Urinary lipoarabinomannan in individuals with sputum-negative pulmonary tuberculosis

BACKGROUND OBJECTIVES

Tuberculosis (TB) is a major global cause of ill health. Sputum microscopy for confirmation of presumptive pulmonary TB (PTB) has a reportedly low sensitivity of 22-43 per cent for single smear and up to 60 per cent under optimal conditions. National TB Elimination Programme in India recommends the use of cartridge-based nucleic acid amplification test (CBNAAT) and culture for microbiological confirmation in presumptive PTB individuals with sputum smear negative test. The use of lateral flow urine lipoarabinomannan (LF-LAM) is usually recommended for the diagnosis of TB in HIV-positive individuals with low CD4 counts or those who are seriously ill. The objective of this study was to detect urinary LAM using cage nanotechnology that does not require a physiologic or immunologic consequence of HIV infection for LAM quantification in human urine in 50 HIV-seronegative sputum smear-negative PTB individuals.

METHODS

To study the diagnostic value of urinary LAM in sputum smear negative PTB individuals, a cage based nanotechnology ELISA technique was used for urinary LAM in three different groups of participants. Fifty smears negative PTB clinically diagnosed, 15 smear positive PTB and 15 post TB sequel individuals. Sputum was tested by smear, CBNAAT, and culture along with urine LAM before treatment. The results were interpreted by ROC curve in comparison to the standard tests like CBNAAT and culture.

RESULTS

The mean urinary LAM value was 0.84 ng/ml in 37 culture-positive [Mycobacterium tuberculosis (M.tb)] and 0.49 ng/ml in 13 culture-negative (M.tb) smear-negative individuals with PTB, respectively. In 47 smear-negative PTB cases with microbiologically confirmed TB by CBNAAT, the mean urinary LAM was 0.76 ng/ml. The mean urinary LAM in post-TB sequel individuals was 0.47 ng/ml. As per the receiver operating characteristic curve, cut-off value of urinary LAM in individuals with smear-negative PTB microbiologically confirmed by: (i) CBNAAT was 0.695 ng/ml and (ii) culture was 0.615 ng/ml.

INTERPRETATION CONCLUSIONS

The findings of this study suggest that individuals with smear-negative PTB and a urinary LAM value of >0.615 ng/ml were most likely to have microbiological confirmed TB while those with a LAM value <0.615 ng/ml >0.478 ng/ml are less likely and those with a value <0.478 ng/ml are unlikely to have microbiological confirmed TB.

742 Quality of Operative Notes for Renal Transplant Surgery - Is Our Documentation Satisfactory?

Introduction

Operation notes are essential in providing details of the procedure undertaken. The Royal College of Surgeons (RCS) Good Surgical Practice (GSP) guidelines recommend a checklist of 18 documentation items. Although these guidelines are useful, their broad and non-specific nature provides limitations to fields like transplantation, where additional information is needed. Ghoneima et al recommended transplant specific GSP checklist of 32 criteria for operation notes in transplantation. Our aim is to evaluate renal transplantation operation notes against these criteria.

Method

A retrospective audit of renal transplant operation notes was undertaken within Cardiff Transplant Unit between October 2020–2021. Notes were reviewed against new transplant specific GSP checklist.

Results

A total of 85 renal transplants were performed by 8 Consultant Surgeons. Sixty-two (73%) operation notes were hand-written and 23 (27%) electronically typed. Eleven standards had documentation compliance of &gt;95% (e.g., date, surgeons’ names, recipient blood vessels, incision, allograft vascular anatomy, perfusion timings, closure, signature, etc).

Some important transplant-specific information (e.g., primary renal disease, details of current renal replacement therapy, reperfusion characteristics, donor details (e.g., age, comorbidities), HLA mismatch, prosthesis (ureteric stent) details) were poorly documented (0–27% documentation compliance). Antibiotic and DVT prophylaxis documentation was also very poor (1–30%). Post-operative instructions did not record target blood pressure (0%) and postoperative potassium and ultrasound scan instructions were recorded in 65% of notes.

Discussion

Clear documentation is important for good surgical practice. This study highlights the need for a transplant-specific operation notes template, to not only improve the documentation but to standardize the key information recorded for every transplant performed.

Effects of Bacillus sp. MR-1/2 and magnetite nanoparticles on yield improvement of rice by urea fertilizer under different watering regimes

AIMS

The present research aimed to examine the use of magnetite nanoparticles (MNPs) in combination with phyto-beneficial rhizobacterium (PhBR) for improvement of applied N recovery (ANR) from urea fertilizer in rice grown under deficient and optimum watering conditions.

METHODS AND RESULTS

The Bacillus sp. MR-1/2 was positive for acetylene reduction, phosphate solubilization and ACC deaminase activity at temperature ranges 35-45°C. In a pot experiment, urea, MNPs and Bacillus sp. MR-1/2 were applied either alone or in combination to rice plants grown in pots under water deficit and optimal watering conditions. Combined application of urea, MNPs and Bacillus sp. MR-1/2 increased the plant N content and ANR by 27 and 65%, respectively, over their respective control values in rice grown under optimum watering conditions, whereas these increases were 27 and 41%, respectively, in rice grown under water deficit conditions. This treatment also increased the kernel weight and plant dry matter by 36 and 60%, respectively, over control (urea alone) values in rice grown under water deficit conditions, whereas these increases were 31 and 21·8%, respectively, in rice grown under optimum watering conditions. Values of malondialdehyde (MDA) contents, ascorbate peroxidase (APX), catalase and ethylene concentration were higher in control treatment under both the watering regimes. The application of Bacillus sp. MR-1/2 either alone or in combination with MNPs and urea reduced MDA contents, APX, catalase and ethylene production in the rice plants.

CONCLUSION

The combined application of MNPs+Bacillus sp. MR-1/2 reduced the N losses from applied urea, increased N uptake and ANR in rice, decreased MDA contents, APX and catalase activity and ethylene level in rice grown under deficit and optimum water conditions.

SIGNIFICANCE AND IMPACT OF THE STUDY

The application of MNPs together with Bacillus sp. MR-1/2 may help to increase ANR and rice productivity under water deficit conditions with low cost of production.

Dementia patients have greater anti-cholinergic drug burden on discharge from hospital: A multicentre cross-sectional study

Introduction

Anticholinergic medications block cholinergic transmission. The central effects of anticholinergic drugs can be particularly marked in patients with dementia. Furthermore, anticholinergics antagonise the effects of cholinesterase inhibitors, the main dementia treatment.

Objectives

This study aimed to assess anticholinergic drug prescribing among dementia patients before and after admission to UK acute hospitals.

Methods

352 patients with dementia were included from 17 hospitals in the UK. All were admitted to surgical, medical or Care of the Elderly wards in 2019. Information about patients’ prescriptions were recorded on a standardised form. An evidence-based online calculator was used to calculate the anticholinergic drug burden of each patient. The correlation between two subgroups upon admission and discharge was tested with Spearman’s Rank Correlation.

Results

Table 1 shows patient demographics. On admission, 37.8% of patients had an anticholinergic burden score ≥1 and 5.68% ≥3. At discharge, 43.2% of patients had an anticholinergic burden score ≥1 and 9.1% ≥3. The increase was statistically significant (rho 0.688; p=2.2x10-16). The most common group of anticholinergic medications prescribed at discharge were psychotropics (see Figure 1). Among patients prescribed cholinesterase inhibitors, 44.9% were also taking anticholinergic medications.

Conclusions

This multicentre cross-sectional study found that people with dementia are frequently prescribed anticholinergic drugs, even if also taking cholinesterase inhibitors, and are significantly more likely to be discharged with a higher anticholinergic drug burden than on admission to hospital.

Conflict of interest

This project was planned and executed by the authors on behalf of SPARC (Student Psychiatry Audit and Research Collaborative). We thank the National Student Association of Medical Research for allowing us use of the Enketo platform. Judith Harrison was su

CT for detection of malignant posterior intercostal lymph nodes in patients undergoing pre-operative staging for malignant pleural mesothelioma

INTRODUCTION

Recent evidence suggests that patients with malignant pleural mesothelioma (MPM) undergoing extended pleurectomy/decortication (eP/D) with metastasis to the posterior intercostal lymph nodes (PILN) have a worse prognosis. In this study, we determine if MPM PILN metastasis can be reliably detected on computed tomography (CT).

MATERIALS AND METHODS

Preoperative staging CT exams were reviewed for the presence of PILN in MPM patients undergoing eP/D between 2007-2013 with surgical sampling of their PILN. CT images were reviewed by two thoracic radiologists blinded to clinical records, including operative pathology reports. The number and short axis size of PILN were recorded and correlated with surgical pathology. Statistical analysis examined the value of preoperative CT to detect metastatic PILN.

RESULTS

Of 36 patients that underwent eP/D with PILN sampling had preoperative CT images for review. At surgery, 22 of these patients had metastatic PILN and 14 had benign PILN. The positive and negative predictive values for one or more nodes seen on preoperative CT were 60 % and 38 % respectively. The number of PILN on preoperative CT did not predict metastasis (p = 0.40) with an average of 2 PILN seen, regardless of PILN pathology. The average nodal short axis size was 4.6 mm and 4.8 mm for benign and malignant PILN, respectively, and PILN short axis size did not predict metastasis (p = 0.39). There was little inter-observer variability between the size and number of nodes detected by each radiologist.

CONCLUSIONS

CT does not reliably identify metastatic PILN on preoperative CT for patients with MPM undergoing extended pleurectomy/decortication.

Older Donation After Circulatory Death Kidneys for Older Recipients: A Single-Center Experience

The number of older patients is increasing on the transplant waiting list. Donation after circulatory death (DCD) kidney transplantation has increased, but there remains hesitancy in use of older DCD organs. The aim of this study was to evaluate outcomes of directing older DCD donor kidneys into older recipients.

METHODS

Patients 60 years or older who received transplants from DCD donors 60 years or older, between February 2010 and January 2014, were identified from a prospectively maintained database.

RESULTS

Over a 4-year period, 88 patients 60 years or older received DCD kidney transplants from donors 60 years or older. Of these 44 (55%) were 60 to 69 years old and 40 (45%) were 70 years or older. Median follow up was 63 months. Patient survival was 95% and 79% at 1 and 5 years, respectively, with a survival in those 70 years and older (69%) compared with those aged 60 to 69 (88%) years (P = .01). Censored for death graft survival was 94% and 80% at 1 and 5 years, respectively. Median estimated glomerular filtration rate at 12 months and 36 months was 36 mL/min (range, 11-70 mL/min) and 39.5 mL/min (range, 11-77 mL/min), respectively.

CONCLUSIONS

Older DCD kidneys, when transplanted into older recipients, result in good patient and graft survival and an acceptable graft function, especially considering their age. This represents a good use of this organ resource.

Cutaneous lupus erythematosus and the risk of deep venous thrombosis and pulmonary embolism: A Danish nationwide cohort study

Background

Venous thromboembolism (VTE) is a major public health concern. Lupus erythematosus (LE) is a chronic autoimmune disease ranging from localized cutaneous disease (CLE) to systemic involvement (SLE). Patients with SLE have an increased risk of venous thromboembolism (VTE), but little is known about the CLE-related risk of VTE.

Methods

To evaluate the risk of VTE in patients with SLE and CLE as compared to the general population, a retrospective cohort study was conducted. Incidence rates and hazard ratios (HRs) with 95% confidence intervals (CIs) from multivariable Cox regression models were used to evaluate and compare the risk of VTE. Registries of hospitalizations, outpatient visits, and prescription drug use were studied to determine the risk of VTE in patients with CLE and SLE and the general population between 1997 and 2011.

Results

A total of 3234 patients with CLE and 3627 patients with SLE were identified and compared to 5,590,070 individuals in the reference population. The incidence rates per 1000 year of VTE were higher in patients with LE, i.e. 1.20, 3.06, and 5.24 for the reference population, CLE, and SLE, respectively. In adjusted models, both CLE (HR 1.39; 95% CI 1.10–1.78) and SLE (HR 3.32; 95% CI 2.73–4.03) were associated with a statistically significant increased risk of VTE, compared to the reference population.

Conclusion

In this nationwide study, both CLE and SLE were significant risk factors for VTE. The results add to our understanding of comorbidities in patients with LE, and call for further studies and increased awareness of thromboembolic complications in patients with CLE.

Risk of psoriasis in patients with childhood asthma: a Danish nationwide cohort study

BACKGROUND

Psoriasis and asthma are disorders driven by inflammation. Psoriasis may carry an increased risk of asthma, but the reverse relationship has not been investigated.

OBJECTIVES

To investigate the risk of psoriasis in subjects with childhood asthma in a nationwide Danish cohort.

METHODS

Data on all Danish individuals aged 6-14 years at study entry between 1 January 1997 and 31 December 2011 (n = 1,478,110) were linked at an individual level in nationwide registers. Incidence rates per 10,000 person-years were calculated, and incidence rate ratios (IRRs) adjusted for age, sex, concomitant medication and comorbidity were estimated by Poisson regression models.

RESULTS

There were 21,725 cases of childhood asthma and 6586 incident cases of psoriasis. There were 5697 and 889 incident cases of mild and severe psoriasis, respectively. The incidence rates of overall, mild and severe psoriasis were 4.49, 3.88 and 0.61 for the reference population, and 5.95, 5.18 and 0.83 for subjects with childhood asthma, respectively. The IRRs for overall, mild and severe psoriasis were 3.94 [95% confidence interval (CI) 2.16-7.17], 5.03 (95% CI 2.48-10.21) and 2.27 (95% CI 0.61-8.42) for patients with childhood asthma.

CONCLUSIONS

Childhood asthma was associated with a significantly increased risk of psoriasis. Further studies are warranted to determine the clinical significance and effects of therapeutic interventions on this association.

Failure-to-rescue and interprovider comparisons after elective abdominal aortic aneurysm repair

BACKGROUND

The use of postoperative complication rates to derive metrics such as failure-to-rescue (FTR) is of increasing interest in assessing the quality of care. The aim of this study was to quantify FTR rates for elective abdominal aortic aneurysm (AAA) repair in England using administrative data, and to examine its validity against case-note review.

METHODS

A retrospective observational study using Hospital Episode Statistics (HES) data was combined with a multicentre audit of data quality. All elective AAA repairs done in England between 2005 and 2010 were identified. Postoperative complications were extracted, FTR rates quantified, and differences in FTR and in-hospital death rates established. A multicentre case-note review was performed to establish the accuracy of coding of complications, and the impact of inaccuracies on FTR rates derived from HES data.

RESULTS

A total of 19 638 elective AAA repairs were identified from HES; the overall mortality rate was 4·6 per cent. Patients with complications (19·2 per cent) were more likely to die than those without complications (odds ratio 12·22, 95 per cent c.i. 10·51 to 14·21; P < 0·001) and had longer hospital stays (P < 0·001). FTR rates correlated strongly with death rates, whereas complication rates did not. On case-note review (661 procedures), 41·5 per cent of patients had a complication recorded in the case notes. There was evidence of systematic under-reporting of complications in HES, leading to an overall misclassification rate of 36·3 (95 per cent c.i. 33·7 to 39·2) per cent (P < 0·001), which was less pronounced for surgical complications (12·6 (11·1 to 13·9) per cent; P <0·001). Despite this, the majority of FTR rates derived from HES were not significantly different from those derived from case-note data.

CONCLUSION

Postoperative complication and FTR rates after elective AAA repair can be derived from HES data. However, use of the metric for interprovider comparisons should be done cautiously, and only with concurrent case-note validation given the degree of miscoding identified.

Variability in management of T1 colorectal cancer in Wales

INTRODUCTION

The management of T1 colorectal cancer is controversial. Surgical resection should offer cure in the majority of patients and can stage lymph nodes accurately. Nevertheless, there can be significant associated morbidity and it potentially risks overtreating the patient. Endoscopic/local excision has significantly reduced morbidity but risks undertreating undetected metastatic lymph nodes, thereby compromising oncological outcomes. The aim of this study was to review the practice across Wales over a two-year period.

METHODS

Data on T1 tumours for the period of 2009-2011 were collected from the Cancer Network Information System Cymru.

RESULTS

A total of 161 patients were diagnosed as having T1 colorectal cancer (without prior neoadjuvant treatment). The median age was 68 years (range: 14-91 years) and 66% of the patients were male. Forty-eight (30%) of these tumours were screen detected. There were 112 colonic and 49 rectal tumours. Ninety-five patients with colonic tumours (85%) underwent major surgical resections, 51% of which were laparoscopic. Forty patients with rectal cancers (82%) underwent major surgical resection and 45% of these procedures were laparoscopic. The rest of the patients underwent local excision in the form of endoscopic polypectomy or transanal resection.

CONCLUSIONS

This study demonstrates that there is no consensus in the management of T1 disease across Wales. With the advent of screening and the development of more sophisticated endoscopic techniques, the decision of how to treat T1 colorectal cancer will become a more regular challenge for the colorectal multidisciplinary team. The treatment needs standardisation. For now, however, this balance of risk will need to be made on an individual patient basis.

Evaluation of Pakgen 99mTc generators loaded with indigenous fission 99Mo

Fission produced 99Mo/99mTc generators, called Pakgen, have been manufactured at the PINSTECH generator production facility since 2000 for nuclear medicine applications in Pakistan. These generators were loaded with fission 99Mo imported from NTP South Africa. Recently production of fission 99Mo has begun in the Molybdenum-99 Production Facility at PINSTECH. Prior to use in the clinic, eight sets of generators were produced, 23 GBq and 74 GBq at time of calibration, and they were subjected to various quality control procedures recommended in the pharmacopoeia to assess their performance. The elution profile, volume, activity, pH, radionuclidic, chemical, radiochemical and biological purity, and expiry time of the eluates were examined. Labeling efficiency tests were also carried out with a number of the more widely used in vivo radiopharmaceutical kits like DTPA, MDP and MIBI. Performance of 99mTc generators loaded with locally produced and imported fission 99Mo was comparable, and the users of Pakgen generators were fully satisfied. The effect of a wet vs. a dry column on 99mTc yields of generators loaded with low and high activity was also studied for the first time.

Large thymic carcinoma presenting with right ventricular failure: a case report

Thymic carcinoma is an overall rare tumour with variable clinical manifestations. Right ventricular failure remains an uncommon occurrence and has not been reported in literature so far. A 40-year-old lady presented with the complaints of progressively worsening retrosternal chest pain, shortness of breath, easy fatigability and cough since 1 year. Computed tomography scan of the thorax revealed a mass measuring 12 x 10 cm in the anterior mediastinum. This mass appeared to be adherent to both lungs and pericardium and was impinging on the right atrium and right ventricle. It appeared to be infiltrating the ascending aorta, pulmonary arteries and superior vena cava. Ultrasound of the abdomen showed hepatomegaly and moderate ascites. Echocardiography showed evidence of right ventricular dysfunction as well as elevated right ventricular systolic pressures secondary to extrinsic compression. Percutaneous biopsy of the thymus was performed showing a malignant thymoma. Radical thymectomy with resection of pericardium was planned. Intra-operatively, the tumour was separated from the right and left lungs, pulmonary artery and aortic arch. Morphologically, immunochemically and clinically, the features were consistent with those seen in Masoka stage III thymic carcinoma. She also received six cycles of chemotherapy (PAC regimen) including cisplatin (50 mg/m2), doxorubicin (50 mg/m2) and cyclophosphamide (500 mg/m2). Radiation therapy in the adjuvant setting was planned but the patient was lost to follow-up after 4 months. Although right ventricular failure is a very rare presentation of thymic carcinoma, clinicians should be aware of this presentation to appreciate the complete clinical spectrum of presentation of this neoplasm.

Prevalence of specific fears in children of karachi

Introduction

Children's fears are not only a part of their development but can also reflect unique cultural and societal norms as well as the influence of current affairs on cognition & behaviour

Objectives

Identifying prevalent fears in children of Karachi,Pakistan and gender/age differences.

Aims

Identifying common fears and assessing the impact of sociopolitical factors on children's perception

Methods

1171 children (731 boys, 440 girls) from classes 3–10 of a large school were selected and completed the Fear Survey Schedule for Children (Revised).

Results

The highest overall fear was of’Bombing attacks/being invaded’, which was also the highest in boys (’Snakes’ in girls). The greatest gender difference was seen in the fear of lizards (p < 0.001). The overall average FSSC-R score was 133(27.5) and frequency of intense fears was 16(12.4), both higher in girls. Younger children had greater scores and intense fears compared to adolescents.

Conclusions

Children are uniquely sensitive to “adult” issues, evidenced by the highest fear overall: bombing attacks/invasions, while fear of terrorists also ranked high (#11). Fears related to academic performance increased with age whereas younger children were more fearful of items perceived as causing physical harm; reflecting that stresses of education displace fears of danger and injury. Of the ten items with the greatest gender-differences, all belonged to the “Minor Injury/Small Animals” category. Lastly, comparison with previous studies showed no significant difference (p > 0.1) in either total scores or intensity of fears, suggesting that despite varying individual fears the overall profile remained constant for children of different cultures.

Elevated C-reactive protein levels are not a feature of uncomplicated radiation-induced bowel injury

An elevated C-reactive protein (CRP) is a valuable marker of disease activity in Crohn's disease and predicts colectomy in ulcerative colitis. It is sometimes elevated in patients with chronic gastrointestinal symptoms following pelvic radiotherapy. Its significance in this context has not been evaluated. The aim of this study was to investigate the significance of elevated CRP in patients with new gastrointestinal symptoms starting after pelvic radiotherapy. Patients at presentation to a specialist clinic had their CRP measured. The diagnoses reached were grouped into categories and correlated with the level of the CRP using logistic regression analysis. Between 2001 and 2004, 159 patients [91 women (median age 61 years), 68 men (median age 69.5 years)] with new gastrointestinal symptoms after pelvic radiotherapy (median 3 years previously) had their CRP checked. In total, 132 (83%) patients had a normal CRP (<10 mg/L). Twenty-seven had an elevated CRP (median 18, range 10-79 mg/L). Eight categories of diagnosis were recorded for patients, including advanced neoplasia (n = 18), small bowel disease (n = 43), large bowel disease (n = 42), ano-rectal disease (n = 72), infection (n = 5), pancreatic insufficiency (n = 5), drugs (n = 7) and normal/other (n = 45). On univariate analysis, presence of advanced neoplasia [P = 0.01 (OR 3.85, 95% CI 1.34-11.1)] and the presence of pancreatic insufficiency [P = 0.026 (OR 8.13, 95% CI 1.29-51.23)] were associated with an elevated CRP. An elevated CRP level is not a prominent feature of uncomplicated chronic radiation-induced toxicity in the gastrointestinal tract. If present in patients with suspected radiation-induced damage, other causes must be sought.

Symptoms and weight loss in patients with gastrointestinal and lung cancer at presentation

INTRODUCTION

Weight loss is an independent prognostic factor for decreased survival in cancer patients. The effectiveness of treatment is impaired in patients with weight loss. The aetiology of this weight loss is complex and poorly characterised. Decreased calorie intake may be important. The reasons for decreased intake are unknown.

AIMS AND METHODS

To determine in adult patients with cancer, who had not started chemotherapy or radiotherapy, the prevalence of symptoms which carry a risk to nutritional status and how these relate to weight loss, tumour burden and primary tumour site. New patients referred for treatment of any form of gastrointestinal (GI) cancer, non-small cell lung cancer or lung mesothelioma completed a validated questionnaire recording symptoms contributing to weight loss (Patient-generated Subjective Global Assessment--PG-SGA). In a subset of patients without metastatic disease, computed tomography scans were assessed to determine tumour burden.

RESULTS

Between August and October 2004, 122 patients with GI and 29 with lung cancers were recruited. There were 48% of GI and 28% of lung cancer patients who had lost weight. Sixty-two percent of the patients had one or more symptoms at presentation. The frequency of symptoms varied according to the site of disease. The most common symptom at all tumour sites was loss of appetite (38%). There was a weak but significant correlation between the number of symptoms and amount of weight loss (r=0.347). Patients reporting a reduced food intake had more symptoms than patients who had not lost weight. Tumour burden did not correlate with weight loss.

CONCLUSION

The symptoms in cancer patients occur across different types of primary tumours, may affect food intake and have a part in causing weight loss. More information on the role of symptom management in improving nutritional status is needed.