A Five-Year Study of Intrapleural Fibrinolytic Therapy in Loculated Pleural Collections

BACKGROUND

Pleural fluid loculations due to complicated parapneumonic effusion (CPE), empyema, tubercular effusion and traumatic hemothorax can be managed either by video-assisted thoracoscopic surgery (VATS) or intrapleural ibrinolytic therapy (IPFT). The former is more invasive, not easily available and is also more expensive. On the other hand, IPFT is less invasive, cheaper, easily accessible and if used early, in loculated pleural collections, break loculations and early pleural peel, thereby facilitating pleural space drainage.

OBJECTIVE

To study the efficacy of IPFT in facilitating pleural space drainage in loculated pleural collections of diverse aetiologies.

METHODS

A five-year retrospective, observational study of 200 patients, with loculated pleural collections and failed tube drainage and managed with IPFT was carried out. Responders were defined as those with significant volume of fluid drained and significant radiological resolution.

RESULTS

There were 106 (53%) cases of CPE, 59 (29.5%) cases of tubercular effusion, 23 (11.5%) cases of empyema and 12 (6%) cases of hemothorax. Responders were 148 (74%) in number. The distribution of responders as per type of loculated pleural collection was as follows: CPE 88 (83%), tubercular 37 (62.7%), empyema 14 (60.8%) and traumatic hemothorax 11 (91.6%). The adverse effects were mild and included chest pain in six patients and low-grade transient fewer in three cases.

CONCLUSIONS

Intrapleural fibrinolytic therapy is a safe and cost-effective option in the management of selected patients with loculated pleural effusions.

Building operational research capacity in the Pacific

Operational research (OR) in public health aims to investigate strategies, interventions, tools or knowledge that can enhance the quality, coverage, effectiveness or performance of health systems. Attention has recently been drawn to the lack of OR capacity in public health programmes throughout the Pacific Islands, despite considerable investment in implementation. This lack of ongoing and critical reflection may prevent health programme staff from understanding why programme objectives are not being fully achieved, and hinder long-term gains in public health. The International Union Against Tuberculosis and Lung Disease (The Union) has been collaborating with Pacific agencies to conduct OR courses based on the training model developed by The Union and Médecins Sans Frontières Brussels-Luxembourg in 2009. The first of these commenced in 2011 in collaboration with the Fiji National University, the Fiji Ministry of Health, the World Health Organization and other partners. The Union and the Secretariat of the Pacific Community organised a second course for participants from other Pacific Island countries and territories in 2012, and an additional course for Fijian participants commenced in 2013. Twelve participants enrolled in each of the three courses. Of the two courses completed by end 2013, 18 of 24 participants completed their OR and submitted papers by the course deadline, and 17 papers have been published to date. This article describes the context, process and outputs of the Pacific courses, as well as innovations, adaptations and challenges.

Pre-treatment loss to follow-up among smear-positive pulmonary tuberculosis cases: a 10-year audit of national data from Fiji

SETTING

All tuberculosis (TB) diagnostic and treatment centres in Fiji.

OBJECTIVES

To report on pre-treatment loss to follow-up rates over a 10-year period (2001-2010) and to examine if patients' age, sex and geographic origin are associated with the observed shortcomings in the health services.

METHODS

A retrospective review of routine programme data reconciling TB laboratory and treatment registers.

RESULTS

A total of 690 sputum smear-positive TB patients were diagnosed in the laboratory, of whom 579 (84%) were started on anti-tuberculosis treatment-an overall pre-treatment loss to follow-up of 111 (16%). Peak loss to follow-up rates were seen in 2003, 2004 and 2010. Pre-treatment losses were all aged ≥15 years. In the Western Division of Fiji, 33% of sputum-positive patients were declared pre-treatment loss to follow-up; this division had over five times the risk of such an adverse outcome compared to the Central Division (OR 5.2, 95%CI 3.1-8.9, P < 0.0001).

CONCLUSION

This study has identified an important shortcoming in programme linkage, communication and feedback between TB diagnostic and treatment services, leading to high pre-treatment loss to follow-up rates. This negatively influences TB services, and ways to rectify this situation are discussed.

Studies on Acoustic and Thermodynamic Behaviour of Terbium Laurate and Myristate in Mixed Organic Solvents

Ultrasonic measurements were made on terbium laurate and myristate in 60/40 benzene-methanol mixture (v/v), to determine the critical micellar concentration (CMC), ultrasonic velocity and other acoustic parameters. The results confirm that there is a significant interaction between the soap and solvent molecules. The critical micellar concentration and thermodynamic parameters for dissociation and micellization process for terbium laurate and myristate in a mixture of 60/40 benzene-methanol (v/v) at different temperature were evaluated from conductivity measurements. The results showed that these soaps behave as weak electrolytes in dilute solutions.

Isolation and characterization of microsomal omega-6-desaturase gene (fad2-1) from soybean

A genomic DNA sequence (fad2-1) encoding seed specific microsomal 0-6 desaturase was isolated from soybean (Glycine max. L cv. Pusa-9702). A positive genomic clone of 1852 nucleotides containing a single uninterrupted 3' end exonic region with an ORF of 1140 bp encoding a peptide of 379 amino acids, a complete 3' UTR of 206 bp and 86 bp of 5' UTR interrupted by a single intron of 420 bp was obtained on screening the sub-genomic library of soybean. Southern blots revealed at least two copies of the gene per haploid genome. Analysis of the translated product showed the presence of three histidine boxes, with the general sequence HXXXH and five probable transmembrane segments reported to be involved in substrate specificity.

Vector control in leishmaniasis

Indoor residual spraying is a simple and cost effective method of controlling endophilic vectors and DDT remains the insecticide of choice for the control of leishmaniasis. However resistance to insecticide is likely to become more widespread in the population especially in those areas in which insecticide has been used for years. In this context use of slow release emulsified suspension (SRES) may be the best substitute. In this review spraying frequencies of DDT and new schedule of spray have been discussed. Role of biological control and environment management in the control of leishmaniasis has been emphasized. Allethrin (coil) 0.1 and 1.6 per cent prallethrin (liquid) have been found to be effective repellents against Phlebotomus argentipes, the vector of Indian kalaazar. Insecticide impregnated bednets is another area which requires further research on priority basis for the control of leishmaniasis. Role of satellite remote sensing for early prediction of disease by identifying the sandflygenic conditions cannot be undermined. In future synthetic pheromons can be exploited in the control of leishmaniasis.

Preservation of Leishmania donovani promastigotes in blood agar slants

Long-term cultivation of Leishmania promastigotes by weekly passage to fresh medium was reported to be disadvantageous because needs labor, risk of contamination, lowering in infectivity and virulence pattern. Cryopreservation and Lyophilization require expensive facilities which could be a burden and unaffordable to most laboratories of developing countries where the disease is endemic. These problems could be minimized by simple preservation of Leishmania donovani promastigotes in blood agar slants at 7-8 degrees C for 6-7 months. The preserved promastigotes were examined for viability up to one year at a regular interval of one month. Viable promastigotes were found and revived successfully from all the slants stored up to 7 months after that, the viability of promastigotes was found to be decreased in the slants of 8-9 month storage. No viable promastigotes were recovered from the slants stored up to 11-12 months. By this method, the promastigotes can easily be stored up to 7 months without loss of biological activity. The number of passage of promastigotes to fresh medium has been greatly reduced by this method from 30 times to 01 when compared with weekly passage in liquid medium. This simple and economical method can be recommended for short storage of Leishmania culture without loss of any activity.

Evaluation of a dot-immunoblot assay for detecting leishmanial antigen in naturally infected Phlebotomus argentipes (Diptera: Psychodidae)

A simple and highly reproducible dot-immunoblot assay was developed to detect leishmanial antigen in Phlebotomus argentipes that were naturally infected with Leishmania donovani. The test was sensitive to as little as 10 ng of antigenic protein (equivalent to the gut content of one laboratory-infected sandfly) and also appeared to be specific, in that it gave a positive result with some P. argentipes (the primary vector of L. donovani in India) and L. donovani but not with P. papatasi or other pathogens. When used to investigate a large number of sandflies collected from two areas of the Indian state of Bihar where visceral leishmaniasis is endemic, the assay appeared sufficiently sensitive and specific to detect the naturally infected insects. The simplicity, reproducibility, high sensitivity and high specificity of the assay should make it useful for field studies, particularly in determining the prevalence of sandfly infection, the local level of transmission, and the impact of vector-control programmes.

Morphological variations in Phlebotomus argentipes (Diptera: Psychodidae) Annandale and Brunetti

Morphological variations were observed in Phlebotomus argentipes, the vector for visceral leishmaniasis reported from the endemic states of Bihar, West Bengal and Uttar Pradesh. The taxonomic features distinguishing vector and nonvector species of P. argentipes were relative length of ascoid and antennal segment IV. Three morphotypes were characterized as <0.4, = 0.4 and >0.4 respectively. Other characteristics of wing width, wing length, eye, style, antennal segment III, IV, V was found statistically significant (p<0.05) and eleven other morphological measurements were not significant. This study suggests three different morphotypes of P. argentipes in these three endemic states. The genetic and reproductive isolation among such morphotypes will establish the variability in further studies.

Evaluation of cholinesterase level in an endemic population exposed to malathion suspension formulation as a vector control measure

The manuscript describes a study on the blood cholinesterase (ChE) level in an exposed population at different interval of time after spraying with malathion suspension (SRES) use for kala-azar vector control in an endemic area of Bihar, India. The toxicity of a 5% malathion formulation in the form of a slow release emulsified suspension (SRES) was assessed by measuring serum ChE levels in spraymen and in the exposed population. The study showed a significant decrease in ChE levels in the spraymen (p < 0.01) after one week of spraying and in exposed population one week and one month after of spraying (p < 0.01), but was still within the normal range of ChE concentration, one year after spraying, the ChE concentration in the exposed population was the same as prior to spraying (p > 0.01). On no occasion was the decrease in ChE level alarming. A parallel examination of the clinical status also showed the absence of any over toxicity or any behavioural changes in the exposed population. Hence, it may be concluded that 5% malathion slow release formulation, SRES, is a safe insecticide for use as a vector control measure in endemic areas of kala-azar in Bihar, India so long as good personal protection for spraymen is provided to minimize absorption and it can substitute the presently used traditional DDT spray.

Susceptibility of Phlebotomus argentipes against DDT in endemic Districts of North Bihar, India

Susceptibility status of Indian kala-azar vector Phlebotomus argentipes after DDT spray from endemic areas of Muzaffarpur and Vaishali district and unsprayed non-endemic area of Patna district, Bihar, India were compared. Higher Lc50 viz. 2.6% and 3.2% and LT50, values 51.0 and 69.0 minutes to 4% DDT were observed for P. argentipes of Muzaffarpur and Vaishali district, whereas P. argentipes of Patna district was 100% susceptible to same concentration, indicating increased tolerance in P. argentipes. It is concluded DDT resistant P. argentipes, particularly in endemic zone growing. The possible explanation could be long-term insecticidal pressure.

Pacific Telepathlogy Service at Fiji School of Medicine

Pacific Telepathology service has been established at Fiji school of Medicine (FSM) with technical support from University of Basel. The service is designed for remote consultation, continuing medical education (CME) health care research (HCR). To develop Telepathology services for participation with international Telepathology community for improving quality of health care in the Pacific. Telepathology server for "Pacific Pathology Group" has been set up at http://telepath.patho.unibas.ch/, which is dedicated for Telepathology consultations bring together health care professionals in the Pacific to overcome limitations of distance, lack of resources and to improve quality of healthcare services, Accessed by a computer possessing Internet and email connection, members send cases and questions, review and comment on other cases and receive consultation via web or email. Benefits are tremendous in terms of remote consultation, CME, HCR and improving quality of modern health care even at remote islands devoid of health care resources. Internet speed or reliability is not a limiting factor. Virtual institute of pathology has been established in Switzerland with over 400 Pathologists and is providing consultations to many countries including Solomon Islands where there is no pathologist. The institute is functioning efficiently with average reporting turnaround time of 48 hours. Efficiency is the result of organization and communication. Presently this Service has been established at the FSM in Fiji Islands primarily for education & remote consultation with plans to expand to other island countries.

Management Strategies for Microalbuminuria in Diabetes Mellitus – an Overview

Microalbuminuria (MA) in individuals with diabetes mellitus (DM) is associated with markedly reducedsurvival, increased risk of cardiovascular disease and is predictive of later development of an overt DiabeticKidney Disease (DKD) and progressive renal failure. Patients with type 1 DM from 5 years after diagnosisand type 2 DM from the time of diagnosis should be screened annually for MA by sensitive stick test in spotcollection or Albumin Excretion Rate (AER) in the timed collection of urine. AER. of 20-200µg/min (30-300mg/24hr) or Albumin : Creatinine ratio (ACR) >2.5 is labelled as MA. ACE Inhibitor / Angiotensin IIReceptor Blocker (ARB) therapy along with improved glycaemic control is the key to prevent or slow theprogression of DKD.Key Words: Microalbuminuria, Diabetes Mellitus, Diabetic Kidney Disease.