Optimal size threshold for PIRADSv2 category 5 upgrade and its positive predictive value: is it predictive of "very high" likelihood of clinically-significant cancer?

AIM

To identify the optimal size metric and threshold for Prostate Imaging Reporting and Data System (PIRADS) 5 upgrade, calculate its positive predictive value (PPV) for clinically-significant prostate cancer (csPCA), and determine if it is indicative of a "very high" likelihood of csPCA.

MATERIALS AND METHODS

One hundred and forty-three PIRADS 4 or 5 lesions were evaluated. Lesion diameters were used to calculate lesion volume (LV). Pearson correlation between maximum lesion diameter (MLD) and LV was calculated. Area under the curve (AUC) for discriminating csPCA (Gleason grade ≥ 3 + 4) was calculated using MLD and LV. Optimal size thresholds (using Youden index) and highly predictive size thresholds were identified for the whole prostate (WP), peripheral zone (PZ), and transitional zone (TZ).

RESULTS

There was high correlation between MLD and LV (r=0.77-0.81), with comparable AUCs for MLD and LV in the identification of csPCA in the WP (0.73, 0.72), PZ (0.73, 0.73), and TZ (0.79, 0.75). Optimal MLD thresholds were 1.4, 1.4, and 1.6 cm in the WP, PZ, and TZ respectively, with PPVs of 76%, 81%, and 69%, respectively. An MLD threshold of 2.7 cm would be needed in the WP to achieve a PPV approaching 90%, with sensitivity decreasing to 10%.

CONCLUSIONS

There is high correlation between MLD and LV with comparable discrimination of csPCA using each. PIRADSv2's 1.5 cm MLD threshold is near the optimal threshold for PIRADS 5 upgrade but has moderate PPV. A much higher threshold would be needed to increase its PPV, with significant sacrifice in sensitivity.

TB programme stakeholder views on lessons from the COVID-19 response in South Africa

BACKGROUND

The global COVID-19 pandemic has reversed many of the hard-won gains made in TB programmes and the associated reduction in the number of TB deaths, case notifications and incidence over the last three decades. Modelling estimates show that the impact will be lasting. There are global calls to recover the shortfalls along the TB care cascade that have resulted from COVID-19, with the recognition that the COVID-19 response holds lessons to inform more robust and comprehensive TB programmes and services.

OBJECTIVE

To explore lessons from response measures to the COVID-19 pandemic in two high TB burden South African provinces.

DESIGN

This was an exploratory qualitative study. We conducted interviews with TB programme stakeholders (managers and facility-level staff: n = 35) between February and June 2022.

RESULTS

We identified eight facilitators of the COVID-19 response, including political will, rapid policy development, multi-sectoral collaboration, patient-centred models of care delivery, community engagement, mHealth and telehealth technologies, rigorous contact tracing and widespread mask wearing. Political will was singled out as a critical driver of the response.

CONCLUSION

Leveraging COVID-19 inspired collaborations, technologies and avenues for health service delivery is an opportunity to maximise benefits for the TB programme. Reinvestment in national TB programmes and political prioritisation of TB are critical.

TB preventive therapy preferences among children and adolescents

BACKGROUND: TB preventive therapy (TPT) is critical for ending TB, yet implementation remains poor. With new global guidelines expanding TPT eligibility and regimens, we aimed to understand TPT preferences among children, adolescents and caregivers.METHODS: We undertook a discrete choice experiment among 131 children, 170 adolescents and 173 caregivers, and conducted 17 in-depth interviews in 25 clinics in Cape Town, South Africa. The design included attributes for location, waiting time, treatment duration, dosing frequency, formulation/size, side effects, packaging and taste. Mixed-effects logistic regression models were used for analysis.RESULTS: Among children and caregivers, the number and size of pills, taste and side effects were important drivers of preferences. Among adolescents and caregivers, clinic waiting times and side effects were significant drivers of preferences. Adolescents expressed concerns about being stigmatised, and preferred services from local clinics to services delivered in the community. Dosing frequency and treatment duration were only significant drivers of choice among adolescents, and only if linked to fewer clinic visits.CONCLUSIONS: Introducing shorter TPT regimens in isolation without consideration of preferences and health services may not have the desired effect on uptake and completion. Developing TPT delivery models and formulations that align with preferences must be prioritised.

Reasons for poor uptake of TB preventive therapy in South Africa

BACKGROUND

South Africa has one the highest TB and HIV burdens globally. TB preventive therapy (TPT) reduces the risk of TB disease and TB-related mortality in adults and children living with HIV and is indicated for use in TB-exposed HIV-negative individuals and children. TPT implementation in South Africa remains suboptimal.

METHODS

We conducted a pragmatic review of TPT implementation using multiple data sources, including informant interviews (n = 134), semi-structured observations (n = 93) and TB patient folder reviews in 31 health facilities purposively selected across three high TB burden provinces. We used case descriptive analysis and thematic coding to identify barriers and facilitators to TPT implementation.

RESULTS

TPT programme implementation was suboptimal, with inadequate monitoring even in health districts with well-functioning TB services. Health workers reported scepticism about TPT effectiveness, deprioritised TPT in practice and expressed divergent opinions about the cadres of staff responsible for implementation. Service- and facility-level barriers included ineffective contact tracing, resource shortages, lack of standardised reporting mechanisms and insufficient patient education on TPT. Patient-level barriers included socio-economic factors.

CONCLUSIONS

Improving TPT implementation will require radically simplified and more feasible systems and training for all cadres of health workers. Partnership with communities to stimulate demand driven service uptake can potentially facilitate implementation.

Early interactions with newly diagnosed TB patients in hospital can support linkage to care

BACKGROUND:

In South Africa, failure to link individuals diagnosed with TB to care remains an important gap in the TB care cascade. Compared to people diagnosed at primary healthcare (PHC) facilities, people diagnosed in hospitals are more likely to require additional support to be linked with PHC TB treatment services. We describe a patient interaction process to support linkage to TB care.

METHODS:

We implemented a step-by-step early patient interaction process with 84 adults newly diagnosed with TB in one district hospital in Khayelitsha, Cape Town, South Africa (August 2020–March 2021). We confirmed patient contact details, provided TB and health information, shared information on accessing care at PHC facilities and answered patients’ questions in their home language.

RESULTS:

Most patients (54/84, 64%) provided updated telephone numbers, and 19/84 (23%) reported changes in their physical address. Patients welcomed practical and health information in their home language. The majority (74/84, 88%) were linked to care after hospital discharge.

CONCLUSIONS:

A simple early patient interaction process implemented as part of routine care is a feasible strategy to facilitate early TB treatment initiation and registration.

An insight of dysregulation of microRNAs in the pathogenesis of diabetic kidney disease

BACKGROUND

Worldwide, diabetic kidney disease (DKD) remains the leading cause of chronic kidney disease (CKD) and its successor, the end stage renal disease, both of which constitute major morbidity and mortality concerns.

CONTENT

The residual risk of disease progression remains despite the advert of newer therapeutic modalities and current biomarkers. Meanwhile, microRNAs (miRNAs) are small non-coding RNAs, which regulate gene expression post-translationally by binding to specific mRNAs. Circulating miRNAs are increasingly recognised as novel biomarker or therapeutic targets, owing to their unique characteristics, such as their resilience to degradation by endogenous RNases, multiple downstream targets, involvement in biological processes, some degree of tissue specificity, relatively easy access and quantification. Unlike proteins, there are far less miRNAs and mature miRNAs are highly stable, structurally less complex without post-translational modification with high degree of conservation across species. Aberrant expression of miRNAs has been established in both in vitro and in vivo models of DKD. An up-to-date compilation of previous studies involving selected circulating miRNAs in blood and urine samples of DKD patients is discussed herein.

SUMMARY

This review highlights the unmet clinical challenges and dysregulation of miRNAs in the pathogenesis of DKD.

The COVID-19 and TB syndemic: the way forward

Together, SARS-CoV-2 and M. tuberculosis have killed approximately 5.7 million people worldwide over the past 2 years. The COVID-19 pandemic, and the non-pharmaceutical interventions to mitigate COVID-19 transmission (including social distancing regulations, partial lockdowns and quarantines), have disrupted healthcare services and led to a reallocation of resources to COVID-19 care. There has also been a tragic loss of healthcare workers who succumbed to the disease. This has had consequences for TB services, and the fear of contracting COVID-19 may also have contributed to reduced access to TB services. Altogether, this is projected to have resulted in a 5-year setback in terms of mortality from TB and a 9-year setback in terms of TB detection. In addition, past and present TB disease has been reported to increase both COVID-19 fatality and incidence. Similarly, COVID-19 may adversely affect TB outcomes. From a more positive perspective, the pandemic has also created opportunities to improve TB care. In this review, we highlight similarities and differences between these two infectious diseases, describe gaps in our knowledge and discuss solutions and priorities for future research.

POS1259 AXIAL SPONDYLOARTHRITIS, AGE AND MALE GENDER IMPACT COVID VACCINATION AEs MORE THAN RHEUMATOID ARTHRITIS

Background

Rheumatologists recommend vaccination in rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) patients, but there are few studies on the occurrence of adverse events (AEs), particularly worsening disease related activity and unrelated immune reactions in these groups.

Objectives

To evaluate the uptake of COVID vaccination in RA and axSpA patients, compare the frequency of AEs, and identify risk factors associated with vaccine AEs in two prospective cohorts comprised of these patients.

Methods

The IMPACT study is a monthly survey of two prospective cohorts of established RA and axSpA patients in northern Alberta, Canada from November 2020-2021 who answered at least one or more Redcap surveys through de-identified email link surveying demographics, disease characteristics, COVID symptoms, treatment of RA and axSpA, health care utilization, vaccination status, vaccine AEs and use of cannabis. Univariate analyses evaluated independent variables associated with the dependent variables of (1) any AE, (2) any severe AE, (3) any arthritis flare, and (4) any severe arthritis flare, followed by multivariate analyses of these four dependant variables using all clinically relevant variables from the univariate analysis.

Results

773/2167 patients (RA 574, axSpA 197) responded to at least one survey. 32/663 (5%) were single vaccinated, 631 (95%) double vaccinated and 230 (54%) triple vaccinated with 80% receiving Pfizer, 24% Moderna, 28% AstraZeneca and 30% “other”. 456 (69%) reported at least one AE (Figure 1) with 21 (3%) patients seeing a physician for their AE. Increased age was associated with all AEs. RA patients had lower reported AEs versus axSpA patients for all AE definitions except for severe arthritis flares. Generally, males reported worse AEs (Table 1). “Any arthritis flare” was lower in patients reporting cannabis use.

Table 1.

Summary of Multivariate Level Mixed-Effect Logistic Regression Models Evaluating the IMPACT of RA and axSpA Disease Characteristics on Vaccine AEs

VariableAny Adverse EventOR (95 % CI) p valueSevere Adverse Event* OR 95 % CI) p valueAny Arthritis Flare or Joint Ache Adverse Event OR (95 % CI) p valueAny Severe Arthritis Flare or Joint Ache* OR (95 % CI) p valueGenderMale1.47 (0.89 – 2.43)p=0.132.10 (1.30-3.41)p=0.0032.05 (1.20 – 3.50) p=0.013.97 (1.84 – 8.57)p=0.0004FemaleAge1.06 (1.04 – 1.08)p<0.011.05 (1.03 – 1.06)p<0.011.03 (1.01 – 1.04)p=0.0031.03 (1.01 – 1.06)p=0.004Rheumatic Disease TypeRA0.42 (0.23 – 0.76)p=0.050.55 (0.31 – 0.98)p=0.040.52 (0.28 – 0.98)p=0.040.78 (0.34 – 1.78)p=0.55axSpASteroidsYes0.85 (0.40 – 1.83) P=0.680.66 (0.32 – 1.35) p=0.250.84 (0.36 – 1.95) p=0.690.38 (0.15 – 0.97)p=0.04NoNSAIDSYes1.11 (0.81 – 1.52) p=0.511.03 (0.75 – 1.41)p=0.861.05 (0.74 – 1.48)p=0.801.17 (0.73 – 1.89)p=0.52NoCurrent Disease Activity0.95 (0.88 – 1.03) p=0.230.90 (0.83 – 0.97)p=0.190.92 (0.85 – 1.00)p=0.060.82 (0.74 – 0.92)p=0.001HAQ1.08 (0.73 – 1.61) p=0.700.77 (0.52 – 1.14)p=0.010.74 (0.48 – 1.13)p=0.170.65 (0.38 – 1.11)p=0.12Nicotine productsYes1.33 (0.75 – 2.37) p=0.341.42 (0.80 – 2.52)p=0.241.15 (0.60 – 2.01)p=0.760.97 (0.43 – 2.17)p=0.94NoCannabis productsYes0.78 (0.49 – 1.25) p=0.300.87 (0.55 – 1.38)p=0.550.51 (0.31 – 0.83)p=0.070.66 (0.35 – 1.26)p=0.21NoDMARDsYes1.98 (1.28 – 3.06)p=0.0021.52 (1.01 – 2.28)p=0.051.43 (0.91 – 2.23) p=0.121.86 (1.03 – 3.36)p=0.04NoBiologic DMARDYes0.72 (0.42 – 1.25) p=0.240.79 (0.45 – 1.41) p=0.431.20 (0.66 – 2.18 p=0.541.39 (0.63 – 3.08)p=0.42No

*Severe = Any of the following: ranked moderate to severe and/or lasting more than 7 days and/or saw physician

Conclusion

RA and axSpA patients showed high uptake of COVID vaccination with largely minor AEs. Older age and male gender were associated with more general and arthritis specific AEs. The association of any AE and/or arthritis-specific AEs in SpA versus RA patients is a novel finding which may correlate with the male predominance of SpA. The association of cannabis with fewer arthritis AEs may reflect the nociceptive properties of cannabis.

Acknowledgements

Epidemiology Coordinating and Research (EPICORE) Centre provided support for the REDCAP survey and biostatistical analyses.

Disclosure of Interests

Stephanie Keeling Speakers bureau: Pfizer, Abbvie, GSK, UCB, Consultant of: Abbvie, GSK, UCB, AstraZeneca, Sandoz, Pfizer, Grant/research support from: Abbvie, Sandoz, Merck, UCB, Bo Pan: None declared, Edna Hutchings Shareholder of: BMS, Stephanie Wichuk: None declared, Mohammed Osman Speakers bureau: Boehringer Ingelheim, Takeda Pharmaceuticals, Grant/research support from: Boehringer Ingelheim and CSL-Behring, Ameeta Singh: None declared, Ashlesha Sonpar Speakers bureau: Novartis, Ilan Swartz: None declared, Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, Boehringer Ingelheim, Celegene, Eli-Lilly, Galapagos, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer, UCB

POS1258 LESS THAN EXPECTED IMPACT OF RHEUMATOID ARTHRITIS AND AXIAL SPONDYLOARTHRITIS DISEASE ON COVID SEVERITY

Background

Throughout the pandemic, there has been ongoing concern that people with autoimmune diseases such as rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) will have more severe COVID-19 disease due to immune dysfunction associated with autoimmune diseases and their treatment.

Objectives

We aimed to compare the severity of COVID-19 in patients with RA versus axSpA and characterize the predictors of COVID-19 severity during the pre-Omicron pandemic phases.

Methods

The IMPACT (IMPact of inflammatory Arthritis on COVID Outcomes STudy) study is a monthly survey of two established northern Alberta, Canada prospective cohorts of RA and axSpA patients from November 2020-2021 who answered Redcap surveys through de-identified email link surveying patient demographics, disease characteristics, COVID-19 symptoms, treatment of RA and axSpA, health care utilization, vaccination status and vaccine adverse events. Descriptive and univariate analyses (dependent variable = severe COVID-19) were performed followed by multivariate analyses of all significant and clinically relevant independent variables from the univariate analysis. Infection severity was defined as any patient with COVID-19 symptoms who visited a doctor, ER or required hospital admission.

Results

773 of 2167 (36%) patients (RA n=574, axSpA n=197) registered in both cohorts answered at least one baseline survey, 28 (4%) reporting positive COVID-19 tests (24 positive once). Of 442 reporting COVID-19 symptoms during the survey, 11 (3%) were admitted for a mean of 4 days, 2 requiring ICU or blood clot treatment and 1 requiring advanced therapy. 116 (26%) visited a physician for Covid symptoms. Univariate analysis showed that the use of steroids, NSAIDs and increased disease activity were associated with having less severe infection but these associations were not significant in the multivariate analysis (Table 1). There were no significant impacts of RA vs axSpA, age, gender, treatment, disease activity, or smoking.

Table 1.

Multivariate Level Mixed-Effect Logistic Regression Model: IMPACT of RA and axSpA Disease Characteristics on COVID Infection Severity Defined as Patients with COVID Symptoms Requiring Visit to Doctor, Emergency Room and/or Hospital Admission.

VariableCoefficient (S.E)Odds Ratio (95 % Confidence Interval)P-valueGenderMale0.17 (0.34)1.18 (0.61 – 2.31)0.6193FemaleReferenceAge-0.01 (0.01)0.99 (0.97 – 1.01)0.2543Rheumatic Disease TypeRA0.18 (0.40)1.20 (0.58 – 2.48)0.6213SpAReferenceSteroidsYes-0.40 (0.56)0.67 (0.23 – 2.01)0.4757NoReferenceNSAIDSYes-0.20 (0.26)0.82 (0.49 – 1.37)0.4508NoReferenceCurrent Disease Activity-0.04 (0.06)0.96 (0.85 – 1.09)0.5275HAQ-0.03 (0.29)0.97 (0.55 – 1.70)0.9041Nicotine productsYes-0.67 (0.37)0.51 (0.25 – 1.06)0.0714NoReferenceCannabis productsYes-0.45 (0.31)0.64 (0.35 – 1.18)0.1510NoReferenceDMARDsYes0.26 (0.30)1.30 (0.72 – 2.35)0.3860NoReferenceBiologic DMARDYes-0.46 (0.43)0.63 (0.27 – 1.46)0.2813NoReference

Conclusion

Possible disease related risk factors for increased COVID-19 severity in RA and axSpA patients preceding the onset of the Omicron variant including use of steroids or DMARDs were not associated with severe infection. These findings are consistent with other international studies whereby other non-rheumatic disease comorbidities played a greater role in infection severity.

Acknowledgements

Epidemiology Coordinating and Research (EPICORE) Centre provided support for the REDCAP survey and biostatistical anayses.

Disclosure of Interests

Stephanie Keeling Speakers bureau: Abbvie, GSK, Pfizer, UCB, Consultant of: Abbvie, GSK, Pfizer, Sandoz, UCB, Eli-Lilly, Galapagos, Novartis, Grant/research support from: Abbvie, UCB, Sandoz, Pfizer, Merck, Bo Pan: None declared, Edna Hutchings Shareholder of: BMS, Stephanie Wichuk: None declared, Mohammed Osman Speakers bureau: Boehringer Ingelheim, Takeda Pharmaceuticals, Grant/research support from: Yes, Boehringer Ingelheim and CSL-Behring, Ameeta Singh: None declared, Ashlesha Sonpar Speakers bureau: Novartis, Ilan Swartz: None declared, Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB

, Consultant of: Abbvie, Boehringer Ingelheim, Celegene, Eli-Lilly, Galapagos, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer, UCB

HER3 overexpression and hypomethylation in colorectal adenocarcinoma

INTRODUCTION

Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cancer in Malaysia. Despite advanced therapies, many cases of recurrence and resistance have been reported. Aberrant DNA methylation of HER3 has been implicated in carcinogenesis of CRC mainly through the regulation of gene expression. Hence, the objective of this study was to determine the status of HER3 DNA methylation and its effects on gene expression in CRC.

MATERIALS AND METHODS

Fifty-nine of archival formalin-fixed, paraffin-embedded CRC cases with the adjacent normal colon tissues were retrieved. Manual micro-dissection was performed prior to RNA and DNA extraction. HER3 gene expression and DNA methylation status was evaluated by qPCR and methylation-specific PCR (MSP) techniques respectively.

RESULTS

Upregulation of HER3 mRNA was found in CRC tissue compared to its adjacent normal colon tissue (8.04-fold). Of 59 CRC samples, 8.5% were methylated and 91.5% were unmethylated (hypomethylation). In the adjacent normal colon tissues, methylated and unmethylated tissue were observed in 6.8%and 93.2% respectively. DNA methylation of HER3 showed a significant association with tumour differentiation and tumour location.

CONCLUSION

This study showed upregulation and hypomethylation of the HER3 gene in CRC cases. Epigenetic alterations were also found in the adjacent normal colon tissues. Thus, upregulation and hypomethylation of HER3 may play a key role in carcinogenesis of CRC. Hypomethylation of CpG islands might be associated with early steps during carcinogenesis. The findings of this biomarker serve a powerful approach to improve the current diagnostic and therapeutic measures.

Plant Lectins as Potent Anti-coronaviruses, Anti-inflammatory, Antinociceptive and Antiulcer Agents

Lectins are defined as carbohydrate-binding proteins/glycoproteins of none immune origin, they are ubiquitous in nature, exist from bacteria to human cells. And due to their carbohydrate-binding recognition capacity, they have been a useful biological tool for the purification of glycoproteins and their subsequent characterization. Some plant lectins have also been revealed to own antinociceptive, antiulcer, and anti-inflammatory properties, where these features, in many instances, depending on the lectin carbohydrate-binding site. Coronavirus disease of 2019 (COVID-19) is a respiratory disease that struck the entire world leaving millions of people dead and more infected. Although COVID-19 vaccines have been made available, and quite a large number of world populations have already been immunized, the viral infection rates remained in acceleration, which continues to provoke major concern about the vaccines' efficacy. The belief in the ineffectiveness of the vaccine has been attributed in part to the recurrent mutations that occur in the epitope determinant fragments of the virus. Coronavirus envelope surface is extensively glycosylated being covered by more than sixty N-linked oligomannose, composite, and hybrid glycans with a core of Man3GlcNAc2Asn. In addition some O–linked glycans are also detected. Of these glyco-chains, many have also been exposed to several mutations, and a few remained conserved. Therefore, numerous plant lectins with a specificity directed towards these viral envelope sugars have been found to interact preferentially with them and are suggested to be scrutinized as a possible future tool to combat coronaviruses including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through blocking the viral attachment to the host cells. In this review, we will discuss the possible applications of plant lectins as anti-coronaviruses including SARS-CoV-2, antinociceptive, anti-inflammatory, and antiulcer agents with the proposed mechanism of their actions.

Spilled gallstone mimicking right middle lobe pulmonary nodule

Laparoscopic cholecystectomy is the standard of care for the surgical management of symptomatic gallstone disease. Gallstone spillage at laparoscopic cholecystectomy is common, with a reported incidence of 0.2-20%. In the majority of cases there are no complications associated with this spillage, but a series of studies report patients with complications of free peritoneal gallstones. We present a case of migration of gallstone to the lung resulting in an inflammatory mass in the right middle lobe as a complication of spillage at laparoscopic cholecystectomy.

Use of interactive messaging to reduce pre-diagnosis loss to follow-up for TB care

OBJECTIVE: To investigate the uptake and usage of a WhatsApp-based interactive communication strategy to avert pre-diagnosis loss to follow-up (LTFU) from TB care in a high-incidence setting.METHODS: We enrolled adults (≥18 years) who underwent routine sputum TB testing in two primary healthcare clinics in Khayelitsha, Cape Town, South Africa. The intervention consisted of structured WhatsApp-based reminders (prompts) sent prior to a routine clinic appointment scheduled 2-3 days after the diagnostic visit. Pre-diagnosis LTFU was defined as failure to return for the scheduled appointment and within 10 days.RESULTS: We approached 332 adults with presumptive TB, of whom 103 (31%) were successfully enrolled; 213 (64%) did not own a WhatsApp-compatible phone. Of 103 participants, 74 (72%) actively responded to WhatsApp prompts; 69 (67%) opted to include a close contact in group communication to co-receive reminders. Pre-diagnosis LTFU was low overall (n = 7, 6.8%) and was not associated with failure to respond to WhatsApp prompts.CONCLUSION: In this high-incidence setting, enrolment in a WhatsApp-based communication intervention among adults with presumptive TB was low, mainly due to low availability of WhatsApp-compatible phones. Among participants, we observed high message response rates and low LTFU, suggesting potential for interactive messaging services to support pre-diagnosis TB care.

Breast implant illness: scientific evidence of its existence

INTRODUCTION

More than one million breast augmentation procedures using silicone breast implants (SBI) have been performed worldwide. Adverse events of SBI include local complications such as pain, swelling, redness, infections, capsular contracture, implant rupture and gel-bleed. Furthermore, patients experience systemic symptoms such as chronic fatigue, arthralgias, myalgias, pyrexia, sicca, and cognitive dysfunction. These symptoms received different names such as autoimmune/inflammatory syndrome induced by adjuvants (ASIA) due to silicone incompatibility syndrome and breast implant illness (BII). Because of chronic immune activation, BII/ASIA, allergies, autoimmune diseases, immune deficiencies and finally lymphomas may develop in SBI patients.

AREAS COVERED

Causality for SBI-related BII/ASIA is reviewed. To address the role of silicone implants in promoting causality, we utilized the Bradford-Hill criteria, with results highlighted in this article.

EXPERT OPINION

We conclude that there is a causal association between SBIs and BII/ASIA. Using data derived from patients with BII/ASIA and from other medically implanted devices, there appears to be clear pathogenic relationship between SBI and BII/ASIA. Breast implants cause characteristic systemic reactions in certain women, leading to symptoms of sufficient severity to warrant device removal. The morbidity suffered is variable. SBI removal resolves the symptoms in most women and removal is the most effective treatment.

Spilled gallstone mimicking right middle lobe pulmonary nodule

Laparoscopic cholecystectomy is the standard of care for the surgical management of symptomatic gallstone disease. Gallstone spillage at laparoscopic cholecystectomy is common, with a reported incidence of 0.2-20%. In the majority of cases there are no complications associated with this spillage, but a series of studies report patients with complications of free peritoneal gallstones. We present a case of migration of gallstone to the lung resulting in an inflammatory mass in the right middle lobe as a complication of spillage at laparoscopic cholecystectomy.

Trends in cardiovascular mortality of cancer patients in the US over two decades 1999–2019

Background

Cancer is the second most common cause of death globally after cardiovascular (CV) disease. The present study sought to compare the trends in CV mortality between patients with and without cancer in the US over two decades (1999 to 2019), stratified by sociodemographic factors such as age, sex and geographical location.

Methods

In this retrospective study, the number of deaths, crude- and age-adjusted mortality rates between January 1, 1999, and December 31, 2019, were obtained from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) data set

Results

We examined a total of 53,422,612 deaths between 1999 and 2019; of which 33.4% were defined as CV mortality and 25.6% had malignancy. During this period, among patients with cancer, the age-adjusted mortality rate dropped by 52%. (Vs, 38% in patients with no malignancy). CV mortality was highest in patients with gastrointestinal and prostate malignancy where CV mortality accounts together for over 40% of all CV mortality in patients with cancer in 1999 and 33.6% in 2019. The age-adjusted CV mortality rate (per 100,000 people) of patients with GI and prostate cancer nearly halved over twenty years from 2.7 to 1.0 and 2.5 to 1.0.

The CV age-adjusted mortality rate dropped more significantly among patients with gastrointestinal, breast, and prostate malignancy than among patients with hematological malignancy (59–63% vs. 41%. We observed that crude CV mortality rates amongst patients with cancer declined over the study period in all age groups but was more prominent among patients over 65 years old than those aged 55–64 and under 55 (51%-55% Vs. 41%, 25%, respectively).Similar reductions in mortality in men and women (54% and 53% reduction) were observed

During the study period the decline in cardiovascular mortality was more prominent in metro areas which led to lower age adjusted CV mortality in Metro compared to non-Metro areas (5.7–6.3 vs 7.2). The decline in age adjusted CV mortality in patients with cancer differed significantly in different states

Conclusions

In our temporal analysis we show a 50% decline in CV mortality in the US over two decades in both male and female patients with cancer, that has exceeded the reduction in CV mortality seen in the non-cancer population. The greatest reductions in CV mortality were observed in patients with GI, breast and prostate malignancies, those residing in metro areas and in patients aged 65 and over.

Funding Acknowledgement

Type of funding sources: None. CV death among cancer patients

Distinguishing coronavirus disease 2019 from influenza in children remains challenging

Clinical descriptions about influenza-like illness in children seem non-specific during the co-circulation of SARS-CoV-2 and influenza. This paper aimed to summarize recent studies comparing clinical features and outcome, laboratory and radiological findings of COVID-19 patients with influenza patients in the paediatric population.

Persistent chronic respiratory symptoms despite TB cure is poorly correlated with lung function

BACKGROUND: Persistent respiratory symptoms and lung function deficits are common after patients with TB. We aimed to define the burden of post-TB lung disease (PTLD) and assess associations between symptoms and impairment in two high TB incidence communities.METHODS: This was a cross-sectional survey of adults in Cape Town, South Africa who completed TB treatment 1-5 years previously. Questionnaires, spirometry and 6-minute walking distance (6MWD) were used to assess relationships between outcome measures and associated factors.RESULTS: Of the 145 participants recruited (mean age: 42 years, range: 18-75; 55 [38%] women), 55 (38%) had airflow obstruction and 84 (58%) had low forced vital capacity (FVC); the mean 6MWD was 463 m (range: 240-723). Respiratory symptoms were common: chronic cough (n = 27, 19%), wheeze (n = 61, 42%) and dyspnoea (modified MRC dyspnoea score 3 or 4: n = 36, 25%). There was poor correlation between FVC or obstruction and 6MWD. Only low body mass index showed consistent association with outcomes on multivariable analyses. Only 19 (13%) participants had a diagnosis of respiratory disease, and 16 (11%) currently received inhalers.CONCLUSION: There was substantial burden of symptoms and physiological impairment in this "cured" population, but poor correlation between objective outcome measures, highlighting deficits in our understanding of PTLD.

High sensitivity C-reactive protein (hsCRP): Its relationship with metabolic syndrome and Framingham Risk Score

INTRODUCTION

Cardiovascular disease (CVD) remains the leading cause of death in Malaysia. Identification of asymptomatic at-risk individuals is often achieved by means of a risk prediction algorithm. Traditional CVD risk factors and their associated algorithms are, however, limited by residual CVD risk. High sensitivity C-reactive protein (hsCRP) has emerged as a novel CVD risk factor. This study aimed to evaluate hsCRP as an adjunct CVD risk marker among the adult Malaysian population by determining its correlation with the Framingham Risk Score (FRS). Comparison analyses were done according to sociodemographic, clinical and laboratory factors and between subjects with and without Metabolic Syndrome (MetS).

METHOD

This cross-sectional study involved eighty-three (n=83) adults attending a health screening program at Universiti Putra Malaysia (UPM). Demographic data, anthropometric measurements and blood samples for fasting blood glucose (FBG), fasting lipid profile (FSL), glycated haemoglobin (HbA1c) and hsCRP were taken. Respondents were grouped according to FRS and the Joint Interim Statement into 10-year CVD risk categories (low, intermediate and high) and MetS, respectively.

RESULTS

hsCRP was significantly increased in patients with high body mass index (BMI) (p=0.001), at-risk waist circumference (WC) (p=0.001) and MetS (p=0.009). Spearman's correlation coefficient showed a significant positive correlation between hsCRP level and total FRS score (r=0.26, p<0.05) and HDL-C score (r=0.22, p<0.05).

CONCLUSION

The significant difference of hsCRP levels across obesity levels and MetS with its modest correlation with FRS scores supported the adjunctive role of hsCRP in CVD risk prediction, most likely capturing the inflammatory pathological aspect and thus partly accounting for the residual CVD risk.

Comparison between intracoronary versus intravenous bolus injection of tirofiban on infarct size during primary PCI in patients with acute anterior ST segment elevation myocardial infarction

Background

The latest guidelines considered glycoprotein IIb/IIIa inhibitors (GPI) as a bailout strategy in selected situations in patients presented with acute ST segment elevation myocardial infarction (STEMI) however, did not recommend route of administration over another and did not correlate it to infarct size. Infarct size correlates generally with prognosis following acute myocardial infarction and Reduction in infarct size can boost clinical outcomes and decrease rate of heart failure hospitalization.

Purpose

To evaluate intracoronary vs intravenous use of tirofiban on reduction of infarct size in STEMI treated with primary PCI.

Methods

Between February, 2018, and October, 2019, one hundred patients presented within 6 hours of anterior STEMI undergoing primary PCI after exclusion of (rescue PCI, TIMI flow less than II post PCI, Previous MI, Stent thrombosis, Previous CABG, Significant left main occlusion, Pulmonary edema and Cardiogenic shock).

Group (A): 50 patients who were treated by intracoronary bolus infusion of tirofiban followed by IV maintenance dose infusion of tirofiban.

Group (B): 50 patients who were treated by intravenous bolus infusion of tirofiban followed by IV maintenance dose infusion of tirofiban.

Primary endpoint: Infarct size was assessed 1 month after randomization by SPECT.

Secondary endpoint: Major adverse cardiovascular events (MACE) during hospital stay (cardiac death, MI, stroke or target vessel revascularization), heart failure and bleeding.

Results

Patients randomized to intracoronary tirofiban compared with intravenous tirofiban had a significant decrease in the primary end point of infarct size (mean [SD], 14.46% [7.79%] vs 18.06% [7.83%]; P=0.02). Also associated with lower incidence of heart failure (number [%], 8 [16%] vs 17 [34%]; P=0.037). There were no significant differences in any of the MACE or bleeding between the randomized groups at 30 days.

Conclusions

In patients with anterior STEMI presenting early after symptom onset, intracoronary tirofiban administration when compared to intravenous route during primary PCI resulted in infarction size reduction and lower heart failure incidence mainly driven by enhanced left ventricular systolic function however no distinction between two strategies on MACE or bleeding risk.

Results

Funding Acknowledgement

Type of funding source: None

Attitudes towards risk-reducing early salpingectomy with delayed oophorectomy for ovarian cancer prevention: a cohort study

OBJECTIVE

To determine risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) acceptability and effect of surgical prevention on menopausal sequelae/satisfaction/regret in women at increased ovarian cancer (OC) risk.

DESIGN

Multicentre, cohort, questionnaire study (IRSCTN:12310993).

SETTING

United Kingdom (UK).

POPULATION

UK women without OC ≥18 years, at increased OC risk, with/without previous RRSO, ascertained through specialist familial cancer/genetic clinics and BRCA support groups.

METHODS

Participants completed a 39-item questionnaire. Baseline characteristics were described using descriptive statistics. Logistic/linear regression models analysed the impact of variables on RRESDO acceptability and health outcomes.

MAIN OUTCOMES

RRESDO acceptability, menopausal sequelae, satisfaction/regret.

RESULTS

In all, 346 of 683 participants underwent risk-reducing salpingo-oophorectomy (RRSO). Of premenopausal women who had not undergone RRSO, 69.1% (181/262) found it acceptable to participate in a research study offering RRESDO. Premenopausal women concerned about sexual dysfunction were more likely to find RRESDO acceptable (odds ratio [OR] = 2.9, 95% CI 1.2-7.7, P = 0.025). Women experiencing sexual dysfunction after premenopausal RRSO were more likely to find RRESDO acceptable in retrospect (OR = 5.3, 95% CI 1.2-27.5, P < 0.031). In all, 88.8% (143/161) premenopausal and 95.2% (80/84) postmenopausal women who underwent RRSO, respectively, were satisfied with their decision, whereas 9.4% (15/160) premenopausal and 1.2% (1/81) postmenopausal women who underwent RRSO regretted their decision. HRT uptake in premenopausal individuals without breast cancer (BC) was 74.1% (80/108). HRT use did not significantly affect satisfaction/regret levels but did reduce symptoms of vaginal dryness (OR = 0.4, 95% CI 0.2-0.9, P = 0.025).

CONCLUSION

Data show high RRESDO acceptability, particularly in women concerned about sexual dysfunction. Although RRSO satisfaction remains high, regret rates are much higher for premenopausal women than for postmenopausal women. HRT use following premenopausal RRSO does not increase satisfaction but does reduce vaginal dryness.

TWEETABLE ABSTRACT

RRESDO has high acceptability among premenopausal women at increased ovarian cancer risk, particularly those concerned about sexual dysfunction.

A pilot study on pattern B lipoprotein profile in Malaysia

INTRODUCTION

Dyslipidaemia is a recognised conventional risk factor for cardiovascular disease (CVD). However, even when traditional lipid parameters are normal, CVD risk can exist. Small dense lowdensity lipoprotein cholesterol (sdLDL) has appeared as a significant risk marker for CVD. This study aimed to determine the prevalence and associated factors of atherogenic lipoprotein Pattern B in the Malaysian population.

MATERIALS AND METHODS

This cross-sectional study included 150 subjects aged 30 years and above who attended a health screening in a Malaysian tertiary institution. Sociodemographics, clinical characteristics and laboratory parameters (lipids, glucose, and sdLDL) were obtained. Lipoprotein subfraction was analysed using the polyacrylamide gel electrophoresis method.

RESULTS

Malays and females made up the majority of subjects and the median age was 37 years. Normolipidaemic Pattern B was significantly higher in women (p=0.008). Significant independent predictors of Pattern B were gender (p=0.02), race (p=0.01), body mass index (BMI) [p=0.02] and lipid status (p=0.01). Triglyceride was the only independent predictor of sdLDL (p=0.001).

CONCLUSION

The prevalence of Pattern B of 33% in this study was comparatively high, of which 6.7% were normolipidaemic. Chinese males with dyslipidaemia and increased BMI independently predicted Pattern B. Differences in triglyceride levels alone among these ethnic groups do not fully explain the differences in the prevalence of Pattern B although it was the only lipid parameter to independently predict sdLDL. Individuals with atherogenic normolipidaemia are at greater risk for a CVD event as they are not included in the protective measures of primary CVD prevention.

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.

Prevalence and genetic diversity of Campylobacter spp. in the production chain of broiler chickens in Lebanon and its association with the intestinal protozoan Blastocystis sp

Campylobacter jejuni is recognized as the most common foodborne pathogen associated with human gastroenteritis worldwide. Broilers are frequently infected by the bacteria and are considered the main source of exposure to humans. However, despite its public health impact, no recent data are currently available in Lebanon about Campylobacter spp. in poultry and human population. Therefore, this study aimed to determine the prevalence and genetic diversity of Campylobacter spp. in 227 ceca and on 227 carcasses of broiler chickens collected in Lebanese slaughterhouses. Overall, the prevalence of Campylobacter was shown to reach 67.0% in ceca and 17.2% on carcasses of Lebanese poultry. The only 2 Campylobacter species identified were C. jejuni and C. coli, with a slightly higher prevalence of C. coli in ceca and of C. jejuni on carcasses. A high level of genetic diversity was reported among the 51 C. jejuni isolates selected, since 25 distinct profiles were identified according to the comparative genomic fingerprinting typing method based on a subset of 40 genes using the 90% similarity threshold. Predominant clusters observed in Lebanese poultry isolates were also frequently found among French human clinical cases, highlighting that broiler chickens represent a potential reservoir for human campylobacteriosis. In addition, a significantly higher prevalence of Campylobacter spp. was found in slaughterhouse workers than in a cohort of hospitalized patients with no contact with poultry, confirming that contaminated broiler chickens in slaughterhouse appeared to be a non-negligible source of Campylobacter spp. transmission. Interestingly, a significant association between Campylobacter spp. and Blastocystis sp. has been observed. This correlation suggested that the presence of Campylobacter spp. would be favored when Blastocystis sp. is present and, similarly, the absence of one would favor the absence of the other. This is the first large-scale investigation focusing on the impact of Campylobacter spp. in broiler chickens in Lebanon and confirmed the need to implement prevention and control measures in the poultry production to reduce the burden of campylobacteriosis in the human population.

Evaluation of Transient Response of Different Earthing Configurations due to Lightning Impulses

Earthing system is very important in order to protect the electrical equipment as well as the human’s safety against over voltages. The main function of the earthling system is to remove unwanted excessive electrical currents caused by unusual conditions such as fault and lightning or switching over voltages by providing a low resistance path to the earth. Researchers had studied the behaviour of the earthling system to improve its performance for the past few years. There are few factors that influence the performance of the earthling system such as soil resistivity and soil ionization which need to be focused in order to improve the earthling. Thus, this paper evaluates on the factors that affect the behaviour of the earthling system based on simulation works using MATLAB and Safe Grid Software. Some analytical calculations are used to obtain the soil resistivity and resistance as well as the touch and step voltages. The simulation results were validated based on comparison with other studies on the factors that influence the earthling system performance. The results reveal that the variation of soil resistivity, the configuration of electrodes, current magnitude and frequency dependence can result in a change of transient response of the systems.