Knowledge and attitude towards children's oral health: findings from a sample of first-time mothers in Malaysia

INTRODUCTION

Women's important roles within families which include modelling appropriate oral health behaviours require them to have good knowledge and positive attitude in oral health. This study determined knowledge and attitude towards children's oral health among first-time mothers and factors associated with the attributes.

MATERIALS AND METHODS

A total of 154 first-time mothers in the third trimester of pregnancy who attended two health clinics in the state of Sarawak, Malaysia for antenatal care participated in this cross-sectional study. A structured selfadministered questionnaire was used to measure the variables of interest.

RESULTS

Most mothers could correctly identify the aetiological factors of dental caries and strategies for preventing the disease in children. However, a substantial portion could not identify certain cariogenic and noncariogenic foods or drinks. Most pregnant women have appropriate attitudes towards children's oral health although some showed unfavourable attitude about care of primary teeth. Women who were older and had attended a talk on children's oral health were more likely to have higher mean knowledge score than their respective counterparts, and higher mean knowledge score was associated with higher mean attitude score.

CONCLUSION

Most first-time mothers in this study had correct knowledge and favourable attitude about children's oral health, although misunderstandings and misperceptions in several issues were also common. Significant association found between experience of attending oral health talk and oral health knowledge, and between oral health knowledge and attitude, substantiate the importance of an educational intervention program to optimise the mothers' roles in caries prevention in children.

Phlebectomy versus Sclerotherapy in Varicose Vein Patients: A Comparative Study

Varicose veins are part of the spectrum of chronic venous disease and include spider telangiectasias, reticular veins, and true varicosities. It may present without advanced signs of chronic venous insufficiency. Sclerotherapy is a treatment choice for patients with varicose veins of lower extremity; it uses the intravenous injection of chemical drugs to achieve the goal of inflammatory occlusion. Phlebectomy, a minimally invasive procedure usually used for higher diameter of varicose veins at the surface of the skin. Objective of the study was to compare the outcome of Phlebectomy and Sclerotherapy in varicose vein patients. It was a quasi experimental study was conducted in the Department of Vascular Surgery in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka during the period of June 2019 to May 2020. Patients admitted with varicose vein and varicosity of the lower limbs with valves and perforator incompetence in the Department of Vascular Surgery, BSMMU, Dhaka, Bangladesh. During this period 60 patients were selected purposive randomly. Patients were divided to 30 patients were treated with Phlebectomy (Group I) 30 patients were treated with Sclerotherapy (Group II). Data were collected according to the pre-designed semi-structured data collection sheet. After editing data analysis were carried out by using the Statistical Package for Social Science (SPSS) version 22.0 Windows software. This study shows average age 40.73±15.50 years in Phlebectomy (Group I) and 38.43±11.08 years in Sclerotherapy (Group II). Males are more commonly involved than females between two groups which was 76.7% in Phlebectomy (Group I) and 70.0% in Sclerotherapy (Group II). The change CEAP improved to 93.3% in patients who underwent phlebectomy when compared to 83.3% in patients who underwent sclerotherapy. During the follow-up with duplex at treated veins showed 93.3% complete occlusion of treated veins in the phlebectomy group, while only 70.0% of the patients in the sclerotherapy group showed evidence of complete occlusion. In phlebectomy group recurrence of leg varicosities were found 6.7% of the patients, while 26.7% of the patients in the sclerotherapy group. The difference was statistically significant between two groups (p=0.038). This study shows phlebectomy to be much better option than sclerotherapy for the treatment of varicose veins and hence can be used routinely. Both phlebectomy and sclerotherapy not only revealed minimal time taken for return to normal activity but also proved to be safer with regard to complications.

Brain DNA methylomic analysis of frontotemporal lobar degeneration reveals OTUD4 in shared dysregulated signatures across pathological subtypes

Frontotemporal lobar degeneration (FTLD) is an umbrella term describing the neuropathology of a clinically, genetically and pathologically heterogeneous group of diseases, including frontotemporal dementia (FTD) and progressive supranuclear palsy (PSP). Among the major FTLD pathological subgroups, FTLD with TDP-43 positive inclusions (FTLD-TDP) and FTLD with tau-positive inclusions (FTLD-tau) are the most common, representing about 90% of the cases. Although alterations in DNA methylation have been consistently associated with neurodegenerative diseases, including Alzheimer's disease and Parkinson's disease, little is known for FTLD and its heterogeneous subgroups and subtypes. The main goal of this study was to investigate DNA methylation variation in FTLD-TDP and FTLD-tau. We used frontal cortex genome-wide DNA methylation profiles from three FTLD cohorts (142 FTLD cases and 92 controls), generated using the Illumina 450K or EPIC microarrays. We performed epigenome-wide association studies (EWAS) for each cohort followed by meta-analysis to identify shared differentially methylated loci across FTLD subgroups/subtypes. In addition, we used weighted gene correlation network analysis to identify co-methylation signatures associated with FTLD and other disease-related traits. Wherever possible, we also incorporated relevant gene/protein expression data. After accounting for a conservative Bonferroni multiple testing correction, the EWAS meta-analysis revealed two differentially methylated loci in FTLD, one annotated to OTUD4 (5'UTR-shore) and the other to NFATC1 (gene body-island). Of these loci, OTUD4 showed consistent upregulation of mRNA and protein expression in FTLD. In addition, in the three independent co-methylation networks, OTUD4-containing modules were enriched for EWAS meta-analysis top loci and were strongly associated with the FTLD status. These co-methylation modules were enriched for genes implicated in the ubiquitin system, RNA/stress granule formation and glutamatergic synaptic signalling. Altogether, our findings identified novel FTLD-associated loci, and support a role for DNA methylation as a mechanism involved in the dysregulation of biological processes relevant to FTLD, highlighting novel potential avenues for therapeutic development.

Integrative transcriptomic analysis of the amyotrophic lateral sclerosis spinal cord implicates glial activation and suggests new risk genes

Amyotrophic lateral sclerosis (ALS) is a progressively fatal neurodegenerative disease affecting motor neurons in the brain and spinal cord. In this study, we investigated gene expression changes in ALS via RNA sequencing in 380 postmortem samples from cervical, thoracic and lumbar spinal cord segments from 154 individuals with ALS and 49 control individuals. We observed an increase in microglia and astrocyte gene expression, accompanied by a decrease in oligodendrocyte gene expression. By creating a gene co-expression network in the ALS samples, we identified several activated microglia modules that negatively correlate with retrospective disease duration. We mapped molecular quantitative trait loci and found several potential ALS risk loci that may act through gene expression or splicing in the spinal cord and assign putative cell types for FNBP1, ACSL5, SH3RF1 and NFASC. Finally, we outline how common genetic variants associated with splicing of C9orf72 act as proxies for the well-known repeat expansion, and we use the same mechanism to suggest ATXN3 as a putative risk gene.

The Manchester experience – a novel technique for supra-annular placement of the Edwards SAPIEN 3 Ultra TVH prosthesis in severe bicuspid aortic valve stenosis

Background

Bicuspid AV disease has been excluded from the seminal trials evaluating transcatheter heart valve (THV) placement in severe aortic stenosis. Although registry data has shown good results overall, case selection likely involves more challenging anatomical subsets being treated either surgically or medically in this very heterogenous condition. Conventional annular placement, as well as high annular placement in tapered anatomies remain the commonest deployment techniques. We reasoned that marked supra-annular placement with the mid-portion of the SAPIEN 3 Ultra (S3U) valve sealing skirt placed at the narrowest opening point at commissural level could be an alternative strategy allowing treatment of additional patient groups. This proposed technique takes advantage of elliptical expansion at commissural level with more circular expansion above and below this point to prevent embolisation, as well as sealing skirt positioning at the narrowest opening point to prevent paravalvular leak.

Aims

We examined the feasibility of marked supra-annular placement of the balloon-expandable S3U prosthesis with the mid-point of the sealing skirt placed at commissural level in patients with severe bicuspid aortic valve stenosis and relative contra-indications to annular placement.

Methods

We assessed patients with severe bicuspid aortic stenosis undergoing TAVI at our centre over a 9-month period and identified those with relative contra-indications to conventional annular placement. These included: (i) excessive annular size (ii) severe leaflet and raphe calcification with risk of rupture into the right ventricle (iii) excessive leaflet length with potential leaflet overhang. CT imaging was used to define the narrowest opening location at commissural level, typically 10–15mm supra-annular. The diameter at this level was used to select THV size. Calculations were made to approximate the mid skirt level to this supra-annular position. In most cases this involved supra-annular positioning with the lower THV border 5–8mm supra-annular. This was achieved in most cases by aligning the unexpanded border with the annulus.

Results

Out of 9 patients with biscupid AV, 4 had relative contra-indications for annular placement. In all 4 cases, excellent valvular expansion with only minimal paravaulvar leak was achieved with placement of the S3U prosthesis at 5–7mm above the annulus and with supra-annular sealing at commissural level. Annular dimensions of 35.5mm and 31.5mm were successfully treated with 29mm and 26mm valves due to significant tapering at commissural level in 2 patients. There were no procedural complications, incidences of AV blocks or valve embolisation.

Conclusion

As a proof of concept, we have demonstrated excellent outcomes with marked supra-annular TAVI placement in patients with severe bicuspid AV stenosis and anatomy unfavourable for conventional annular placement. This is the first description of this completely novel deployment technique.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Manchester Royal Infirmary

Transcriptomic analysis of frontotemporal lobar degeneration with TDP-43 pathology reveals cellular alterations across multiple brain regions

Frontotemporal lobar degeneration (FTLD) is a group of heterogeneous neurodegenerative disorders affecting the frontal and temporal lobes of the brain. Nuclear loss and cytoplasmic aggregation of the RNA-binding protein TDP-43 represents the major FTLD pathology, known as FTLD-TDP. To date, there is no effective treatment for FTLD-TDP due to an incomplete understanding of the molecular mechanisms underlying disease development. Here we compared postmortem tissue RNA-seq transcriptomes from the frontal cortex, temporal cortex, and cerebellum between 28 controls and 30 FTLD-TDP patients to profile changes in cell-type composition, gene expression and transcript usage. We observed downregulation of neuronal markers in all three regions of the brain, accompanied by upregulation of microglia, astrocytes, and oligodendrocytes, as well as endothelial cells and pericytes, suggesting shifts in both immune activation and within the vasculature. We validate our estimates of neuronal loss using neuropathological atrophy scores and show that neuronal loss in the cortex can be mainly attributed to excitatory neurons, and that increases in microglial and endothelial cell expression are highly correlated with neuronal loss. All our analyses identified a strong involvement of the cerebellum in the neurodegenerative process of FTLD-TDP. Altogether, our data provides a detailed landscape of gene expression alterations to help unravel relevant disease mechanisms in FTLD.

Transcriptomic analysis of frontotemporal lobar degeneration with TDP-43 pathology reveals cellular alterations across multiple brain regions

Frontotemporal lobar degeneration (FTLD) is a group of heterogeneous neurodegenerative disorders affecting the frontal and temporal lobes of the brain. Nuclear loss and cytoplasmic aggregation of the RNA-binding protein TDP-43 represents the major FTLD pathology, known as FTLD-TDP. To date, there is no effective treatment for FTLD-TDP due to an incomplete understanding of the molecular mechanisms underlying disease development. Here we compared postmortem tissue RNA-seq transcriptomes from the frontal cortex, temporal cortex, and cerebellum between 28 controls and 30 FTLD-TDP patients to profile changes in cell-type composition, gene expression and transcript usage. We observed downregulation of neuronal markers in all three regions of the brain, accompanied by upregulation of microglia, astrocytes, and oligodendrocytes, as well as endothelial cells and pericytes, suggesting shifts in both immune activation and within the vasculature. We validate our estimates of neuronal loss using neuropathological atrophy scores and show that neuronal loss in the cortex can be mainly attributed to excitatory neurons, and that increases in microglial and endothelial cell expression are highly correlated with neuronal loss. All our analyses identified a strong involvement of the cerebellum in the neurodegenerative process of FTLD-TDP. Altogether, our data provides a detailed landscape of gene expression alterations to help unravel relevant disease mechanisms in FTLD.

1097 17 Years of Treating Deep Sternal Wound Infections at A Single Institution: Outcomes and Lessons Learned

Introduction

Deep sternal wound infections (DSWI) are a serious complication following cardiac surgery that comprise of any infection penetrating the subcutaneous tissue of the sternum. DSWI have been found to increase mortality and worsen prognostic outcomes following surgery.

Method

We conducted a retrospective cohort study using hospital e-records from 2000 to 2017 of all adult patients operated on with a median sternotomy at our institution. Univariate and multivariate analysis along with mortality and Kaplan-Meier survival curves compared the DSWI population against the remaining study population, using SPSS-25 software.

Results

Of 15521 total patients in the study, 145 (0.9%) suffered a DSWI. Variables that were associated with DSWI included age at operation (p = 0.019), gender (p = 0.007), BMI (p = 0.001), diabetes (p < 0.0001), renal disease (p = 0.008), operative urgency (p = 0.007), type of operation (p = 0.02), Euroscore (p = <0.0001), bypass-time (p = 0.038) and crossclamp-time (p = 0.008). A logistic regression encompassing significant variables revealed that gender (p = 0.031 CI 1.45-1.96), BMI (p < 0.0001 CI 1.03-1.10), diabetes (p = 0.007 CI 1.20-3.67) and type of operation (p = 0.018 CI 1.23-1.87) remained significant when covariate contribution was eliminated. DSWI subgroup mortality was insignificant at 30 days (3.4%vs2.9%, p = 0.68) but significantly worse at 90 days (8.3%vs3.7%, p = 0.004) and at 1 year (17.2%vs5.4%, p < 0.0001). Kaplan-Meier analysis depicted a significantly worse survival distribution for the DSWI population compared to rest of study (Log-Rank<0.05).

Conclusions

At our centre, DSWI are attributable to certain modifiable and set demographics and contribute heavily to medium-term mortality. A better understanding of DSWI risk factors may pinpoint those at risk and benefit the multidisciplinary team to ultimately reduce the rate of DSWI.

302 Is Age Just A Number in Cardiac Surgery? Evaluating Outcomes of An Octogenarian Cohort at A Single Cardiac Centre

Introduction

Cardiac surgery in octogenarians contains many age-specific perioperative risk factors and outcomes yet to be fully understood.

Method

All adults (N = 4957) undergoing cardiac surgery between 2011-2017 at our institution were retrospectively studied, encompassing 312 octogenarians. Data was evaluated with univariate and multivariate testing and mortality with Kaplan-Meier and cox-regression analyses.

Results

Compared to septuagenarians, octogenarians revealed more patients having previous surgery (p = 0.016), less diabetic patients (p = 0.034), lower BMI (0.002), and longer hospital stay (p < 0.000). Compared to rest of study, octogenarians contained more females (p = 0.012), a greater Euroscore (p < 0.000), spent longer in ITU (p = 0.001) and contained more ITU readmissions (p = 0.023). The octogenarians did not contain significant 30- and 90-day mortality but revealed significant mortality at 1-year versus septuagenarians (p = 0.039) and rest of study (p = 0.001). Variables testing significant in a multivariate regression were inserted into a cox-regression that found octogenarian group-membership to be insignificant (p = 0.051) in a 12-covariate model. Independent risk factors for mortality included emergency surgery (p = 0.04), reoperation (p < 0.000), cardiac procedure (p = 0.007), ITU time (p = 0.041) and diabetes (p = 0.023).

Conclusions

We report specific differences for octogenarians in perioperative characteristics along with promising short- and medium-term survival. Such outcomes must constantly be monitored so that cardiac surgery can be further tailored to this elderly cohort.

512 Trauma Meetings in the Time of COVID

Trauma & Orthopaedics (T&O) has taken a backseat during COVID-19. As the focus has shifted to care of COVID patients, other specialties have adjusted their daily working. At our local hospital, the dedicated Orthopaedic ward was absorbed into the Intensive Care department, necessitating migration to a smaller, shared working space. This project looked at ways of increasing clinical efficiency, patient safety and education within the T&O department.

Members of the T&O department at The Princess Alexandra Hospital were invited to attend daily trauma meetings virtually via Microsoft Teams. In addition, the impact of moving to a larger, dedicated meeting space was assessed. Pre- and post-intervention questionnaires were delivered to assess response.

Post-intervention questionnaires revealed a significant improvement in the perception of ability to see XRs (p < 0.001), quality of handover (p = 0.018), ability to discuss and formulate management plans (p = 0.002), social distancing (p < 0.001), location (p = 0.002) and trauma meetings overall (p < 0.000). The educational value of trauma meetings did not improve as anticipated, however.

Virtual Trauma Meetings are a useful adjunct, allowing clinicians safely contribute to clinical care. In addition, the location of daily trauma meetings is an important factor to consider, both for the safety of patients and for the safety of clinicians.

Breaking free from thermodynamic constraints: thermal acclimation and metabolic compensation in a freshwater zooplankton species

Respiration rates of ectothermic organisms are affected by environmental temperatures, and sustainable metabolism at high temperatures sometimes limits heat tolerance. Organisms are hypothesized to exhibit acclimatory metabolic compensation effects, decelerating their metabolic processes below Arrhenius expectations based on temperature alone. We tested the hypothesis that either heritable or plastic heat tolerance differences can be explained by metabolic compensation in the eurythermal freshwater zooplankton crustacean Daphnia magna We measured respiration rates in a ramp-up experiment over a range of assay temperatures (5-37°C) in eight genotypes of D. magna representing a range of previously reported acute heat tolerances and, at a narrower range of temperatures (10-35°C), in D. magna with different acclimation history (either 10 or 25°C). We discovered no difference in temperature-specific respiration rates between heat-tolerant and heat-sensitive genotypes. In contrast, we observed acclimation-specific compensatory differences in respiration rates at both extremes of the temperature range studied. Notably, there was a deceleration of oxygen consumption at higher temperature in 25°C-acclimated D. magna relative to their 10°C-acclimated counterparts, observed in active animals, a pattern corroborated by similar changes in filtering rate and, partly, by changes in mitochondrial membrane potential. A recovery experiment indicated that the reduction of respiration was not caused by irreversible damage during exposure to a sublethal temperature. Response time necessary to acquire the respiratory adjustment to high temperature was lower than for low temperature, indicating that metabolic compensation at lower temperatures requires slower, possibly structural changes.

Outcome of Management of Liver Abscess by Surgical Approach in a Tertiary Care Hospital

Liver abscess is a serious, life threatening condition. A recent development in the management of liver abscesses, facilitated by advances in diagnostic and interventional radiology, has decreased mortality rates. The purpose of this study is to search for the clinical presentations and surgical outcomes of liver abscess in our country. The markers of the outcome are mortality, duration of hospital stay and complications such as wound infection, residual disease following surgery, biliary leakage, intra abdominal abscess formation. This observational cross sectional study was conducted in Mymensingh Medical College & Hospital (MMCH), Bangladesh for 12 months from 1st January 2017 to 31st December 2017. Total 25 patients presenting with the features of liver abscess were included in this study by convenient and purposive sampling according to the inclusion and exclusion criteria. Surgical principles of liver abscess management were applied and outcomes were observed. The patients were diagnosed on the basis of clinical feature, findings of abdominal ultrasound and occasionally by doing CT scan. Most of the patients (28%) were in the age group of 51-60 years. Regarding sex distribution majority of the patients (64%) was male. Most of patients presented with fever (92%), anorexia and vomiting (32%), upper abdominal pain (84%). Hepatomegaly and reactive pleural effusion are the important findings present in 9(36%) and 8(32%) patients respectively. Size of the liver abscess was more than 5cm in 72% patients. Among the patients right lobe was predominantly involved. It was found during laparotomy that 4 patients (16%) had spontaneous rupture of abscess into peritoneal cavity. One (4%) patient developed biliary leakage after surgical drainage. No intra abdominal abscess or residual diseases was observed after surgery. Among the patients 24% developed wound infection. The overall mortality rate was 12%. The median length of hospital stay was 8 days (range: 1-15 days). Outcome of surgical drainage of liver abscess in tertiary care hospital of our country shows satisfactory result. So, patients with large multiple liver abscess, septic shock, failures of percutaneous drainage should be treated by early open surgical intervention.

Efficacy of Intra-peritoneal Tramadol Instillation for Postoperative Pain Management after Laparoscopic Cholecystectomy

Gall stone disease is one of the most common conditions encountered in general surgical practices in adult population. The gold standard treatment for symptomatic gall stone disease is laparoscopic cholecystectomy. It results in less post-operative pain as compared to open cholecystectomy but post-operative pain may be mild, moderate or even severe in some patients. This Randomized control trail was conducted to In-patient department of Surgery, Mymensingh Medical College & Hospital (MMCH), Mymensingh, Bangladesh from April 2018 to September 2018. It was undertaken to evaluate the analgesic effect of intra-peritoneal tramadol instillation in patients undergoing laparoscopic cholecystectomy. Total 70 patients with symptomatic gallstone disease undergoing laparoscopic cholecystectomy were randomized equally in two groups. Then patients were selected in according to the inclusion and exclusion criteria. In first group (Group A), patients were received intra-peritoneal tramadol 100mg (diluted in 20.0ml distilled water). Sprayed 10.0ml diluted tramadol into the sub diaphragmatic area, 5.0ml into the area of gall bladder bed and 5.0ml into the space between the liver and kidney under direct vision just before removal of trocars. In second group (Group B) the conventional operative procedure was followed. Postoperatively, patient was extubated and shifted to recovery room. Data recorded and analyzed, such as post-operative pain score at 1, 4, 8, and 24 hour; cumulative 1, 8 and 24 hour analgesic consumption. In addition that postoperative hospital period monitoring of heart rate, blood pressure, respiratory rate, temperature at 0, 4, 8, 24 hours was also analyzed. Intensity of pain was assessed by Visual Analogue Scale (VAS) scoring system. Patients showed a VAS ≥3 or patients who requested for analgesia was administrated a supplemental dose of analgesic. In the present study the mean pain scores in Group A were found to be low at1hourpost-operative was 0.60±0.56 and there was a gradual increase in score in respect of time interval with peak of 2.07±0.91 at 24 hours. Whereas, in Group B the mean pain scores immediate post-operative period were at its peak was, 2.50±0.82 which decreased to 1.30±0.84 at 1 hour and further there was rise at 4 hours (2.10±0.71) and 24 hours (2.33±0.0.71). But at any point of time the mean VAS remained significantly low (p<0.050) in patients with Group A compared to Group B except at 1st 24 hours (p=0.210). Intra-peritoneal instillation of tramadol for postoperative pain control in laparoscopic cholecystectomy has beneficial effect in terms of postoperative pain relief following laparoscopic cholecystectomy.

Association of Estimated GFR (By MDRD) with the Carotid Intima Media Thickness (CIMT) in Different Stages of CKD among Patients with Type 2 Diabetes Mellitus

Most of the mortalities among Diabetic Nephropathy patients are cardiovascular, if we identify the risk factor, measures can be taken to prevent it. Hence an objective was set to evaluate the association between carotid artery intima media thickness (CIMT) with eGFR in patients of CKD stage III, IV and V among patients with type 2 diabetes mellitus; also, correlation with age, BMI, lipid profile. This cross-sectional, observational study was performed in 70 patients in different stages of CKD in Diabetic Patients selected by Inclusion Criteria (Diabetic nephropathy patients with stages III, IV, V and exclusion Criteria (Acute kidney injury, History of carotid surgery, Patients of MI and stroke). This study was performed in Department of Nephrology, Dhaka Medical College in collaboration with the Department of Radiology and Imaging, laboratory of Department of Biochemistry and Department of Microbiology at Dhaka Medical College Hospital (By standard method in laboratory) from 1st January 2016 to 31st December 2016. eGFR was measured by MDRD formula and the CIMT was measured using an ultrasonographic examination. The mean CIMT was 0.9±0.21mm, and 62.9% of the subjects showed IMT thickening (≥1mm). The carotid IMT elevated significantly with the stage progression of CKD (Overall eGFR mean 28.8±14.5mL/min/1.73m² in CIMT<1mm with range from 6 to 54 and 9.1±9.0mL/min/1.73m² in CIMT ≥1mm with range from 3 to 32 (p=0.001). The eGFR was significantly lower in the patients with CIMT thickening than those without CIMT thickening. eGFR was also significantly associated with CKD stages (p=0.001), serum creatinine (p=0.001), BMI (r = -0.330, p=0.005), and negatively associated with age group, duration of hypertension, smoking. However, the CIMT was not significantly different among the patients at different stages of diabetic nephropathy (r = -0.172, p=156) and age group. It has been concluded that the mean CIMT was markedly high in patients with CKD compared to normal expected value. This study showed a relationship between the CIMT and the renal parameters as eGFR and the stages of diabetic nephropathy with a confirm association between the CIMT and diabetic macroangiopathy.

Utility of the microcolony method for evaluation of multidrug-resistant tuberculosis patients in Karachi, Pakistan

OBJECTIVE: To compare the microcolony method (MCM) with the reference culture method to evaluate culture conversion in multidrug-resistant tuberculosis (MDR-TB) patients.MATERIAL AND METHODS: Adult patients with Mycobacterium tuberculosis culture-positive MDR-TB undergoing second-line anti-tuberculosis treatment were recruited from two tertiary care chest clinics from January 2013 to October 2014. The MCM was performed in addition to MGIT™ and Löwenstein-Jensen medium (reference method) on sputum samples submitted on a monthly basis.RESULTS: Of 140 patients, culture conversion could be evaluated in 95 patients. The MCM showed 100% agreement with the reference M. tuberculosis culture in 83 of 95 patients who achieved culture conversion. In smear-positive and smear-negative cases, the mean time to positivity was 9.1 and 11.4 days for the MCM and 16.1 and 23.2 days for the reference M. tuberculosis culture respectively. The contamination rate for the MCM was 4.5% in comparison with 6.1% for the reference M. tuberculosis culture. The cost of MCM was estimated to be 30% that of the reference method.CONCLUSION: The MCM can be used in non-urban laboratories as a safe, rapid and cost-effective substitute for the reference M. tuberculosis culture to assess culture conversion in MDR-TB patients.Note: Abstract has been published in International Journal of Mycobacteriology 2015; 4: 159-160.

Response of Proliferative Lupus Nephritis with Pulse Cyclophosphamide Therapy during Induction Period: A Single Centre Study in Bangladesh

This prospective study was conducted to assess the response of proliferative lupus nephritis with pulse cyclophosphamide therapy during induction period in the department of Nephrology of Dhaka Medical College, Dhaka, Bangladesh from December 2012 to November 2013. A total of 35 clinically diagnosed SLE patients of class III/IV lupus nephritis were included. But 3 patients were dropped out during follow-up, therefore finally 32 patients (class III = 4, class IV = 28) were studied. The patients were evaluated for response on the basis of proteinuria, serum creatinine & active sediment in urine after 6th cycle of cyclophosphamide and 62.5% patients achieved complete response, 25% patients achieved partial response & 12.5% patients achieved no response. The factors favored complete response was early clinical presentation (7 months duration), proteinuria ≤3gm/day& normal renal function during their initial presentation. And higher anti ds DNA titre was an independent predictor for partial response/no response.

Pattern of first- and second-line drug resistance among pulmonary tuberculosis retreatment cases in Pakistan

BACKGROUND

Drug resistance in general, and multidrug-resistant tuberculosis (MDR-TB) in particular, threatens global tuberculosis (TB) control efforts. Population-based estimates of drug resistance are needed to develop strategies for controlling drug-resistant TB in Pakistan.

OBJECTIVE

To obtain population-based data on Mycobacterium tuberculosis drug resistance in Pakistan.

METHODS

To obtain drug resistance data, we conducted a population-based study of TB cases in all provinces of Pakistan. We performed culture and drug susceptibility testing on M. tuberculosis isolates from patients with a prior history of anti-tuberculosis treatment (retreatment cases) from all over the country.

RESULTS

Of 544 isolates from previously treated cases, 289 (53.1%) were susceptible to all first-line drugs, 255 (46.9%) were resistant to at least one anti-tuberculosis drug and 132 (24.3%) were MDR-TB. Among MDR-TB isolates, 47.0% were ofloxacin (OFX) resistant. Extensively drug-resistant TB was found in two (0.4%) isolates.

CONCLUSION

Prevalence of drug resistance in retreatment isolates was high. The alarmingly high prevalence of OFX resistance among MDR-TB isolates may threaten the success of efforts to control and treat MDR-TB.

Antibiotic susceptibility in Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes in Pakistan: a review of results from the Survey of Antibiotic Resistance (SOAR) 2002-15

OBJECTIVES

To investigate changes in the antibiotic susceptibility of Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes from the Survey of Antibiotic Resistance (SOAR) in community-acquired respiratory tract infections (CA-RTIs) between 2002 and 2015 in Pakistan.

METHODS

This is a review based on previously published studies from 2002-03, 2004-06 and 2007-09 and also new data from 2014-15. Susceptibility was determined by Etest(®) or disc diffusion according to CLSI and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 706 isolates from CA-RTIs comprising 381 S. pneumoniae, 230 H. influenzae and 95 S. pyogenes were collected between 2002 and 2015 and tested against a range of antibiotics. Antibiotic resistance in S. pneumoniae rose steeply from 2002 to 2009, with isolates non-susceptible to penicillin and macrolides increasing from 10% to 34.1% and from 13%-14% to 29.7%, respectively. Susceptibility to amoxicillin/clavulanic acid (and by inference amoxicillin) remained between 99.4% and 100% from 2002 to 2015. Over the years, the prevalence of susceptibility to cefuroxime was 98%-100% among S. pneumoniae. Resistance in S. pneumoniae to some older antibiotics between 2007 and 2009 was high (86.8% for trimethoprim/sulfamethoxazole and 57.2% for tetracycline). Between 2002 and 2015, ampicillin resistance (β-lactamase-positive strains) among H. influenzae has remained low (between 2.6% and 3.2%) and almost unchanged over the years (H. influenzae was not tested during 2004-06). For S. pyogenes isolates, macrolide resistance reached 22%; however, susceptibility to penicillin, amoxicillin/clavulanic acid and cefuroxime remained stable at 100%.

CONCLUSIONS

In S. pneumoniae from Pakistan, there has been a clear reduction in susceptibility to key antibiotics since 2002, but not to amoxicillin/clavulanic acid (amoxicillin) or cefuroxime. However, susceptibility in H. influenzae has remained stable. Local antibiotic susceptibility/resistance data are essential to support informed prescribing for CA-RTIs and other infections.

A rare case of primary epithelioid angiosarcoma of the ureter

Angiosarcoma is an extremely rare vascular malignancy with a 1-year survival rate of 50%, regardless of tumour origin. Distant metastases are common and occur in the lungs, bone, lymph nodes and soft tissues. The majority of patients with angiosarcoma present with localised disease, although 25-45% have distant metastases at presentation. There are few reported cases of angiosarcomas of the bladder and we report the second case in the literature of primary angiosarcoma of the ureter. We suggest that, in atypical manifestations of suspected urothelial malignancy, the multidisciplinary team considers the possibility of rarer, aggressive tumours early. This may influence clinical decision making towards offering radical treatments earlier, before it is too late to do so owing to aggressive oncological behaviour.

A Case of Massive Pleural Effusion: Pleurodesis by Bleomycin

Malignant pleural effusion is a common complication of primary and metastatic pleural malignancies. Pleurodesis for the management of malignant pleural effusion is intended to achieve symphysis between parietal and visceral pleura, and to prevent relapse of pleural effusion. Many chemical agents are tried to induce inflammation and damage of the pleural mesothelial layer to achieve this symphysis. Hemorrhagic pleural effusion, especially in the right hemithorax commonly occurs as presentation of primary and metastatic pleural malignancies. This case reports massive right-sided hemorrhagic pleural effusion as the sole manifestation of primary lung cancer in a 45 year old man. Patient attended our department of thoracic surgery complaining of cough, shortness of breath and right sided chest pain. A chest X-ray and chest computer tomography (CT) radiograph shows right sided massive pleural effusion. Right sided tube thoracotomy done. Pleural fluid study was done. Fluid for cytopathology was positive for malignant cell. Computed tomography guided fine needle aspiration cytology from right lung lesion was also done. Diagnosis was as small cell carcinoma. Pleural effusion resolved after 9(th) post operative day of chest tube insertion. Bleomycin pleurodesis was done. Day after pleurodesis intra thoracic tube was removed and patient was discharged from hospital on 10(th) Post operative day with an advice to attend the oncology department for further treatment. The protocol of tube thoracostomy and chemical pleurodesis was almost always successful in giving symptomatic relief of respiratory distress for a considerable period of time. However, chemical pleurodesis is not possible in all cases of malignant pleural effusion because it has got potential complication including death.

Coracobrachialis muscle: morphology, morphometry and gender differences

PURPOSE

Coracobrachialis (CBM) is a complex muscle with a wide range of variations in its morphology and innervation. The goal of this study was to elucidate the morphology, morphometry, gender differences of CBM and precise anatomical position of the musculocutaneous nerve (MCN) with reference to surrounding anatomical landmarks in an adult Sri Lankan population.

METHOD

Cadaveric upper limbs (n = 312) were examined for the proximal and distal attachments, length, width, thickness of CBM and its relationship with the MCN.

RESULTS

The CBM originated from the tip of the coracoid process of the scapula and lateral, posterior and medial aspects of the tendon of short head of biceps brachii. Gender differences were observed in all morphometrical parameters of CBM. In 83.33 %, MCN perforated the CBM. In 50 % the MCN pierced the middle one-third of CBM while none pierced the lower one-third. The distance from the coracoid process to the point of entry of MCN into CBM (distance P) was 50.62 mm. A positive correlation was observed between the arm length and distance P indicating that arm length provides an accurate and reliable means of gauging the distance P of an individual.

CONCLUSION

The present study provides new evidence pertaining to the origin of CBM. Further, it was revealed that the predicted distance P of any upper extremity can be calculated by dividing the arm length by 5. Precise anatomical location of MCN in relation to CBM using unequivocal and well-defined anatomical landmarks will be imperative in modern surgical procedures.

Anti-tuberculosis drug resistance in Bangladesh: reflections from the first nationwide survey

OBJECTIVE

To determine the prevalence of tuberculosis (TB) drug resistance in Bangladesh.

DESIGN

Weighted cluster sampling among smear-positive cases, and standard culture and drug susceptibility testing on solid medium were used.

RESULTS

Of 1480 patients enrolled during 2011, 12 falsified multidrug-resistant TB (MDR-TB) patients were excluded. Analysis included 1340 cases (90.5% of those enrolled) with valid results and known treatment antecedents. Of 1049 new cases, 12.3% (95%CI 9.3-16.1) had strains resistant to any of the first-line drugs tested, and 1.4% (95%CI 0.7-2.5) were MDR-TB. Among the 291 previously treated cases, this was respectively 43.2% (95%CI 37.1-49.5) and 28.5% (95%CI 23.5-34.1). History of previous anti-tuberculosis treatment was the only predictive factor for first-line drug resistance (OR 34.9). Among the MDR-TB patients, 19.2% (95%CI 11.3-30.5; exclusively previously treated) also showed resistance to ofloxacin. Resistance to kanamycin was not detected.

CONCLUSION

Although MDR-TB prevalence was relatively low, transmission of MDR-TB may be increasing in Bangladesh. MDR-TB with fluoroquinolone resistance is rapidly rising. Integrating the private sector should be made high priority given the excessive proportion of MDR-TB retreatment cases in large cities. TB control programmes and donors should avoid applying undue pressure towards meeting global targets, which can lead to corruption of data even in national surveys.