The effect of surgery on the outcome of treatment for multidrug-resistant tuberculosis: a systematic review and meta-analysis

BACKGROUND

In 2014 only 50 % of multidrug-resistant tuberculosis (MDR-TB) patients achieved a successful treatment outcome. With limited options for medical treatment, surgery has re-emerged as an adjuvant therapeutic strategy. We conducted a systematic review and meta-analysis to assess the evidence for the effect of surgery as an adjunct to chemotherapy on outcomes of adults treated for MDR-TB.

METHODS

Databases and grey literature sources were searched using terms incorporating surgery and MDR-TB. No language or publication type limits were applied. Articles published pre-1990, without a comparator group, or reporting <10 surgical participants were excluded. Two-stage sifting in duplicate was employed. Data on WHO-defined treatment outcomes were abstracted into a standardised database. Study-level risk of bias was evaluated using standardised tools. Outcome-level evidence quality was assessed using GRADE. Forest plots were generated, random effects meta-analysis conducted, and heterogeneity assessed using the I(2) statistic.

RESULTS

Of 1024 unique citations identified, 62 were selected for full-text review and 15 retained for inclusion. A further four articles were included after bibliography/citation searching, and one additional unpublished manuscript was identified, giving 20 articles for final inclusion. Six were meta-analyses/systematic reviews and 14 were primary research articles (observational studies). From the 14 primary research articles, a successful outcome (cured/treatment completed) was reported for 81.9 % (371/453) and 59.7 % (1197/2006) in the surgical and non-surgical group respectively, giving a summary odds ratio of 2.62 (95 % confidence interval 1.94-3.54). Loss to follow-up and treatment failure were lower in the surgery group (both p = 0.01). Overall GRADE quality of evidence for all outcomes considered was "very low".

CONCLUSIONS

This meta-analysis suggests that surgery as an adjunct to chemotherapy is associated with improved treatment outcomes in MDR-TB patients. However, inherent limitations in observational study design, insufficient reporting, and lack of adjustment for confounders, led to grading of the evidence as very low quality. Data on rationale for surgical referral, subsequent outcomes and resource-limited settings are scarce, precluding evidence-based recommendations on the suitability of surgery by patient characteristics or setting. It is hoped that highlighted methodological and reporting gaps will encourage improved design and reporting of future surgical studies for MDR-TB.

The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review

BACKGROUND

Globally it is estimated that 480 000 people developed multidrug-resistant tuberculosis (MDR-TB) in 2014 and 190 000 people died from the disease. Successful treatment outcomes are achieved in only 50 % of patients with MDR-TB, compared to 86 % for drug susceptible disease. It is widely held that delay in time to initiation of treatment for MDR-TB is an important predictor of treatment outcome. The objective of this review was to assess the existing evidence on the outcomes of multidrug- and extensively drug-resistant tuberculosis patients treated early (≤4 weeks) versus late (>4 weeks) after diagnosis of drug resistance.

METHODS

Eight sources providing access to 17 globally representative electronic health care databases, indexes, sources of evidence-based reviews and grey literature were searched using terms incorporating time to treatment and MDR-TB. Two-stage sifting in duplicate was employed to assess studies against pre-specified inclusion and exclusion criteria. Only those articles reporting WHO-defined treatment outcomes were considered for inclusion. Articles reporting on fewer than 10 patients, published before 1990, or without a comparison of outcomes in patient groups experiencing different delays to treatment initiation were excluded.

RESULTS

The initial search yielded 1978 references, of which 1475 unique references remained after removal of duplicates and 28 articles published pre-1990. After title and abstract sifting, 64 papers underwent full text review. None of these articles fulfilled the criteria for inclusion in the review.

CONCLUSIONS

Whilst there is an inherent logic in the theory that treatment delay will lead to poorer treatment outcomes, no published evidence was identified in this systematic review to support this hypothesis. Reports of programmatic changes leading to reductions in treatment delay exist in the literature, but attribution of differences in outcomes specifically to treatment delay is confounded by other contemporaneous changes. Further primary research on this question is not considered a high priority use of limited resources, though where data are available, improved reporting of outcomes by time to treatment should be encouraged.

Zoonotic tuberculosis in occupationally exposed groups in Pakistan

BACKGROUND

Bovine tuberculosis (bTB) remains a public health threat in low-income countries. Data on human tuberculosis (TB) due to Mycobacterium bovis are poorly documented in developing countries.

AIMS

To determine the occurrence of active pulmonary TB due to M. bovis in abattoir workers, butchers, livestock farmers and veterinarians and to document their knowledge and practices regarding bTB.

METHODS

A cross-sectional study of abattoir workers, butchers, livestock farmers, veterinary doctors and veterinary assistants, which obtained data on socio-demographic conditions, knowledge and practices regarding TB. Sputum samples were collected from respondents with a chronic cough. The chi-squared test was used for statistical analysis.

RESULTS

A total of 141 abattoir workers, 317 butchers, 50 livestock farmers, five veterinary doctors and three veterinary assistants took part. Four out of 16 abattoir workers and 1 out of 50 livestock farmers were positive for M. bovis by PCR analysis. Duration of work as an abattoir worker was significantly associated (P < 0.05) with prevalence of zoonotic TB. The knowledge of abattoir workers, butchers, livestock farmers and veterinary assistants regarding transmission of bTB from animals to humans and the symptoms of TB in humans was very poor. Most of these workers did not use protective equipment and appropriate safe working techniques and were considered at high risk of acquiring zoonotic TB.

CONCLUSIONS

Zoonotic TB is a significant public health issue among professionally exposed groups in Peshawar, Pakistan and suggests a need for further detailed investigations of the disease in this and similar areas.

Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? An analysis of operational data from Yangon and the nationwide prevalence survey

Background

Although there is a large increase in investment for tuberculosis control in Myanmar, there are few operational analyses to inform policies. Only 34 % of nationally reported cases are from women. In this study, we investigate sex differences in tuberculosis diagnoses in Myanmar in order to identify potential health systems barriers that may be driving lower tuberculosis case finding among women.

Methods

From October 2014 to March 2015, we systematically collected data on all new adult smear positive tuberculosis cases in ten township health centres across Yangon, the largest city in Myanmar, to produce an electronic tuberculosis database. We conducted a descriptive cross-sectional analysis of sex differences in tuberculosis diagnoses at the township health centres. We also analysed national prevalence survey data to calculate additional case finding in men and women by using sputum culture when smear microscopy was negative, and estimated the sex-specific impact of using a more sensitive diagnostic tool at township health centres.

Results

Overall, only 514 (30 %) out of 1371 new smear positive tuberculosis patients diagnosed at the township health centres were female. The proportion of female patients varied by township (from 21 % to 37 %, p = 0.0172), month of diagnosis (37 % in February 2015 and 23 % in March 2015 p = 0.0004) and age group (26 % in 25–64 years and 49 % in 18–25 years, p < 0.0001). Smear microscopy grading of sputum specimens was not substantially different between sexes. The prevalence survey analysis indicated that the use of a more sensitive diagnostic tool could result in the proportion of females diagnosed at township health centres increasing to 36 % from 30 %.

Conclusions

Our study, which is the first to systematically compile and analyse routine operational data from tuberculosis diagnostic centres in Myanmar, found that substantially fewer women than men were diagnosed in all study townships. The sex ratio of newly diagnosed cases varied by age group, month of diagnosis and township of diagnosis. Low sensitivity of tuberculosis diagnosis may lead to a potential under-diagnosis of tuberculosis among women.

Tick fauna of Malaysian red jungle fowl (Gallus gallus) in Bangi, Malaysia

Aim:

The red jungle fowl is generally considered as one of the endangered Asian wild Galleopheasants due to man-made encroachment of their habitats, coupled with the effect of disease and disease causing organisms like ticks and tick-borne infections. This study aimed to determine the tick fauna of the red jungle fowl and their predilection sites based on developmental stages.

Materials and Methods:

A total of 33 jungle fowls were sampled for this study from Bangi area of Selangor State, Peninsular Malaysian. The birds were captured using a locally made trap made-up of loops and bites. Ticks present on their bodies were detached using fine forceps and identified morphologically under a dissecting microscope.

Results:

91% of the jungle fowls were infested with ticks, all of which belongs to the species Haemaphysalis wellingtoni. The ear region appeared to be the most common predilection site (63%) for all the developmental stages in which the larval stages are solely restricted to that region. Nymphal and adult stages were distributed on the comb, wattle, and facial region in addition to the ear region.

Conclusion:

This study was the first in its kind and showed a high prevalence of tick infestation among jungle fowls. H. wellingtoni was known to be a vector in transmission of many tick-borne pathogens. Therefore, there is the need for further investigation to identify the various pathogens associated with this tick.

Radical cystectomy: Analysis of trends in UK practice 2004–2012, from the British Association of Urological Surgeons’ (BAUS) Section of Oncology Dataset

Objective:

To analyse the British Association of Urological Surgeons’ (BAUS) radical cystectomy (RC) dataset, to examine the trends in patient selection, use of neoadjuvant chemotherapy (NAC) and operative technique.

Methods:

Data for RC were entered into a database voluntarily, by operating surgeons. A comparison was made to the Hospital Episode Statistics (HES) data, to estimate the proportion of cases captured by the dataset.

Results:

From 2004 to 2012, data was collected on 5321 patients undergoing RC. This constituted 37.1% of all HES RC cases during the corresponding time period. Notable trends were: An increasing use of NAC, the introduction of minimally-invasive surgery (23.5% in 2012), a dramatic reduction in blood transfusion rates and the increasing yields from lymph node dissection. The ileal conduit urinary diversion predominated as the urinary diversion of choice (80% of cases).

Conclusions:

This analysis of a large multi-centre dataset provides insight into RC practice in the UK, over 8 years. The major weaknesses of the study were that only one-third of cases were recorded and that outcome data was very limited. Mandatory publication of outcome data from 2016 should increase the recording of cases and provide material for a more complete analysis.

Cissus quadrangularis Linn exerts dose-dependent biphasic effects: osteogenic and anti-proliferative, through modulating ROS, cell cycle and Runx2 gene expression in primary rat osteoblasts

OBJECTIVES

This report highlights phytoconstituents present in Cissus quadrangularis (CQ) extract and examines biphasic (proliferative and anti-proliferative) effects of its extract on bone cell proliferation, differentiation, mineralization, ROS generation, cell cycle progression and Runx2 gene expression in primary rat osteoblasts.

MATERIALS AND METHODS

Phytoconstituents were identified using gas chromatography-mass spectroscopy (GC-MS). Osteoblasts were exposed to different concentrations (10-100 μg/ml) of CQ extract and cell proliferation and cell differentiation were investigated at different periods of time. Subsequently, intracellular ROS intensity, apoptosis and matrix mineralization of osteoblasts were evaluated. We performed flow cytometry for DNA content and real-time PCR for Runx2 gene expression analysis.

RESULTS

CQ extract's approximately 40 bioactive compounds of fatty acids, hydrocarbons, vitamins and steroidal derivatives were identified. Osteoblasts exposed to varying concentrations of extract exhibited biphasic variation in cell proliferation and differentiation as a function of dose and time. Moreover, lower concentrations (10-50 μg/ml) of extract slightly reduced ROS intensity, although they enhanced matrix mineralization, DNA content in S phase of the cell cycle, and levels of Runx2 expression. However, higher concentrations (75-100 μg/ml) considerably induced the ROS intensity and nuclear condensation in osteoblasts, while it reduced mineralization level, proportion of cells in S phase and Runx2 level of the osteogenic gene.

CONCLUSIONS

These findings suggest that CQ extract revealed concentration-dependent biphasic effects, which would contribute notably to future assessment of pre-clinical efficacy and safety studies.

Good quality locally procured drugs can be as effective as internationally quality assured drugs in treating multi-drug resistant tuberculosis

Background

Owing toGiven the high costs of drugs to treat multi-drug resistant tuberculosis (MDR-TB), the Green Light Committee (GLC) initiative enables TB programs to procure quality-assured drugs at reduced prices. Despite price reductions, internationally quality assured (IQA) drugs can be more expensive than locally procured drugs. There is little evidence to inform decision-makers about whether IQA drugs are more effective than local drugs. This is the first study to compare outcomes between MDR-TB patients treated using IQA, and locally procured drugs in the same hospitals during the same time period.

Methods/Findings

A retrospective cohort study was conducted in three hospitals across Pakistan. Data on baseline characteristics and treatment outcomes during the first six months of treatment were extracted from hospital records of adult culture-positive pulmonary MDR-TB patients starting treatment between January 2011 and June 2012. Two cohorts were defined: patients receiving IQA drugs, and patients receiving locally procured non-IQA drugs. Data were analysed using Kaplan-Meier curves and Cox proportional hazards regression. The primary outcome compared between cohorts was time to culture conversion. Of 231 patients, 90 were in the IQA and 141 in the non-IQA cohorts. Baseline characteristics were similar except for higher frequency of quinolone resistance in the IQA cohort. Overall, 193 patients (84%) culture converted. Culture conversion was not faster in the IQA cohort; the median time was 81 and 68 days in the IQA and non-IQA cohorts, respectively. Unadjusted and adjusted hazard ratios for culture conversion in IQA verses non-IQA cohorts were 0.82 (95%-CI, 0.62-1.10) and 0.95 (95%-CI, 0.66-1.36) respectively.

Conclusions

Use of good quality, locally procured drugs can be effective in treating MDR-TB, may involve lower costs than using IQA drugs and could strengthen developing country drug quality assurance systems. This may be a suitable alternative in lieu of or whilst awaiting arrival of internationally procured medicines.

Comparison of the utility of Cocaine- and Amphetamine-Regulated Transcript (CART), chromogranin A, and chromogranin B in neuroendocrine tumor diagnosis and assessment of disease progression

CONTEXT

Prognosis in patients with neuroendocrine tumors (NETs) is often poor, frequently reflecting delayed diagnosis. Hence, accurate and practical NET markers are needed. Cocaine- and amphetamine-regulated transcript (CART) peptide is a potential novel NET marker.

DESIGN AND PARTICIPANTS

Circulating levels of CART peptide and the established NET markers chromogranin A (CgA) and chromogranin B (CgB) were measured using RIA in 353 patients with NET (normal renal function) and in controls. Clinical data were collected retrospectively.

MAIN OUTCOME MEASURE(S)

The comparative and combined utility of CART, CgA, and CgB for diagnosis and assessment of disease progression was measured in different NET subtypes.

RESULTS

CgA and CgB in combination improved diagnostic accuracy in patients with gut NETs, nongastroenteropancreatic NETs, and NETs with an unknown primary origin compared with each biomarker alone. Measuring CART did not further improve diagnosis in these NET subtypes. For pancreatic NETs, CgB was superior to CgA and CART in detecting stable disease (P < .007), whereas CgA and CART in combination were most effective in identifying progressive disease. In phaeochromocytomas/paragangliomas (PCC/PGL), CART was the most useful biomarker for identifying stable (P < .001) and progressive (P = .001) disease. Consistent with this, plasma CART decreased following PCC/PGL tumor resection, remaining low in all patients in remission, but increasing in those with progressive disease.

CONCLUSIONS

CART is a useful marker for identifying progressive pancreatic NETs. CART is superior to CgA and CgB in detecting stable and progressive PCC/PGLs, and may have a role as a surveillance marker for PCC/PGL patients.

Quantitatively evaluating the effect of social barriers: a case-control study of family members' opposition and women's intention to use contraception in Pakistan

Background

Uptake of family planning services in Pakistan has remained slow over the past decade despite a rapid increase in availability and awareness, indicating that social barriers may be preventing uptake. Social barriers such as opposition by family members have largely been studied qualitatively; there is a lack of quantitative evidence about the effect of different family members’ opposition on women’s intention to use contraceptives. The objective of this study was to quantitatively evaluate the effect of family members’ opposition to family planning on intention to use contraception amongst poor women in Pakistan who have physical access to family planning services.

Methods

An unmatched case control study (nested within a larger cohort study) was conducted in two public hospitals in Karachi, Pakistan. Univariable and multivariable logistic regression analyses were conducted to compare risk factors between women that were not intending to use any contraceptive methods in the future (cases) and women that were planning to use contraceptive methods (controls).

Results

248 cases and 496 controls were included in the study. Negative contraceptive intent was associated with no knowledge of contraception (AOR = 3.79 [2.43-5.90]; p < 0.001), husband’s opposition (AOR = 21.87 [13.21-36.21]; p < 0.001) and mother-in-law’s opposition (AOR = 4.06 [1.77-9.30]; p < 0.001).

Conclusions

This study is the first to quantitatively assess the effect of opposition by different family members on women’s contraceptive intent in Pakistan. Our results indicate that of all family members, husband’s opposition has the strongest effect on women’s intention to use contraception, even when the women have knowledge of and physical access to family planning services.

Engaging for-profit providers in TB control: lessons learnt from initiatives in South Asia

There has been a huge expansion in the private health-care sector over the past two decades, particularly in South Asia, resulting in over 80% of patients seeking care from private health providers. Despite concerns about the quality and equity of private sector service provision, most government public health bodies recognize that the private sector reaches individuals that public institutions cannot cater to, thereby being important in moving closer to universal health coverage. Numerous initiatives have been launched and are being planned to involve private practitioners in effectively diagnosing, reporting and managing infectious diseases such as tuberculosis. However, there is a notable dearth of papers discussing which elements of private sector engagement strategies are more or less successful and the ethical issues that arise when engagement strategies are operationalized. This article brings together the authors' experiences of working on projects to engage private allopathic health providers in Pakistan, Bangladesh and India for improved tuberculosis control. Motivations of and strategies required to engage private allopathic heath providers, specifically doctors, diagnostic laboratories and pharmacies, and some of the ethical issues that arise when designing programmes for engagement are discussed.

Systematic review of prostate cancer risk and association with consumption of fish and fish-oils: analysis of 495,321 participants

INTRODUCTION

Fish-oils have a potential role in inflammation, carcinogenesis inhibition and favourable cancer outcomes. There has been increasing interest in the relationship of diet with cancer incidence and mortality, especially for eicosapantaenoic acid (EPA) and docosahexaenoic acid (DHA). This systematic-analysis of the literature aims to review evidence for the roles of dietary-fish and fish-oil intake in prostate-cancer (PC) risk, aggressiveness and mortality.

METHODS

A systematic-review, following PRISMA guidelines was conducted. PubMed, MEDLINE and Embase were searched to explore PC-risk, aggressiveness and mortality associated with dietary-fish and fish-oil intake. 37 studies were selected.

RESULTS

A total of 495,321 (37-studies) participants were investigated. These revealed various relationships regarding PC-risk (n = 31), aggressiveness (n = 8) and mortality (n = 3). Overall, 10 studies considering PC-risk found significant inverse trends with fish and fish-oil intake. One found a dose-response relationship whereas greater intake of long-chain-polyunsaturated fatty acids increased risk of PC when considering crude odds-ratios [OR: 1.36 (95% CI: 0.99-1.86); p = 0.014]. Three studies addressing aggressiveness identified significant positive relationships with reduced risk of aggressive cancer when considering the greatest intake of total fish [OR 0.56 (95% CI 0.37-0.86)], dark fish and shellfish-meat (p < 0.0001), EPA (p = 0.03) and DHA (p = 0.04). Three studies investigating fish consumption and PC-mortality identified a significantly reduced risk. Multivariate-OR (95% CI) were 0.9 (0.6-1.7), 0.12 (0.05-0.32) and 0.52 (0.30-0.91) at highest fish intakes.

CONCLUSIONS

Fish and fish-oil do not show consistent roles in reducing PC incidence, aggressiveness and mortality. Results suggest that the specific fish type and the fish-oil ratio must be considered. Findings suggest the need for large intervention randomised placebo-controlled trials.

Formulation and evaluation on human skin of a water-in-oil emulsion containing Muscat hamburg black grape seed extract

BACKGROUND

Vitis vinifera 'muscat hamburg' (Vitaceae) is a blue-black grape variety commonly found in Pakistan. It has been consumed and used in traditional medicine for centuries. Compared to other grapes, M. hamburg records one of the greatest amount of polyphenols and displays potent antioxidant activities, which make it a great candidate for its exploitation in the development of stable cream emulsions destined to improve the skin appearance.

OBJECTIVE

Evaluate the effects of stable water-in-oil (W/O) emulsion containing 2% M. hamburg grape seed extract ('formulation') on human cheek skin in comparison with the placebo ('base').

METHODS

An occlusive patch test, containing either the formulation or the base, was topically tested for 8 weeks during a winter period in young adult and healthy Pakistani male volunteers. The subjects were instructed to use twice a day the base and the formulation on their right and left cheek skin, respectively. Non-invasive measurements on these skin areas were carried out every week to assess any effects produced on melanin, elasticity and sebum. Skin compatibility assay (Burchard test) was used to report any potential skin reactivity. ANOVA, paired sample t-test and LSD test were applied to determine the statistical data significance.

RESULTS

Significant differences (P ≤ 0.05) were found between the placebo and the formulation in terms of their respective skin effects elicited on melanin, elasticity and sebum content. Nevertheless, placebo and formulation exerted similar effects on skin erythema and moisture contents. Importantly, no skin hypersensitivity cases were reported during the whole course of the study.

CONCLUSION

The developed grape-based cream could be efficiently and safely applied to improve a number of skin conditions (e.g. hyper-pigmentation, premature ageing, acne).

Systematic review of live surgical demonstrations and their effectiveness on training

BACKGROUND

Live surgical demonstrations are commonly performed for surgical conferences. These live procedures have recently come under scrutiny, in particular with issues pertaining to patient safety. This systematic review aimed to explore the evidence for live surgery as a training tool, and to investigate the safety of live surgical broadcasts.

METHODS

PubMed, Embase, MEDLINE and Cochrane Library databases were searched using a predefined search strategy from January 1980 to October 2013. Specialty Societies and primary Colleges of Surgeons were searched for guidelines or position statements on live surgical teaching.

RESULTS

Educational value criteria demonstrated for live surgery included feasibility, acceptability, construct and concurrent validity. Complication rates during live procedures were not compromised in the majority of studies. Patient safety, however, may be affected during live procedures as success rates have been found to be lower in some studies. Only Cardiothoracic, Urology and Vascular Surgical Societies currently offer guidelines on conducting live surgical demonstrations.

CONCLUSION

Little evidence exists on the safety and educational value of live surgery, with few studies of high quality conducted. Guidance on live procedures is scarce, with only three major surgical specialties offering any advice. More needs to be done to establish and promote evidence for the value of live surgery demonstrations.

Tuberculosis--frequency and differential diagnosis--analysis of cases in Pakistan

BACKGROUND

Tuberculosis is highly prevalent in Pakistan and the numbers are on increase each year. Cervical lymphadenopathy, a common finding in tuberculosis and other inflammatory, infectious and malignant etiologies, is commonly encountered in hospital setting in Karachi, Pakistan. Signs and symptoms of tuberculosis are blood tinged sputum, weight loss, night sweats, loss of appetite and weakness. A through history, complete physical examination and investigations are needed to diagnose tuberculosis.

OBJECTIVE

To determine the burden of tuberculosis in cases of cervical lymphadenopathy and to find the most common etiologies of cervical lymphadenopathy in hospital setup in Karachi, Pakistan.

METHODS AND MATERIALS

Patients with cervical lymphadenopathy attending the surgical outpatient department of Jinnah Post Graduate Center, Karachi, Pakistan were conveniently sampled for this study without age and gender limitations. This cross sectional, descriptive study was conducted from January 2010 to January 2011.

RESULTS

A total of 250 patient cases with cervical lymphadenopathy were studied. The age group with the highest number of patients was between 21 to 40 years, which included 97 females and 21 males. The patients with unilateral single cervical lymph node swelling were found to be 13.2%, while 86.8 % patients had multiple bilateral lymph node swellings. Tuberculosis was found in majority of patients, 63.6% followed by inflammatory hyperplasia which was present in 28.4% patients, other causes included lymphoma 5.2% and metastasis 2.8%.

CONCLUSION

Tuberculosis is the most common etiology of cervical lymphadenopathy, followed by inflammatory hyperplasia, lymphoma and metastasis.

A rare case of hemolytic anemia in a pediatric patient due to ring dehiscence after mitral valve repair: utility of real-time three-dimensional imaging and management

A rare case of hemolytic anemia in a 3-year-old child due to mitral valve ring dehiscence is described. The dehiscence of mitral valve ring was diagnosed utilizing real-time three-dimensional echocardiography. The patient subsequently underwent reoperation with successful resolution of hemolysis after replacement of the ring.

Learning Curve of Basic Surgical Skill Acquisition on the Sep Robot

The benefits of minimally invasive surgery have led to adoption of laparoscopic assisted robotic surgery across several surgical specialties. Surgeons have acquired considerable expertise in conventional laparoscopic surgery but robotic assistance has allowed performance of similar tasks with greater ease. However, the embracing of minimal invasive surgical techniques demands the rapid acquisition of new skills by surgical trainees and practising surgeons.

Unusual sex differences in tuberculosis notifications across Pakistan and the role of environmental factors

In developing countries, only one-third of new tuberculosis cases notified are from women. It is not clear whether tuberculosis incidence is lower in women than men, or whether notification figures reflect under-detection of tuberculosis in women. Pakistan, however, presents an unusual pattern of sex differences in tuberculosis notifications. While 2 of the 4 provinces (Sindh and Punjab) report more notifications from men (female to male ratios 0.81 and 0.89 respectively in 2009), the other 2 provinces (Khyber-Pakhtunkhwa and Balochistan) consistently report higher numbers of smear-positive tuberculosis notifications from women than men (1.37 and 1.40). No other country is known to have such a large variation in the sex ratios of notifications across regions. Large variations in female to male smear-positive notification ratios in different settings across a single country may indicate that environmental factors, rather than endogenous biological factors, are important in influencing the observed sex differences in tuberculosis notifications.

Genetic associations of psoriasis in a Pakistani population

BACKGROUND

Genetic predisposition to psoriasis, an inflammatory skin disease affecting 0·2-4% of the world population, is well established. Thus far, 41 psoriasis susceptibility loci reach genome-wide significance (P ≤ 5 × 10(-8) ). Identification of genetic susceptibility loci in diverse populations will help understand the underlying biology of psoriasis susceptibility.

OBJECTIVES

The primary objective of this study was to examine psoriasis susceptibility associations previously reported in Chinese and caucasian populations in a Pakistani cohort.

METHODS

Blood samples and phenotype data were collected from psoriasis cases and controls in Islamabad, Pakistan. DNA was isolated and genotypes of selected susceptibility markers were determined. The data were analysed using χ(2) tests or logistic regression for psoriasis association.

RESULTS

HLA-Cw6 showed the strongest association [odds ratio (OR) 2·43, P = 2·3 × 10(-12) ]. HLA-Cw1 showed marginally significant association (OR 1·66, P = 0·049), suggesting that the HLA-Cw1-B46 risk haplotype may be present in the Pakistani population. Three other loci (IL4/IL13, NOS2, TRAF3IP2) showed nominally significant association (P < 0·05).

CONCLUSIONS

HLA-Cw6 is strongly associated with psoriasis susceptibility in the Pakistani population, as has been found in every other population studied. In addition, HLA-Cw1 showed marginal association, reflecting the relative geographical proximity and thus likely genetic relatedness to other populations in which the HLA-Cw1-B46 haplotype is known to be associated. A larger cohort and a denser marker set will be required for further analysis of psoriasis associations in the South Asian population.