PET-CT-guided characterisation of progressive, preclinical tuberculosis infection and its association with low-level circulating Mycobacterium tuberculosis DNA in household contacts in Leicester, UK: a prospective cohort study

BACKGROUND

Incipient tuberculosis, a progressive state of Mycobacterium tuberculosis infection with an increased risk of developing into tuberculosis disease, remains poorly characterised. Animal models suggest an association of progressive infection with bacteraemia. Circulating M tuberculosis DNA has previously been detected in pulmonary tuberculosis by use of Actiphage, a bacteriophage-based real-time PCR assay. We aimed to investigate whether serial [18F]fluorodeoxyglucose ([18F]FDG)-PET-CT could be used to characterise the state and progressive trajectory of incipient tuberculosis, and examine whether these PET-CT findings are associated with Actiphage-based detection of circulating M tuberculosis DNA.

METHODS

We did a prospective 12-month cohort study in healthy, asymptomatic adults (aged ≥16 years) who were household contacts of patients with pulmonary tuberculosis, and who had a clinical phenotype of latent tuberculosis infection, in Leicester, UK. Actiphage testing of participants' blood samples was done at baseline, and [18F]FDG PET-CT at baseline and after 3 months. Baseline PET-CT features were classified as positive, indeterminate, or negative, on the basis of the quantitation (maximum standardised uptake value [SUVmax]) and distribution of [18F]FDG uptake. Microbiological sampling was done at amenable sites of [18F]FDG uptake. Changes in [18F]FDG uptake after 3 months were quantitatively categorised as progressive, stable, or resolving. Participants received treatment if features of incipient tuberculosis, defined as microbiological detection of M tuberculosis or progressive PET-CT change, were identified.

FINDINGS

20 contacts were recruited between Aug 5 and Nov 5, 2020; 16 of these participants had a positive result on IFNγ release assay (QuantiFERON-TB Gold Plus [QFT]) indicating tuberculosis infection. Baseline PET-CT scans were positive in ten contacts (all QFT positive), indeterminate in six contacts (three QFT positive), and negative in four contacts (three QFT positive). Four of eight PET-CT-positive contacts sampled had M tuberculosis identified (three through culture, one through Xpert MTB/RIF Ultra test) from intrathoracic lymph nodes or bronchial wash and received full antituberculosis treatment. Two further unsampled PET-CT-positive contacts were also treated: one with [18F]FDG uptake in the lung (SUVmax 9·4) received empirical antituberculosis treatment and one who showed progressive [18F]FDG uptake received preventive treatment. The ten untreated contacts with [18F]FDG uptake at baseline (seven QFT positive) had stable or resolving changes at follow-up and remained free of tuberculosis disease after 12 months. A positive baseline Actiphage test was associated with the presence of features of incipient tuberculosis requiring treatment (p=0·018).

INTERPRETATION

Microbiological and inflammatory features of incipient tuberculosis can be visualised on PET-CT and are associated with M tuberculosis detection in the blood, supporting the development of pathogen-directed blood biomarkers of tuberculosis risk.

FUNDING

MRC Confidence in Concept.

P-313 The Cyprus women’s health research (COHERE) initiative: estimating the prevalence, symptomatology, associated risk factors and economic burden of endometriosis in an Eastern Mediterranean population

Study question

In this previous undescribed population of women, what is the prevalence of endometriosis and associated symptomatology, and how are women affected?

Summary answer

Prevalence of endometriosis was 5.4% (95%CI; 4.9%-5.9%). Cases suffered from worse physical health, higher use of pain medication and decreased productivity at work.

What is known already

There is a lack of population level data on prevalence and distribution of women’s health conditions, such as endometriosis, from the Eastern Mediterranean region, despite their known negative effects on quality of life. In addition, there is a complete absence of any health statistics from Northern Cyprus, an emerging region in Europe. Most current endometriosis research comes from Western populations and is not generalisable to non-Western populations due to differences in culture, lifestyle, and care seeking patterns. Therefore, it is important to investigate endometriosis in a variety of settings.

Study design, size, duration

The COHERE Initiative is a cross-sectional, population-based study that recruited 7,646 women between the ages 18-55 residing in Northern Cyprus between January 31st 2018, and January 31st 2020. Recruitment took place face-to-face (90%) and online (10%). Participants completed an expanded version of the WERF Endometriosis Phenome and Biobanking Harmonisation Project (EPHect) questionnaire, consisting of previously validated measurement instruments, such as the Short-Form-36-version-2 questionnaire (SF-36v2) and the Work Productivity and Impairment Questionnaire: General Health (WPAI:GH).

Participants/materials, setting, methods

Endometriosis cases were defined using a combination of self-reported and pelvic ultrasound data. Controls were women without endometriosis. Chi-square, Fisher’s exact test, Student’s t-test, linear regression, and multivariable logistic regression were used for data analysis. The significance level was set at p < 0.05.

Main results and the role of chance

Endometriosis prevalence was 5.4% (95%CI; 4.9%-5.9%;n=410). The mean age women with endometriosis reported to first experience related-symptoms was 25.9-years, despite average age of first menstrual-pain occurring at 16.2-years. Average age of first gynaecologist visit was 21.0-years and endometriosis diagnostic-delay was 1.5-years. Physical health-related-quality-of-life was lower in women with endometriosis compared to those without (48.4 vs 50.2, p = 0.001). Cases had a higher mean percentage of activity impairment (25.8% vs 22.5%, p = 0.03) and reduced effectiveness whilst working (23.4% vs 19.5%, p = 0.006) than controls. Hormone-use was higher in women with endometriosis compared to controls for heavy-bleeding (5.9% vs 1.4%, p < 0.001), irregular periods (14.4% vs 7.2%, p < 0.001) and pelvic-pain (9.3% vs 1.7%, p < 0.001), though overall hormone use was low at 24.1%. Iron and vitamin-D deficiency were the most reported co-morbidities, and these proportions were significantly different from women without endometriosis (38.8% vs 28.3%, 23.9% vs 17.0% respectively, p < 0.001). Migraine headaches were more frequent in women with endometriosis than in those without (19.8% vs 13.2%, p < 0.001). Women with endometriosis were more likely to have ever used drugs for pain relief (77.1% vs 60.5%, p < 0.001). Further analysis will include estimation of economic burden of endometriosis and investigation into Mediterranean-specific factors including sun-exposure and dietary-habits.

Limitations, reasons for caution

Given the cross-sectional nature of this study, causality cannot be inferred. The majority of endometriosis cases are self-reported which is not as reliable as hospital diagnosis/surgeries and laparoscopy is not available in Northern Cyprus. However, research has shown that women self-report endometriosis diagnoses with reasonable accuracy (>70%).

Wider implications of the findings

This is the first study that has estimated prevalence of endometriosis in the region and provided insight into the current-status of healthcare. It has highlighted gaps in the public’s general knowledge of common gynaecological conditions. The results form the basis for targeted follow-up-studies and promotes evidence-based reproductive-medicine in the Eastern-Mediterranean-region.

Trial registration number

Not applicable

The Cyprus Women’s Health Research (COHERE) initiative: normative data from the SF-36v2 questionnaire for reproductive aged women from the Eastern Mediterranean

Purpose

Describe the health-related quality of life for a representative cohort of women aged 18–55 in Northern Cyprus.

Methods

We utilised the SF-36-Health-Survey-version-2 (SF-36v2) questionnaire as part of the COHERE Initiative study to calculate the eight physical and mental subscale scores, as well as the two overall summary measures for physical and mental health, where we present results using Cyprus-specific scoring as well as scores based on the test developers’ algorithms. We examined associations between sociodemographic characteristics for both scores.

Results

A total of 7089 women fully completed the SF-36v2 questionnaire (mean age = 36.9), which was reliable and valid in this population. We observed better physical health in ages 18–25 compared to 46–55 (53.32 vs. 46.72 (p < 0.001)) and better mental health in women aged 46–55 compared to 18–25 (52.07 vs. 47.95 (p < 0.001)). Women in employment had better physical and mental health compared to those who were unemployed (physical: 50.25 vs 49.95, p < 0.001 and mental: 50.25 vs 49.24, p = 0.083) and scores increased as educational attainment increased (physical: 47.55 for primary to 51.58 for postgraduate, mental: 48.88 to 50.59, p < 0.001). Turkish Cypriot women had higher scores than Turkish women (physical: 50.42 vs 49.30, mental: 50.43 vs 49.10, p < 0.001).

Conclusion

These are the first population normative values published from a large representative sample of women between 18 and 55 years from the Eastern Mediterranean region. We found better physical health in younger women and better mental health in older women. Turkish Cypriot women and non-migrant women had better mental health, and HRQOL was highest in those in paid employment and those with a higher educational achievement.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03100-7.

Autopsy in suspected COVID-19 cases

The severe acute respiratory syndrome (SARS)-coronavirus-2 (CoV-2) outbreak in Wuhan, China has now spread to many countries across the world including the UK with an increasing death toll. This will inevitably lead to an increase in the number of suspected coronavirus disease 2019 (COVID-19)-related deaths at autopsy. The Royal College of Pathologists has responded to this concern with the release of a briefing on autopsy practice relating to COVID-19. The following article is a summary and interpretation of these guidelines. It includes a description of hazard group 3 organisms, the category to which SARS-CoV-2 has been assigned, a brief description of what is currently known about the pathological and autopsy findings in COVID-19, a summary of the recommendations for conducting autopsies in suspected COVID-19 cases and the techniques for making the diagnosis at autopsy. It concludes by considering the clinicopathological correlation and notification of such cases.

The Role of Big Endothelin-1 in Colorectal Cancer

Introduction

Changes in liver blood flow caused by an unknown splanchnic vasoconstrictor have been noted in colorectal cancer patients with liver metastases. This prospective study was performed to assess whether plasma levels of big endothelin-1 (big ET-1) were raised in patients with colorectal cancer.

Methods

Plasma samples from peripheral vein of patients who underwent surgery for primary colorectal cancer (n=60) and those with known colorectal liver metastases (n=45) for a period of 15 months were taken prior to treatment and compared to age- and sex-matched controls (n=20). Plasma samples were analysed by using a single-step sandwich enzyme immunoassay. Immunohistochemistry and in situ hybridisation were also performed on tumour sections to investigate the expression of ET-1 by cancer cells.

Results

The median (range) plasma concentration of big ET-1 in controls was 2.1 pg/mL (1.2–13.4 pg/mL). The median (range) plasma concentration of big ET-1 in colorectal cancer patients with no overt hepatic metastases was 3.8 pg/mL (1.2–15.8 pg/mL), p=0.002, and the median (range) plasma concentration of big ET-1 in colorectal cancer patients with hepatic metastases was 5.2 pg/mL (1.7–30 pg/mL), p=0.0001; both were significantly elevated compared to the control group. A significant difference in immunostaining for big ET-1 was noted between paired normal colonic mucosa (median score-1) and tumour sections (median score-3), p=0.01.

Conclusion

This study has demonstrated elevated concentrations of big ET-1 in colorectal cancer patients, especially in those with hepatic metastases. Upregulation of ET activity in colorectal cancer could be inferred by the increased immunostaining of big ET-1 in cancer cells. Therefore, plasma big ET-1 levels should be evaluated as a potential tumour marker for the identification of hepatic metastases at an earlier stage.

Characterization of GSK'963: a structurally distinct, potent and selective inhibitor of RIP1 kinase

Necroptosis and signaling regulated by RIP1 kinase activity is emerging as a key driver of inflammation in a variety of disease settings. A significant amount has been learned about how RIP1 regulates necrotic cell death through the use of the RIP1 kinase inhibitor Necrostatin-1 (Nec-1). Nec-1 has been a transformational tool for exploring the function of RIP1 kinase activity; however, its utility is somewhat limited by moderate potency, off-target activity against indoleamine-2,3-dioxygenase (IDO), and poor pharmacokinetic properties. These limitations of Nec-1 have driven an effort to identify next-generation tools to study RIP1 function, and have led to the identification of 7-Cl-O-Nec-1 (Nec-1s), which has improved pharmacokinetic properties and lacks IDO inhibitory activity. Here we describe the characterization of GSK′963, a chiral small-molecule inhibitor of RIP1 kinase that is chemically distinct from both Nec-1 and Nec-1s. GSK′963 is significantly more potent than Nec-1 in both biochemical and cellular assays, inhibiting RIP1-dependent cell death with an IC₅₀ of between 1 and 4 nM in human and murine cells. GSK′963 is >10 000-fold selective for RIP1 over 339 other kinases, lacks measurable activity against IDO and has an inactive enantiomer, GSK′962, which can be used to confirm on-target effects. The increased in vitro potency of GSK′963 also translates in vivo, where GSK′963 provides much greater protection from hypothermia at matched doses to Nec-1, in a model of TNF-induced sterile shock. Together, we believe GSK′963 represents a next-generation tool for examining the function of RIP1 in vitro and in vivo, and should help to clarify our current understanding of the role of RIP1 in contributing to disease pathogenesis.

Detergent

Osteological assessment of human remains forms an essential part of forensic work, especially during the examination of extensively decomposed, dismembered, or burnt bodies. Currently employed methods for removal of adherent soft tissue reflect practices often used by museum curators, notably insect consumption, enzymatic maceration, or boiling of the bones, with subsequent manual removal of material. This study was designed to assess the effectiveness of detergents for the purpose of soft-tissue removal from animal-derived specimens. The results indicate that such a means is comparable to enzymatic maceration but with fewer health and safety issues and greater advantages regarding transportation and availability of materials when an investigator is in a fieldwork scenario.

Forensic web watch

A search for forensic odontology sites on the Internet revealed thousands of 'hits', of which many constituted dentists offering a private service on their homepages. Several organisations and associations were identified following extensive sifting through these addresses and, despite its growing acceptance in the forensic community, the resources available were superficial and of only moderate educational content. Although many of the sites provided non-specialist information and points of contact for local experts only one was commended for its design and depth. The need for improvement in this field is therefore recommended.

Forensic Web Watch – medicolegal aspects of paediatric pathology

The trials over the deaths of Matthew Eappen and Victoria Climbie have highlighted the importance of forensic evidence in cases of suspected child abuse. The debate as to whether bruises, fractures or head injuries have been sustained as a result of previous trauma or non-accidental injury is central to these, and other, cases. A variety of subjects are encountered in forensic paediatric pathology, including Shaken Baby Syndrome, non-accidental injury, retinal haemorrhage, skeletal injury, Sudden Infant Death, sexual abuse and Munchausen Syndrome by Proxy. The coverage of these areas on the internet was assessed using two search engines (Google and the meta-search engine Mamma) and revealed patchy coverage. The majority of sites uncovered were, unsurprisingly, aimed at the layperson concerned by such issues; however, several sites containing useful information for the professional are available.

The histological features of microwave coagulation therapy: an assessment of a new applicator design

Microwave ablation of tumours within the liver may become an adjunct or alternative to resection in patients with primary or secondary cancers. This technique combines the benefits of a large, localized coagulative effect with a single insertion of the applicator, in a significantly shorter time than comparable treatments. A new range of microwave applicators were developed and tested in animal models and both ex-vivo and in-vivo specimens of human liver at resection. At laparotomy, the applicator tip was inserted into normal liver parenchyma and tumours, with each specimen subjected to irradiation for 180 s or more and at varying power outputs. On sectioning an area of spherical blanching was observed around the applicator cavity. Microscopically a zone of coagulative necrosis was seen adjacent to the site of probe insertion. Damage to blood vessels and bile ducts occurred distal to the probe cavity suggesting the passage of heated fluid, a finding that was diminished by temporary occlusion of the hepatic vasculature (a Pringle manoeuvre). Ultra-structural damage was confirmed within the burn zone and selected liver enzymes were shown to be functioning beyond this region. We suggest this indicates the surrounding liver parenchyma is functioning normally and therefore the volume of microwave-induced damage is controllable. We are confident that the new applicator design will allow the effective treatment of larger tumours in a safe and controlled manner with a single application of energy.

The human ear: its role in forensic practice

The human ear has much to offer investigators in relation to many areas of forensic practice including forensic pathology, anthropology, identification and facial reconstruction and yet its full potential is often overlooked. This review paper explores current knowledge related to the human ear drawing attention to those situations where the ear could play a valuable role in a forensic investigation.

Experimental study of large-volume microwave ablation in the liver

BACKGROUND

Microwave coagulation therapy is useful in the destruction of small, irresectable liver tumours of primary and secondary origin. Unfortunately, the small lesion size produced by currently available equipment makes it difficult and time consuming completely to ablate lesions larger than 3 cm in diameter. A microwave system capable of producing large-volume ablations in very short periods of time has been developed. Using a large-animal model the ability of the equipment to produce large-volume lesions in a safe, predictable and dose-dependent manner was tested.

METHODS

Fourteen large white pigs were anaesthetized and underwent multiple microwave treatments. The animals were killed at different timepoints to investigate lesion size and evolution.

RESULTS

The microwave system was able to generate large-volume ablations of up to 6.5 cm in diameter in a controlled and dose-dependent manner.

CONCLUSION

This novel microwave system allows the ablation of large volumes of liver tissue in a short period of time. The ability to produce lesions reproducibly and safely highlights the potential of this system in the future treatment of irresectable liver tumours.

Death certification: an audit of practice entering the 21st century

AIMS

Death certification, a legal duty of doctors, continues to be poorly performed despite Royal College recommendations and increased education at an undergraduate level. Therefore, the current performance of certifying doctors was audited within a large teaching hospital entering the new century.

METHODS

A total of 1000 completed certificate counterfoils were examined retrospectively for appropriateness of completion and the ability to construct a logical cause of death cascade.

RESULTS

Only 55% of certificates were completed to a minimally accepted standard, and many of these failed to provide relevant information to allow adequate ICD-10 coding. Nearly 10% were completed to a poor standard, being illogical or inappropriately completed.

CONCLUSIONS

The results show no improvement in the state of certification. Possible interventions to improve outcomes are discussed; however, in light of a recent high profile legal case a current Home Office review of death certification may suggest the passing of statutory law to ensure accurate completion.

An estimation of the post-mortem interval in human skeletal remains: a radionuclide and trace element approach

Estimation of the post-mortem interval remains a contentious issue, with forensic pathologists often relying upon the recognition of morphological changes.A radionuclide approach has often been suggested in the literature, although limitations have prevented its application, most notably those of diagenesis. Within this pilot study, we show for the first time that there is a correlation between certain radionuclide content and time since death.A larger study is proposed to confirm these findings and possibly provide a calibration against which bones uncovered can be dated.

Meniscal ossification in spontaneous osteoarthritis in the guinea-pig

OBJECTIVE

The purpose of this study was to evaluate the ossification state of the meniscus in the guinea-pig stifle joint using micro-computerized tomography.

DESIGN

Hind limbs from six (N=12) and 24 (N=11) month-old male Hartley guinea-pigs were removed and the joints were imaged using high resolution micro-computerized tomography. The ossified volume of the medial and lateral menisci from both groups of animals was quantified.

RESULTS

Ossification of both the medial and lateral menisci of the both the 6- and 24-month-old animals was observed. In both age groups, the ossified region of the medial meniscus was significantly larger than the lateral meniscus. In addition, there is a significant increase in ossified volume of the medial meniscus between 6 and 24 months of age.

CONCLUSIONS

There is a significant amount of ossification of the menisci in the male Hartley guinea-pig, with the medial compartment showing more bone than the lateral. In addition, as the animals age, there is an increase in ossification within the medial compartment. Bone remodeling and cartilage degeneration is evident in the medial compartment within these animals as they age. It is possible that the increased ossification of the medial meniscus could alter the joint biomechanics and, in part, stimulate this medial compartment joint destruction.

Dating human skeletal remains: investigating the viability of measuring the equilibrium between 210Po and 210Pb as a means of estimating the post-mortem interval

Estimating the post-mortem interval in skeletal remains is a notoriously difficult task; forensic pathologists often rely heavily upon experience in recognising morphological appearances. Previous techniques have involved measuring physical or chemical changes within the hydroxyapatite matrix, radiocarbon dating and 90Sr dating, though no individual test has been advocated. Within this paper it is proposed that measuring the equilibrium between two naturally occurring radio-isotopes, 210Po and 210Pb, and comparison with post-mortem examination samples would produce a new method of dating human skeletal remains. Possible limitations exist, notably the effect of diagenesis, time limitations and relative cost, though this technique could provide a relatively accurate means of determining the post-mortem interval. It is therefore proposed that a large study be undertaken to provide a calibration scale against which bones uncovered can be dated.

Porcelain veneers: the effects of contaminants and cleaning regimens on the bond strength of porcelain to composite

An in-vitro study was carried out to investigate the effects of contamination of the porcelain surface on the shear-bond strength of a dual-cure composite luting cement to etched, silanated porcelain. Furthermore, the effects of different cleaning regimens were studied. A total of 390 etched, silanated porcelain specimens were randomly divided into 13 groups of 30. Shear-bond strengths were measured for a control group and for specimens contaminated with saliva, die stone, and latex gloves. Freshly contaminated samples were subject to three cleaning regiments; water wash and dry, cleansing with acetone, and cleansing with 37% phosphoric acid gel. Bond strengths to the cleansed surfaces were measured. Weibull analysis and analysis of variance were applied to the results. Saliva and latex glove contamination did not significantly affect shear-bond strength. Die stone contamination markedly reduced the bond strength and cleaning did not restore the bond strength for these specimens. Contact between porcelain veneers and stone models should therefore be avoided. The wash/dry and phosphoric acid cleaning regimens did not significantly improve or reduce bond strengths for contaminated specimens. Acetone cleaning produced a marked reduction in bond strength under all experimental conditions and should not be used.

Severe withdrawal syndrome after substitution of a short-acting benzodiazepine for a long-acting benzodiazepine

A severe withdrawal syndrome occurred in a patient after oxazepam 10 mg bid was substituted for diazepam 5 mg bid. The onset of symptoms was consistent with the rate of decline of diazepam and its active metabolite, desmethyldiazepam. Reintroduction of diazepam produced prompt symptom remission. This report and others suggest the need for caution when substituting a short-acting drug for a long-acting one, even when usual doses of each are used. The chronic use of benzodiazepines for eight months or longer prior to substitution or withdrawal appears to place the patient at a higher risk of incurring withdrawal phenomena. Slow and careful tapering of drug is required in such patients to reduce the risk of withdrawal symptoms.