Effective acute care handover to GP: optimising the structure to improve discharge documentation

Time and resource constraints have often led to the use of assessment records as discharge communications from acute and emergency departments. However, whether this addresses the primary care needs has not been demonstrated. This study examined the optimal structure that can impart key discharge information effectively using feedback from general practitioners (GP). We implemented an electronic assessment template that focused on the most relevant headings. Prespecified process measures were examined and qualitative thematic analysis of free-text comments from GP surveys were conducted to optimise the document. Our findings suggest that the structure of a discharge summary can influence the quality of information, users' compliance and readers' perceptions of the length of the letter.

Molecular analysis and genotype-phenotype correlation of Diamond-Blackfan anemia

Diamond-Blackfan anemia (DBA) features hypoplastic anemia and congenital malformations, largely caused by mutations in various ribosomal proteins. The aim of this study was to characterize the spectrum of genetic lesions causing DBA and identify genotypes that correlate with phenotypes of clinical significance. Seventy-four patients with DBA from across Canada were included. Nucleotide-level mutations or large deletions were identified in 10 ribosomal genes in 45 cases. The RPS19 mutation group was associated with higher requirement for chronic treatment for anemia than other DBA groups. Patients with RPS19 mutations, however, were more likely to maintain long-term corticosteroid response without requirement for further chronic transfusions. Conversely, patients with RPL11 mutations were less likely to need chronic treatment. Birth defects, including cardiac, skeletal, hand, cleft lip or palate and genitourinary malformations, also varied among the various genetic groups. Patients with RPS19 mutations had the fewest number of defects, while patients with RPL5 had the greatest number of birth defects. This is the first study to show differences between DBA genetic groups with regards to treatment. Previously unreported differences in the rate and types of birth defects were also identified. These data allow better patient counseling, a more personalized monitoring plan, and may also suggest differential functions of DBA genes on ribosome and extra-ribosomal functions.

Clinical profile of nonsmall cell lung carcinoma patients treated in a single unit at a tertiary cancer care center

BACKGROUND

Recent advances and understanding in the field of lung cancer and advent of newer treatments have shown a significant improvement in survival in the patients. The present study was conducted to analyze the clinical profile of nonsmall cell lung cancer (NSCLC) patients treated in a single unit at a tertiary cancer care center.

MATERIALS AND METHODS

In this retrospective analysis, 322 consecutive NSCLC patients from the year 2011 to 2012 treated in a single unit were included in the study. Patients with proven NSCLC were included in the study. The details of the patients included the demographic profile, pathological diagnosis as well as imaging data, tumor profile, details of treatment, and follow-up information.

RESULTS

The majority of the patients (95.6%) were in the age group >40 years. A large group of the patients (57.1%) were present/reformed smokers. The major histological type was adenocarcinoma (60.9%), of which 22.8% patients were found to be epidermal growth factor receptor positive. Anaplastic lymphoma kinase rearrangement positivity rate was 4.8%. Furthermore, 68% patients had Stage 4 disease. Upfront palliative chemotherapy (CT) was offered in 61.8% patients and pemetrexed with platinum compounds was the main CT regimen (46.6%). Partial response was achieved in 45.7% patients, whereas stable disease was observed in 10.9% cases. Median progression-free survival was 5 months and overall survival was 55% at 36 months.

CONCLUSION

NSCLC forms the largest subgroup of lung cancer with the patients presenting with advanced stages of disease. This area needs to be explored for the early detection and subsequently the radical treatment of the patients. Personalized approach may be considered for the management of lung cancer by identifying new predictive and prognostic biomarkers of this disease.

Oral supplementation with liposomal glutathione elevates body stores of glutathione and markers of immune function

BACKGROUND/OBJECTIVES

Glutathione (GSH) is the most abundant endogenous antioxidant and a critical regulator of oxidative stress. Maintenance of optimal tissues for GSH levels may be an important strategy for the prevention of oxidative stress-related diseases. We investigated if oral administration of liposomal GSH is effective at enhancing GSH levels in vivo.

SUBJECTS/METHODS

A 1-month pilot clinical study of oral liposomal GSH administration at two doses (500 and 1000 mg of GSH per day) was conducted in healthy adults. GSH levels in whole blood, erythrocytes, plasma and peripheral blood mononuclear cells (PBMCs) were assessed in 12 subjects at the baseline and after 1, 2 and 4 weeks of GSH administration.

RESULTS

GSH levels were elevated after 1 week with maximum increases of 40% in whole blood, 25% in erythrocytes, 28% in plasma and 100% in PBMCs occurring after 2 weeks (P<0.05). GSH increases were accompanied by reductions in oxidative stress biomarkers, including decreases of 35% in plasma 8-isoprostane and 20% in oxidized:reduced GSH ratios (P<0.05). Enhancements in immune function markers were observed with liposomal GSH administration including Natural killer (NK) cell cytotoxicity, which was elevated by up to 400% by 2 weeks (P<0.05), and lymphocyte proliferation, which was elevated by up to 60% after 2 weeks (P<0.05). Overall, there were no differences observed between dose groups, but statistical power was limited due to the small sample size in this study.

CONCLUSIONS

Collectively, these preliminary findings support the effectiveness of daily liposomal GSH administration at elevating stores of GSH and impacting the immune function and levels of oxidative stress.

Comprehensive geriatric assessment in 326 older women with early breast cancer

Background:

One-third of new early breast cancer diagnoses occur in women over 70 years old. However, older women are less likely to receive radical curative treatments. This study prospectively evaluated a cohort of older women using a Comprehensive Geriatric Assessment (CGA) to determine whether fitness explained the apparent under-treatment in this patient group.

Methods:

In this multi-centre prospective study, patients aged ⩾70 years with Stages I–III breast cancer underwent a pretreatment baseline CGA consisting of eight assessment tools. Patients were defined as ‘fit’ if they had normal score in seven out of eight of the assessment tools. ‘High risk’ patients were defined as those with grade 3, ER negative, HER2 positive, or node positive breast cancer.

Results:

Data on 326 patients were available for full analysis. The median age was 77 years. In all, 182 (56%) of the total population were defined as high risk, with 49%, 61% and 53% of those in the 70–74, 75–84 and ⩾85 years age groups respectively having high risk tumours. A total of 301 patients had sufficient CGA records of whom 131 (44%) were reported as fit, with 34%, 54% and 12% of them in the 70–74, 75–84 and ⩾85 years age groups respectively. More fit than unfit patients underwent primary breast surgery (100% vs 91%, P=0.0002), axillary surgery (92% vs 84%, P=0.0340), and adjuvant chemotherapy for high-risk disease (51% vs 20%, P=0.0001). Rates of adjuvant radiotherapy after wide local excision were not significantly different (88% vs 90% respectively, P=0.8195).

Conclusions:

In this study, all women ⩾70 years deemed fit by CGA underwent primary surgery. Nearly 50% of fit women with high-risk disease did not receive adjuvant chemotherapy suggesting under treatment in this group.

Effect of immobilisation on production of rapamycin by Streptomyces hygroscopicus

Numerous antibiotics as secondary metabolites have been isolated from microbes specifically Streptomyces sp. Rapamycin is one of these, which exhibits many roles as immunosuppressant, antifungal antibiotic, anti-tumour etc. Constant thrust has been put by many researchers to improve the production of rapamycin by Streptomyces hygroscopicus. Past research show that whole cell immobilisation is a useful strategy for antibiotic production with economical advantage. This study is another attempt in this direction which involves immobilisation of producer organism on various supports such as polyutherane foam, sintered beads, glass beads and foam peanuts. These support materials have been selected based on their availability and were pre-treated chemically to improve their adsorption capacity. Comparative profiles have been studied to identify the most suited support for the growth of Streptomyces sp. Variation of biomass immobilisation on various support materials with respect to time in batch culture was studied. Cell release study for the carriers was carried out in production medium to evaluate the performance of beads. Also, scanning electron microscopy (SEM) has been employed for visualisation and analysis of immobilised biomass and measurement of pore size. This study aims to determine a suitable support for immobilisation of Streptomyces hygroscopicus which could be used for rapamycin production in batch and continuous mode.

Lepton-Flavor-Dependent Angular Analysis of B→K^{*}ℓ^{+}ℓ^{-}

We present a measurement of angular observables and a test of lepton flavor universality in the B→K^{*}ℓ^{+}ℓ^{-} decay, where ℓ is either e or μ. The analysis is performed on a data sample corresponding to an integrated luminosity of 711  fb^{-1} containing 772×10^{6} BB[over ¯] pairs, collected at the ϒ(4S) resonance with the Belle detector at the asymmetric-energy e^{+}e^{-} collider KEKB. The result is consistent with standard model (SM) expectations, where the largest discrepancy from a SM prediction is observed in the muon modes with a local significance of 2.6σ.

Comparison of ventricular drain location and infusion test in hydrocephalus

OBJECTIVES

Suspected cerebrospinal fluid shunt (CSF) dysfunction in hydrocephalic patients poses a diagnostic uncertainty. The clinical picture can be non-specific and CT imaging alone is not always pathognomonic. Infusion tests are an increasingly used investigation for real-time hydrodynamic assessment of shunt patency. We report the correlation between infusion test results with the quality of ventricular drain placement on CT scans in a large retrospective group of hydrocephalic patients.

MATERIALS & METHODS

Three hundred and six infusion test results performed in 200 patients were correlated with 306 corresponding CT head scans. Nominal logistic regression was used to correlate shunt catheter position on CT imaging to patency of ventricular drain as determined by infusion tests.

RESULTS

Infusion test results of shunt patency are statistically congruent with the analysis of shunt catheter position on CT head scans. Catheter tips completely surrounded by either parenchyma or CSF on CT imaging are strongly associated with evidence of occlusion or patency from infusion tests, respectively (χ² = 51.68, P < 0.0001, n = 306 and χ² = 31.04, P < 0.0001, n = 306).

CONCLUSIONS

The most important anatomical factor for shunt patency is the catheter tip being completely surrounded by CSF. Infusion tests provide functional and reliable assessment of shunt patency in vivo and are strongly correlated with the position of the ventricular catheter on CT imaging.

Histopathological Significance and Prognostic Impact of Tumor Budding in Colorectal Cancer

BACKGROUND

Colorectal cancer (CRC) is a heterogeneous disease with complex etiology. New prognostic factors for this group of disease need to be investigated. This study evaluated the histopathological significance and prognostic impact of tumor budding in CRC.

DESIGN

A total of 60 treatment naive consecutive patients undergoing surgical resection for CRC during the period of January 2011 to December 2013 were included in the study. Details of each patient related to their demographic and tumor profile were recorded. Pan Cytokeratin immunohistochemistry was applied on chosen sections and tumor budding was assessed.

RESULTS

The most frequent site of involvement was rectosigmoid and sigmoid colon (31.6%). The majority of the cases were moderately differentiated (75%) in morphology, and showed tumor invasion into the pericolic/subserosal fat (66.6%), and were stage III (38.3%). Nodal involvement was present in 50% cases. Correlations between tumor budding and nodal involvement (p-value 0.039) and AJCC stage (p-value 0.021) were found to be statistically significant.

CONCLUSION

Tumor budding may be a promising and powerful predictor of lymphnodal metastasis and a higher stage of tumor and can be used as a marker for assessing the aggressiveness of CRC. Routine hemotoxylin-eosin staining supported by cytokeratin immunostain can aid in the grading of tumor budding in CRC.

Aetiology of Preoperative Anaemia in Patients Undergoing Elective Cardiac Surgery—the Challenge of Pillar One of Patient Blood Management

Preoperative anaemia is common in patients undergoing cardiac surgery. Whilst there is a strong association with increased morbidity and mortality, it is currently unclear whether treatment of anaemia leads to patient benefit. This retrospective study aimed to determine the aetiology of preoperative anaemia in a cohort of patients undergoing elective cardiac surgery over two years at a tertiary hospital. Laboratory data obtained at the preoperative assessment clinic visit were assessed to stratify patients into four groups—iron deficiency anaemia (IDA), possible IDA, anaemia of chronic disease (ACD) and non-anaemic patients with low ferritin according to the ‘Preoperative haemoglobin assessment and optimisation template’ of the Australian Patient Blood Management (PBM) Guidelines. Of patients with preoperative anaemia, 23.1% had IDA, 6.6% had possible IDA and 70.3% had possible ACD. Of the patients with possible ACD, 30% had a ferritin <100 μg/l, representing limited iron stores or coexisting absolute iron deficiency in the setting of chronic disease. In addition, 46.2% of those with possible ACD had iron studies indicative of functional iron deficiency. Time between assessment and surgery was as little as one day in a third of patients and in only 7% was it more than seven days. Our findings indicate that about one-third of our patients with preoperative anaemia had evidence of iron deficiency, a potentially reversible cause of anaemia. In addition, a significant number had either limited iron stores that may render them iron deficient by surgery, or a functional iron deficiency.

Indian Council of Medical Research Consensus Document for the Management of Non-Hodgkin's Lymphoma (High Grade)

This consensus document is based on the guidelines related to the management of Non Hodgkin's Lymphoma (High grade) in the Indian population as proposed by the core expert committee. Accurate diagnosis in hematolymphoid neoplasm requires a combination of detailed history,clinical examination, and various investigations including routine laboratory tests, good quality histology section (of tumor and also bone marrow aspirate/biopsy), immunostaining, cytogenetic and molecular studies and radiology investigations. The staging system used for adult high grade lymphomas is based on the Ann Arbor system and includes various parameters like clinical, haematology, biochemistry, serology and radiology. Response should be evaluated with radiological evaluation after 3-4 cycles and at the end of treatment based on criteria including and excluding PET. Treatment of high grade lymphomas is based on histologic subtype, extent of disease, and age of the patient. Autologous stem cell transplantation after high dose chemotherapy is effective in the treatment of relapsed NHL. Newer RT techniques like 3 dimensional conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT) can significantly reduce radiation doses to surrounding normal tissues in lymphoma patients. Patients should be followed up every 3 to 4 months for the first 2 years, followed by 6 monthly for the next 3 years and then annually.

A prospective audit of complications in 100 consecutive pediatric percutaneous renal biopsies done under real-time ultrasound guidance

Despite being a common procedure, percutaneous renal biopsy (PRB) carries the potential for complications. The British Association of Paediatric Nephrologist (BAPN) has published standards for pediatric PRB. As Indian data are scarce, we conducted a prospective audit of 100 consecutive pediatric renal biopsies (60% males) under real-time ultrasound guidance. Nephrotic syndrome was the most common indication for PRB (68%) with minimal change disease (30%) and focal segmental glomerulosclerosis (25%) being the most common histopathological lesions. Gross hematuria was observed in six cases. Major complications was noted in one case, who needed longer hospital stay. The result of the audit demonstrated achievability of BAPN standards. In addition, we also show the usefulness of 16 gauge biopsy needle over 18 gauge biopsy needles (median number of glomeruli 25, range 3–90 vs 13, range 6–46, P = 0.001) without any increase in complications. Being a single center study, we do hope that our results will encourage a wider survey on the current state of pediatric PRB.

The evolving clinical management of cerebral metastases

Concepts in the management of brain metastases are evolving. Until recently, brain metastases have been considered as a homogenous condition, managed with whole brain radiotherapy, surgical resection for large lesions and stereotactic radiosurgery for smaller lesions. Increasingly, specific systemic medical therapies are being used to treat brain metastases based on the primary site of disease. This disease specific management is causing a change in perspective about brain metastases and has led to improved survival for patients with primary disease subtypes amenable to tailored medical therapies. We review the recent literature to present evidence for the use of subtype specific medical therapies, advances in surgical resection techniques and stereotactic radiosurgery as the primary treatment modalities. The decline in use of whole brain radiotherapy as first line treatment is also discussed. Based on the recent literature, we propose a new management algorithm to reflect the progress in available options for tailoring disease specific treatments and support the change in paradigm to consider brain metastases as separate disease states based on the primary site of cancer rather than as a homogenous entity.

Variable Presentations of Sinonasal Polypoid Masses: A Tertiary Institution Experience

Background Lesions of the sinonasal area are varied, but they mostly present as polypoid masses which require meticulous work-up to reach at the most probable diagnosis. Objective Analysis of polypoid sinonasal masses in terms of etiology, clinical presentations, brief demographic profile, clinico-histologic correlate where possible, and follow-up results. Method In this descriptive, longitudinal study, 198 patients with polypoid sinonasal masses attending the otolaryngology clinic of a tertiary teaching institute were selected using proper selection criteria and analyzed through a pre-set proforma and algorithm for a diagnostic work-up (that included histopathology where necessary). Result Common presentations were nasal obstruction (~89%), discharge (~70%) and hyposmia (~22%). Though nearly 87% was clinically benign and 8% indeterminate, therapeutic and diagnostic interventions (including histopathology) showed 91% truly benign, of which polyposis formed the bulk. Sensitivity of clinical detection was 75% for benign lesions and 62% for malignancies. Diagnosis depended on histopathology in 52.52% cases, including the clinically malignant, the "grey zone", and more than 40% of the clinically benign lesions. There was male predilection (2.16 for benign lesions and 1.57 for malignant), rural preponderance, and above 60% of the patients were within 50-70 years. There was ~26% recurrence in the follow-up period of a minimum of one year, predominantly in polyposis (29.55%) and malignancies (~39%). Conclusion Presentations of polypoid sinonasal masses are variable, etiology of which is mostly benign. Proper clinico-histologic correlate is necessary for correct diagnosis. A low threshold of suspicion is required because of this variability, necessitating follow-up for further evaluation.

Lifestyle and Sporadic Colorectal Cancer in India

BACKGROUND

The study evaluated the patient, lifestyle and tumor profile in patients undergoing upfront surgery for sporadic colorectal cancer (CRC) in Indian population.

MATERIALS AND METHODS

One hundred consecutive patients were included. Details related to their demographic profile, habits, signs and symptoms, tumor profile, further treatment and follow up were recorded.

RESULTS

The majority of the patients had colonic cancer (68%), advanced tumor stage 3 and 4 (46%), moderately differentiated tumors (70%) with absence of lymphatic invasion (60%) and metastasis (90%). Correlations between tumor location and abdominal pain (p-value 0.002), bleeding per rectum (p-value <0.001), difficulty in micturition (p-value 0.012) and constipation (p-value 0.007) were found to be statistically significant. Abdominal pain was more frequently reported in patients with metastasis (p-value 0.031). Loss of weight statistically correlated with absence of lymphatic invasion (p-value 0.047). Associations between tumor stage and alcohol intake (p-value 0.050) and non vegetarian diet (p-value 0.006); lymphatic invasion and intake of spicy food (p-value 0.040) and non vegetarian diet (p-value 0.001) and metastasis and alcohol intake (p-value 0.041) were also observed. Age and tumor grade were also correlated (p-value 0.020).

CONCLUSIONS

Minimizing the adverse lifestyle factors can help in reducing the overall incidence of CRC in the Indian population.

Spiradenoma causing longitudinal splitting of the nail

Longitudinal splitting of the nails can occur as a result of any growth arising in the nail matrix. We present a case of a 50-year-old woman who presented with an 18-month history of longitudinal splitting of the nail on her right little finger, along with pain in the proximal nail fold region, which was extremely tender to touch. Magnetic resonance imaging revealed an intensely enhancing lesion, while colour Doppler imaging revealed hypervascularity within the mass. A provisional diagnosis of glomus tumour was considered. Histopathology demonstrated presence of a well-circumscribed tumour comprising a dual population of cells, which stained negatively with periodic-acid-Schiff. The histopathological features were consistent with those of eccrine spiradenoma (ES). In this case, glomus tumour was considered as the first differential diagnosis, but histopathology confirmed it as an ES.