Ketogenic Diet Intervention on Metabolic and Psychiatric Health in Bipolar and Schizophrenia: A Pilot Trial

The ketogenic diet (KD, also known as metabolic therapy) has been successful in the treatment of obesity, type 2 diabetes, and epilepsy. More recently, this treatment has shown promise in the treatment of psychiatric illness. We conducted a 4-month pilot study to investigate the effects of a KD on individuals with schizophrenia or bipolar disorder with existing metabolic abnormalities. Twenty-three participants were enrolled in a single-arm trial. Results showcased improvements in metabolic health, with no participants meeting metabolic syndrome criteria by study conclusion. Adherent individuals experienced significant reduction in weight (12 %), BMI (12 %), waist circumference (13 %), and visceral adipose tissue (36 %). Observed biomarker enhancements in this population include a 27 % decrease in HOMA-IR, and a 25 % drop in triglyceride levels. In psychiatric measurements, participants with schizophrenia showed a 32 % reduction in Brief Psychiatric Rating Scale scores. Overall Clinical Global Impression (CGI) severity improved by an average of 31 %, and the proportion of participants that started with elevated symptomatology improved at least 1-point on CGI (79 %). Psychiatric outcomes across the cohort encompassed increased life satisfaction (17 %) and enhanced sleep quality (19 %). This pilot trial underscores the potential advantages of adjunctive ketogenic dietary treatment in individuals grappling with serious mental illness.

Lip, oral and oropharyngeal cancer incidence among Aboriginal and Torres Strait Islander Peoples: First report from Australian population-based cancer registry, 1999-2018

BACKGROUND

The Australian Burden of Disease Study has shown that cancer is the single most important entity responsible for the greatest cause of health burden in Australia. Unfortunately, Aboriginal and Torres Strait Islander peoples experience a greater burden of this disease, with cancer of the lung, breast, bowel and prostrate being the most common. Lip, oral cavity and pharyngeal cancer incidence is rapidly rising globally and is now the sixth most common cancer in Australia. This paper aims to summarize, for the first time, the incidence and prevalence trends of lip, oral cavity and pharyngeal cancers in Aboriginal and Torres Strait Islander Australians.

METHODS

Data were obtained from the Australian Cancer Database (ACD), which is compiled at the Australian Institute of Health and Welfare (AIHW) from 1999 to 2018 to estimate the incidence and prevalence of certain head and neck cancers (ICD-10 codes C00-C10, C14). The other variables requested were age groups and sex.

RESULTS

Results were stratified by ICD-10 code, sex and age group at diagnosis and time period (i.e. grouped years of diagnosis). The total incidence of lip, oral cavity and pharyngeal cancers increased by 1.3 times from 1999 to 2008 (107/100 000) to 2009-2018 (135/100 000). The overall 5-year prevalence of lip, oral cavity and pharyngeal cancers was 0.17% (0.24% for men and 0.09% for women).

CONCLUSIONS

The significantly increased incidence of lip, oral cavity and pharyngeal cancers in Aboriginal and Torres Strait Islander peoples in Australia is concerning and should be explored. A targeted, comprehensive and culturally safe model of care for Aboriginal and Torres Strait Islander peoples with lip, oral cavity and pharyngeal cancers is imperative.

The role of hyperbaric oxygen in osteoradionecrosis-a prophylactic insight

BACKGROUND

Osteoradionecrosis (ORN) is an uncommon and debilitating consequence of head and neck radiotherapy and hyperbaric oxygen therapy (HBOT) has been advocated for prophylaxis prior to performing dentoalveolar procedures. The aim of this study was to evaluate a prophylactic HBOT protocol and describe the outcomes of susceptible individuals.

METHODS

A retrospective audit of adults who attended the Oral and Maxillofacial Surgery department at the Royal Adelaide Hospital (South Australia) who received dental extractions with a history of radiotherapy to the jaws from 2008 to 2020. Data including demographic information and outcomes of osteoradionecrosis and delayed healing was recorded.

RESULTS

A total of 121 individuals were eligible for case note review; 68.6% of individuals were male and 55.4% were aged over 67 years. Osteoradionecrosis occurred in 9.1% of individuals and delayed healing for 3.3%; fifteen individuals (12.4%) were unable to complete the HBOT protocol. The individuals who were diagnosed with ORN had a significant association with age (P = 0.006) and binary analysis showed alcohol consumption to be a significant predictor.

CONCLUSIONS

Prophylactic HBOT protocol had a lower proportion of individuals diagnosed with ORN and those who were diagnosed were more likely to be younger males and have current alcohol consumption.

The impact of enzyme replacement therapy on the oral health manifestations of hypophosphatasia among children: a scoping review

PURPOSE

A scoping review to describe the use of enzyme replacement therapy (ERT) in the form of asfotase alfa to decrease the severity of oral manifestations in children with hypophosphatasia (HPP).

METHODS

Six databases were searched using keywords and index terms related to "hypophosphatasia," "children," and "enzyme replacement therapy." Duplicates were removed and two independent reviewers screened the titles and abstracts to identify articles for full-text review. Extracted data was summarised narratively.

RESULTS

The systematic search identified 3548 articles, with 171 suitable for full-text review and a final 22 that met inclusion criteria. Enzyme replacement therapy generally resulted in a reduction in the presence and severity of oral manifestations of HPP. However, numerous studies failed to report specific details regarding the nature of oral health outcomes and there were reported cases of further loss of primary teeth.

CONCLUSIONS

The available evidence suggests that that ERT in the form of asfotase alfa for HPP in infants and young children leads to improved oral health outcomes. It is recommended that the outcomes are improved with earlier initiation of ERT. Further, well-designed clinical research is required to assess oral health improvements and decreased morbidity associated with the early loss of teeth.

Advertising and general dental practice: how compliant are practice websites in Australia with legal requirements?

BACKGROUND

The Australian Health Practitioner Regulation Agency (AHPRA) requires general dental practitioners (GDPs) to agree to regulatory advertising guidelines on initial registration and annual renewal. The aim of this study was to determine the compliance of GDPs websites to these requirements.

METHODS

A representative sample of GDPs websites from each state and territory in Australia was based on the total AHPRA registrant distribution. Assessment of compliance was used across five domains consisting of 17 criteria related to AHPRA's advertising of regulated health services guidelines, as well as section 133 of the National Law. Inter-rater reliability was estimated using Fleiss's Kappa.

RESULTS

One hundred and ninety-two GDPs websites were reviewed with 85% non-compliant with at least one of the legal and regulatory requirements relating to advertising. Of these websites, 52% displayed false and misleading information, 12.8% had offers and inducement without clear terms and conditions, 11.5% used written testimonials, 33.9% created unrealistic expectation of benefit and 39.6% encouraged indiscriminate and unnecessary use of health services.

CONCLUSIONS

More than 85% of GDP websites in Australia did not comply with legal and regulatory requirements related to advertising. A multi-stakeholder approach involving AHPRA, professional dental bodies and dental registrants is necessary to improve compliance.

Molar-incisor hypomineralisation prevalence in a cohort of Australian children with type 1 diabetes

PURPOSE

Systemic diseases or drugs administered early in life may cause a disruption in amelogenesis and contribute to the qualitative defect of enamel described as molar-incisor hypomineralisation (MIH). Therefore, an increase in prevalence of MIH in children with type 1 diabetes (T1D) may be expected as this systemic disorder is commonly diagnosed in early childhood. The aim of this study was to determine the prevalence of MIH in a cohort of children with T1D and investigate diagnosis of MIH with T1D factors.

METHODS

Cross-sectional study of children with T1D recruited from paediatric diabetes clinics at the Women's and Children's Hospital (South Australia). A detailed medical history, comprehensive dental and MIH examination according to the European Academy of Paediatric Dentistry (EAPD) long form classification was collected for each child. All upper and lower first permanent molars and central incisors were scored.

RESULTS

A total number of 73 participants; 35 (47.95%) males were examined including 584 teeth. The mean age of the participants was 13.25 ± 2.58 years, with a mean age of diagnosis 7.75 ± 3.58 years, and a mean HbA1c of 8.5 ± 1.6%. 42 out of 73 children (54.8%) had enamel defects on at least one of the teeth examined. However, 19.2% met the criteria for MIH. Univariate and bivariate analyses were conducted but no significant associations were noted between MIH and risk factors including diabetes control (p > 0.1).

CONCLUSION

There was a high prevalence of enamel defects and MIH amongst children with T1D. More research is required to establish association between T1D and MIH.

Tuberculous meningitis in the elderly

OBJECTIVE

Although the elderly population remains at high risk for tuberculosis, studies addressing tuberculous meningitis (TBM) in this age group are scarce. The present study aimed to evaluate the spectrum and outcome of geriatric TBM and document differences between older and young patients.

METHODS

A prospective cohort study was conducted in the adult TBM patients admitted at PGIMER, Chandigarh (India). Consecutive older patients aged 60 years and above were enrolled from January 2019 to December 2020, and young adults aged 18-59 years were enrolled from July 2019 to December 2019.

RESULTS

Fifty-five older patients with a mean age of 66.6 years and 73 young patients with a mean age of 35.1 years were enrolled. At admission, older patients were more likely to have altered mental status (96.4% vs. 78.1%, P = 0.003) and advanced disease with British medical research council staging 2 or 3 (98.2% vs. 89.0%, P = 0.043); however, headache (38.2% vs. 67.1%, P = 0.001), vomiting (18.2% vs. 35.6%, P = 0.030) and fever (80.0% vs. 91.8%, P = 0.052) were less common. Cerebrospinal fluid (CSF) abnormalities were less marked in older patients, with a significant difference in median total cells (70 vs. 110/µl, P = 0.013). Hydrocephalous and infarct were common neuroimaging abnormalities in both groups; however, tuberculomas were significantly less in the elderly (15.1% vs. 35.2%, P = 0.012). Older patients had a significantly low survival rate (56.4% vs. 76.7%, P = 0.021).

CONCLUSION

Significant differences in clinical, CSF and radiological characteristics exist between elderly and young TBM patients, with survival remains dismal in the elderly.

1026 Assessing the Reliability of 3D Imaging for Wound Measurements

Aim

To investigate the inter and intra reliability of using 3D imaging to measure wounds.

Method

20 wound models of 4 different shaped wounds in 5 different colours were created from plastic mouldable beads. 3D images were taken using the BlasterX Senz3D camera and measured using the GPC Wound Measure application (version 3.15.0.0, UK). Intra-user reliability was determined comparing 20 wound measurements of each wound model. Inter-user reliability was determined by 5 different clinicians photographing each model and independently measuring each wound photo. The inter- and intra-rater measurements for wound surface area and volume were compared using the ICC and differences from the overall mean plotted on Bland-Altman graphs.

Results

The interclass co-efficient (ICC) for inter-rater reliability in measuring surface area was 0.958 (95% CI 0.919-0.981, p < 0.005). The intra-rater reliability when measuring wound surface area was 0.996 (95% CI 0.993-0.998, p < 0.005). For wound volume, the ICC for inter-rater reliability was 0.925 (95% CI 0.857-0.967, p < 0.005) and 0.999 (95% CI 0.998-0.999, p < 0.005) for intra-user reliability. 5.5% of measurements were outside 2 SD of the mean for wound volume.

Conclusions

3D imaging offers a quick, reliable, and easy to use solution to measuring wounds. We have shown it is a reliable and reproducible method of measuring wounds between different clinicians.

1023 An Audit of The Prevalence of Frailty and The Impact on Surgical Management and Resource Use, For Vascular Inpatients Using the National Vascular Registry (NVR) Frailty Classifications

Aim

To determine if the NVR frailty score was being routinely collected on all relevant vascular patients on admission, identify the prevalence of frailty in vascular inpatients and determine if frailty was associated with a higher mortality and morbidity.

Method

A prospective audit of consecutive patients admitted onto the vascular ward who were eligible for inclusion on the NVR. Data was collected from electronic patient records and paper case notes between November 2019 and February 2020. The primary outcome was completeness of frailty assessment. Secondary outcomes were prevalence of frailty and mortality and morbidity associated with frailty score.

Results

Frailty status was documented in 65% of patients. 43% (28/65) were assessed to be frail. The 30-day mortality rate was 1.53% (1/65). 26.15% (17/65) had one or more complication. The commonest complications were graft occlusions, acute kidney injury, hospital acquired pneumonia and groin infections. 93.84% (61/65) were discharged home. There was no correlation between frailty and number of post-operative complications (p = 0.394), length of stay (p = 0.171) or mortality (p = 0.371).

Conclusions

This audit found frailty assessment is poorly assessed and the current NVR frailty classification did not correlate to increase mortality or morbidity in this patient cohort.

Association of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and Ureaplasma species infection and organism load with cervicitis in north Indian population

Cervicitis is predominantly caused by Neisseria gonorrhoeae and Chlamydia trachomatis, which accounts for almost half of all the cases of cervicitis. The role of newer organisms like Mycoplasma genitalium and Ureaplasma sp. and association of bacterial load with cervicitis are also not well established. So the study aimed to determine the relative frequency of these organisms and their load in association with cervicitis cases from north India. A case-control study involving 300 women was conducted using quantitative real-time PCR from endocervical swabs for identification of organisms and quantification of bacterial load. Among 150 cervicitis cases, C. trachomatis, N. gonorrhoeae, M. genitalium and Ureaplasma parvum were detected in 5 (3·3%), 10 (6·6%), 37(24·6%) and 47 (31·3%) respectively. Old age (<0·001, chi-squared test) and irregular menstrual cycles (<0·001, chi-squared test) were significantly associated with cervicitis. M genitalium was the only organism to be associated significantly with cervicitis with regard to age (<0·031) and symptoms like discharge (P < 0·033, chi-squared test) and dysuria (P < 0·044, chi-squared test) in multivariate analysis. Our finding suggests that the bacterial load of these organisms is not significantly associated with cervicitis. However, we found significant association of M. genitalium infection with clinical characteristics of cervicitis cases.

Diagnostic accuracy of TB-LAMP assay in patients with pulmonary tuberculosis-a case-control study in northern India

SETTING

A tertiary care hospital in North India.

OBJECTIVE

Tuberculosis (TB) remains a major public health problem in developing countries. The diagnosis of tuberculosis is still challenging in primary care settings in endemic countries like India. WHO has endorsed loop mediated isothermal amplification assay (LAMP) for TB as a replacement for smear microscopy for peripheral settings, however, more data is required to establish the specificity of this modality for the diagnosis of TB. In this study we aim to determine the diagnostic accuracy of the TB-LAMP assay in pulmonary tuberculosis.

DESIGN

A total of 236 patients (117 cases suspected of TB and 119 patients with non-TB pulmonary disease) were enrolled between February to July, 2018. Microbiological workups consisting of mycobacterial smear microscopy, culture, Xpert MTB/Rif and TB-LAMP were performed.

RESULTS

From 236 samples, 18 (7.6%) were excluded from the study. TB-LAMP and Xpert MTB/RIF were positive in 46 (21.1%) and 49 (22.5%) of the samples, respectively. The sensitivity of Xpert MTB/RIF and TB-LAMP, when culture was taken as a reference standard, was 90% (95%CI: 78.2-96.7) and 82% (95%CI: 68.6-91.4), respectively. The specificity, positive predictive value (PPV), and negative predictive value (NPV) of TB-LAMP assay were 96.8% (95%CI: 92.8-98.9), 89.1% (95%CI: 77.4-95.2), and 94.4% (95%CI: 90.4-96.5), respectively.

CONCLUSION

The TB-LAMP assay showed a good specificity and sensitivity for detection ofM. tuberculosis in adults, however, for programmatic implementation, more studies are required to be conducted at peripheral level healthcare settings.

Diagnostic accuracy of Xpert MTB/RIF ultra for detection of Mycobacterium tuberculosis in children: a prospective cohort study

The Xpert MTB/RIF Ultra is a recent advancement in molecular diagnostics of tuberculosis (TB) with higher sensitivity compared to its predecessor, the Xpert MTB/RIF assay. Prospective studies evaluating the performance of Xpert MTB/RIF Ultra in children with suspected TB are lacking. In this study, we evaluated the Xpert MTB/RIF Ultra for detection of Mycobacterium tuberculosis in samples from 156 children, of which one was excluded from the analysis. Of the remaining 155 samples, 6·5% (10/155), 21·3% (33/155), 20% (31/155) and 21·9% (34/155) were positive by smear examination, MGIT culture, Xpert MTB/RIF and Xpert MTB/RIF Ultra, respectively. The Xpert MTB/RIF and Xpert MTB/RIF Ultra had a similar overall sensitivity of 81·8% (95% CI: 64·5-93) and 84·8% (95% CI: 68·1-94·9), respectively. In suspected pediatric TB patients, the Xpert MTB/RIF Ultra had higher sensitivity compared to the Xpert MTB/RIF (72·7 vs 63·6). The AUC (area under the curve) of 0·905 for the Xpert MTB/RIF and 0·893 for the Xpert MTB/RIF Ultra indicate similar and good overall performance. Both Xpert assays were found to be equally efficient, however Xpert MTB/RIF Ultra showed better detection rate in suspected TB cases.

Low carbohydrate ketogenic therapy as a metabolic treatment for binge eating and ultraprocessed food addiction

PURPOSE OF REVIEW

The aim of this study was to highlight the recent advancements and future directions for potential use of a low carbohydrate ketogenic dietary approach to treat binge eating and ultraprocessed food addiction. Herein, we explore proposed mechanisms of why a diet low in refined carbohydrates, processed sugar and higher fat content may be helpful in alleviating symptoms.

RECENT FINDINGS

Emerging evidence suggests there may be a metabolic role in development of maladaptive eating. These findings broaden our understanding of eating psychopathology causes. Ultraprocessed, refined or high glycemic index carbohydrates are a possible trigger mediating neurochemical responses similar to addiction. The carbohydrate-insulin model of obesity supports observations of these foods triggering abnormal blood sugar and insulin spikes subsequently leading to changes in metabolic and neurobiological signaling. This results in overeating symptoms and hunger exacerbation, which differs from observed effects of healthy fat consumption and lack of similar insulin spikes. As supported in recent case series, significantly reducing or abstaining from these addictive-like ultraprocessed foods and highly refined carbohydrates could be considered a treatment approach.

SUMMARY

The current review highlights recent and pertinent evidence with respect to theoretical and practical application of low carbohydrate ketogenic therapeutic approaches for ultraprocessed food addiction and binge eating symptoms. VIDEO ABSTRACT:.

Ketogenic diet as a metabolic treatment for mental illness

PURPOSE OF REVIEW

Ketogenic diets, which have been used to treat drug-refractory paediatric epilepsy for over 100 years, are becoming increasingly popular for the treatment of other neurological conditions, including mental illnesses. We aim to explain how ketogenic diets can improve mental illness biopathology and review the recent clinical literature.

RECENT FINDINGS

Psychiatric conditions, such as schizophrenia, depression, bipolar disorder and binge eating disorder, are neurometabolic diseases that share several common mechanistic biopathologies. These include glucose hypometabolism, neurotransmitter imbalances, oxidative stress and inflammation. There is strong evidence that ketogenic diets can address these four fundamental diseases, and now complementary clinical evidence that ketogenic diets can improve the patients' symptoms.

SUMMARY

It is important that researchers and clinicians are made aware of the trajectory of the evidence for the implementation of ketogenic diets in mental illnesses, as such a metabolic intervention provides not only a novel form of symptomatic treatment, but one that may be able to directly address the underlying disease mechanisms and, in so doing, also treat burdensome comorbidities (see Video, Supplementary Digital Content 1, http://links.lww.com/COE/A16, which summarizes the contents of this review).

Treating binge eating and food addiction symptoms with low-carbohydrate Ketogenic diets: a case series

BACKGROUND

Many patients with obesity and comorbid binge eating symptoms present with the desire to lose weight. Although some studies suggest that dietary restriction can exacerbate binge eating, others show dietary restriction is associated with significant reductions in binge eating. The effect of a particular type of dieting on binge eating, the ketogenic diet (a high fat, moderate protein, very low carbohydrate diet), is not known.

CASE PRESENTATIONS

We report on the feasibility of a low-carbohydrate ketogenic diet initiated by three patients (age 54, 34, and 63) with obesity (average BMI 43.5 kg/m2) with comorbid binge eating and food addiction symptoms. All patients tolerated following the ketogenic diet (macronutrient proportion 10% carbohydrate, 30% protein, and 60% fat; at least 5040 kJ) for the prescribed period (e.g., 6-7 months) and none reported any major adverse effects. Patients reported significant reductions in binge eating episodes and food addiction symptoms including cravings and lack of control as measured by the Binge-Eating Scale, Yale Food Addiction Scale, or Yale-Brown Obsessive-Compulsive Scale modified for Binge Eating, depending on the case. Additionally, the patients lost a range of 10-24% of their body weight. Participants reported maintenance of treatment gains (with respect to weight, binge eating, and food addiction symptoms) to date of up to 9-17 months after initiation and continued adherence to diet.

CONCLUSIONS

Although the absence of control cases precludes conclusions regarding the specific role of ketogenic diets versus other forms of dietary restriction, this is the first report to demonstrate the feasibility of prescribing a ketogenic diet for patients with obesity who report binge eating and food addiction symptoms. Further research should seek to reproduce the observed effects in controlled trials as well as to explore potential etiologies.

Loop mediated isothermal amplification assay for detection of Trichomonas vaginalis in vaginal swabs among symptomatic women from North India

Trichomonas vaginalis is one of the most common curable sexually transmitted pathogens infecting both men and women worldwide. Unlike traditional methods such as microscopy and culture, nucleic acid amplification tests rapidly detect this agent, assisting in treatment. Conventional polymerase chain reaction (PCR), the loop-mediated isothermal amplification (LAMP), and the Xpert TV assay were evaluated using 28 microscopy positive T. vaginalis samples and 125 microscopy negative samples from symptomatic females of reproductive age. The sensitivity of all tests was 100% and the specificity was 100%, 100%, and 99·2% for PCR, Xpert TV, and LAMP, respectively. The inter-rater reliability was excellent for PCR: Xpert TV (kappa-coefficient = 1) and good for LAMP assay: Xpert TV/PCR (kappa-coefficient = 0·98) and conventional PCR: LAMP (kappa-coefficient = 0·98). The study highlights the importance of PCR for screening T. vaginalis in women, particularly in laboratories where the Xpert-TV assay is not available or not affordable. The LAMP assay showed a lower positive predictive value which merits further evaluation. SIGNIFICANCE AND IMPACT OF THE STUDY: Trichomonas vaginalis is a common sexually transmitted pathogen associated with considerable morbidity and risk of complications. Due to the limitations of traditional diagnostic modalities, three molecular assays were compared: conventional polymerase chain reaction (PCR), Xpert TV assay, and loop mediated isothermal amplification (LAMP) assay for detecting T. vaginalis in symptomatic females. All tests had a sensitivity of 100% and the inter-rater reliability was excellent for PCR: Xpert TV, and good for LAMP assay: Xpert TV/PCR. The translational impact of this study lies in the possible use of conventional PCR and LAMP in laboratories where the Xpert TV assay is not available or not affordable.

Hospitalization due to community-acquired pneumonia in patients with chronic obstructive pulmonary disease: incidence, epidemiology and outcomes

OBJECTIVES

Community-acquired pneumonia (CAP) is an important complication in patients with chronic obstructive pulmonary disease (COPD). This study aimed to define incidence, and outcomes of COPD patients hospitalized with pneumonia in the city of Louisville, and to estimate the burden of disease in the US population.

METHODS

This was a secondary analysis of a prospective population-based cohort study of residents in Louisville, Kentucky, 40 years old and older, from 1 June 2014 to 31 May 2016. All adults hospitalized with CAP were enrolled. The annual incidence of pneumonia in COPD patients in Louisville was calculated and the total number of adults with COPD hospitalized in the United States was estimated. Clinical outcomes included time to clinical stability (TCS), length of hospital stay (LOS) and mortality.

RESULTS

From a Louisville population of 18 246 patients with COPD, 3419 pneumonia hospitalizations were documented during the 2-year study. The annual incidence was 9369 patients with pneumonia per 100 000 COPD population, corresponding to an estimated 506 953 adults with COPD hospitalized due to pneumonia in the United States. The incidence of CAP in patients without COPD was 509 (95% CI 485-533) per 100 000. COPD patients had a median (interquartile range) TCS and LOS of 2 (1-4) and 5 (3-9) days respectively. The mortality of COPD patients during hospitalization, at 30 days, 6 months and 1 year was 193 of 3419 (5.6%), 400 of 3374 (11.9%), 816 of 3363 (24.3%) and 1104 of 3349 (33.0%), respectively.

CONCLUSIONS

There was an annual incidence of 9369 cases of hospitalized CAP per 100 000 COPD patients in the city of Louisville. This was an approximately 18-fold greater incidence of CAP in COPD patients than in those without COPD.

A loop-mediated isothermal amplification assay for the diagnosis of pulmonary tuberculosis

Quantitated Mycobacterium tuberculosis (M.tb) H37Rv DNA was used to analyse the sensitivity and the specificity was assessed using DNA isolated from the reference strain H37Rv, 12 nontuberculous mycobacterium (NTM) species and five nonmycobacterium species. Furthermore, performance of the assay was evaluated on the sputum samples and compared with smear microscopy, culture and PCR. mpt64 (also called mpb64 or Rv1980c) loop-mediated isothermal amplification (LAMP) successfully detected 1 pg DNA within 40 min and successfully rejected NTMs and other bacterial species tested. It specifically detected all the 119 confirmed TB cases and 100 of the 104 control cases. The resulting sensitivity and specificity of LAMP assay was found to be 100% (95% CI: 96·79-100%) and 96·15% (95% CI; 90·44-98·94%) respectively. SIGNIFICANCE AND IMPACT OF THE STUDY: Loop-mediated isothermal amplification (LAMP) is a technique for isothermal DNA amplification suitable for cost-limited settings as it prevents the use of sophisticated instruments. Using mpt64 antigenic protein gene, we developed a LAMP assay especially for organisms of the M. tuberculosis complex. mpt64 LAMP assay showed 100% sensitivity and detected all the bacteriologically and clinically positive TB cases not detected by smear, culture or PCR methods.

Evaluation of the TB-LAMP assay for the rapid diagnosis of pulmonary tuberculosis in Northern India

SETTING

A tertiary care hospital in North India.

OBJECTIVE

To evaluate a commercial kit-based loop-mediated isothermal amplification (TB-LAMP) assay for the diagnosis of pulmonary tuberculosis (PTB).

DESIGN

A total of 530 patients presenting with PTB symptoms were enrolled and one sputum sample was collected from each patient. The TB-LAMP assay (Loopamp™ MTBC Detection kit) was performed on the raw sputum sample. The remaining sample was used for smear microscopy and mycobacterial culture. A cartridge-based nucleic acid amplification test (NAAT, Xpert® MTB/RIF assay) was also performed on the processed pellet.

RESULTS

The sensitivity and specificity of the TB-LAMP assay in culture-positive samples obtained from 453 patients presenting with PTB symptoms (77 specimens were excluded) were respectively 100% (95%CI 94.7-100) and 99.2% (95%CI 97.8-99.8). The sensitivity and specificity of Xpert in culture-positive samples were respectively 82.6% (95%CI 71.5-90.6) and 94.9% (95%CI 92.2-96.8). A concordance of 0.75 was obtained between the two NAATs (TB-LAMP assay and Xpert) using the κ statistic.

CONCLUSION

The TB-LAMP assay showed high sensitivity and specificity with limited requirement of testing infrastructure, and is thus a promising diagnostic tool for TB diagnosis in resource-poor settings.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P &lt; 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

GenoType MTBDRplus assay for screening and characterization of isoniazid and rifampicin resistance-associated mutations in multidrug-resistant Mycobacterium tuberculosis from India

Multidrug resistant tuberculosis (MDR-TB) is rising and the World Health Organization has recommended the line probe assay (LPA) for screening. In this study we assess LPA at a tertiary care centre from North India in 1758 samples from suspected MDR-TB cases. All smear-positive and/or Mycobacterium tuberculosis culture confirmed cases (n = 1170) were subjected to the GenoType-MTBDR assay. Amongst these the majority were retreatment cases, smear-positive at diagnosis (n = 637). An MDR prevalence of 7·8% was observed with the highest cases reported amongst MDR contacts (33·3%). The most common rifampicin resistance encoding mutation seen overall and in individual patient groups was H531L (53·3%). A higher prevalence of H526D mutation was observed in retreatment cases, smear-positive at 4 months of anti-tubercular therapy vs other patient groups (P = 0·052). The most common mutation encoding isoniazid resistance was S315T1 in the katG (79·9%) and C-15T in the inhA gene (91·1%). Thirty rifampicin and nine isoniazid resistant isolates had wild type gene deletion but no detectable mutation by LPA. Although LPA is a practical and rapid screening method for most mutations expected to result in MDR-TB, we observed that it only detects the known major mutations in specific genes. Such studies can provide the knowledge required to formulate customized strips based on prevalent mutations in our region and in specific patient groups.

SIGNIFICANCE AND IMPACT OF THE STUDY

To the best of our knowledge this is the largest study evaluating the GenoType-MTBDR line probe assay from India. We have studied the prevalence of mutations encoding rifampicin and isoniazid resistance in different patient groups based on criteria for multidrug resistance (MDR) suspicion. The translational impact of this study is in the design of customized country- or region-wise line probe assay strips. The identification of a few mutations in particular patient groups and the detection of wild type deletion mutants with no observable mutations both point toward the need for such customization enabling us to combat the rising trend of MDR tuberculosis.

Polychlorinated biphenyl and polybrominated diphenyl ether profiles in serum from cattle, sheep, and goats across California

It has been previously been shown by our lab and others that persistent organic pollutants, such as polychlorinated biphenyls (PCBs) and polybrominated diphenyl ethers (PBDEs), are contaminants in milk produced for human consumption. To further this research we determined the concentration of 21 PCB and 14 PBDE congeners in livestock serum, mainly bovine, across California. Congeners were extracted from serum using solid phase extraction (SPE), cleaned up by silica cartridge and quantified using gas chromatography-triple quadruple mass spectrometry. We detected significant differences among species and the production class of cattle (beef or dairy). The sum of all 21 PCB congeners (ΣPCBs) in caprine and ovine sera had a mean value of 9.26 and 9.13 ng/mL, respectively, compared to 3.98 ng/mL in bovine sera. The mean value for the sum of all 14 PBDE congeners (ΣPBDEs) in caprine and ovine sera was 2.82 and 2.39 ng/mL, respectively, compared to 0.91 ng/mL in bovine sera. Mean ΣPCBs in dairy cattle was 5.92 ng/mL compared to 2.70 ng/mL in beef cattle. Mean ΣPBDEs in dairy cattle was 1.33 ng/mL compared to 0.70 ng/mL in beef cattle. There were no regional differences in the ΣPCBs or ΣPBDEs in cattle distributed across California. These results highlight the fact that livestock are still being exposed to these pollutants yet little is known about where this exposure may be coming from.

Loop-mediated isothermal amplification assay for detection of Mycobacterium tuberculosis complex in infertile women

BACKGROUND

Female genital tuberculosis (FGTB) has a profound impact on the reproductive health of patients including infertility. Conventional diagnostic techniques have low sensitivity and specificity as well as long turnaround time. There is a need of developing newer, rapid and practically adaptable technique, especially in low-income countries.

OBJECTIVE

To standardize and evaluate loop-mediated isothermal amplification (LAMP) technique for diagnosis of FGTB.

METHODS

A total of 300 endometrial biopsy samples from infertile females were subjected to Ziehl-Neelsen (ZN) staining, Lowenstein-Jensen culture, automated culture (BACTEC mycobacterial growth indicator tube), histopathological examination (HPE), nucleic acid amplification by polymerase chain reaction (PCR) and LAMP technique. Composite gold standard (either smear/culture/HPE/PCR positive) was considered for calculation of outcome parameters.

RESULTS

The observed sensitivities of ZN smear, culture, HPE, PCR and LAMP were 2.94%, 10.29%, 8.82%, 95.59% and 66.18%, respectively. Overall concordance between PCR and LAMP was 63%, which shows a good agreement.

CONCLUSION

This study is the first to evaluate LAMP in the diagnosis of FGTB and found it to be a rapid and convenient technique, especially in low resource endemic settings.

Hemorrhagic Herpes Simplex Virus Type 1 Nephritis: An Unusual Cause of Acute Allograft Dysfunction

Interstitial nephritis due to viruses is well-described after solid organ transplantation. Viruses implicated include cytomegalovirus; BK polyomavirus; Epstein-Barr virus; and, less commonly, adenovirus. We describe a rare case of hemorrhagic allograft nephritis due to herpes simplex virus type 1 at 10 days after living donor kidney transplantation. The patient had a favorable outcome with intravenous acyclovir and reduction of immunosuppression.

Temporal IgG Subtype Changes in Recurrent Idiopathic Membranous Nephropathy

Determination of the IgG subtypes within the immune deposits in membranous nephropathy (MN) may be helpful in the differential diagnosis. IgG4 is the predominant subtype in idiopathic MN and recurrent MN, while IgG1, IgG2, and IgG3 subtypes are more common in secondary MN and de novo disease in the allograft. The temporal change of IgG subclasses in individual patients and its correlation with clinical variables have not been studied. We reviewed all posttransplantation protocol and indication biopsies (49) in 18 patients with recurrent MN who underwent transplantation at our center between 1998 and 2013 and performed IgG subtyping (IgG1-4). We tested serum for M-type phospholipase A2 receptor (PLA2 R) autoantibodies or performed PLA2 R antigen staining on the kidney biopsy. IgG4 was the (co)dominant IgG subtype in 10 of 14 biopsies at the diagnosis of recurrence regardless of PLA2 R association. In 8 of 12 transplantations with serial biopsies, the (co)dominant subtype did not change over time. There was a trend toward IgG1 and IgG3 (co)dominance in biopsies >1 year from recurrence and more IgG1 (co)dominant subtyping in the setting of more-advanced EM deposits. Treatment with rituximab did not affect the IgG subtype. In conclusion, the dominant IgG subtype did not change over time in recurrent MN.

Distribution and association of Mycobacterium tuberculosis CAS lineage with multidrug resistance in North India

SETTING

A tertiary care hospital in North India.

OBJECTIVES

To determine the prevalence of different genotypes and examine their association with drug resistance among clinical isolates of Mycobacterium tuberculosis from the northern region of India.

DESIGN

We analysed 100 clinical isolates of M. tuberculosis using mycobacterial interspersed repetitive units genotyping and TbD1 analysis.

RESULTS

The analysis revealed that 34% of strains belonged to the Delhi/CAS (TbD1-) lineage, 32% had unknown patterns (27 TbD1-, 5 TbD1+), 18% were of Beijing genotype (TbD1-) and 11% were of EAI lineages (TbD1+). Twenty-one strains were multidrug-resistant tuberculosis (MDR-TB), 9 of which belonged to the Delhi/CAS lineage, 4 were of Beijing lineage, 6 were of unknown pattern and one was of EAI lineage. Our meta-analysis showed the overall proportion of CAS lineage to be 42.96% (95%CI 33-52); the CAS lineage had no association with MDR-TB (OR 0.89, 95%CI 0.66-1.20).

CONCLUSION

The study highlights the high proportion of CAS lineage strains and absence of association with MDR-TB. The distribution and identification of different genotypes of M. tuberculosis could help in better understanding the factors that influence disease transmission and drug resistance.

Paired kidney exchange transplantation: Maximizing the donor pool

In the last decade, paired kidney exchange (PKE) transplantation has gained popularity worldwide as a viable alternative for end stage renal disease (ESRD) patients who have incompatible or sensitized donors. This study presents our experience with PKE transplantation and compares outcome between PKE and non-PKE renal transplant recipients. Between February 2010 and November 2013, 742 transplants were performed, of which 26 (3.5%) were PKE transplantations. All were two-way exchanges. PKE recipients were significantly older than non-PKE (46.73 ± 9.71 vs. 40.08 ± 13.36 years; P = 0.012) while donor ages were comparable. PKE patients had significantly higher number of HLA mismatches (5.03 ± 1.14 vs. 3.49 ± 1.57; P < 0.0001). After a median follow-up of 20 months (range: 3–47 months), there was no significant difference in patient survival (PKE 96.16% vs. non-PKE 96.65%; P = 0.596) and death censored graft survival (PKE 96.16% vs. non-PKE 96.37%; P = 1). Mean serum creatinine at 1 month and at last follow-up was lower in PKE versus non-PKE group (0.98 ± 0.33 vs. 1.3 ± 0.61 mg/dl; P = 0.008 and 0.96 ± 0.30 vs. 1.27 ± 0.57 mg/dl, P = 0.006, respectively). Biopsy proven acute rejection rate was 11.5% in PKE group and 16.89% in non-PKE patients (P = 0.6). To conclude, paired kidney donation is an excellent way of increasing the donor pool and needs to be promoted to overcome the shortage of suitable kidney in our country.

Direct costs of first-generation protease inhibitors for the treatment of genotype 1 chronic hepatitis C viral infection

To evaluate the cost-effectiveness of Hepatitis C therapy, robust real-world data are needed to understand the costs and benefits of treatment alternatives. The objective of this study was to evaluate the true direct cost of treatment in an unselected sequential population of patients treated at a tertiary care centre for hepatitis C virus genotype 1. A total of 200 consecutive patients were treated with interferon, ribavirin and a first-generation direct-acting antiviral agent (DAA) between 2011 and 2013. A total of 41% had cirrhosis, 31% were prior relapsers, and 41% were prior partial or null responders. Costs used were wholesale acquisition cost prices for medications, average hospital costs per day for each diagnosis code based on US inpatient hospital charges. All costs were adjusted to 2013 dollars. Sustained virologic response (SVR) was achieved in 97 patients (48.5%). A total of 14% experienced relapse, 19% breakthrough or nonresponse, and 18.5% discontinued secondary to side effects. Twenty per cent of patients had at least one hospitalization attributable to a complication of therapy. Thirty-seven per cent of patients required erythropoietin-stimulating agents, 16% received filgastrim, and 15% needed a red blood cell transfusion. The mean overall cost of treatment was $83,851 per patient. The cost per SVR was $172,889; $266,670 for patients with cirrhosis. The costs per SVR after treatment with first-generation DAAs are dependent on the stage of disease and therapy side effects. These real-world costs significantly exceed those described in prior cost-effectiveness assessments and should be used instead for future studies.

Preferential decoding of emotion from human non-linguistic vocalizations versus speech prosody

This study used event-related brain potentials (ERPs) to compare the time course of emotion processing from non-linguistic vocalizations versus speech prosody, to test whether vocalizations are treated preferentially by the neurocognitive system. Participants passively listened to vocalizations or pseudo-utterances conveying anger, sadness, or happiness as the EEG was recorded. Simultaneous effects of vocal expression type and emotion were analyzed for three ERP components (N100, P200, late positive component). Emotional vocalizations and speech were differentiated very early (N100) and vocalizations elicited stronger, earlier, and more differentiated P200 responses than speech. At later stages (450-700ms), anger vocalizations evoked a stronger late positivity (LPC) than other vocal expressions, which was similar but delayed for angry speech. Individuals with high trait anxiety exhibited early, heightened sensitivity to vocal emotions (particularly vocalizations). These data provide new neurophysiological evidence that vocalizations, as evolutionarily primitive signals, are accorded precedence over speech-embedded emotions in the human voice.

Intra-ocular lens opacification in the anterior chamber leading to loss of vision in an adolescent

OBJECTIVE

To report a rare case of intraocular lens (ACIOL) opacification in the anterior chamber in an adolescent and to discuss the possible mechanism of its occurrence and the ways of its prevention.

CASE

A 16-year-old male underwent cataract surgery for developmental cataract with placement of a foldable posterior chamber IOL in the anterior chamber. There was subsequent opacification of the IOL, which was replaced by a scleral fixated posterior chamber intraocular lens. The post-operative visual acuity improved to 6/18.

CONCLUSION

The posterior chamber IOL implanted in the anterior chamber can get opacified possibly due to postoperative intraocular inflammation.

Intracellular proliferation of S. aureus in osteoblasts and effects of rifampicin and gentamicin on S. aureus intracellular proliferation and survival

Staphylococcus aureus is the most clinically relevant pathogen regarding implant-associated bone infection and its capability to invade osteoblasts is well known. The aim of this study was to investigate firstly whether S. aureus is not only able to invade but also to proliferate within osteoblasts, secondly to delineate the mechanism of invasion and thirdly to clarify whether rifampicin or gentamicin can inhibit intracellular proliferation and survival of S. aureus. The SAOS-2 osteoblast-like cell line and human primary osteoblasts were infected with S. aureus EDCC5055 and S. aureus Rosenbach 1884. Both S. aureus strains were able to invade efficiently and to proliferate within human osteoblasts. Immunofluorescence microscopy showed intracellular invasion of S. aureus and transmission electron microscopy images could demonstrate bacterial division as a sign of intracellular proliferation as well as cytosolic bacterial persistence. Cytochalasin D, the major actin depolymerisation agent, was able to significantly reduce S. aureus invasion, suggesting that invasion was enabled by promoting actin rearrangement at the cell surface. 7.5 μg/mL of rifampicin was able to inhibit bacterial survival in SAOS-2 cells with almost complete elimination of bacteria after 4 h. Gentamicin could also kill intracellular S. aureus in a dose-dependent manner, an effect that was significantly lower than that observed using rifampicin. In conclusion, S. aureus is not only able to invade but also to proliferate in osteoblasts. Invasion seems to be associated with actin rearrangement at the cell surface. Rifampicin is effective in intracellular eradication of S. aureus whereas gentamicin only poorly eliminates intracellularly replicating bacteria.