Modern cemented Furlong hemiarthroplasty: Are dislocations rates better?

BACKGROUND

Dislocation following hip hemiarthroplasty is a major complication with increased mortality and morbidity. Data looking at dislocation following contemporary bipolar stems are lacking in literature.

METHODS

Retrospective review of our prospective national hip fracture database over a two-year period. Group 1 comprised of consecutive patients receiving bipolar Furlong prosthesis (N222) while Group 2 was made up of a historical cohort (uncemented; N254). Clinical and radiological records were reviewed to determine dislocation rates, causes and associative factors of dislocations. Data were analysed using SPSS.

RESULTS

Following 476 hemiarthroplasties performed during the study period, 12 (2.5%) dislocations were reported (eight in Group 1; four in Group 2). There was no significant difference in dislocation rates (3.6% vs 1.6%) between groups (p = 0.159). Subgroup analysis of Group 1 demonstrated a significant difference in dislocations with Furlong cemented (6%) as compared with Furlong uncemented (0%) hemiarthroplasties (p = 0.024). Following dislocation, death rates increased to 8.3% from 1.7% in both groups.

CONCLUSION

There is a statistically significant increase in dislocation rate following use of cemented Furlong prosthesis when compared to similar uncemented prosthesis at the same treatment period. However, when compared to traditional uncemented prosthesis, there is no difference in dislocation rates.

In hospital outcomes of orbital/rotational coronary atherectomy in diabetic vs non-diabetic population: insights from the nationwide inpatient sample

Background

Atherectomy (AT) using an orbital/rotational system is useful in altering calcified plaque thereby facilitating stent placement and optimal stent expansion. Patients with diabetes mellitus (DM) are known to have a higher rate of complications after percutaneous coronary intervention. We aimed to assess the incidence of major adverse cardiovascular events after atherectomy in the diabetic population using a nationwide inpatient sample (NIS).

Methods

NIS-HCUP database from 2015–2017 was used to identify patients who underwent atherectomy. A cohort of patients with and without diabetes was identified. Demographics, in-hospital outcomes, complications in both groups were compared. Statistical significance was assigned at p<0.05.

Results

Out of 6184 patients who underwent AT, 3134 (50.6%) patients had DM. Baseline characteristics have been outlined in the table below. Complications were comparable between the two groups except for higher incidence of post-procedure VTE in Diabetic patients. In-hospital mortality was lower among patients with DM (2.24% vs 3.29%, p-0.27), while the mean length of stay (5.92 vs 4.91 days, p-0.002) and the hospitalization charges ($165118.4 vs 151226, p-0.04) were higher, but this difference in length of stay and hospitalization charges were nullified on multivariate regression.

Conclusion

Our study suggests that an AT for severely calcified plaque in the coronary artery is a safe option in patients with DM with comparable in-hospital complications and outcomes to non-DM patients.

Funding Acknowledgement

Type of funding sources: None. Demographics and Outcomes of Atherectomy

Idiopathic CD4+ T lymphocytopenia: A case report

Idiopathic CD4+ T lymphocytopenia (ICL) is a very rare immunodeficiency syndrome with an unexplained depletion of CD4+ T lymphocytes and no evidence of Human Immunodeficiency Virus (HIV) infection. Here we report a 29-year-old male patient who had severe ulcerative colitis with low level CD4+ count of 254 cells/mm³, and had no evidence of HIV or Human T cell Lymphotrophic virus type I or II infections. He had recurrent Candidiasis infection and his CD4 count was just 53 cells/mm³ after 3 months. The cause for the decline of CD4 T lymphocytes was unknown.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effectiveness of a continuous patient position monitoring system in improving hospital turn protocol compliance in an ICU: A multiphase multisite study in India

Purpose

Hospital-acquired pressure ulcers are a significant cause of morbidity and consume considerable financial resources. Turn protocols (repositioning patients at regular intervals) are utilized to reduce incidence of pressure ulcers. Adherence to turn protocols is particularly challenging for nursing teams, given the high number of interventions in intensive care unit, and lack of widely available tools to monitor patient position and generate alerts. We decided to develop and evaluate usefulness of a continuous patient position monitoring system to assist nurses in improving turn protocol compliance.

Methods

We conducted a prospective, non-randomized, multiphase, multicentre trial. In Phase I (control group), the function of the device was not revealed to nurses so as to observe their baseline adherence to turn protocol, while Phase II (intervention group) used continuous patient position monitoring system to generate alerts, when non-compliant with the turn protocol. All consecutive patients admitted to one of the two intensive care units during the study period were screened for enrolment. Patients at risk of acquiring pressure ulcers (Braden score < 18) were considered for the study (Phase I (N = 22), Phase II (N = 25)).

Results

We analysed over 1450 h of patient position data collected from 40 patients (Phase I (N = 20), Phase II (N = 20)). Turn protocol compliance was significantly higher in Phase II (80.15 ± 8.97%) compared to the Phase I (24.36 ± 12.67%); p < 0.001.

Conclusion

Using a continuous patient position monitoring system to provide alerts significantly improved compliance with hospital turn protocol. Nurses found the system to be useful in providing automated turn reminders and prioritising tasks.

Cost of treating ventilator-associated pneumonia post cardiac surgery in the National Health Service: Results from a propensity-matched cohort study

Background

Ventilator-associated pneumonia is associated with significant morbidity, mortality and healthcare costs. Most of the cost data that are available relate to general intensive care patients in privately remunerated institutions. This study assessed the cost of managing ventilator-associated pneumonia in a cardiac intensive care unit in the National Health Service in the United Kingdom.

Methods

Propensity-matched study of prospectively collected data from the cardiac surgical database between April 2011 and December 2014 in all patients undergoing cardiac surgery (n = 3416). Patients who were diagnosed as developing ventilator-associated pneumonia, as per the surveillance definition for ventilator-associated pneumonia (n = 338), were propensity score matched with those who did not (n = 338). Costs of treating post-op cardiac surgery patients in intensive care and cost difference if ventilator-associated pneumonia occurred based on Healthcare Resource Group categories were assessed. Secondary outcomes included differences in morbidity, mortality and cardiac intensive care unit and in-hospital length of stay.

Results

There were no significant differences in the pre-operative characteristics or procedures between the groups. Ventilator-associated pneumonia developed in 10% of post-cardiac surgery patients. Post-operatively, the ventilator-associated pneumonia group required longer ventilation (p < 0.01), more respiratory support, longer cardiac intensive care unit (8 vs 3, p < 0.001) and in-hospital stay (16 vs 9) days. The overall cost for post-operative recovery after cardiac surgery for ventilator-associated pneumonia patients was £15,124 compared to £6295 for non-ventilator-associated pneumonia (p < 0.01). The additional cost of treating patients with ventilator-associated pneumonia was £8829.

Conclusion

Ventilator-associated pneumonia was associated with significant morbidity to the patients, generating significant costs. This cost was nearer to the lower end for the cost for general intensive care unit patients in privately reimbursed systems.

International cancer seminars: a focus on esophageal squamous cell carcinoma

The International Agency for Research on Cancer (IARC) and the US National Cancer Institute (NCI) have initiated a series of cancer-focused seminars [Scelo G, Hofmann JN, Banks RE et al. International cancer seminars: a focus on kidney cancer. Ann Oncol 2016; 27(8): 1382-1385]. In this, the second seminar, IARC and NCI convened a workshop in order to examine the state of the current science on esophageal squamous cell carcinoma etiology, genetics, early detection, treatment, and palliation, was reviewed to identify the most critical open research questions. The results of these discussions were summarized by formulating a series of 'difficult questions', which should inform and prioritize future research efforts.

Effect of Two Long-acting Treatments, The Paliperidone Palmitate 1-month and 3-month Formulations on Caregiver Burden in European patients with Schizophrenia

Introduction

Schizophrenia puts a significant burden on caregivers.

Objectives

To explore the effects of two long-acting treatments (LAT), paliperidone palmitate 1-month and 3-month formulations on caregiver burden (CGB) in European patients with schizophrenia using the Involvement Evaluation Questionnaire (IEQ)

Aims

To conduct a subgroup analysis of two randomized, double-blind studies (NCT01515423 and NCT01529515).

Methods

Caregivers (≥ 1 h of contact/week with the patients) were offered to complete the IEQ (31 items, each scoring: 0–4; total score: sum of 27 items [0–108]).

Results

Among 756 European caregivers (53% parents, 18% spouse/partner or girl/boyfriend, 10% sister/brother), 60% reported a CGB of ≥ 32 hours/week at open-label baseline (BL-OL). CGB reduced significantly for patients with both BL-OL and at least one double-blind IEQ sum-score (n = 433): mean improvement [SD] (9.9 [12.66], P < 0.001) from BL-OL (mean [SD] 26.0 [13.30]) to study end (16.0 [10.47]); (reduction in burden associated with worrying [2.9 points] and urging [4.3 points]). CGB significantly improved in patients on prior oral antipsychotics post-switching to LAT with less leisure days impacted and less hours spent in caregiving (P < 0.001). There was significant relationship between improvements and relapse status, patient age (P < 0.001), age at diagnosis (P < 0.002), and number of prior psychiatric hospitalizations in the last 24 months (P < 0.05). Prior use of long-acting antipsychotics other than paliperidone palmitate 1-month or 3-month formulations at BL-OL and duration of prior psychiatric hospitalizations in the last 24 months did not show significant effect on improvements.

Conclusion

Switching from an oral antipsychotic to an LAT can provide a meaningful and significant improvement in caregiver burden.

Disclosure of interest

All authors are employees of Janssen Research & Development, LLC and hold stocks in the company.

Profile of pancreatic tumors at a tertiary care center

BACKGROUND

Pancreas, a relatively inaccessible organ, poses diagnostic difficulties with overlapping presentation among benign and malignant tumors. In the present study, pancreatic aspirates obtained by computed tomography (CT) guided procedures were used for cytodiagnosis. Our study aims at correlating clinical, cytological, biochemical, and histopathological results in obtaining a final diagnosis.

METHODOLOGY

A retrospective study of 2 years was done which included 32 cases of pancreatic tumors at a tertiary care center. Patient data were retrieved and analyzed.

RESULTS

Twenty-seven of the 32 (84.37%) cases were malignant tumors. Age distribution in malignant tumors was predominantly seen in the fourth to eighth decade, whereas in benign, it ranged in the second to third decade. Thirteen out of the 32 (40.62%) cases reported were females, with male:female ratio of 1.46:1. The most common presenting symptom was abdominal pain followed by jaundice and vomiting. Three of the 32 cases had visceral metastasis at the time of diagnosis. CT-guided aspirates in most cases yielded diagnostic material. Cytological and histopathological results concurred except for three cases. Cancer Antigen 19-9 was worked up for 14 of 27 malignant cases, 11 of which showed grossly elevated values (700-7000), and three cases showed mildly elevated values (100-300). Three of the four benign cases worked up for CA 19-9 showed normal values.

CONCLUSIONS

Among the mass forming lesions in pancreas, malignancy was more common compared to benign tumors. A multidisciplinary approach in the assessment and diagnosis of pancreatic tumors yields accurate results in spite of the limitations faced in obtaining adequate samples by needle aspirates.

Systematic review of use of β-blockers in sepsis

Background and Aims:

We proposed a review of present literature and systematic analysis of present literature to summarize the evidence on the use of β-blockers on the outcome of a patient with severe sepsis and septic shock.

Material and Methods:

Medline, EMBASE, Cochrane Library were searched from 1946 to December 2013. The bibliography of all relevant articles was hand searched. Full-text search of the grey literature was done through the medical institution database. The database search identified a total of 1241 possible studies. The citation list was hand searched by both the authors. A total of 9 studies were identified.

Results:

Most studies found a benefit from β-blocker administration in sepsis. This included improved heart rate (HR) control, decreased mortality and improvement in acid-base parameters. Chronic β-blocker usage in sepsis was also associated with improved mortality. The administration of β-blockers during sepsis was associated with better control of HR. The methodological quality of all the included studies, however, was poor.

Conclusion:

There is insufficient evidence to justify the routine use of β-blockers in sepsis. A large adequately powered multi-centered randomized controlled clinical trial is required to address the question on the efficacy of β-blocker usage in sepsis. This trial should also consider a number of important questions including the choice of β-blocker used, optimal dosing, timing of intervention, duration of intervention and discontinuation of the drug. Until such time based on the available evidence, there is no place for the use of β-blockers in sepsis in current clinical practice.

Pathologically confirmed breast cancer in Malawi: a descriptive study: Clinical profile of breast cancer

BACKGROUND

Breast cancer is the most common female cancer in Africa, yet no published studies have investigated breast cancer in Malawi. Understanding the clinical profile of breast cancer is important to develop early diagnosis efforts.

AIM

To describe clinical and pathological characteristics of breast specimens from a pathology laboratory at a national teaching hospital.

METHODS

Secondary analysis of pathology reports from July 2011 to September 2013.

RESULTS

Among 85 breast cancer cases, 55% were < 50 years. Median tumor size was 4 cm and 49% were grade 3. Median symptom duration was eight months.

CONCLUSIONS

Malawian women with breast cancer commonly have long symptom durations prior to diagnosis, young age, and poorly differentiated tumors. Improved clinical and pathological characterization, including hormone receptor status, are urgently needed to better understand this disease in Malawi.

Review: Head and neck squamous cell carcinoma in sub-Saharan Africa

AIM

Review the literature from 1990 to 2013 to determine known anatomic sites, risk factors, treatments, and outcomes of head and neck squamous cell carcinoma (HNSCC) in sub-Saharan Africa.

METHODS

Using a systematic search strategy, literature pertaining to HNSCC in sub-Saharan Africa was reviewed and patient demographics, anatomic sites, histology, stage, treatment, and outcomes were abstracted. The contributions of human immunodeficiency virus (HIV), human papillomavirus (HPV) and behavioural risk factors to HNSCC in the region were assessed.

RESULTS

Of the 342 papers identified, 46 were utilized for review, including 8611 patients. In sub-Saharan Africa, the oropharyngeal/oral cavity was found to be the most common site, with 7750 cases (90% of all cases). Few papers distinguished oropharyngeal from oral cavity, making identification of possible HPV-associated oropharyngeal squamous cell carcinoma (SCC) difficult. SCC of the nasopharynx, nasal cavity, or paranasal sinuses was identified in 410 patients (4.8% of all cases). Laryngeal SCC was found in 385 patients (4.5% of all cases), and only 66 patients (0.8% of all cases) with hypopharyngeal SCC were identified. In 862 patients with data available, 43% used tobacco and 42% used alcohol, and reported use varied widely and was more common in laryngeal SCC than that of the oropharyngeal/oral cavity. Toombak and kola nut use was reported to be higher in patients with HNSCC. Several papers reported HIV-positive patients with HNSCC, but it was not possible to determine HNSCC prevalence in HIV-positive compared to negative patients. Reports of treatment and outcomes were rare.

CONCLUSIONS

The oropharyngeal/oral cavity was by far the most commonly reported site of HNSCC reported in sub-Saharan Africa. The roles of risk factors in HNSCC incidence in sub-Saharan Africa were difficult to delineate from the available studies, but a majority of patients did not use tobacco and alcohol.

Functional profiling in Streptococcus mutans: construction and examination of a genomic collection of gene deletion mutants

A collection of tagged deletion mutant strains was created in Streptococcus mutans UA159 to facilitate investigation of the aciduric capability of this oral pathogen. Gene-specific barcoded deletions were attempted in 1432 open reading frames (representing 73% of the genome), and resulted in the isolation of 1112 strains (56% coverage) carrying deletions in distinct non-essential genes. As S. mutans virulence is predicated upon the ability of the organism to survive an acidic pH environment, form biofilms on tooth surfaces, and out-compete other oral microflora, we assayed individual mutant strains for the relative fitness of the deletion strain, compared with the parent strain, under acidic and oxidative stress conditions, as well as for their ability to form biofilms in glucose- or sucrose-containing medium. Our studies revealed a total of 51 deletion strains with defects in both aciduricity and biofilm formation. We have also identified 49 strains whose gene deletion confers sensitivity to oxidative damage and deficiencies in biofilm formation. We demonstrate the ability to examine competitive fitness of mutant organisms using the barcode tags incorporated into each deletion strain to examine the representation of a particular strain in a population. Co-cultures of deletion strains were grown either in vitro in a chemostat to steady-state values of pH 7 and pH 5 or in vivo in an animal model for oral infection. Taken together, these data represent a mechanism for assessing the virulence capacity of this pathogenic microorganism and a resource for identifying future targets for drug intervention to promote healthy oral microflora.

Incidence of tardive dyskinesia: a comparison of long-acting injectable and oral paliperidone clinical trial databases

BACKGROUND

To assess the tardive dyskinesia (TD) rate in studies of once-monthly long-acting injectable (LAI) paliperidone palmitate (PP) and once-daily oral paliperidone extended release (Pali ER).

METHODS

Completed schizophrenia and bipolar studies for PP and Pali ER (≥ 6 month duration with retrievable patient-level data) were included in this post hoc analysis. Schooler-Kane research criteria were applied using Abnormal Involuntary Movement Scale (AIMS) scores to categorise probable (qualifying AIMS scores persisting for ≥ 3 months) and persistent TD (score persisting ≥ 6 months). Spontaneously reported TD adverse events (AEs) were also summarised. Impact of exposure duration on dyskinesia (defined as AIMS total score ≥ 3) was assessed by summarising the monthly dyskinesia rate.

RESULTS

In the schizophrenia studies, TD rates for PP (four studies, N = 1689) vs. Pali ER (five studies, N = 2054), were: spontaneously reported AE, 0.18% (PP) vs. 0.10% (Pali ER); probable TD, 0.12% (PP) vs. 0.19% (Pali ER) and persistent TD, 0.12% (PP) vs. 0.05% (Pali ER). In the only bipolar study identified [Pali ER (N = 614)], TD rate was zero (spontaneously reported AE reporting, probable and persistent TD assessments). Dyskinesia rate was higher within the first month of treatment with both PP (13.1%) and Pali ER (11.7%) and steadily decreased over time (months 6-7: PP: 5.4%; Pali ER: 6.4%). Mean exposure: PP, 279.6 days; Pali ER, 187.2 days.

CONCLUSIONS

Risk of TD with paliperidone was low (< 0.2%), regardless of the formulation (oral or LAI), in this clinical trial dataset. Longer cumulative exposure does not appear to increase the risk of dyskinesias.

Quantitative X-ray microradiography for high-throughput phenotyping of osteoarthritis in mice

OBJECTIVE

To investigate and validate digital X-ray microradiography as a novel, high-throughput and cost-effective screening approach to identify abnormal joint phenotypes in mice.

METHOD

Digital X-ray microradiography was used to quantify the subchondral bone mineral content (BMC) in the medial tibial plateau. Accuracy and reproducibility of the method were determined in 22 samples from C57BL/6(B6Brd;B6Dnk;B6N-Tyr(c-Brd)) wild-type mice. The method was then validated in wild-type mice that had undergone surgical destabilisation of medial meniscus (DMM) and in a genetically modified mouse strain with an established increase in trabecular bone mass.

RESULTS

The measurement of subchondral BMC by digital X-ray microradiography had a coefficient of variation of 3.6%. Digital X-ray microradiography was able to demonstrate significantly increased subchondral BMC in the medial tibial plateau of male mice 4 and 8 weeks after DMM surgery and in female mice 8 weeks after surgery. Furthermore, digital X-ray microradiography also detected the increase in subchondral BMC in a genetically modified mouse strain with high trabecular bone mass.

CONCLUSION

Quantitation of subchondral BMC by digital X-ray microradiography is a rapid, sensitive and cost-effective method to identify abnormal joint phenotypes in mice of both genders at several ages.

Validation of cardiac output studies from the Mostcare compared to a pulmonary artery catheter in septic patients

BACKGROUND

The Mostcare monitor is a non-invasive cardiac output monitor. It has been well validated in cardiac surgical patients but there is limited evidence on its use in patients with severe sepsis and septic shock.

METHODS

The study included the first 22 consecutive patients with severe sepsis and septic shock in whom the floatation of a pulmonary artery catheter was deemed necessary to guide clinical management. Cardiac output measurements including cardiac output, cardiac index and stroke volume were simultaneously calculated and recorded from a thermodilution pulmonary artery catheter and from the Mostcare monitor respectively. The two methods of measuring cardiac output were compared by Bland-Altman statistics and linear regression analysis. A percentage error of less than 30% was defined as acceptable for this study.

RESULTS

Bland-Altman analysis for cardiac output showed a Bias of 0.31 L.min-1, precision (=SD) of 1.97 L.min-1 and a percentage error of 62.54%. For Cardiac Index the bias was 0.21 L.min-1.m-2, precision of 1.10 L.min-1.m-2 and a percentage error of 64%. For stroke volume the bias was 5 mL, precision of 24.46 mL and percentage error of 70.21%. Linear regression produced a correlation coefficient r2 for cardiac output, cardiac index, and stroke volume, of 0.403, 0.306, and 0.3 respectively.

CONCLUSION

Compared to thermodilution cardiac output, cardiac output studies obtained from the Mostcare monitor have an unacceptably high error rate. The Mostcare monitor demonstrated to be an unreliable monitoring device to measure cardiac output in patients with severe sepsis and septic shock on an intensive care unit.

Causes of cervical lymphadenopathy at Kamuzu Central Hospital

AIM

Description of pathologic causes of cervical lymphadenopathy at Kamuzu Central Hospital.

INTRODUCTION

The evaluation of cervical lymphadenopathy is a common diagnostic challenge facing clinicians. Previously at Kamuzu Central Hospital (KCH) tuberculosis (TB) was reported to be the most common cause of cervical lymphadenopathy However, no recent study has assessed this common diagnostic challenge in Malawi, particularly since the beginning of the HIV epidemic and the subsequent scale-up of antiretroviral therapy.

METHODS

We conducted a cross-sectional study of all cervical lymph node specimens from the KCH pathology laboratory between 1 July 2011 and 28 February 2013 and describe patient age, gender, and pathologic diagnoses.

RESULTS

Our search of the KCH pathology database yielded 179 cases. Of these, 143 (77%) were histologic specimens (open biopsy or core needle samples) while 34 (23%) were cytology specimens. The age range was from 0 to 76 years with a mean of 30 (SD: 19). In adults, the most common diagnosis was malignancy (n=41, 35%), while in children 15 cases each of malignancy and benign masses were diagnosed. Only 6 cases (5%) of TB were diagnosed in adults, and 4 cases (6%) of TB were diagnosed in children.

CONCLUSION

Our study shows more malignancy and much less TB than a prior study of cervical lymphadenopathy at KCH. With the successful initiaion of the KCH Pathology Laboratory in 2011, we recommend biopsy or FNA early in the workup of cervical lymphadenopathy to prevent long delays in diagnosis and treatment of curable cancers.

Biochemical characterization of radical scavenging polyphenols from Nyctanthes arbortristis

Context:

Antioxidants are quenchers of free radical that are responsible for inducing oxidative stress generated via reactive oxygen species-induced degenerative diseases such as cancer, diabetes, and cardiovascular diseases etc. Plant and plant products are recognized as safe and potential health promoting and nutritive sources.

Aims:

To investigate the antioxidant potency of polyphenol extract (PE) of Nyctanthes arbortristis leaves and identification of the active constituent by HPLC.

Materials and Methods:

PE of N. arbortristis leaves was investigated for antioxidant activity employing various established in vitro systems, such as lipid peroxidation in liposome, DPPH and hydroxyl radical scavenging, reducing power assay, and iron ion chelation. Identification of active constituent in PE of N. arbortristis responsible for antioxidant activity by HPLC. Statistical analysis used: All experiments were carried out in triplicates. Data were shown as mean ± standard deviation (SD). SPSS 10.0.5 version for windows (SPSS software Inc., USA) computer program was used for statistical analysis.

Results:

Identification of active constituent in PE revealed gallic acid 75.8 ± 0.21, protocatechuic acid 14.6 ± 0.5, chlorogenic acid 6.79 ± 0.43, and caffeic acid 5.34 ± 0.2 μg/ml. PE showed strong inhibitory activity of 73% at 200 μg/ml toward lipid peroxidation in egg lecithin, concentration-dependent inhibition of deoxyribose oxidation at 200 μg/ml was 85% inhibition, and considerable antioxidant activity in DPPH radical assay system at 200 μg/ml was 79% inhibition. BHA and gallic acid showed significant observations.

Conclusion:

The antioxidant potency significantly correlated with the phenolic content of PE. Considering that medicinal herbs contain potent phytochemicals, which is effectively utilized for various degenerative disease, these in vitro results showed that N. arbortristis leaves could be effectively employed in functional food, to alleviate oxidative stress.

Alpha-actinin interactions with syndecan-4 are integral to fibroblast-matrix adhesion and regulate cytoskeletal architecture

All cells of the musculoskeletal system possess transmembrane syndecan proteoglycans, notably syndecan-4. In fibroblasts it regulates integrin-mediated adhesion to the extracellular matrix. Syndecan-4 null mice have a complex wound repair phenotype while their fibroblasts have reduced focal adhesions and matrix contraction abilities. Signalling through syndecan-4 core protein to the actin cytoskeleton involves protein kinase Cα and Rho family G proteins but also direct interactions with α-actinin. The contribution of the latter interaction to cell-matrix adhesion is not defined but investigated here since manipulation of Rho GTPase and its downstream targets could not restore a wild type microfilament organisation to syndecan-4 null cells. Microarray and protein analysis revealed no significant alterations in mRNA or protein levels for actin- or α-actinin associated proteins when wild type and syndecan-4 knockout fibroblasts were compared. The binding site for syndecan-4 cytoplasmic domain was identified as spectrin repeat 4 of α-actinin while further experiments confirmed the importance of this interaction in stabilising cell-matrix junctions. However, α-actinin is also present in adherens junctions, these organelles not being disrupted in the absence of syndecan-4. Indeed, co-culture of wild type and knockout cells led to adherens junction-associated stress fibre formation in cells lacking syndecan-4, supporting the hypothesis that the proteoglycan regulates cell-matrix adhesion and its associated microfilament bundles at a post-translational level. These data provide an additional dimension to syndecan function related to tension at the cell-matrix interface, wound healing and potentially fibrosis.

Pilot randomized trial of nutritional supplementation in patients with tuberculosis and HIV-tuberculosis coinfection receiving directly observed short-course chemotherapy for tuberculosis

OBJECTIVE

To investigate the effects of nutritional supplementation on the outcome and nutritional status of south Indian patients with tuberculosis (TB) with and without human immunodeficiency virus (HIV) coinfection on anti-tuberculous therapy.

METHOD

Randomized controlled trial on the effect of a locally prepared cereal-lentil mixture providing 930 kcal and a multivitamin micronutrient supplement during anti-tuberculous therapy in 81 newly diagnosed TB alone and 22 TB-HIV-coinfected patients, among whom 51 received and 52 did not receive the supplement. The primary outcome evaluated at completion of TB therapy was outcome of TB treatment, as classified by the national programme. Secondary outcomes were body composition, compliance and condition on follow-up 1 year after cessation of TB therapy and supplementation.

RESULTS

There was no significant difference in TB outcomes at the end of treatment, but HIV-TB coinfected individuals had four times greater odds of poor outcome than those with TB alone. Among patients with TB, 1/35 (2.9%) supplemented and 5/42(12%) of those not supplemented had poor outcomes, while among TB-HIV-coinfected individuals, 4/13 (31%) supplemented and 3/7 (42.8%) non-supplemented patients had poor outcomes at the end of treatment, and the differences were more marked after 1 year of follow-up. Although there was some trend of benefit for both TB alone and TB-HIV coinfection, the results were not statistically significant at the end of TB treatment, possibly because of limited sample size.

CONCLUSION

Nutritional supplements in patients are a potentially feasible, low-cost intervention, which could impact patients with TB and TB-HIV. The public health importance of these diseases in resource-limited settings suggests the need for large, multi-centre randomized control trials on nutritional supplementation.

A 52-week open-label study of the safety and tolerability of paliperidone palmitate in patients with schizophrenia

The safety and tolerability of paliperidone palmitate, an injectable atypical antipsychotic agent, were assessed in a 1-year open-label extension of a double-blind study in patients with schizophrenia. Patients from the double-blind study who experienced a recurrence, remained recurrence free until study end, or who were in the transition, maintenance or double-blind phases and had received at least one injection of paliperidone palmitate when enrollment was stopped, were eligible for the open-label extension. Patients received gluteal injections of paliperidone palmitate once every 4 weeks: starting dose 50 mg eq. followed by 25, 50, 75, or 100 mg eq. flexible dosing. Of the 388 patients enrolled, 288 completed the open-label extension. During the open-label extension, the median (range) duration of exposure to paliperidone palmitate was 338 days (10; 390), and 74% of patients received all 12 open-label injections of paliperidone palmitate. The most frequent (≥ 5% in total group) adverse events were insomnia (7%); worsening of schizophrenia; nasopharyngitis; headache; and weight increase (6% each). Potentially prolactin-related adverse events occurred in 13 (3%) patients, mostly women, and none resulted in study discontinuation. Extrapyramidal treatment-emergent adverse events were reported in 25 (6%) patients; tremor was the most frequently reported (n = 8, 2%). At open-label extension endpoint, investigator-rated redness at the injection site was observed in ≤ 4% of patients in each group. Injection-site pain was rated by investigators as absent in 82-87% of patients. Schizophrenia symptoms measured by Positive and Negative Syndrome Scale and personal and social performance changes improved during the open-label extension.

The relationship between hospital volume and mortality following mechanical ventilation in the Intensive Care Unit

BACKGROUND

A number of recent studies in North America and Europe have investigated the relationship between hospital volume and outcomes following mechanical ventilation in an Intensive Care Unit (ICU). All of these studies have revealed an association between worse outcomes and smaller-volume hospitals. This relationship has not been investigated recently in the UK.

METHODS

A retrospective cohort study was performed using data from the Birmingham and Black Country Critical Care Network database. Adult patients who received mechanical ventilation for more than 24 hours from the period from April 1, 1996, to March 31, 2006, were included in the study. The odds ratio for death in the ICU was calculated in relation to the hospital's volume of ventilation. Estimates accounted for clustering within hospitals and were adjusted for patient demographics (sex, age), APACHE II score, year of ventilation, length of ICU stay and urgency status.

RESULTS

A total of 17132 adult patient episodes were included in the analysis. The adjusted odds ratio for death in the ICU following mechanical ventilation for more than 24 hours was 1.11 (95% confidence interval: 0.91 to 1.35; P=0.297).

CONCLUSION

There is no relationship between hospital volume and mortality following mechanical ventilation in the ICU. Further larger prospective studies are needed to confirm this apparent lack of a relationship between hospital volume and mortality following mechanical ventilation in ICUs in a network of hospitals in the UK.

Intra- and inter-rater reliability of the Knee Society Knee Score when used by two physiotherapists in patients post total knee arthroplasty

Background and Purpose: It has yet to be shown whether routine physiotherapy plays a role in the rehabilitation of patients post totalknee arthroplasty (Rajan et al 2004). Physiotherapists should be using validoutcome measures to provide evidence of the benefit of their intervention. The aim of this study was to establish the intra and inter-rater reliability of the Knee Society Knee Score, a scoring system developed by Insall et al(1989). The Knee Society Knee Score can be used to assess the integrity of theknee joint of patients undergoing total knee arthroplasty. Since the scoreinvolves clinical testing, the intra-rater reliability of the clinician should be established prior to using the scores as datain clinical research. W here multiple clinicians are involved, inter-rater reliability should also be established.Design: This was a correlation study.Subjects: A  sample of thirty patients post total knee arthroplasty attending the arthroplasty clinic at Johannesburg Hospital between six weeks and twelve months postoperatively.M ethod: Recruited patients were evaluated twice with a time interval of one hour between each assessment. Statistical A nalysis: The intra- and inter-rater reliability were estimated using Intraclass Correlation Coefficient (ICC). R esults: The intra-rater reliability showed excellent reliability (h= 0.95) for Examiner A  and good reliability (h= 0.71)for Examiner B. The inter-rater reliability showed moderate reliability (h= 0.67 during test one and h= 0.66 during test two).Conclusion: The KSKS has good intra-rater reliability when tested within a period of one hour. The KSKS demonstrated moderate agreement for inter rater reliability.

Practical guidance for dosing and switching paliperidone palmitate treatment in patients with schizophrenia

OBJECTIVE

This article overviews the recommended dosing strategies for the treatment of schizophrenia patients using the recently FDA-approved once-monthly long-acting injectable atypical antipsychotic, paliperidone palmitate.

METHODS

Using pharmacokinetic (PK), efficacy and safety data from clinical trials and a comprehensive population PK simulation model, dosing recommendations for paliperidone palmitate have been generated.

RESULTS

The recommended initiation regimen is 150 mg eq. paliperidone palmitate (234 mg) on Day 1 followed by 100 mg eq. paliperidone palmitate (156 mg) on Day 8, each administered into the deltoid muscle, using a 1-inch 23 gauge (G) needle in those <90 kg and a 1.5-inch 22 G needle in those > or =90 kg. No oral supplementation is required. Monthly maintenance doses of paliperidone palmitate range from 25-150 mg eq. (39-234 mg; recommended dose of 75 mg eq. [117 mg]) injected into the deltoid (using weight-adjusted needle) or gluteal (using 1.5 inch 22 G needle) muscle. The Day 8 dose may be administered +/-2 days and monthly doses +/-7 days, without a clinically significant impact on plasma concentrations. In patients with mild renal impairment (creatinine clearance [CrCL]: 50-80 mL/min), dosage should be adjusted. No dose adjustment is required in patients with mild or moderate hepatic impairment; no data currently exist regarding severe hepatic impairment. Elderly patients with normal renal function should receive the same dosage as younger adult patients with normal renal function. In the event of an age-related decline in CrCL, dosage should be adjusted accordingly. Paliperidone palmitate treatment can be initiated the day after discontinuing previous oral antipsychotic treatment. Paliperidone palmitate should be initiated at the next scheduled injection, and monthly thereafter, in patients switching from other long-acting injectable antipsychotics, including long-acting risperidone.

CONCLUSIONS

These data provide practical guidance to clinicians on how to use paliperidone palmitate in adult patients with schizophrenia.

The Current Role of the Pulmonary Artery Catheter in Critical Care: A Case Report and Review of the Literature

The clinical use of the pulmonary artery catheter (PAC) has changed the modern practice of intensive care medicine. However, the effect of invasive haemodynamic monitoring on patient outcome remains uncertain. We report an unusual case of malposition of a PAC in the left internal mammary vein and we discuss the role of this monitor in the intensive care setting. Overall, the literature does not suggest a positive effect of PAC use on patient outcome. It has been suggested that PAC insertion may be of little benefit unless linked to specific therapies which may alter outcome. It is essential to understand the capabilities and limitations of the PAC in order to minimise potential complications and maximise benefits.