence of a large effusion. The absence of microvoltage makes the presence of cardiac tamponade unlikely.

Is a vegetarian diet adequate for children

The number of people who avoid eating meat is growing, especially among young people. Benefits to health from a vegetarian diet have been reported in adults but it is not clear to what extent these benefits are due to diet or to other aspects of lifestyles. In children concern has been expressed concerning the adequacy of vegetarian diets especially with regard to growth. The risks/benefits seem to be related to the degree of restriction of he diet; anaemia is probably both the main and the most serious risk but this also applies to omnivores. Vegan diets are more likely to be associated with malnutrition, especially if the diets are the result of authoritarian dogma. Overall, lacto-ovo-vegetarian children consume diets closer to recommendations than omnivores and their pre-pubertal growth is at least as good. The simplest strategy when becoming vegetarian may involve reliance on vegetarian convenience foods which are not necessarily superior in nutritional composition. The vegetarian sector of the food industry could do more to produce foods closer to recommendations. Vegetarian diets can be, but are not necessarily, adequate for children, providing vigilance is maintained, particularly to ensure variety. Identical comments apply to omnivorous diets. Three threats to the diet of children are too much reliance on convenience foods, lack of variety and lack of exercise.

Effects of hyaluronic acid/carboxymethylcellulose gel on bowel anastomoses in the New Zealand white rabbit

Intra-abdominal adhesions form in more than 90% of patients undergoing major abdominal surgery and can lead to significant complications. Application of a bioresorbable gel consisting of chemically modified hyaluronic acid (HA) and carboxymethylcellulose (CMC) has shown promise as a means of preventing intra-abdominal adhesions, but there have been concerns that the presence of the gel might interfere with the integrity and healing of bowel anastomoses. We tested the effects of HA/CMC gel on adhesion formation and anastomotic healing in 60 New Zealand white rabbits after transection and complete (100%) or incomplete (90%) anastomosis of the ileum. Half of the animals underwent application of HA/CMC gel and half served as control subjects. Animals were killed at 4, 7, or 14 days after surgery. Anastomotic adhesions were scored in a blinded fashion. Integrity of the anastomosis was tested by measuring bursting pressure at the anastomotic site and in an adjacent section of intact bowel. With complete anastomosis, HA/CMC gel significantly reduced adhesion formation at 7 and 14 days after surgery (P<0.05), but gel application did not inhibit adhesion formation when the anastomosis was incomplete. Anastomosed segments of bowel burst at a lower pressure than intact bowel 4 days after surgery, but bursting pressures were normal at 7 and 14 days. Burst pressures of anastomoses receiving an application of HA/CMC gel were nearly identical to control anastomoses at all three time points. HA/CMC gel did not interfere with the normal healing process of bowel anastomoses. Furthermore, HA/CMC gel decreased adhesion formation after complete anastomoses, yet it did not affect adhesion formation in the presence of anastomotic disruption.