A chylothorax in a young woman: The difficulties of medical management

Lymphangioleiomyomatosis is a rare pulmonary disease affecting women of childbearing age. Whilst chylothorax is a well-recognized complication of the condition, management strategies aren't well-defined, have low success rates and are often only available at tertiary or specialist centres. We describe a case of a young woman referred to pleural clinic with a chylous effusion found to be secondary to lymphangioleiomyomatosis. Initial medical management was unsuccessful and recurrent drainages caused significant complications. Remission was ultimately achieved with a combination of mTOR inhibitors and interventional radiology techniques.

Twists and turns: A case report of cecal volvulus

We present a case of a 22-year-old male presenting in the emergency room with colicky abdominal pain, vomiting, and abdominal distension for which an early computed tomography scan was done and diagnosed as cecal volvulus. Following diagnosis case was managed promptly by laparotomy with right hemicolectomy and primary anastomosis.

Landscape of cancer biomarker testing in England following genomic services reconfiguration: insights from a nationwide pathologist survey

AIMS

Cancer diagnostics have been evolving rapidly. In England, the new National Health Service Genomic Medicine Service (GMS) provides centralised access to genomic testing via seven regional Genomic Laboratory Hubs. The PATHways survey aimed to capture pathologists' experience with current diagnostic pathways and opportunities for optimisation to ensure equitable and timely access to biomarker testing.

METHODS

A nationwide survey was conducted with consultant pathologists from regional laboratories, via direct interviews based on a structured questionnaire. Descriptive analysis of responses was undertaken using quantitative and qualitative methods.

RESULTS

Fifteen regional centres completed the survey covering a median population size of 2.5 (1.9-3.6) million (each for n=12). The median estimated turnaround time (calendar days) for standard molecular markers in melanoma, breast and lung cancers ranged from 2 to 3 days by immunohistochemistry (excluding NTRKfus in breast and lung cancers, and PD-L1 in melanoma) and 6-15 days by real-time-PCR (excluding KIT for melanoma), to 17.5-24.5 days by next-generation sequencing (excluding PIK3CA for breast cancer). Tests were mainly initiated by pathologists and oncologists. All respondents discussed the results at multidisciplinary team (MDT) meetings. The GMS roll-out was perceived to have high impact on services by 53% of respondents, citing logistical and technical issues. Enhanced education on new pathways, tissue requirements, report interpretation, providing patient information and best practice sharing was suggested for pathologists and other MDT members.

CONCLUSION

Our survey highlighted the role of regional pathology within the evolving diagnostic landscape in England. Notable recommendations included improved communication and education, active stakeholder engagement, and tackling informatics barriers.

Health literacy correlates with abbreviated full-scale IQ in adolescent and young adults with sickle cell disease

INTRODUCTION

Sickle cell disease (SCD) is a chronic condition with progressive neurocognitive deficits. Health literacy (HL) is essential during adolescence and young adulthood, as the transition to adult care requires healthcare decisions. HL is known to be low in SCD; however, relation between general cognitive ability and HL has not been investigated.

METHODS

This cross-sectional study included adolescent and yound adults (AYAs) with SCD from two institutions. Logistic regression measured the association between HL, measured by the Newest Vital Sign tool, and general cognitive ability, measured with abbreviated full-scale intelligence quotient (FSIQ) on the Wechsler Abbreviated Scale of Intelligence.

RESULTS

Our cohort contained 93 participants at two sites: 47 (51%) at Memphis, TN and 46 (49%) at St. Louis, MO, ranging from ages 15-45 years (mean = 21 years) and with a majority (70%) possessing a high school education or greater. Only 40/93 participants (43%) had adequate HL. Lower abbreviated FSIQ (p < .0001) and younger age at assessment (p = .0003) were associated with inadequate HL. For every standard score point increase in abbreviated FSIQ, the odds of having adequate HL compared to limited or possibly limited HL increase by 1.142 (95% confidence interval [CI]: 1.019-1.322) and 1.116 (95% CI: 1.045-1.209), respectively, after adjusting for age, institution, income, and educational attainment.

CONCLUSIONS

Understanding and addressing HL is imperative in improving self-management and health outcomes. Among AYA with SCD, low HL was prevalent and influenced by abbreviated FSIQ. Routine screening for neurocognitive deficits and HL should be performed to guide development of interventions to adapt to the HL of AYA with SCD.

Synthesizing biochar-based slow-releasing fertilizers using vermicompost leachate, cow dung, and plant weed biomass

Biochar-based slow-releasing fertilizers (BSRF) have been recommended widely for efficient soil nutrient management and crop production. In this study, we examined the N, P, and K release behaviour of pyrolysed (at 350 °C) cow dung (CDB), vermicompost (VCB), and Lantana (LB) weed and impregnated LB (LBVW) and CDB (CDBVW) with vermicompost leachate (1:1 v/v) under a lab-scale trial. BSRFs (CDB, VCB, LBVW and VCBVW) characterization (FT-IR, SEM-EDX and surface area analysis) was done and then tested for its suitability for soil-plant applications. Soil incubation study indicated the slow-releasing behaviour of BSRFs and overall P, N, and K release was found to be in the ranges of 72.3-84.5%, 73.1-79.0%, and 43.1-85.3%, respectively in different BSRFs setups. Furthermore, lab trials suggested the highest P (64.5%), N (75.3%), and K (86.8%) uptakes by the plant (Vigna radiata) in CDBVW and LBVW setups. Moreover, pot trails with moong bean (Vigna radiata) suggested a high growth in shoot and root and plant yield as well in seedlings cultivated with BSRFs. This study indicates that animal manure, vermicompost and terrestrial weed Lantana biochar can be used effectively to prepare BSRFs for efficient soil-plant nutrient management with multiple environmental benefits.

Gene Therapy and Hemophilia: Where Do We Go from Here?

Gene therapy for hemophilia using adeno-associated virus (AAV) derived vectors can reduce or eliminate patients' disease-related complications and improve their quality of life. Broad implementation globally will lead to societal gains and foster health equity. Several vector products each for factor IX (FIX) or factor VIII (FVIII) deficiency are in advanced clinical development. Safety data are reassuring. Efficacy data for up to 8 and 5 years, respectively, vary considerably among vector types and among individuals, but indicate significant reduction in bleeds and factor use. Products will soon be approved for marketing. This review highlights the relevant considerations for implementation of hemophilia gene therapy, specifically across a broad range of socioeconomic backgrounds globally, based on recent publications and our own experience. We address the current efficacy and safety data and relevant aspects of vector immunology. We then discuss pertinent implementation steps including pre-implementation and readiness assessments, considerations on cost, cost-effectiveness and payment models, approaches to education and informed consent, and the operational needs as well as the need for monitoring of health outcomes and implementation outcomes. To prevent a lag or complete lack of establishing access to this life-changing therapy option for all patients with hemophilia worldwide, adaptable pathways supported by collaborative and international efforts of all stakeholders are needed.

Understanding factors associated with continuation of use of injectable contraceptives in Karnataka and Maharashtra, India: a cross-sectional household study

The Government of India has worked to expand access to injectable contraceptives through the introduction of a three-monthly injectable contraceptive MPA under the ‘Antara’ program in 2017. However, the uptake of injectable contraceptives has remained low, and few studies have investigated the experiences of public health facility injectable clients in India. We examined factors associated with continuing, discontinuing, and switching methods among injectable users obtaining services from public health facilities in the Indian states of Karnataka and Maharashtra. The study team recruited respondents (N=1009) that had received their first injectable dose from in public sector facilities between February – May 2019 and conducted a follow-up visit at their residence in December 2020. We used multivariate logistic regression to study the association of the demographic characteristics, service quality, satisfaction with services, follow-up visits, and decision-making on injectable continuation and switching to other family planning methods. Injectable usage rates declined significantly, with 44% of clients receiving a second dose and only 16% receiving a third dose. Over half of women (54%) cited problems related to periods as the reason for discontinuing injectable use after the first dose. Respondents were more likely to continue their method at third dose if they were older (25-35 years) (OR:1.68, p<0.05) and had received a reminder for a follow-up dose (OR: 2.41, p Our results also highlight the importance of addressing side-effects experience by women, which may be better managed by community-based follow-up visits and high-quality counselling services.

Testing Herzberg’s two factor theory on millennials

This study tests Herzberg’s two-factor theory of motivation on working millennials. The purpose of the study is to evaluate what the assumptions and the findings of the original study hold for millennials. With the increasing trend of amalgamation of work life and personal life, job satisfaction and general job happiness have never been more on an individual’s personal life. This impact is far-reaching, with strong indications of affecting the employees’ physical, mental, and social health. In such a scenario, organizations need to keep their employees motivated and satisfied. For studying Herzberg’s two-factor theory of motivation on working millennials, we have selected respondents with work experience of at least one year. We have not restricted the study to any particular industry; hence our sample is across all industries. The type of sampling used was convenient sampling. From the analysis, we have found that for the concerned sample, hygiene factors tower above the motivating factors in terms of job satisfaction for millennials. From the data collection and analysis, we proved that both motivators and hygiene factors affect job satisfaction, unlike what has been said by Herzberg. This study will contribute to the exciting literature on motivation.

Suitability of endobronchial ultrasound-guided transbronchial needle aspiration samples for programmed death ligand-1 testing in non-small cell lung cancer, the Bristol experience

Treatment for non-small cell lung cancer (NSCLC) is now personalised using molecular mutation testing. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy suitability for anaplastic lymphoma kinase (ALK) and epidermal growth factor receptor (EGFR) mutation testing is established. Less is currently known about EBUS-TBNA suitability for PD-L1 (programmed death ligand-1) testing. To assess EBUS-TBNA biopsy adequacy for ALK, EGFR and PD-L1 testing, we conducted a prospective study of 279 consecutive NSCLC patients referred to a tertiary EBUS-TBNA centre in South West England. One hundred eight-four (62.6%) patients were found to have adenocarcinoma, 83 (28.2%) had squamous cell carcinoma, and 27 (9.2%) were identified as NSCLC-not otherwise specified. EGFR testing was successful in 166 of 168 patients (98.8%), ALK testing in all 115 and PD-L1 testing in 43 of 49 patients (88.2%). Previous EGFR and ALK testing did not affect biopsy PD-L1 testing success. PD-L1 testing failures occurred in three of five (60.0%) of 22G needle biopsies, one of five (20.0%) of 21G needle biopsies and two of 39 (5.1%) of 19G needle biopsies, P = .016. EBUS-TBNA biopsies are mostly suitable for PD-L1 testing. Larger needle size may improve PD-L1 (but not EGFR and ALK) testing success but requires further study in a controlled trial.

Understanding factors associated with continuation of intrauterine device use in Gujarat and Rajasthan, India: a cross-sectional household study

The Government of India has promoted the expansion of access to and uptake of intrauterine devices (IUDs), during both the interval (IIUD) and postpartum (PPIUD) periods, as part of its Family Planning 2020 initiative. This study, conducted by EngenderHealth as part of the Expanding Access to IUD Services in India project, examines IIUD and PPIUD continuation rates over time and investigates factors associated with IUD continuation. We recruited respondents (N = 5024) through a repeated cross-sectional household study between February and December 2019. We identified respondents using IUD client data from public health facility registers in 20 districts of Gujarat and Rajasthan. We compared continuation rates for IIUD and PPIUD adopters and used regression analyses to measure the association between continuation and demographic, quality of care, and counselling variables. IIUD continuation rates decreased from 85.6% to 78.3% and PPIUD rates decreased from 78.5% to 70.7% between month 3 and month 12. Clients experiencing side effects or other problems were 15 times more likely to discontinue IUD use than clients who did not. Clients who received IUD counselling prior to insertion were more likely to continue than those who did not. IUD continuation increased significantly in cases where both partners jointly selected the method compared to situations where women decided alone. Several sociodemographic factors were associated with continuation. Our study demonstrates the value and benefits of programmes offering IUD services emphasising quality counselling and client-centred care to increase access, uptake, and continuation.

377 Global Recruitment for The RESECT Study (Transurethral Resection and Single-Instillation Intravesical Chemotherapy Evaluation in Bladder Cancer Treatment): An International Observational Cohort Study Aiming to Improve the Quality of Surgery for Non-Muscle Invasive Bladder Cancer

Introduction

Non-muscle invasive bladder cancer (NMIBC) can be curatively treated with ‘good quality’ transurethral resection of the bladder tumour (TURBT). However, despite evidence-based international guidelines, there is anecdotal evidence that practice varies widely, and this may affect oncological outcomes. Launching in 2020, RESECT aims to measure and report variation in TURBT quality globally, and determine if outcome reporting improves outcomes.

Method

RESECT was advertised internationally through social media, mailing lists, websites, and in person. Collaborators at each registered site will collect data about current practice and the experience of local TURBT surgeons. The primary outcome is the rate of achievement of key TURBT quality indicators.

Results

As of August 27, 508 collaborators have registered to participate. Collaborators represent 321 centres from 54 countries, with the highest number from the United Kingdom (54.5%), Spain (5.9%), and Argentina (3.7%). 51.2% are trainees, 29.9% consultants, and 17.5% medical students. Based on current registrations, patient recruitment will far exceed initial projections and considerably improve statistical power.

Conclusions

RESECT has attracted a large number of collaborators globally and from all training levels. Therefore, the RESECT study has the potential to improve the quality of TURBT surgery across the world.

P57 Global recruitment for the RESECT study (transurethral REsection and Single-instillation intravesical chemotherapy Evaluation in bladder Cancer Treatment) - an international observational cohort study aiming to improve the quality of surgery for non-muscle invasive bladder cancer

Introduction

Non-muscle invasive bladder cancer (NMIBC) is one of the most expensive cancers to treat, driven by high recurrence rates and disease progression. Mortality rates in the UK for all bladder cancers have remained relatively stable over the past decade. NMIBC can be curatively treated with transurethral resection of the bladder tumour (TURBT). Despite international evidence-based guidelines on the TURBT procedure and postoperative single instillation of mitomycin-C, TURBT quality continues to vary widely. RESECT will be the first ever international study of TURBT surgery evaluating the achievement of TURBT quality indicators globally and assessing if audit and performance feedback can improve surgical outcomes.

Methods

RESECT is a prospective, multicentre international observational cohort study. Collaborators at each site will collect data using REDCap about local TURBT practice, early recurrence rates and the experience of local TURBT surgeons. The primary outcome is the rate of achievement of key TURBT quality indicators. Advertisement for the study launched in 2020.

Results

As of October 1st, 2020, 524 collaborators have registered to participate. Collaborators represent 334 centres from 54 countries, with the highest number of centres from the United Kingdom (133), Spain (17), and India (16). 50.8% are trainees, 30.3% consultants, and 17.2% medical students. Based on current registrations, patient recruitment will far exceed initial projections and considerably improve statistical power.

Conclusion

RESECT has attracted many collaborators internationally from consultants and trainees at all stages. RESECT has significant potential to positively impact TURBT practice, health economics and ultimately improve outcomes for patients with NMIBC globally.

Using an educational intervention to assess and improve disease-specific knowledge and health literacy and numeracy in adolescents and young adults with haemophilia A and B

INTRODUCTION

Health literacy (HL) and health numeracy (HN) are underestimated barriers to treatment adherence in patients with haemophilia.

AIM

To test the ability of an educational intervention to improve knowledge, HL, HN, adherence and joint health in adolescent and young adult (AYA) males with haemophilia.

METHODS

We performed a longitudinal pilot study of 41 participants aged 12-21 years with haemophilia A or B during two clinic visits 6-12 months apart. The first visit included a comprehensive pre-intervention assessment: demographics, knowledge survey, Montreal Cognitive Assessment testing, 5-question tool to assess baseline HN, assessment of HL with the Rapid Estimate of Adolescent Literacy in Medicine tool, history of adherence and Haemophilia Joint Health Score (HJHS). An educational intervention using a visual aid explained basic pharmacokinetic (PK) concepts and personal teaching regarding haemophilia treatment regimens was used during this visit. The second visit included a post-intervention assessment: a reassessment of knowledge, HL, HN, HJHS, adherence to prescribed therapy and number of joint bleeds since the pre-intervention visit.

RESULTS

Forty-one males with haemophilia A or B were enrolled in the study. Of these, 33 completed the post-intervention assessment. Knowledge (p = .002) and HN (p = .05) were significantly improved post-intervention, although the HL, number of joint bleeds, adherence to prescribed therapy and HJHS were not.

CONCLUSIONS

Participants with low HL and/or HN may benefit from alternate methods of education such as audiovisual material. Education using audiovisual materials improved knowledge and HN in this study; however, this did not affect adherence to prescribed therapy.

The not so innocent bystander: an unusual cause of progressive breathlessness

This case report discusses a 76-year-old man who presented with symptomatic diffuse alveolar-septal and tracheobronchial amyloidosis with a low-grade monoclonal gammopathy. This patient had a combination of both symptomatic diffuse alveolar-septal interstitial disease and tracheobronchial amyloidosis, features that contradict the widely accepted presentations seen in this disease. First, tracheobronchial amyloidosis has been documented as localised disease without systemic involvement. Second, diffuse alveolar-septal interstitial disease is rarely identified with clinical symptoms unless there is significant cardiac involvement. This case highlights a number learning points in the diagnosis and management of systemic amyloid light chain amyloidosis;(1) There is a need for a high index of suspicion for diagnosis due to the potential subtlety of a plasma cell clone underlying AL amyloidosis, requiring serum-free light chain assays to increase sensitivity; (2) Haematological response and recovery of organ dysfunction are not a linear relationship due to the slower reversal of amyloid deposition; therefore, ongoing monitoring is required to identify those in need of repeated therapy. However, haematological response is a marker of overall survival and (3) Multisystem assessment and multidisciplinary collaboration are critical in optimising the care of patients with systemic AL amyloidosis.

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Methicillin-Resistant Staphylococcus Aureus Nasal Carriers among Laboratory Technical Staff of Tertiary Hospital in Eastern Nepal

Background Methicillin-resistant Staphylococcus aureus (MRSA) has been the leading cause of nosocomial and community infections worldwide. In particular, healthcare workers are at constant risk to develop MRSA carriage. There is a paucity of data regarding the epidemiology of MRSA in laboratory workers who are constantly in contact with these pathogens in almost every hospital. Objective This study was undertaken to identify the burden of MRSA nasal carriers and the antibiotic susceptibility pattern of the isolates among laboratory technical staff. Method Sterile nasal swabs were taken from 50 laboratory technical staff working in the Central and Emergency laboratory of BP Koirala Institute of Health Sciences (BPKIHS). Standard procedures were followed for isolation, identification and antibiotic sensitivity testing. Antibiotic susceptibility tests were performed using disc diffusion and growth on Oxacillin screen agar based on Clinical and Laboratory Standards Institute (CLSI) guidelines. Result Out of 50 isolates of Staphylococcus aureus, 44 (88%) were Methicillin-sensitive (MSSA) while six (12%) were Methicillin-resistant (MRSA). All 50 isolates of S. aureus were found resistant to Penicillin while all were found sensitive to Teicoplanin, Linezolid, and Levofloxacin. Only five (10%) were sensitive to Erythromycin while 49 (98%) were sensitive to both Amikacin and Gentamicin. However, none of the MRSA isolates were found sensitive to all tested antimicrobial agents. Conclusion This repertoire portrays the emergence of MRSA in laboratory workers which clearly indicates the necessity of complying with the sanitary and antibacterial guidelines and adhering to the rational use of antibiotics to prevent nosocomial infections.

Digital pathology is a practical alternative to on-site intraoperative frozen section diagnosis in thoracic surgery

AIMS

Telepathology uses digitised image transfer to allow off-site reporting of histopathology slides. This technology could facilitate the centralisation of pathology services, which may improve their quality and cost-effectiveness. The benefits may be most apparent in frozen section reporting, in which turnaround times (TATs) are vital. We moved from on-site to off-site telepathology reporting of thoracic surgery frozen section specimens in 2016. The aim of this study was to compare TATs before and after this service change.

METHODS AND RESULTS

All thoracic frozen section specimens analysed 4 months prior and 4 months following the service change were included. Demographics, operation, sample type, time taken from theatre, time received by laboratory, time reported by laboratory, TAT, frozen section diagnosis, final histopathological diagnosis and final TNM staging were recorded. The results were analysed with spss statistical software version 24. In total, there were 65 samples from 59 patients; 34 before the change and 31 after the change. Specimens included 51 lung, six lymph node, three bronchial, three chest wall and two pleural biopsies. Before the change, the median TAT was 25 min [interquartile range (IQR) 20-33 min]. No diagnoses were deferred. No diagnoses were changed on subsequent paraffin analysis. After the change, with the use of digital pathology, the median TAT was 27.5 min (IQR 21.75-38.5 min). This difference was not significant (P = 0.581). Diagnosis was deferred in one case (3.23%). There was one (3.23%) mid-case technical failure resulting in the sample having to be transported by courier, resulting in a TAT of 106 min. No diagnoses were changed on subsequent paraffin analysis.

CONCLUSIONS

There was no significant difference in reporting times between digital technology and an on-site service, although one sample was affected by a technical failure requiring physical transportation of the specimen for analysis. Our study was underpowered to detect differences in accuracy.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The effect of 19-gauge endobronchial ultrasound-guided transbronchial needle aspiration biopsies on characterisation of malignant and benign disease. The Bristol experience

EBUS-TBNA is a recent mediastinal staging and diagnostic technique. We have previously reported superior characterisation with 21G biopsies over 22G biopsies for benign and malignant mediastinal nodes. A new 19G needle now exists but there are limited studies. We hypothesised 19G biopsies would improve both benign and malignant characterisation due to larger samples. We retrospectively analysed sequential patients referred for EBUS-TBNA with unexplained mediastinal adenopathy performed with 19G, 21G and 22G needles respectively (100 patients each). Contingency table analysis was performed.  There were no complications. Sensitivity for malignancy was highest in the 19G group (95.7% versus 94.7% and 87.5%, respectively). The 19G group had higher mean lymph node size (19.4mm versus 18.6mm and 13.5mm, respectively), the highest proportion of lymphoma (9% versus 5% and 0%, respectively), the lowest proportion of NSCLC-NOS (2% versus 12% and 5%, respectively), the highest proportion of subcharacterised benign disease (89.6% versus 69.8% and 37.9%, respectively). This large single centre retrospective UK study suggests the 19G needle appears safe with the suggestion of better sensitivity for malignancy subcharacterisation of benign disease but this requires further study in adequately powered comparative controlled studies with univariate and multivariate analysis.

Pleuroparenchymal sarcoidosis - A recognised but rare manifestation of disease

Pleural involvement is rare in sarcoidosis. The presence of a large symptomatic effusion in a patient with sarcoidosis should therefore prompt further investigation for an alternate aetiology. Here we present a case of confirmed pleuro-parenchymal sarcoidosis. We discuss the important differential diagnoses and review the current literature.

Design and fabrication of a magnetically actuated non-invasive reusable drug delivery device

We present a novel approach of designing and fabricating a noninvasive drug delivery device which is capable of delivering the drug to the target site in a controlled manner. The device utilizes a reservoir which can be reused once the drug has completely diffused from it. This micro-reservoir based fabricated device has been successfully tested using niosomes of insulin drug filled in, which was then sealed with a magnetic membrane of 20 µm thick and was actuated by applying magnetic field. The deflection of the membrane on application of magnetic field results in the drug release from the reservoir. The discharge of the drug solution and the release rates was controlled by external magnetic field. The simulation of the membrane deflection using COMSOL software was carried out to optimize the concentration of the ferrous nanopowder in PDMS matrix. The characterization of the devices was implemented in-vitro on water and in-vivo on Wistar rats. It was also validated using high-performance liquid chromatography (HPLC) by observing characteristic peak of insulin. The blood samples showed the retention time of 2.79 min at λ_max of 280 nm which further authenticated the effectiveness of the proposed work. This noninvasive fabricated device provides reusability, precise control and can enable the patient or a physician to actively administrate the drug when required.

Optimising molecular diagnostic capacity for effective control of tuberculosis in high-burden settings

The World Health Organization's 2035 vision is to reduce tuberculosis (TB) associated mortality by 95%. While low-burden, well-equipped industrialised economies can expect to see this goal achieved, it is challenging in the low- and middle-income countries that bear the highest burden of TB. Inadequate diagnosis leads to inappropriate treatment and poor clinical outcomes. The roll-out of the Xpert(®) MTB/RIF assay has demonstrated that molecular diagnostics can produce rapid diagnosis and treatment initiation. Strong molecular services are still limited to regional or national centres. The delay in implementation is due partly to resources, and partly to the suggestion that such techniques are too challenging for widespread implementation. We have successfully implemented a molecular tool for rapid monitoring of patient treatment response to anti-tuberculosis treatment in three high TB burden countries in Africa. We discuss here the challenges facing TB diagnosis and treatment monitoring, and draw from our experience in establishing molecular treatment monitoring platforms to provide practical insights into successful optimisation of molecular diagnostic capacity in resource-constrained, high TB burden settings. We recommend a holistic health system-wide approach for molecular diagnostic capacity development, addressing human resource training, institutional capacity development, streamlined procurement systems, and engagement with the public, policy makers and implementers of TB control programmes.

Two neutrophilic dermatoses captured simultaneously on histology

A number of neutrophilic dermatoses are associated with malignancies and their treatment. These rarely occur together in the same patient.

A Caucasian 72-year-old male was treated for acute myeloid leukemia (AML) with chemotherapy including daunorubicin and cytarabine. Within 48 hours of commencing treatment, he developed pyrexia and, two days later, disseminated non-tender pink plaques on the limbs and trunk. A skin biopsy showed a dermal interstitial infiltrate of lymphocytes, histiocytoid cells and predominantly neutrophils. This extended into the subcutis, where a neutrophilic lobular panniculitis was seen. These findings are consistent with Sweet’s syndrome. In addition, a neutrophilic and lymphocytic infiltrate was also present around eccrine coils and lower ducts. The eccrine epithelium showed squamous metaplasia with dyskeratosis and sloughing into the lumen. These latter findings are consistent with neutrophilic eccrine hidradenitis (NEH).

These two histologically distinct entities form part of the neutrophilic dermatoses that have been described in oncology patients with reports of concurrent or sequential occurrence of various neutrophilic dermatoses in the same patient. Ours, however, is only the second reported case of simultaneously captured Sweet’s and NEH in the setting of AML. The most likely explanation is that of an epiphenomenon, whereby the neutrophilic infiltrate extended around the sweat glands in the context of the neutrophilic dermatosis.

What is the role of a specialist regional mesothelioma multidisciplinary team meeting? A service evaluation of one tertiary referral centre in the UK

BACKGROUND

Multidisciplinary team meetings are standard care for cancer in the UK and Europe. Professional bodies recommend that mesothelioma cases should be discussed at specialist multidisciplinary team meetings. However, no evidence exists exploring the role of the specialist mesothelioma multidisciplinary team meeting.

OBJECTIVES

To evaluate the clinical activity of 1 specialist mesothelioma multidisciplinary team meeting and to determine how often a definitive diagnosis was made, whether the core requirements of the meeting were met and whether there was any associated benefit or detriment.

DESIGN AND SETTING

A service evaluation using routinely collected data from 1 specialist mesothelioma multidisciplinary team meeting in a tertiary referral hospital in the South-West of England.

PARTICIPANTS

All cases discussed between 1/1/2014 and 31/12/2015.

OUTCOME MEASURES

The primary outcome measure was whether a definitive diagnosis was made. Secondary outcomes included whether treatment advice was offered, information on clinical trials provided or further investigations suggested. Additional benefits of the multidisciplinary team meeting and time taken from referral to outcome were also collected.

RESULTS

A definitive diagnosis was reached in 171 of 210 cases discussed (81%). Mesothelioma was diagnosed in 153/210 (73%). Treatment advice was provided for 127 of 171 diagnostic cases (74%) and further investigations suggested for all 35 non-diagnostic cases. 86/210 cases (41%) were invited to participate in a trial, of whom 43/86 (50%) subsequently enrolled. Additional benefits included the avoidance of postmortem examination if the coroner was satisfied with the multidisciplinary team decision. The overall process from referral to outcome dispatch was <2 weeks in 75% of cases.

CONCLUSIONS

This specialist mesothelioma multidisciplinary team meeting was effective at making diagnoses and providing recommendations for further investigations or treatment. The core requirements of a specialist mesothelioma multidisciplinary team meeting were met. The process was timely, with most outcomes returned within 2 weeks of referral.

An unusual mediastinal mass

We report a case of a mediastinal mass indenting the left lateral tracheal wall of a 35-year-old male who presented with weight loss, cough and breathlessness. Flow volume loop and thyroid function tests were normal and thyroid peroxidase antibodies were negative. Technetium scintigraphy and positron emission tomography both showed no uptake. Endobronchial ultrasound-guided fine needle aspiration confirmed ectopic mediastinal thyroid tissue. Mediastinal ectopic thyroid tissue is very rare. Most patients are asymptomatic and euthyroid with positive signals on scintigraphy. False negative technetium scintigraphy can occur in areas of necrosis, carcinoma and from substernal tissue. Ectopic thyroid tissue is a rare but important differential diagnosis when investigating mediastinal lesions and should be considered even if scintigraphy is negative in the right clinical context. Endobronchial ultrasound-guided fine needle aspiration can be used when scintigraphy is not diagnostic.

Integrative review on the non-invasive management of lower urinary tract symptoms in men following treatments for pelvic malignancies

AIM

To develop a non-invasive management strategy for men with lower urinary tract symptoms (LUTS) after treatment for pelvic cancer, that is suitable for use in a primary healthcare context.

METHODS

PubMed literature searches of LUTS management in this patient group were carried out, together with obtaining a consensus of management strategies from a panel of authors for the management of LUTS from across the UK.

RESULTS

Data from 41 articles were investigated and collated. Clinical experience was sought from authors where there was no clinical evidence. The findings discussed in this paper confirm that LUTS after the cancer treatment can significantly impair men's quality of life. While many men recover from LUTS spontaneously over time, a significant proportion require long-term management. Despite the prevalence of LUTS, there is a lack of consensus on best management. This article offers a comprehensive treatment algorithm to manage patients with LUTS following pelvic cancer treatment.

CONCLUSION

Based on published research literature and clinical experience, recommendations are proposed for the standardisation of management strategies employed for men with LUTS after the pelvic cancer treatment. In addition to implementing the algorithm, understanding the rationale for the type and timing of LUTS management strategies is crucial for clinicians and patients.

Lesson of the month 1: A cough that doesn't fit the mould

Aspergillus disease has a wide spectrum of manifestations within the lungs; however invasive Aspergillus is most commonly associated with immunocompromise or pre-existing respiratory disease. Here we present a case of Aspergillus tracheobronchitis causing right middle lobe collapse, masquerading as late-onset asthma in a patient with no pre-existing risk factors following massive inhalation of Aspergillus spores from working with compost. This case highlights the importance of having a high index of suspicion for Aspergillus-related disease even in those with no traditional risk factors.

A newborn with massive intra-abdominal haemorrhage

We describe an unusual case of an intra-abdominal teratoma with massive bleeding presenting as sudden cardiovascular collapse immediately after birth. The infant required massive volume and blood product transfusion, alongside emergent tumour resection, in order to obtain haemostasis and haemodynamic stabilisation. Haemorrhage of a sacrococcygeal teratoma is a known entity, but we are not aware of a previous report of massive intra-abdominal haemorrhage due to a teratoma, immediately after birth. This case emphasises the need to consider intra-abdominal pathology, including a teratoma, in the differential diagnosis of any newborn with early hypovolaemic shock and abdominal distention.

Looking after patients, not looking for patients

How transfers from ward to ward can affect continuity of care.