Comparison of the diagnostic yield of transbronchial lung biopsies by forceps and cryoprobe in diffuse parenchymal lung disease

Background

Transbronchial lung cryobiopsy (TBLC) in the diagnosis of diffuse parenchymal lung disease (DPLD) has shown a promising yield in recent times, with low post-procedural mortality and morbidity.

Objectives

To compare the yield of TBLC and conventional transbronchial forceps lung biopsy (TBLB).

Methods

A prospective study was carried out in patients with DPLD over a period of 1 year in a tertiary respiratory care institute in New Delhi, India. All 87 patients enrolled underwent both TBLB and TBLC. The procedures were performed in the bronchoscopy suite under conscious sedation and local anaesthesia, with an attempt to take a minimum of three biopsy specimens by conventional TBLB followed by TBLC. A 1.9 mm cryoprobe with a freezing time of 4 - 5 seconds was used. An Arndt endobronchial blocker was used to control bleeding along with locally administered medications.

Results

TBLB and TBLC led to a definitive diagnosis in 27 (31.0%) and 69 (79.3%) cases, respectively. The commonest diagnoses were hypersensitivity pneumonitis, sarcoidosis and pulmonary tuberculosis. TBLC led to additional diagnoses in 42 cases (48.3%). Pneumothorax was observed in 12 cases (13.8%), and moderate bleeding occurred in 63 (72.4%). There were no procedure-related deaths.

Conclusion

TBLC had a better diagnostic yield than conventional TBLB in DPLD. It has the potential to become a safe day-care procedure in a resource-limited setting, if certain precautions are taken.

Study synopsis

What the study adds. Compared with transbronchial forceps lung biopsy, transbronchial lung cryobiopsy (TBLC) led to additional diagnoses in 42 (48.3%) of 87 patients with clinicoradiological features of diffuse parenchymal lung disease. Pneumothorax was observed in 12 cases (13.8%) and moderate bleeding in 63 (72.4%). TBLC without rigid bronchoscopy or advanced airway devices under conscious sedation had a good diagnostic yield with an acceptable adverse events profile.Implications of the findings. TBLC under conscious sedation is not resource intensive and can be carried out in settings with limited resources.

Implementing the Good Participatory Practice Guidelines in the Girls Achieve Power Trial in South Africa

The Good Participatory Practice (GPP) guidelines provide a framework for stakeholder engagement within clinical trials, to ensure a study's acceptability, feasibility, and improving the overall research quality; however, they have rarely been applied beyond this setting, and no literature exists on its application in adolescent research. A review of the 2011 GPP guidelines was undertaken to identify which 16 GPP topic areas could be applied and adapted for implementing an ecological asset building intervention, that is, the Girls Achieve Power (GAP Year) cluster randomized controlled trial for reducing school dropout and increasing reporting of gender-based violence in Gauteng and Western Cape province in South Africa. The 16 GPP topic areas were adapted and implemented to guide stakeholder engagement for GAP Year. We show the usability and adaptability of the GPP framework for guiding stakeholder engagement in non-clinical trials like GAP Year; however it requires adapting to respond to the unique needs of the beneficiaries.

Prevalence of HIV and HIV-related diseases in the adult medical wards of a tertiary hospital in Durban, South Africa

Our objective was to determine the prevalence of HIV and the distribution of HIV-related diseases among adult, medical inpatients. Consecutive admissions were recruited and a single ELISA assay was used to determine HIV infection. Demographic and clinical details were extracted from clinical records. Of 507 patients, 54% were infected with HIV of which 84% had AIDS. HIV-infected patients were significantly younger (34.9 years) than uninfected patients (47.1 years) and had significantly higher risks for oral/oesophageal candidiasis (risk ratio [RR] 18.6), generalized lymphadenopathy (RR 7.1), unexplained fever (RR 7.0), chronic diarrhoea (RR 6.2) and pulmonary tuberculosis (RR 3.1). Pulmonary tuberculosis was present in 56% of HIV cases. Mortality was 22% for HIV cases and 9% ( P=0.016) for others. The mean length of hospital stay was the same for HIV-infected and uninfected patients. AIDS is the most common reason for admission to adult medical wards and will increasingly limit the number of beds available for non-AIDS patients.

Sexually transmitted infections in pregnancy: prevalence, impact on pregnancy outcomes, and approach to treatment in developing countries

Sexually transmitted infections (STIs) are common in the developing world. Management of STIs in pregnancy in many developing countries has, however, been complicated by the lack of simple and affordable diagnostic tests. This review examines the prevalence and impact on pregnancy outcome of STIs in developing countries and recommends approaches to management of STIs in pregnancy for resource poor settings.

Treatment for syphilis in antenatal care: compliance with the three dose standard treatment regimen

BACKGROUND

In South Africa, three doses of benzathine penicillin 2.4 MU at weekly intervals are recommended for treating syphilis in pregnancy. Limited information is available on compliance with the recommended regimen, in terms of time to starting treatment, number of doses, and timing of treatment.

METHODS

The study was conducted to establish the degree of compliance with treatment for syphilis. Timing of treatment and the titres of the rapid plasma reagin (RPR) positive women were recorded. A retrospective record review was conducted of 18,128 antenatal records. These were records of women attending antenatal care clinics in a tertiary hospital catchment area in KwaZulu Natal between February 2001 and January 2002.

RESULTS

Treatment patterns showed that 15.9% received no treatment, 13.2% one dose, 5.8% received two doses, and 64.8% received three doses. In total, 188 women (1.03%) were found to be RPR positive. Of these 36% were found to be high titre positives (titre > or = 1:8).

CONCLUSION

Completed treatment was significantly associated with age of gestation at first visit (p = 0.029), with women attending later in pregnancy less likely to receive all three doses of treatment.

Lipoblastoma of the neck

Lipoblastoma and lipoblastomatosis are benign tumours arising from embryonal fat cells. These rare tumours essentially occur in infancy and early childhood. The males are affected more than females often in the ratio of 3:1. These tumours usually arise in extremities. The involvement of neck is rare with only 10 cases reported so far in English literature. We herein report lipoblastoma of the neck in a 3 year old girl.

Relation of triglyceride stores in skeletal muscle cells to central obesity and insulin sensitivity in European and South Asian men

AIMS/HYPOTHESIS

To compare the relation between intramyocellular lipid content, central obesity and insulin sensitivity in Europeans and South Asians.

METHODS

Cross-sectional study of 40 South Asian and European non-diabetic men matched for age and body mass index. We measured intramyocellular lipid by proton magnetic resonance spectroscopy of soleus muscle, insulin sensitivity by the short insulin tolerance test, per cent body fat by dual-energy x-ray absorptiometry and visceral fat by single-slice computed tomography of the abdomen.

RESULTS

South Asians compared with Europeans had a higher mean per cent body fat (26.8% vs 22.5%, p = 0.05) and lower insulin sensitivity (mean +/- SEM 2.4 +/- 0.2 vs 3.4%/min +/- 0.3, p = 0.013). Mean (+/- SEM) intramyocellular lipid content was higher in South Asians than in Europeans (72.1 +/- 7.5 vs 53.6 +/- 4.9 mmol/kg dry weight, p = 0.046). In Europeans intramyocellular lipid was correlated with per cent body fat (r = 0.50, p = 0.028), waist:hip ratio (r = 0.74, p < 0.001), visceral fat (r = 0.62, p = 0.004) and insulin sensitivity (r = -0.53, p = 0.016). In South Asians intramyocellular lipid was not significantly related to insulin sensitivity or obesity, and the strongest associations of insulin sensitivity were with fasting plasma triglyceride and waist:hip ratio.

CONCLUSION/INTERPRETATION

The association of intramyocellular lipid with insulin sensitivity and obesity in Europeans is consistent with the hypothesis that muscle triglyceride mediates the effect of obesity on insulin sensitivity. The absence of a similar relation of insulin sensitivity to intramyocellular lipid in South Asians suggests that other mechanisms underlie the high insulin resistance observed in this group.

Histologic variations in the epididymis: findings in 167 orchiectomy specimens

Nonpathologic morphologic variations in the epididymal histology in 167 orchiectomy specimens were analyzed to assess and document the nature, frequency, and possible relation to patient age and underlying testicular pathology. Variations in histology included intranuclear eosinophilic inclusions, lipofuscin pigment, cribriform hyperplasia, Paneth cell-like metaplasia, and nuclear atypia. Intranuclear eosinophilic inclusions were observed in 72.5% of patients, and they appeared to occur at an older age than cribriform hyperplasia and Paneth cell-like metaplasia. Lipofuscin pigment was found in 32.9% of patients; this change was observed predominantly in ductuli efferentes and was more commonly associated with obstructive changes. Cribriform hyperplasia was seen in 41.9% of patients, and it occurred in 1 normal testis and in 33 testes with diverse pathologic alterations. Paneth cell-like metaplasia characterized by bright eosinophilic intracytoplasmic hyaline-like granules and globules, was present in 8.3% of patients and was accompanied by changes of obstruction in almost all instances. The globules were strongly periodic acid-Schiff positive, both before and after diastase digestion, and were negative for chromogranin A, KP-1, and MAC387 immunostains. Nuclear atypia, similar to that seen in seminal vesicles, was focally present in 13.8% of patients and tended to occur at an older age. The authors conclude that variations in epididymal morphology are fairly common and, therefore, surgical pathologists should be aware of these changes. Although exuberant in some patients, in no cases did these variations cause serious diagnostic problems.

An audit of knee radiographs performed for general practitioners

The Royal College of Radiologists (RCR) has published guidelines concerning indications for imaging investigations. These include plain radiography of the knee, the indications for which are locking or signs of restricted movement. This audit consisted of 1153 knee radiographs in a 9 month period, results of a questionnaire sent to general practitioners (GPs), analysis of radiological reports and returned questionnaires (55% of cases), and subsequent comments from the GPs on receiving these results. Only 50% of cases fall within RCR guidelines, 90% of radiographs were normal or showed degenerative change. In 42% of cases, knee radiographs were requested to confirm previously expected degenerative change, and in 30% patient pressure was a significant factor. Most knee radiographs (87%) result in no significant change in management apart from continuation of symptomatic measures. Application of current guidelines, however, would miss some important diagnoses manifest clinically by persistent pain or effusion, for example loose body or Brodie's abscess. In cases of locking, where a radiograph may miss significant soft tissue abnormality, there was concern that reassurance was often gained by a normal examination. This audit shows that many knee radiographs are unnecessary. The guidelines appear appropriate with the proviso that persistent pain and effusion should be included as indications for investigation. Many GPs report medico-legal considerations as important reasons for unnecessary referrals, although the application of guidelines should be protection against this. The referral rate for knee radiographs before and after the communication of these results has not altered.

Biliary distensibility during per-operative cholangiography as compared to pre-operative ultrasound: a four year follow-up study

INTRODUCTION

It is well recognized that corrected bile duct diameters, as measured by endoscopic retrograde cholangiography (ERC), are often significantly greater than the corresponding ultrasound measurement. This can be attributed to variation in bile duct distensibility and is particularly noted in post cholecystectomy patients, possibly due to loss of the gall bladder reservoir effect. It has been suggested that increased bile duct distensibility may be related to the post-cholecystectomy syndrome. We have observed a similar discrepancy between ultrasound and per-operative cholangiography (POC). This trial investigates whether the discrepancy between ultrasound and POC measurements has clinical significance.

METHOD

Seventy-five patients with normal pre-operative ultrasound and POC undergoing standard open cholecystectomy (with benzodiazepine pre-medication) in 1990 were identified. After allowance for magnification, maximum biliary diameters were obtained for the proximal extra-hepatic bile duct. Follow-up was obtained in 67 patients from clinical case notes and contact with general practitioners.

RESULTS

Considerable variation of bile duct distensibility was recorded (range 83% to 410%) with 12 cases having POC biliary diameters outside radiological guidelines (12 mm as recorded on the radiograph). This distension is shown to increase with age. After 4 years, 16 patients had recurrent abdominal pain of which nine had undiagnosed right upper quadrant pain. There were no clinical cases of retained stone post-operatively. There was no correlation between POC measured bile duct diameter or distensibility and post-operative or long term problems. This study suggests that the bile duct has a normal variation of distensibility which increases with age and that radiological guidelines, as regards the upper limit for normal POC biliary diameters can be relaxed.

Covered and duplicate exstrophy with duplication of bladder, urethra, vagina and dextrocardia: a case report

Variants of classical exstrophy are exceedingly rare. We report a case of covered and duplicate exstrophy with duplication of the bladder, urethra and genital tract with dextrocardia.

Lower limb amputation: striking the balance

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Case report: papillary adenoma of the gall-bladder in a child of 9 years

Gall-bladder neoplasms are unusual in childhood and are often not suspected clinically. We wish to report this unusual case of papillary adenoma of the gall-bladder in a 9-year-old male child who had presented with clinical features of acute cholecystitis.

Doppler waveform patterns of the umbilical artery--screening test for high risk pregnancies

Doppler assessment of umbilical artery waveforms using the peak systolic to end diastolic (S/D) ratio was used to determine if complications associated with impaired trophoblastic invasion of placental bed (i.e. pregnancy induced hypertension and intrauterine growth retardation) could be predicted. Values for S/D ratio of at least 4, 3.5 and 3 at 22-26, 30-32 and > or = 37 weeks gestation, respectively, were found to be better predictors of such complications. Pregnancy-induced hypertension could be predicted in 63% and growth retardation in 60% cases at 22-26 weeks of gestation.

Iatrogenic bone collapes

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