Ethnicity, socio-economic deprivation and postpartum outcomes following caesarean delivery: a multicentre cohort study

Disparities relating to postpartum recovery outcomes in different socio-economic and racial ethnic groups are underexplored. We conducted a planned analysis of a large prospective caesarean delivery cohort to explore the relationship between ethnicity, socio-economic status and postpartum recovery. Eligible patients were enrolled and baseline demographic, obstetric and medical history data were collected 18 h and 30 h following delivery. Patients completed postpartum quality of life and recovery measures in person on day 1 (EuroQoL EQ-5D-5L, including global health visual analogue scale; Obstetric Quality of Recovery-10 item score; and pain scores) and by telephone between day 28 and day 32 postpartum (EQ-5D-5L and pain scores). Socio-economic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. Data from 1000 patients who underwent caesarean delivery were included. There were more patients of Asian, Black and mixed ethnicity in the more deprived quintiles. Patients of White ethnicities had shorter postpartum duration of hospital stay compared with patients of Asian and Black ethnicities (35 (28-56 [18-513]) h vs. 44 (31-71 [19-465]) h vs. 49 (33-75 [23-189]) h, respectively. In adjusted models at day 30, patients of Asian ethnicity had a significantly greater risk of moderate to severe pain (numerical rating scale ≥ 4) at rest and on movement (odds ratio (95%CI) 2.42 (1.24-4.74) and 2.32 (1.40-3.87)), respectively). There were no differences in readmission rates or incidence of complications between groups. Patients from White ethnic backgrounds experience shorter postpartum duration of stay compared with patients from Asian and Black ethnic groups. Ethnic background impacts pain scores and recovery at day 1 postpartum and following hospital discharge, even after adjusting for socio-economic group. Further work is required to understand the underlying factors driving differences in pain and recovery and to develop strategies to reduce disparities in obstetric patients.

Dropout from exercise trials among cancer survivors-An individual patient data meta-analysis from the POLARIS study

INTRODUCTION

The number of randomized controlled trials (RCTs) investigating the effects of exercise among cancer survivors has increased in recent years; however, participants dropping out of the trials are rarely described. The objective of the present study was to assess which combinations of participant and exercise program characteristics were associated with dropout from the exercise arms of RCTs among cancer survivors.

METHODS

This study used data collected in the Predicting OptimaL cAncer RehabIlitation and Supportive care (POLARIS) study, an international database of RCTs investigating the effects of exercise among cancer survivors. Thirty-four exercise trials, with a total of 2467 patients without metastatic disease randomized to an exercise arm were included. Harmonized studies included a pre and a posttest, and participants were classified as dropouts when missing all assessments at the post-intervention test. Subgroups were identified with a conditional inference tree.

RESULTS

Overall, 9.6% of the participants dropped out. Five subgroups were identified in the conditional inference tree based on four significant associations with dropout. Most dropout was observed for participants with BMI >28.4 kg/m2 , performing supervised resistance or unsupervised mixed exercise (19.8% dropout) or had low-medium education and performed aerobic or supervised mixed exercise (13.5%). The lowest dropout was found for participants with BMI >28.4 kg/m2 and high education performing aerobic or supervised mixed exercise (5.1%), and participants with BMI ≤28.4 kg/m2 exercising during (5.2%) or post (9.5%) treatment.

CONCLUSIONS

There are several systematic differences between cancer survivors completing and dropping out from exercise trials, possibly affecting the external validity of exercise effects.

Lower oesophageal meat bolus clearance using a radiologically guided balloon catheter: case in a 94-year-old patient

Lower oesophageal foreign body meat bolus obstruction is potentially life-threatening. We report a case in a 94-year-old woman in which conservative measures and flexible oesophagoscopy were unsuccessful. Rigid oesophagoscopy was considered technically difficult and so clearance by interventional radiology was attempted. Through the mouth a radiologically guided balloon catheter was introduced. It was passed beyond the bolus to dilate the site of obstruction, before being withdrawn and inflated above the bolus, pushing it into the stomach. Although successful in this case, the technique is previously unreported and so its complication rate is unknown. It is therefore presented only to be considered when other treatments are neither effective nor possible.

Intra-parenchymal thyroid epidermal cyst presenting with a left recurrent laryngeal nerve palsy

We present a rare case of an intra-parenchymal thyroid epidermal cyst presenting with a left recurrent laryngeal nerve palsy. There was a complete recovery of the nerve function following surgical excision of the lesion. Theories of aetio-pathogenesis of the cyst and underlying mechanisms responsible for the nerve paralysis are explored.

Retropharyngeal haematoma causing airway obstruction: a multidisciplinary challenge

A case of post-traumatic retropharyngeal haematoma causing airway obstruction in an elderly man on anticoagulant therapy is described. The importance of managing the airway, cervical spine and haemostatic problem with the help of a multidisciplinary team is discussed.

Pott's puffy tumour: a rare cause of forehead swelling in a child

We report a case of Pott's puffy tumour in a 12-year-old. Owing to the late development of the frontal sinuses, frontal sinus infection in children is rare. When present it can lead to osteomyelitis associated with forehead swelling. Early diagnosis and active treatment prevent progression to life-threatening intracranial spread.

Langerhans' cell histiocytosis--a rare cause of sudden onset unilateral sensorineural hearing loss

Langerhans' cell histiocytosis is a rare disorder of unknown aetiology in which pathological Langerhans' cells accumulate and destroy local tissue. We report a 38-year-old female who presented with a sudden onset of left sensorineural hearing loss. Magnetic resonance imaging (MRI) revealed a contrast-enhancing lesion in the left mastoid and a second lesion in the hypothalamus. Following left mastoid exploration and biopsy a definitive diagnosis of Langerhans' cell histiocytosis was made and the patient was treated with external beam radiotherapy. Subsequent right femur and right mastoid involvement were successfully treated with steroids and cytotoxic chemotherapy. At one year follow-up the patient had residual left-sided sensorineural hearing loss with normal hearing in the right ear. To our knowledge, Langerhans' cell histiocytosis has not been previously reported as a cause of unilateral sudden onset sensorineural hearing loss. It should be considered in the differential diagnosis of this condition.

The stability of estrogen and progesterone receptor expression on breast carcinoma cells stored as PreservCyt suspensions and as ThinPrep slides

BACKGROUND

Analysis of estrogen receptor (ER) and progesterone receptor (PR) status is an important ancillary test in the evaluation of positive breast fine-needle aspirates. This study compares the detection of ER and PR in breast carcinoma cells suspended in PreservCyt with that achieved with stored ThinPrep slides (TP).

METHODS

ER and PR positive mammary tumor cells (cell line ZR-75-1 spiked in PreservCyt by the American Type Culture Collection) were used to evaluate the stability of immunodetection of ER and PR under two conditions: 1) TP slides prepared immediately from PreservCyt and stored air-dried (stored TP) for up to 56 days, and 2) TP prepared from cells suspended in PreservCyt (newly prepared TP) on Days 1, 2, 5, 14, 21, 42, and 56. At each of the time periods, stored TP and newly prepared TP were analyzed for ER and PR using the same immunocytochemical staining protocol. The percentage of positive cells was calculated by counting 1000 cells/TP.

RESULTS

Positivity for ER and PR was demonstrated in both stored TP and newly prepared TP on Days 1, 2, 5, 14, 21, 42, and 56. Over the 56-day period, the number of ER positive cells ranged from 41% to 57% in stored TP and from 38% to 58% in newly prepared TP. The number of PR positive cells ranged from 31% to 41% in stored TP and from 26% to 37% in newly prepared TP. Mild, nonspecific cytoplasmic and nuclear staining occurred in all newly prepared TP (PR > ER).

CONCLUSIONS

ER and PR antigenicity was preserved in both stored TP and newly prepared TP of mammary tumor cells over a 56-day storage period. This demonstrates that ER and PR status can be evaluated in cytologic material from breast carcinoma using the ThinPrep technique.

Performance of an automated Q-beta replicase amplification assay for Mycobacterium tuberculosis in a clinical trial

We present data from a clinical trial study in which an automated version (Galileo) of a previously described Q-Beta replicase-amplified probe assay (J. S. Shah et al., J. Clin. Microbiol. 33:1435-1441, 1995) was used for the direct detection of Mycobacterium tuberculosis complex in sputum. The assay was designed to target specific regions of 23S rRNA found in M. tuberculosis, Mycobacterium bovis, Mycobacterium africanum, and Mycobacterium microti and had a sensitivity ranging from approximately <10 to 300 CFU. The assay was tested for cross-hybridization by using large numbers (e.g., 10(5)to 10(10) CFU/assay) of 133 other organisms commonly found in respiratory tract samples, including non-M. tuberculosis Mycobacterium spp., other bacteria, fungi, and viruses. All of these competitors tested negative by the assay. Automated assay results for 780 respiratory tract samples (sputum or bronchoalveolar lavage specimens) collected and tested at three trial sites in the United States) were compared with the results of culture and acid-fast microscopy. Aliquots of conventionally digested and decontaminated sputum pellets were heated at 100 degrees C and mechanically disrupted prior to hybridization and background reduction, amplification, and detection in a closed disposable test pack. Pertinent elements of individual patient histories relating to tuberculosis exposure, previous active disease, antituberculosis therapy status, etc., were considered in the resolution of discrepant results for 48 (assay false-positive) samples. Seventy-one of 90 (78.9%) culture-positive samples were positive when tested in the Galileo assay, while 7% of culture-negative samples were assay positive, corresponding to a sensitivity of 79% and a specificity of 93%. Following resolution of discrepant results by chart review, the sensitivity and specificity for the Q-Beta replicase amplification assay with the Galileo analyzer were 84 and 97%, respectively. A total of 69.2% of smear-negative (culture positive) samples were detected by the assay. Ten test packs at a time were automatically processed by the Galileo analyzer without operator intervention following loading of samples. The first result was reported in approximately 3 h, and the last result was available in 6.5 h. To our knowledge, this is the first report of a clinical study with a fully automated amplification probe hybridization assay for the detection of pathogens directly from a clinical specimen.

Reappraisal of femoral hernia in children

BACKGROUND

Femoral hernias are rare in children, accounting for fewer than 1 per cent of all paediatric groin hernias. Misdiagnosis is common and a source of complications. There is no consensus on the age and sex distribution or the optimum method of repair.

METHODS

A personal experience of four children with femoral hernia is reported together with an institutional review of a further ten hernias encountered during the past 11 years.

RESULTS

Peak incidence was between 5 and 10 years of age. Misdiagnosis was common, partly because of the variability in presenting symptoms and signs. In this series, boys were more commonly affected but a literature review indicated a similar sex incidence.

CONCLUSION

A femoral hernia should be positively excluded if the operative findings at inguinal exploration are inconsistent with the preoperative signs and in any child with a suspected recurrent inguinal hernia. Excision of the sac and repair of the femoral canal is curative.

Q-beta replicase-amplified assay for detection of Mycobacterium tuberculosis directly from clinical specimens

We report the results of a study conducted to evaluate the performance of manual Q-Beta replicase-amplified Mycobacterium tuberculosis complex assay compared with that of culture for detecting M. tuberculosis directly from digested sputum pellets. A total of 261 specimens submitted to three tuberculosis testing laboratories were analyzed. Culture and acid-fast bacillus smear results were provided by the tuberculosis testing laboratories. Of these 261 specimens, 34 (13% prevalence rate) were positive for M. tuberculosis by culture. The samples were digested and decontaminated by the testing laboratories by using their standard digestion and decontamination procedures. An aliquot of the digested and decontaminated pellet was sent to GENE-TRAK. The digested and decontaminated pellet was neutralized by washing it with 0.067 M phosphate buffer (pH 6.8), and the bacteria present in the washed pellet were heat inactivated at 100 degrees C for 15 min. The samples were combined with sample processing buffer containing GuSCN and were treated for 6 min in the GENE-TRAK Sample Processing Instrument to release the nucleic acids. The release rRNA was analyzed in a manual Q-Beta replicase assay format which incorporates elements of sandwich hybridization, reversible target capture, and Q-beta replicase signal amplification technologies. In comparison with culture, the overall assay sensitivity and specificity were 97.1 and 96.5%, respectively. The positive predictive value was 80.5%, and the negative predictive value was 99.5%. After analysis of discrepant results, the assay sensitivity and specificity were 97.3 and 97.8, respectively, and the prevalence rate was 14%. The positive predictive value and the negative predictive value were 87.8 and 99.5%, respectively. The Q-Beta replicase assay is rapid sensitive, semiquantitative, and specific for the direct detection of M. tuberculosis from clinical specimens.

Comparison of characteristics of Q beta replicase-amplified assay with competitive PCR assay for Chlamydia trachomatis

In order to study infections due to Chlamydia trachomatis, we have compared semiquantitative PCR and Q beta replicase-amplified assays for detection of this organism. The PCR assay was directed against the C. trachomatis 16S rRNA gene. Quantitation was accomplished by adding known amounts of a plasmid containing a truncated segment of the 16S rRNA gene target to chlamydia-containing samples and then amplifying with a common primer set. The Q beta replicase assay consisted of reversible target capture of C. trachomatis 16S rRNA, which was followed by amplification of an RNA detector probe in the presence of the enzyme Q beta replicase. In a clinical matrix, the lower limit of detection of both the PCR and Q beta replicase assays was five elementary bodies. The Q beta replicase and PCR assays were quantitative over 10,000- and 1,000-fold ranges of organisms, respectively. Analysis of the effects of endocervical matrix on amplification was accomplished by examining 94 endocervical specimens by each technique. Both assays detected five of six culture-confirmed specimens as well as three culture-negative specimens. PCR inhibitors were detected in 13 specimens. The Q beta replicase assay, in contrast, showed no evidence of sample inhibition. The Q beta replicase and PCR assays should allow quantitative investigation of infections due to C. trachomatis. In addition, because it targets highly labile RNA, the Q beta replicase assay may facilitate investigations into the role of active persisting infection in culture-negative inflammatory conditions.

Novel, ultrasensitive, Q-beta replicase-amplified hybridization assay for detection of Chlamydia trachomatis

A sensitive, nonisotopic hybridization assay termed "dual capture" is described. The assay rapidly and specifically detects very low levels of target nucleic acids and organisms. The assay is based on the principles of sandwich hybridization, reversible target capture, and Q-Beta replicase amplification. The assay can be completed in less than 4 h, and in the described model format, it detects Chlamydia trachomatis rRNA or rDNA. Up to 96 samples can be analyzed simultaneously. The assay employs two types of probes: a test-specific capture probe, which mediates the cycling of the target probe complex on and off derivatized magnetic beads, and a replicatable RNA detector molecule containing a sequence complementary to and adjacent to the capture probe site on the target. Following reversible target capture, detection of the signal is accomplished by replication of the detector molecule by Q-Beta replicase in the presence of propidium iodide. A specific assay signal can be detected from as few as 1,000 molecules above the background. In a limited study of 94 urogenital samples the assay detected five of the six culture-positive samples and did not detect the C. trachomatis target in 85 of the 88 culture-negative samples.

Infection with a plasmid-free variant Chlamydia related to Chlamydia trachomatis identified by using multiple assays for nucleic acid detection

Clinical samples in transport media from 40 patients exhibiting pathologies potentially caused by Chlamydia trachomatis infection were analyzed for chlamydial nucleic acid, and the results were compared with those of culture. Chlamydial culture was performed by a shell vial centrifugation method with HeLa 229 host cells. Polymerase chain reaction (PCR) assays were used to detect either regions on a 7.5-kb plasmid characteristic of C. trachomatis (plasmid-PCR) or a segment of the 16S rRNA genes (rRNA-PCR). All PCR results were confirmed by hybridization with probes for the specific amplified products in either a Southern or a dot blot format. An RNase protection (RNP) assay was used to detect genus-specific chlamydial 16S rRNA directly from the clinical samples. The PCR assays detected C. trachomatis but not other bacteria, including Chlamydia spp. C. trachomatis was isolated from six samples which were positive by the rDNA-PCR and plasmid-PCR assays. Five of the culture-positive specimens were positive by the RNP assay. Twenty-two samples were negative by all criteria. Surprisingly, nine samples were positive by rRNA-PCR and RNP assays only. Nucleic acid sequencing of the rRNA-PCR-amplified products indicated a close relationship between the variants and C. trachomatis. The data may indicate an unrecognized process in C. trachomatis infection or that these patients were infected by a variant strain of C. trachomatis which lacks the C. trachomatis-specific plasmid.

Structure of germ line immunoglobulin alpha heavy-chain RNA and its location on polysomes

We describe the structure of the major germ line RNA transcribed from unrearranged immunoglobulin alpha heavy-chain genes in immunoglobulin M-expressing cells of the I.29 mu B-cell lymphoma, a cell line capable of switching to immunoglobulin A expression upon lipopolysaccharide treatment. This germ line alpha RNA has a small open reading frame that does not include the C alpha domain, and this RNA appears to be present on polysomes in I.29 mu cells.

Bilateral facial nerve palsy following secretory otitis media

Facial nerve palsy is a known complication of acute suppurative otitis media. Cases of facial nerve palsy following secretory otitis media have not been reported in the world literature. We report a case of bilateral facial nerve palsy following secretory otitis media.

Immunoglobulin heavy-chain switching may be directed by prior induction of transcripts from constant-region genes

Immunoglobulin heavy-chain switching is effected by a DNA recombination event that replaces the C mu gene with one of the other heavy-chain constant-region (CH) genes located 3' to the C mu gene. How the specificity of this event is controlled is unknown. However, it has been shown that IgM+ cells capable of switching to specific isotypes have the corresponding unrearranged CH genes in an accessible or active chromatin state, as demonstrated by the fact that these specific CH genes are hypomethylated and are transcriptionally active. We now report that the RNAs transcribed from specific unrearranged CH genes are induced prior to switching under conditions that promote switching to these specific CH genes. For example, we find that bacterial lipopolysaccharide, which induces the IgM+ cell line I.29 mu to switch to IgA, induces transcripts from the germ-line C alpha gene(s) in I.29 mu cells prior to switch recombination. Two preparations of T-cell lymphokines (recombinant interleukin 4 and supernatant from the T-cell line 2.19, which contains interleukins 4 and 5) that promote switching to specific isotypes by lipopolysaccharide-treated spleen cells induce transcripts from the corresponding germ-line CH genes prior to expression of the new isotypes. For example, interleukin 4, which appears to be necessary for switching to IgE in vitro and in vivo, induces within 2 days large increases in germ-line C epsilon transcripts in lipopolysaccharide-treated spleen cells and in I.29 mu cells. The most straightforward interpretation of our data is that these lymphokines direct switching to specific isotypes by activating specific CH genes, making them accessible to the putative switch recombinase.

Partial laryngectomy for recurrent cancer after irradiation

Attention is drawn to the problems of surgical resection by partial laryngectomy after full therapeutic dosage of Telecobalt irradiation. Material is presented from 2 main treatment centres to indicate trends in surgical treatment and the complications experienced. End results are given which confirm a reasonable expectation of cure and functional conservation by vertical partial laryngectomy for recurrence of glottic cancer after irradiation. However, the results of treatment of recurrent supraglottic cancer by horizontal partial laryngectomy gave much cause for concern in terms of complications and survival. In conclusion an attempt is made, based on the quoted experience, to define the position of conservation surgery after full dosage irradiation of the larynx.