A prospective study of MRI biomarkers in the brain and lower limb muscles for prediction of lower limb motor recovery following stroke

The aim of this prospective observational longitudinal study was to explore and decipher the predictive value of prospective MRI biomarkers in the brain and lower limb muscles for 3-month lower limb motor recovery following stroke. In the brain, we measured the integrity of the corticospinal tract (fractional anisotropy/"FA"). In the muscles, we measured volume, fatty replacement (fat fraction analysis and proton spectroscopy) and oedema. Measurements were taken at two time points: (1) within 4 weeks of stroke (baseline measurement, clinical and imaging) and (2) 3 months following stroke (follow up measurement, clinical only). Clinical measurements consisted of assessments of functional ability and strength (Fugl-Meyer score, motor NIHSS, Functional Ambulation Category/"FAC", and muscle dynamometry). Twenty-three patients completed imaging and clinical assessments at baseline and follow-up; five patients had partial imaging assessment. The results provided some evidence that damage to the corticospinal tract would result in less motor recovery: recovery of the Fugl-Meyer score and dynamometric ankle plantarflexion, ankle dorsiflexion, and knee extension correlated positively and significantly with fractional anisotropy (0.406-0.457; p = 0.034-p = 0.016). However, fractional anisotropy demonstrated a negative correlation with recovery of the Functional Ambulation Category (-0.359, p = 0.046). For the muscle imaging, significant inverse correlation was observed between vastus lateralis fat fraction vs. NIHSS recovery (-0.401, p = 0.04), and a strong positive correlation was observed between ratio of intra- to extra-myocellular lipid concentrations and the recovery of knee flexion (0.709, p = 0.007). This study supports previous literature indicating a positive correlation between the integrity of the corticospinal tract and motor recovery post-stroke, expanding the limited available literature describing this relationship specifically for the lower limb. However, recovery of functional ambulation behaved differently to other clinical recovery markers by demonstrating an inverse relationship with corticospinal tract integrity. The study also introduces some muscle imaging biomarkers as potentially valuable in the prediction of 3-month lower limb motor recovery following stroke.

974 Paget-Schroetter Syndrome in A Young Fitness Enthusiast with A Negative D-Dimer. Highlighting the Balance Between Clinical Suspicion and Diagnostic Modalities

This case illustrates an athletic 22-year-old, who presented to the hospital with a 3-week history of spontaneous right arm ache, discolouration and swelling. His blood tests were normal, with a negative D-dimer (<150ng/ml). He underwent a CT venogram for suspicion of venous obstruction which was unremarkable. However due to a high clinical suspicion, an ultrasound doppler was performed. This identified the presence of axillary-subclavian thrombosis which in conjunction with other clinical and radiological parameters confirmed the diagnosis of Paget-Schroetter Syndrome (PSS). Our patient was commenced on anticoagulation as the venous obstruction was suspected to be sub-acute with clinical suggestion of collateral formation. Unfortunately, his symptoms failed to resolve over a 6-month period, and he underwent an elective right rib resection with right subclavian bypass using the great saphenous vein with good outcome post-operatively.

PSS is a rare manifestation of venous thoracic outlet syndrome (TOS) commonly seen in young, healthy, athletic individuals. Despite the high effectiveness of D-Dimers in ruling out acute thrombotic process and the accuracy of dedicated CT angiography in excluding vascular thrombotic events, both tests proved inconclusive in this particular case. This latter observation highlights the importance of the clinical context, and risk profiling in guiding results interpretation.

918 COVID-19: A Detailed Analysis on Fit-Testing for Respiratory Protective Equipment in the UK

Introduction

There is limited data in the literature regarding the adequacy of generic FFP3 masks and their facial fit to ensure adequate protection. Mask fit-testing is therefore essential to protect healthcare workers.

Method

Using the Freedom of Information Act, 137 acute NHS trusts in the UK were approached on the 26/3/2020 by an independent researcher to provide data on the outcome of fit testing at each site.

Results

85 Trusts responded to the FOI with 51 trusts providing pertinent data relevant to the FOI request. There was a total of 72 mask types used across 51 trusts. The commonest of which was the FFP3M1863 (used by 47/51 trusts, 92.16%). A positive correlation was found between staff members and number of mask types used (r = 0.75, P = <0.05).

Overall fit-testing pass rates were provided by 32 trusts. The mean percentage pass rate was 80.74%.

Gender specific failure rates were provided by seven trusts. 4386 males underwent fit-testing in comparison to 16305 females. Across all seven trusts 20.08% of men tested failed the fit-test while only 19.89% of women failed the fit-test.

Conclusions

Our results may be utilised in choosing respirators for fit testing programme in healthcare-workers during the COVID-19 pandemic.

Fit-testing of respiratory protective equipment in the UK during the initial response to the COVID-19 pandemic

Background

Public Health England guidance stipulates the use of filtering facepiece (FFP3) masks for healthcare workers engaged in aerosol-generating procedures. Mask fit-testing of respiratory protective equipment is essential to protect healthcare workers from aerosolized particles.

Aim

To analyse the outcome of mask fit-testing across National Health Service (NHS) hospitals in the UK during the first wave of the coronavirus disease 2019 (COVID-19) pandemic.

Methods

Using the Freedom of Information Act, 137 NHS hospitals were approached on May 26^th, 2020 by an independent researcher to provide data on the outcome of fit-testing at each site.

Findings

Ninety-six hospitals responded to the request between May 26^th, 2020 to October 29^th, 2020. There was a total of 86 mask types used across 56 hospitals, 13 of which were used in at least 10% of these hospitals; the most frequently used was the FFP3M1863, used by 92.86% of hospitals. Overall fit-testing pass rates were provided by 32 hospitals with mean pass rate of 80.74%. The most successful masks, in terms of fit-test failure rates, were the Alpha Solway 3030V and the Alpha Solway S–3V (both reporting mean fit-test failures of 2%). Male- and female-specific pass and failure rates were provided by seven hospitals. Across the seven hospitals, 20.1% of men tested failed the fit-test for all masks used, whereas 19.9% of women tested failed the fit-test for all masks used. Failure rates were significantly higher in staff from Black, Asian, and Minority Ethnic (BAME) backgrounds 644/2507 (25.69%) across four hospitals.

Conclusion

Twenty percent of healthcare workers tested during the first response to the pandemic failed fit-testing for masks. A small sample revealed that this was most prominent in staff from BAME backgrounds.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Antibacterial Effect of Curcuma longa (Turmeric) Against Staphylococcus aureus and Escherichia coli

This observational study was conducted during the period from July 2010 to June 2011 in the Department of Pharmacology in the collaboration of Department of Microbiology, Mymensingh Medical College, Mymensingh to determine the profile of antibacterial effect of Crude Turmeric paste aqueous turmeric extract, and standard antibiotic Amikacin against Staphylococcus aureus and Escherichia coli. Three separate experiments were done e.g. (Expt- I) Inhibitory effect of Crude Turmeric paste incorporated into nutrient agar (NA) media, (Expt- II) Minimum inhibitory concentration of (a) Aqueous Turmeric extract and (b) Amikacin by broth dilution technique and (Expt-III) their subculture study in nutrient agar (NA) media for confirmation of respective results of previous experiments. Inhibitory effects were observed against the growth of Staph Aureus and Esch coli at 10% and 30% respectively of Crude Turmeric paste incorporated into NA media. The broth dilution technique was followed to determine the MIC of Aqueous Turmeric extract and Amikacin. The MIC of Aqueous Turmeric extract was 800 μg/ml against Staph aureus and that against Esch coli was 2000 μg/ml and the MIC of Amikacin was 10 μg/ml for both the bacteria. The MIC of Amikacin was the lowest in comparison to MIC of Aqueous Turmeric extract for complete inhibition of growth of Staph aureus and Esch coli. The subculture study showed similar results with that of previous experiments in terms of inhibitory effects of Crude Turmeric paste and MIC of Aqueous Turmeric extract and Amikacin against all of the organisms studied.

Cost recovery beds in public hospitals in Indonesia

A policy of allowing public hospitals to provide some better quality, higher priced hospital beds for those able to pay was introduced as government policy in Indonesia after 1993. A study was conducted in 1998 in three public hospitals in East Java to investigate if the policy objective of cost-recovery was being achieved. Hospital revenue from these commercial beds was less than both the recurrent and total costs of providing them in all three hospitals, but exceeded recurrent costs minus staff salaries in two hospitals. One reason for the low cost-recovery ratios was that between 55% and 66% of the revenue was used as staff incentives, mostly to doctors. This was more than the maximum of 40% stipulated in the policy. The high proportions of total revenue going to staff were a result of hospital management having set bed fees too low. The policy may be contributing to the retention of doctors within public sector employment; however, it is not achieving its stated objective, especially over the longer term where full recovery of salaries and investment costs needs to be considered. Public hospitals that wish to invest in commercial beds need effective management and accounting systems so as to be able to monitor and control costs and set fees at levels that recoup the costs incurred. Further research is required to determine if this form of public-private mix has negative effects on equity and access for poorer patients.

Ankle clonus and thiocyanate, linamarin, and inorganic sulphate excretion in school children in communities with Konzo, Mozambique

We examined 397 school children for ankle clonus in five communities in three districts affected by konzo, spastic paraparesis associated with cassava consumption. From a subsample of 131 children, we analysed urine specimens for urinary thiocyanate, linamarin, and inorganic sulphate. The proportion of children with clonus varied between sites, ranging from 4 to 22 per cent. Geometric mean thiocyanate, linamarin, and inorganic sulphate concentrations were 163 and 60 mumol/l and 4.4 mmol/l, respectively. Children with ankle clonus had higher urinary thiocyanate concentrations. We recommend prevention to reduce cyanide exposure and further monitoring of cyanide exposure and neurological damage in these communities.

Improving quality in public sector hospitals in Indonesia

Indonesia has successfully expanded its health system to improve access and quality of care for the population, promote equity, and expand primary health care. More recently, it has sought to undertake policy initiatives to promote involvement of the private sector and to introduce both incentives for efficiency and payment mechanisms which will increase sustainability. Certain public health sector facilities have been given financial autonomy to set prices, introduce and retain user fees, and promote prepayment mechanisms. The autonomous hospitals, Unit Swadana hospitals, have increased revenue sustainability while promoting quality assurance practices. The managers of these hospitals have become adept at introducing business practices into the hospital's operations to promote efficiency. These have attracted private investors to invest in public hospitals.

Clinical evaluation of encephalitis

A series of 325 or 31.11% children out of 1045 inpatients of neurological cases diagnosed as encephalitis was reviewed in Pediatrics Neurology Subdivision Child Health Department, Medical School, University of North Sumatera/Dr. Pirngadi Hospital Medan since 1985 to 1988. Boys were more than girls with the ratio of 4:3. Most encephalitis cases (249 or 76.80%) of children occurred in the early age namely before 3 years. Associated diseases were respiratory disease in 61 (45.61%) cases, gastrointestinal disease in 48 (34.67%) cases and measles in 13 (9.35%) cases. There were three mayor clinical features of encephalitis i.e. sudden fever, convulsion and consciousness depression. The cerebrospinal fluid investigation might be normal. There was however mild to moderate lymphocitic pleiositosis with cell numbers varying from 20-200 per cubic mm. The protein content was slightly elevated. The mortality rate was 21.53% (70 cases). There was no significant difference (P greater than 0.05) found between mortality rate of boys and girls. There was no significant difference (P greater than 0.05) found between mortality rate below and above 3 years of age.

The costs of public primary health care services in rural Indonesia

Described are the results of a cost study of national rural health services carried out in Indonesia between November 1986 and March 1987. Detailed costings of government inputs to all public health services below the district hospital level were made for 41 subdistricts in five provinces that were representative of the different regions of the country. The total costs of services as well as the average costs for specific service functions were estimated for the whole country as well as for the different provinces. The results indicate a low overall level of government spending on rural primary health care. Regional differences in this respect were not significant, suggesting that the government policy of encouraging regional balance in allocations has been successful. The average costs for most services were much greater than the charges made to patients, and this provided information on the current level of government subsidies. There was a large variability in the average costs, indicating that the existing system is inefficient, that some districts were able to attain much higher levels of efficiency than others within the existing constraints, and that improvements in this respect are possible.