Comparison of chest radiographs against minimum intensity projection reconstruction computed tomography scans for detection of airway stenosis in children with lymphobronchial tuberculosis

BACKGROUND

Ideally, suspected airway compression in symptomatic children with lymphobronchial tuberculosis (TB) would be diagnosed using modern computed tomography (CT) assisted by coronal minimum intensity projection (MinIP) reconstructions. However, in TB-endemic regions with limited resources, practitioners rely on conventional radiography for diagnosing TB and its complications. Furthermore, airway compression detected on conventional radiographs would upgrade a patient into the severe category according to the new World Health Organization guidelines, precluding the patient from shorter treatment protocols. The accuracy of conventional radiographs in the context of detecting airway compression in children with TB has not been specifically evaluated against an imaging gold standard.

OBJECTIVE

We aimed to compare frontal chest radiographs against thick-slab angled coronal CT MinIP in identifying airway stenosis at ten specific sites and to determine observer agreement between the modalities regarding the degree of stenosis.

MATERIALS AND METHODS

This retrospective cross-sectional study compared chest radiographs with standardized angled coronal CT MinIP in children with symptomatic lymphobronchial TB at ten predetermined airway locations. Chest radiographs were evaluated by one pediatric radiologist and CT MinIP reconstructions were independently interpreted by three readers. Sensitivity and specificity were calculated using CT MinIP as the gold standard. Stenosis was graded as 1 for mild (1-50%), 2 for moderate (51-75%), 3a for severe (76-99%), and 3b for total occlusion (100%). Agreement between the two modalities regarding severity of stenosis was calculated using the kappa coefficient for each affected site.

RESULTS

A total of 37 patients were included in the study. The median age of patients was 14.3 months (interquartile range 8.0-23.2). Three hundred and seventy individual bronchi (10 from each of the 37 patients) were evaluated for stenosis. Chest radiographs showed that 31 out of 37 (84%) patients had stenosis in at least one of ten evaluated sites, most commonly the left main bronchus and bronchus intermedius, and this was confirmed via CT MinIP. The gold standard (CT MinIP) demonstrated stenosis in at least one of ten sites in all 37 patients (100%). Left main bronchus stenosis was detected by chest radiography with a 92.9% sensitivity and 100% specificity. Sensitivity and specificity for bronchus intermedius stenosis were 80% and 75%, respectively. There was substantial agreement for grade of stenosis between chest radiographs and CT (kappa=0.67) for the left main bronchus and moderate agreement (kappa=0.58) for the bronchus intermedius. Severe stenosis was found in 78 bronchi on CT compared to 32 bronchi (Grade 3a: 9, Grade 3b: 23) on chest radiographs.

CONCLUSION

The diagnosis of pulmonary TB in children continues to rely heavily on imaging, and we have shown that in young children, chest radiographs had a high sensitivity and specificity for detecting airway stenosis at certain anatomical sites, when adequately visualized, resulting from tuberculous lymph node compression at left main bronchus and bronchus intermedius. For most sites, the interobserver agreement was poor. Stenosis of the left main bronchus and bronchus intermedius should be the focus of chest radiograph interpretation and can assist both diagnosis and classification of patients for treatment.

A comparison of chest radiographic findings in human immunodeficiency virus-positive and -negative children with pulmonary tuberculosis

AIM

To compare chest radiography (CXR) findings in human immunodeficiency virus (HIV)-positive and HIV-negative children who had microbiologically confirmed pulmonary tuberculosis (PTB).

MATERIALS AND METHODS

Retrospective analysis of CXRs from children with known HIV status and microbiologically confirmed PTB (culture or GeneXpert Xpert MTB/RIF positive), who were hospitalised or seen at a primary healthcare centre over a 5-year period. Radiological findings were compared according to HIV and nutritional status.

RESULTS

CXRs of 130 children were analysed from 35 (27%) HIV- positive and 95 (73%) HIV-negative children with confirmed PTB, median age 45.7 months (interquartile range [IQR] 18-81.3 months). CXR changes consistent with PTB were reported in 21/35 (60%) of HIV-positive and 59/95 (62%) of HIV-negative patients, (p=0.81). Normal CXR was identified in 3/35 (8.6%) of HIV-positive and 5/95 (5.3%) of HIV-negative patients (p=0.81). Airway compression was present in 3/35 (8.6%) of HIV-positive and 7/95 (7.4%) of HIV-negative patients (p>0.99). Overall, lymphadenopathy was identified in 42/130 (32.3%) of patients, 11/35 (31.4 %) were HIV-positive compared with 31/95 (32.6%) HIV-negative patients. Airspace consolidation was present in 60% of both HIV-positive (21/35) and HIV-negative patients (57/95). Pleural effusion was present in 2/35 (5.7 %) of HIV-negative and 9/95 (9.5 %) of HIV-negative patients. There were no statistically significant radiological differences by HIV group.

CONCLUSION

There were no significant differences in the CXR findings between the HIV-positive and HIV-negative children with confirmed PTB.

Comparison of single coronal thick-slab minimum intensity projection with flexible bronchoscopy for airway compression in children with lymphobronchial tuberculosis

AIM

To generate standardised coronal minimum intensity projection (MinIP) computed tomography (CT) reconstructions, and compare these with flexible bronchoscopy in children with lymphobronchial tuberculosis (LBTB).

MATERIALS AND METHODS

Standardised coronal MinIP reconstructions were performed from CT images in children with LBTB and the findings of three readers were compared with the reference standard, flexible bronchoscopy (FB), regarding airway narrowing. Intraluminal lesions, the site of the stenosis, and the degree of stenosis were also evaluated. The length of stenosis was evaluated by CT MinIP only.

RESULTS

Sixty-five children (38 males; 58.5% and 27 females; 41.5%), with ages ranging from 2.5 to 144 months were evaluated. Coronal CT MinIP demonstrated a sensitivity of 96% and specificity of 89% against FB. The most common site of stenosis was the bronchus intermedius (91%), followed by the left main bronchus (85%), the right upper lobe bronchus RUL (66%), and the trachea (60%).

CONCLUSION

Coronal CT MinIP reconstruction is useful in demonstrating airway stenosis in children with lymphobronchial TB, with high sensitivity and specificity. CT MinIP had additional advantages over FB in that it allowed objective measurement of the diameter of stenosis, measurement of the length of stenosis, and evaluation of post-stenotic segments of the airways and lung parenchymal abnormalities.

Comparison of chest radiograph findings in ambulatory and hospitalized children with pulmonary tuberculosis

BACKGROUND

The diagnosis of childhood tuberculosis (TB) is, in many instances, solely reliant on chest radiographs (CXRs), as they are often the only diagnostic tool available, especially in TB-endemic areas. Accuracy and reliability of CXRs for detecting TB lymphadenopathy may vary between groups depending on severity of presentation and presence of parenchymal disease, which may obscure visualization.

OBJECTIVE

To compare CXR findings in ambulatory versus hospitalized children with laboratory confirmed pulmonary TB versus other lower respiratory tract infections (LRTI) and test inter-rater agreement for these findings.

MATERIALS AND METHODS

Retrospective review, by two pediatric radiologists, of CXRs performed on children < 12 years old referred for evaluation of LRTI with clinical suspicion of pulmonary TB in inpatient and outpatient settings. Each radiologist commented on imaging findings of parenchymal changes, lymphadenopathy, airway compression and pleural effusion. Frequency of imaging findings was compared between patients based on location and diagnosis and inter-rater agreement was determined. Accuracy of radiographic diagnosis was compared to laboratory testing which served as the gold standard.

RESULTS

The number of enrolled patients was 181 (54% males); 69 (38%) were ambulatory and 112 (62%) were hospitalized. Of those enrolled, 87 (48%) were confirmed to have pulmonary TB, while 94 (52%) were other LRTI controls. Lymphadenopathy and airway compression were more common in TB patients than other LRTI controls, regardless of patient location. Parenchymal changes and pleural effusion were more common in hospitalized than ambulatory patients, regardless of patient diagnosis. Agreement for parenchymal changes was higher in the hospitalized group (kappa [κ] = 0.75), while agreement for lymphadenopathy (κ = 0.65) and airway compression (κ = 0.68) was higher in the ambulatory group. The specificity of CXRs for TB diagnosis (> 75%) was higher than the sensitivity (< 50%) for both ambulatory and hospitalized groups.

CONCLUSION

Higher frequency of parenchymal changes among hospitalized children may conceal specific imaging findings of TB such as lymphadenopathy, contributing to the poor reliability of CXRs. Despite this, the high specificity of CXRs shown in our results is encouraging for continued use of radiographs for TB diagnosis in both settings.

Clinicians' perspective of picture archiving and communication systems at Charlotte Maxeke Johannesburg Academic Hospital

Background

Picture archiving and communication systems (PACS) are now an established means of capturing, storing, distribution and viewing of all radiology images. The study was conducted in a quaternary hospital, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), part of the University of the Witwatersrand teaching circuit, in South Africa.

Objectives

To measure the clinicians' perceived benefits and challenges of PACS. To document perceived views on how the current PACS can be improved.

Method

This was a cross-sectional observational study over a period of 5 months from September 2021 to January 2022 carried out at CMJAH. Questionnaires were distributed to referring clinicians with PACS experience. Descriptive statistics was conducted. Categorical variables were presented as frequency and percentages. The continuous variables were presented as means ± standard deviation.

Results

A survey with a response rate of 54% found the benefits most reported by clinicians were improved patient care, less time needed to review an exam, improved image comparison and consultation efficiency. With respect to perceived challenges, the unavailability of images at the bedside, problems with access and the lack of advanced image manipulating software were noted. The most frequent recommendations on improvements focused on the aforementioned challenges.

Conclusion

Hospital-wide PACS was viewed beneficial by most clinicians. Nonetheless, there are a few aspects that deserve attention to improve the functionality and access of the system.

Contribution

The findings will assist in future hospital or provincial-wide PACS deployment projects.

Stereotactic breast biopsies: Radiological-pathological concordance in a South African referral unit

Background: Stereotactic breast biopsies have become the gold standard for tissue diagnosis in non-palpable, sonographically occult breast abnormalities seen on mammogram. Only limited data exist in South Africa on the correlation between imaging findings and stereotactic biopsy histology.Objectives: To describe the mammographic findings and histological diagnosis in patients who underwent stereotactic breast biopsy at a referral hospital. In addition, to evaluate the proportion of malignancy in each Breast Imaging Reporting and Data System (BI-RADS) category.Method: A retrospective review of stereotactic breast biopsies was performed. Imaging characteristics (including BI-RADS category) and histological diagnosis were recorded. Using histopathology, cases were classified as benign, high-risk or malignant.Results: A total of 131 biopsies, from 123 patients, were included in the study. Most biopsies were performed on asymptomatic patients (79.3%, 104/131). The majority were categorised as BI-RADS 4 and demonstrated calcifications. Histology revealed a malignant diagnosis in 40 (30.5%) patients, a high-risk lesion in 8 (6.1%) patients and a benign diagnosis in 83 (63.4%) patients. There was a stepwise increase in the proportion of malignancy from BI-RADS category 3 to 5. When compared with surgical histology, the stereotactic biopsies demonstrated an overall ductal carcinoma in situ (DCIS) underestimation rate of 10.3%.Conclusion: Despite resource restrictions, stereotactic breast biopsies performed in a South African context produce radiological-pathological concordance in keeping with BI-RADS guidelines, as well as with local and international studies.

CT pulmonary angiography findings in HIV-infected patients referred for suspected pulmonary thrombo-embolic disease

Background

South Africa bares a significant burden of HIV and imaging is commonly performed as part of the workup for respiratory distress.

Objectives

The aim of this study was to document the prevalence of pulmonary thrombo-embolic disease (PTED) and other findings in HIV-infected patients referred for CT pulmonary angiography (CTPA) for suspected PTED.

Method

Forty CTPA studies of documented HIV-infected individuals investigated for suspected PTED during a 1-year period were retrieved, anonymised and interpreted by three consultant radiologists. Inter-reader reliability was calculated using Free Marginal multi-rater Kappa.

Results

Fourteen of the forty cases (35%) were positive for PTED. In the pulmonary embolism (PE)-positive group, 57.14% had peripheral disease and 42.86% had both peripheral and central disease. Associated findings in the PE-positive cases were pulmonary infarcts (17.5%), mosaic attenuation (17.5%) and linear atelectasis (7.5%). The most common incidental findings were solid pulmonary nodules (52.5%), non-wedge-shaped consolidation (45%), cardiomegaly (52.5%) and enlarged intra-thoracic lymph nodes (52.5%). Thirty per cent of the study population had findings related directly to the presence of PTED, whilst most cases in the study (77.5%) had pulmonary findings unrelated to PTED. In the PE-negative cases, 55% reported emergent findings that warranted immediate or urgent medical attention.

Conclusion

Computed tomography pulmonary angiography imaging is critical for diagnosing PE. However, further investigation into the judicious application of CTPA in HIV-infected patients with suspected PTED is required, as CTPA findings in most of the cases in this study were unrelated to PE.

An audit of CT brain findings in adults with new-onset seizures in a resource restricted setting in South Africa

Background

Globally, adults presenting with seizures account for 1% – 2% of visits to emergency departments (EDs), of which 25% are new-onset seizures. Neuroimaging is essential as part of the initial workup. Multiple studies have demonstrated abnormal CT brain (CTB) findings in these patients.

Objectives

To review the CTB findings in adults presenting with new-onset seizures in a resource restricted setting.

Method

A retrospective review of 531 CTBs was conducted at a tertiary hospital in Gauteng on adults presenting to the ED with new-onset seizures.

Results

The mean age of the patients was 45.6 ± 17.1 years, and the male to female ratio was 1.2:1. Generalised and focal seizure types were almost equally represented. Of the total 531 patients, 168 (31.6%) were HIV positive. The CTB findings were abnormal in 257 (48.4%) patients, albeit vascular pathology accounted for 21.9%. Infective pathology accounted for 14.1% with a statistically significant association with HIV (p = 0.003). Trauma related pathology was 2.4%, whilst neoplastic pathology was seen in 3.0%. Other causes included congenital pathology, calcifications, atrophy and gliosis. Clinical factors associated with abnormal CTB findings were age ≥ 40 years, HIV infection, hypertension, focal seizures, low Glasgow Coma Scale (GCS), raised cerebrospinal fluid (CSF) protein and presence of lymphocytes.

Conclusion

A high yield of abnormal CTB findings was noted in adult patients who presented with new-onset seizures, supporting the use of urgent CTB in patients with certain clinical risk factors. Patients without these risk factors can be scanned within 24–48 h in a resource restricted setting.

A proposed CT classification of progressive lung parenchymal injury complicating pediatric lymphobronchial tuberculosis: From reversible to irreversible lung injury

Lymphobronchial tuberculosis (LBTB) is tuberculous lymphadenopathy affecting the airways, which is particularly common in children with primary TB. Airway compression by lymphadenopathy causes downstream parenchymal pathology, which may ultimately result in irreversible lung destruction, if not treated timeously. Computed tomography (CT) is considered the "gold standard" for detecting mediastinal lymph nodes in children with TB. CT is also the best way of imaging the airways of children with LBTB. The CT findings of the parenchymal complications and associations of LBTB on CT have been described, but no severity classification was provided to aid management decisions. Identifying the parenchymal complications of LBTB and recognizing their severity has clinical relevance. Using prior publications on LBTB and post obstructive lung injury we have used an image bank of CT scans in children with pulmonary TB, presenting with airway symptoms, to create a CT severity staging of lung injury in LBTB. The staging focuses on distinguishing nonsalvageable destruction (nonenhancing or cavitated lung) from salvageable lung parenchymal disease (enhancing and noncavitated) to inform the management decisions, which range from bronchoscopic airway clearance to surgical decompression of the compressing nodes.

Role of platelet GARP in TGFB activation

Introduction

Transforming growth factor (TGF)β is known to be a central player in the control of cardiac fibroblast properties and fibrosis. However, cellular and molecular mechanisms that trigger its activation remain poorly understood. Platelets are considered as a major source of TGFβ and recent evidence suggest that they are involved in TGFβ activation via Glycoprotein A Repetitions Predominant (GARP) present on their surface.

Purpose

The present study sought to evaluate the role of platelet GARP in TGFβ activation using platelet specific GARP knockout mice.

Methods

We generated a new Cre transgenic mouse strain that allowed Megakaryocyte/platelet specific invalidation of GARP (GpIba-Cre x GARPfl/fl). The impact of GARP deficiency on platelet function was measured in vitro by flow cytometry using thrombin and CRP. Serum production of total and active TGFβ was assessed by ELISA.

Results

Platelet count and other hematological parameters were normal in platelet specific GARP knockout mice, except platelet volume, which was increased by 10.3%, as compared to wild-type platelets. Stimulation by thrombin and CRP increased GARP exposure at platelet surface. However, platelets without GARP displayed normal agonist induced activation, as reflected by CD62P and αIIbβ3 exposure. Interestingly, the generation of active TGFβ was drastically impaired in the serum of platelet specific GARP knockout mice, while the amount of total TGFβ was not affected.

Conclusion

We provided evidence that platelet GARP is a crucial contributor to the systemic activation of TGFβ. Future work will aim to determine its role in cardiac fibroblast myodifferentiation and fibrosis.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): FRIA

An audit of patients clinically deemed as high risk for malignant breast pathology at the Helen Joseph Hospital Breast Clinic

BACKGROUND

The Helen Joseph Hospital Breast Clinic has implemented a clinical triage system for patients presenting with a variety of breast concerns. The goal of this system is to expedite the process from initial presentation to radiological assessment of patients with suspected breast malignancy or breast abscess in a resource limited setting. The objective was to assess the clinical, imaging and histological diagnoses of breast disease in these patients with malignancy and sepsis.

METHODS

A retrospective audit of patients clinically deemed high risk for malignant breast pathology referred to the breast imaging unit (BIU) in 2018. Patients were triaged based on strict clinical criteria: presence of a breast mass with or without lymph nodes or a breast abscess. Patients that were subsequently referred for mammography/ultrasound were identified using the patient files in the BIU. Results were recorded on Microsoft Excel and analysed using SAS version 9.2.

RESULTS

Three hundred and twenty-five patients were included in this study. Eighty-seven (26.8%) were diagnosed with breast cancer and 236 (72.6%) with benign disease. The most common presenting complaint was a palpable mass (n = 227; 69.9%). Ninety-five per cent of patients characterised as BI-RADS 5 had malignant disease. 55.8% of malignancies diagnosed on ultrasound had locally advanced disease. The most common histological diagnosis of malignancy was invasive ductal carcinoma (n = 67, 77%). The most commonly diagnosed benign disease was breast abscess (n = 42, 17.8%).

CONCLUSION

BI-RADS findings correspond to similar studies, however, a large number of benign breast disease was diagnosed. This may indicate heightened clinical awareness of breast cancer diagnosis and early detection. A significant percentage of malignancies presented as locally advanced. Except for a lower number of invasive lobular carcinoma, the histological spectrum of malignant disease is similar to comparative studies.

An audit of patients clinically deemed as high risk for malignant breast pathology at the Helen Joseph Hospital Breast Clinic

ABSTRACT BACKGROUND: The Helen Joseph Hospital Breast Clinic has implemented a clinical triage system for patients presenting with a variety of breast concerns. The goal of this system is to expedite the process from initial presentation to radiological assessment of patients with suspected breast malignancy or breast abscess in a resource limited setting. The objective was to assess the clinical, imaging and histological diagnoses of breast disease in these patients with malignancy and sepsis METHODS: A retrospective audit of patients clinically deemed high risk for malignant breast pathology referred to the breast imaging unit (BIU) in 2018. Patients were triaged based on strict clinical criteria: presence of a breast mass with or without lymph nodes or a breast abscess. Patients that were subsequently referred for mammography/ultrasound were identified using the patient files in the BIU. Results were recorded on Microsoft Excel and analysed using SAS version 9.2 RESULTS: Three hundred and twenty-five patients were included in this study. Eighty-seven (26.8%) were diagnosed with breast cancer and 236 (72.6%) with benign disease. The most common presenting complaint was a palpable mass (n = 227; 69.9%). Ninety-five per cent of patients characterised as BI-RADS 5 had malignant disease. 55.8% of malignancies diagnosed on ultrasound had locally advanced disease. The most common histological diagnosis of malignancy was invasive ductal carcinoma (n = 67, 77%). The most commonly diagnosed benign disease was breast abscess (n = 42, 17.8% CONCLUSION: BI-RADS findings correspond to similar studies, however, a large number of benign breast disease was diagnosed. This may indicate heightened clinical awareness of breast cancer diagnosis and early detection. A significant percentage of malignancies presented as locally advanced. Except for a lower number of invasive lobular carcinoma, the histological spectrum of malignant disease is similar to comparative studies Keywords: malignant breast pathology, high risk patient, Helen Joseph Hospital Breast Clinic

Parent use of complementary medicine remedies and services for the management of respiratory tract infection in children: a qualitative study

BACKGROUND

The use of complementary and alternative medicine (CAM) is increasing globally, in both adults and children. A common condition where CAM is used in children is acute respiratory tract infection (ARTI). However, limited information exists regarding specific CAM modalities used in children, and the factors that influence a parent's decision to use CAM for ARTI in children. This research aimed to address this knowledge gap.

METHOD

This research used a qualitative descriptive approach. Parents residing in Greater Melbourne, Australia, who had children aged from 0-12 years, and had used CAM for treating ARTI in their children in the last 12 months, were eligible to participate. Parents' perspectives were captured using individual semi-structured interviews, which were then transcribed verbatim. Data were analysed using content analysis.

RESULTS

Twenty-four families were interviewed. Several strategies to improve trustworthiness were implemented. Three themes underpinning the parents' decision to use CAM emerged from the data: safety, internal drivers and external drivers. Parents used a breadth of different treatments, predominantly food as medicine, followed by aromatherapy and other CAM remedies typically found in the kitchen, to manage ARTI in their children. Parents often used both CAM practitioners and mainstream medicine to manage ARTI in their children. While mainstream medicine was typically used to rule out any sinister pathology, CAM was often used as a frontline treatment option, with food as medicine (e.g. soups) dominating. This was due in part to concerns regarding the negative aspects of pharmaceutical use. Parents utilised a diverse range of information sources to inform their decision-making, including friends, families and the internet; traditional sources of research evidence were generally not used.

CONCLUSION

Child safety was a major factor influencing a primary carer's decision to utilise CAM for ARTI. The safety and effectiveness of remedies utilised by parents now warrants further investigation.

Backscattered electron emission after proton impact on gold nanoparticles with and without polymer shell coating

This work aims at measuring experimentally proton induced secondary electron energy spectra after interaction with gold nano particles (GNPs) and polymer-coated GNPs. Backscattered electron energy spectra were collected over a 0 to 1000 eV energy range using a retarding field analyzer (RFA). This paper presents the spectra obtained for proton beam energies of 0.5 and 2 MeV and diameter 2.5 and 3.8 nm GNPs. The spectra were also measured for 3.8 nm GNPs after 5 and 10 MeV proton irradiations. GNPs were deposited on a 100 nm carbon film. Each experimental spectrum was compared with dedicated simulations based on existing numerical models used in the TRAX and Geant4 Monte Carlo codes. For 100 nm carbon target, good agreement between experimental, TRAX and Geant4 simulation results can be observed. For 3.8 nm GNPs, the TRAX simulations reproduce with good agreement the electron energy spectra produced after 0.5, 2, 5 and 10 MeV proton irradiations, while Geant4 spectra display a lower secondary electron yield at low energy (<600 eV) for all the studied energies. This underestimation can mostly be explained by the 790 eV threshold applied in the condensed history model used by Geant4 which impacts the secondary electron energy distribution. Results obtained for carbon and gold targets highlight the impact of the secondary electron production threshold for proton ionization process considered in condensed history models. The experimental results demonstrate that the single interaction approach used in TRAX is adapted to reproduce secondary electron emission from GNPs. On the other hand, the standard electron generation threshold implement in G4BetheBlochModel and G4BraggModel condensed-history models used in Geant4 is not adapted to reproduce low energy electron emission in gold targets. Finally, the results highlight that the GNP coating leads to a decrease of the electron yield and mostly affects low energy electrons (<500 eV) emitted from GNPs.

Nurses' experiences of screening for communication difficulties at 18 months of age

AIM

Early identification of communication disorders is important and may be possible through screening in the child health services. The aim of the study was to investigate nurses' experiences and sense of competence when using the Infant-Toddler Checklist (ITC) communication screening at the 18-month health visit.

METHODS

A mixed-methods design including three focus group interviews (n = 14) and a web-based survey (n = 22) among nurses using the ITC or the standard method. Interview data were analysed through systematic text condensation and a deductive analysis based on implementation theory. Groups were compared using Mann-Whitney tests.

RESULT

Three themes emerged: Using a structured evaluation of communication changes, the dynamic, ITC is a beneficial tool and Implementation of the ITC faces a few challenges. Nurses who used the ITC perceived to a greater extent that they used a structured method (p = 0.003, r = 0.9) and felt more secure in describing the child's communication and language development to parents (p = 0.006, r = 0.83) compared to the standard method group.

CONCLUSION

Using the ITC supported the nurses in their assessment of communication at 18 months. Nurses' sense of competence was higher when using the ITC, both in their assessment and in communicating with parents.

Plasma protein adsorption on Fe3O4-PEG nanoparticles activates the complement system and induces an inflammatory response

BACKGROUND

Understanding of iron oxide nanoparticles (IONP) interaction with the body milieu is crucial to guarantee their efficiency and biocompatibility in nanomedicine. Polymer coating to IONP, with polyethyleneglycol (PEG) and polyvinylpyrrolidone (PVP), is an accepted strategy to prevent toxicity and excessive protein binding.

AIM

The aim of this study was to investigate the feature of IONP adsorption of complement proteins, their activation and consequent inflammatory response as a strategy to further elucidate their biocompatibility.

METHODS

Three types of IONP with different surface characteristics were used: bare (IONP-bare), coated with PVP (IONP-PVP) and PEG-coated (IONP-PEG). IONPs were incubated with human plasma and adsorbed proteins were identified. BALB/c mice were intravenously exposed to IONP to evaluate complement activation and proinflammatory response.

RESULTS

Protein corona fingerprinting showed that PEG surface around IONP promoted a selective adsorption of complement recognition molecules which would be responsible for the complement system activation. Furthermore, IONP-PEG activated in vitro, the complement system and induced a substantial increment of C3a and C4a anaphylatoxins while IONP-bare and IONP-PVP did not. In vivo IONP-PEG induced an increment in complement activation markers (C5a and C5b-9), and proinflammatory cytokines (IL-1β, IL-6, TNF-α).

CONCLUSION

The engineering of nanoparticles must incorporate the association between complement proteins and nanomedicines, which will regulate the immunostimulatory effects through a selective adsorption of plasma proteins and will enable a safer application of IONP in human therapy.

Experimental measurements validate the use of the binary encounter approximation model to accurately compute proton induced dose and radiolysis enhancement from gold nanoparticles

In protontherapy, it has been suggested that nanoparticles of high-Z material like gold (GNP) could be used as radiosensitizers. The origin of this enhancement phenomenon for proton radiation is not yet well understood and additional mechanistic insights are required. Previous works have highlighted the good capabilities of TRAX to reproduce secondary electron emission from gold material. Therefore, TRAX cross sections obtained with the binary encounter approximation (BEA) model for proton ionization were implemented within Geant4 for gold material. Based on the TRAX cross sections, improved Geant4 simulations have been developed to investigate the energy deposition and radical species production around a spherical gold nanoparticle (5 and 10 nm in diameter) placed in a water volume during proton irradiation. Simulations were performed for incident 2 MeV proton. The dose enhancement factor and the radiolysis enhancement factor were quantified. Results obtained with the BEA model were compared with results obtained with condensed-history models. Experimental irradiation of 200 nm gold films were performed to validate the secondary electron emission reproduction capabilities of physical models used in Monte Carlo (MC) simulations. TRAX simulations reproduced the experimental backscattered electron energy spectrum from gold film with better agreement than Geant4. Results on gold film obtained with the BEA model enabled to estimate the electron emission from GNPs. Results obtained in our study tend to support that the use of the BEA discrete model leads to a significant increase of the dose in the near vicinity of GNPs (<20 nm), while condensed history models used in Geant4 seem to overestimate the dose and the number of chemical species for increasing distances from the GNP. Based on discrete BEA model results, no enhancement effect due to secondary electron emitted from the GNP is expected if the GNP is not in close proximity to key cellular functional elements (DNA, mitochondria…).

Cosmetic benefit of a biomimetic lamellar cream formulation on barrier function or the appearance of fine lines and wrinkles in randomized proof-of-concept clinical studies

Objective

Two studies were designed to evaluate the potential cosmetic benefit of a biomimetic, niacinamide‐containing moisturizing cream for the first time in humans.

Methods

In both studies, healthy women were randomized to use two treatments, one for the left side of the body and one for the right, from three options: the test cream, a positive control or no treatment (use of standard cleanser only). Treatments were applied twice daily for 4 weeks to the face and forearms (Study 1) or the face only (Study 2). Instrumental and clinical skin assessments were performed by trained technicians. Study 1 involved tape stripping and a 5‐day no‐treatment (‘regression’) period at the end of the 4 weeks. Independent lay graders were asked to grade the skin texture of subjects in Study 2 from high‐resolution photographs.

Results

In Study 1 (n = 66), the test cream significantly decreased the transepidermal water loss (TEWL) values on the forearm, and in the cheek area of the face, relative to baseline and compared to no treatment, and increased skin Corneometer values. The improvements were partially retained during a subsequent 5‐day period of no treatment. Increases in TEWL values on skin subjected to tape stripping were significantly lower after 4 weeks of using the test cream compared to no treatment. In Study 2 (n = 72 subjects with visible signs of ageing), there was a favourable trend in the change from baseline of a skin roughness parameter, R_a, for the test cream compared to no treatment. There were statistically significant improvements in the Fitzpatrick wrinkle score compared to no treatment, decreases in TEWL and increased Corneometer values and Cutometer values (R5 elasticity parameter). Grading of high‐resolution images failed to detect the improvements in skin texture (defined as pores, smoothness and unevenness) for the test cream vs. no treatment. No treatment‐related serious or severe adverse events were reported.

Conclusion

Twice daily application of the test cream over 4 weeks had beneficial effects on skin barrier function, moisturization, wrinkle dimensions and elasticity compared to no treatment. These studies provide proof‐of‐concept evidence and highlight the cosmetic benefit of the biomimetic lamellar cream formulation. Study registration: NCT03216265, NCT03180645.

An Educational Intervention and Feasibility Assessment of Breast Ultrasound in Rural South Africa

Purpose

Breast cancer is the leading cause of cancer death in women worldwide, with a strikingly high mortality in low- and middle-income countries (LMICs) as a result of the scarcity of detection, diagnosis, and treatment. With mammography unavailable, ultrasound (US) offers a viable alternative. The literature reports successful training in various domains, but a curriculum focused on the breast is novel. We assessed the feasibility—knowledge acquisition, perceived utility, and self-efficacy—of a breast US training program for the detection of breast cancer by nonphysician providers.

Methods

Training was implemented for 12 providers, including professional nurses, nursing assistants, and lay counselors, at Hlokomela clinic in Hoedspruit, South Africa, over 3 weeks. Didactic presentations and example cases were followed by a presurvey (n = 12) that characterized providers’ initial attitudes toward early detection and a pretest (n = 12) that determined immediate retention of knowledge and areas for focused training. All providers received hands-on training with nurses as models. Five providers trained with patients. A post-test (n = 12) assessed overall knowledge retention and acquisition, and a postsurvey (n = 10) gauged program acceptance and provider self-efficacy with breast US.

Results

Pretest to post-test averages improved by 68% overall and in four competencies—foundational knowledge, descriptive categories, benign versus malignant, and lesion identification. On the postsurvey, providers expressed the belief that US could significantly affect breast cancer detection (9.1/10), treatment (7.9/10), and survival (8.7/10) in their communities and endorsed moderate confidence in their scanning (6.3/10) and interpreting abilities (5.6/10).

Conclusion

There is a pressing need for a paradigm shift in breast cancer care in LMICs, with early detection critical to improving outcomes. Our research supports the feasibility of breast US training as part of a breast education program in LMICs. Pretest and post-test results and observed proficiency indicate that training nonphysician providers is achievable. Postsurvey responses indicate program acceptance, provider self-efficacy with US, and community-based ownership of a breast cancer screening and awareness initiative. Follow-up work that is focused on quality improvement and sustainability is ongoing. Future work may show that breast US is viable for early detection when mammography is unavailable.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Susan C. Harvey Consulting or Advisory Role: IBM Watson, Hologic Inc Research Funding: IBM Watson

Deletion of GARP on mouse regulatory T cells is not sufficient to inhibit the growth of transplanted tumors

GARP is a transmembrane protein that presents latent TGF-β1 on the surface of regulatory T cells (Tregs). Neutralizing anti-GARP monoclonal antibodies that prevent the release of active TGF-β1, inhibit the immunosuppressive activity of human Tregs in vivo. In this study, we investigated the contribution of GARP on mouse Tregs to immunosuppression in experimental tumors. Unexpectedly, Foxp3 conditional garp knockout (KO) mice challenged orthotopically with GL261 tumor cells or subcutaneously with MC38 colon carcinoma cells did not show prolonged survival or delayed tumor growth. Also, the suppressive function of KO Tregs was similar to that of wild type Tregs in the T cell transfer model in allogeneic, immunodeficient mice. In conclusion, garp deletion in mouse Tregs is not sufficient to impair their immunosuppressive activity in vivo.

A retrospective analysis of time delays in patients presenting with stroke to an academic emergency department

Background

Stroke presents commonly to the emergency department (ED), and is a common cause of morbidity and mortality in South Africa. Early ED presentation and early neuroimaging are required in order for thrombolysis to be a potential therapeutic modality.

Objectives

To determine the time to ED presentation, time to computed tomography (CT) scan and the potential influencing factors for patients with stroke.

Methods

A retrospective record review of all patients who presented with clinical features of stroke to a tertiary academic ED in Johannesburg, South Africa, from 01 January to 31 December 2014.

Results

Data from 232 eligible stroke patients were analysed. The median time to presentation to the ED was 33 h with the majority of patients (81.3%) presenting after the 4.5 h window for thrombolysis. The median time to CT was 8 h. Only 3.9% of patients had a CT scan within one hour of arrival. Patients with loss of consciousness were associated with earlier hospital presentation (p = 0.001). None of the patients were thrombolysed.

Conclusion

Patients with stroke commonly present late to hospital. If we are to make a difference in this group of vulnerable patients, further education and training needs to be emphasised regarding ‘time is brain’. Communication and commitment is also required by the emergency medical services, ED and radiology staff in order to prioritise stroke patients and to reduce delays.

Impact of the Spinal Instability Neoplastic Score on Surgical Referral Patterns and Outcomes

Background

The Spinal Instability Neoplastic Score (sins) was developed to identify patients with spinal metastases who may benefit from surgical consultation. We aimed to assess the distribution of sins in a population-based cohort of patients undergoing palliative spine radiotherapy (rt) and referral rates to spinal surgery pre-rt. Secondary outcomes included referral to a spine surgeon post-rt, overall survival, maintenance of ambulation, need for re-intervention, and presence of spinal adverse events.

Methods

We retrospectively reviewed ct simulation scans and charts of consecutive patients receiving palliative spine rt between 2012 and 2013. Data were analyzed using Student's t-test, Chi-squared, Fisher's exact, and Kaplan-Meier log-rank tests. Patients were stratified into low (<7) and high (≥7) sins groups.

Results

We included 195 patients with a follow-up of 6.1 months. The median sins was 7. The score was 0 to 6 (low, no referral recommended), 7 to 12 (intermediate, consider referral), and 13 to 18 (high, referral suggested) in 34%, 59%, and 7% of patients, respectively. Eleven patients had pre-rt referral to spine surgery, with a surgery performed in 0 of 1 patient with sins 0 to 6, 1 of 7 with sins 7 to 12, and 1 of 3 with sins 13 to 18. Seven patients were referred to a surgeon post-rt with salvage surgery performed in two of those patients. Primary and secondary outcomes did not differ between low and high sins groups.

Conclusion

Higher sins was associated with pre-rt referral to a spine surgeon, but most patients with high sins were not referred. Higher sins was not associated with shorter survival or worse outcome following rt.

Complementary and alternative medicine utilisation for the management of acute respiratory tract infection in children: A systematic review

INTRODUCTION

As many as one in two children across the globe use complementary and alternative medicine (CAM) to manage a health condition. Despite the high prevalence of use, there is still limited information on the types of CAM used in children, particularly for the management of one of the most common childhood health complaints - acute respiratory tract infection (ARTI). This systematic review was undertaken to address this knowledge gap.

METHODS

Eligible studies reporting the use of CAM in children with ARTI were identified using a targeted search of seven electronic databases and the grey literature. Data were extracted using a customised data extraction form and appraised using the McMaster critical review forms for quantitative and qualitative studies. Findings were synthesised in narrative form.

RESULTS

The search identified 2261 papers, of which 22 studies were eligible for inclusion. The 22 studies reported the use of 118 distinct CAM interventions for the management of ARTI in children. Most (53%, n = 63) of these interventions represented biologically-based therapies, followed by whole medical systems/alternative medical systems (46%, n = 55). No studies reported the use of energy therapies, or manipulative and body-based methods, or mind-body therapies.

CONCLUSION

A diverse range of CAM interventions are used in the management of ARTI in children. These interventions largely represent CAM use in the southern region of Asia - India, Pakistan and Bangladesh. Further research is needed to better understand the types of CAM used among children with ARTI in western countries.

Corrigendum: Paediatric doctors’ error rate in detection of paediatric elbow injuries in Rahima Moosa Mother and Child Hospital

No abstract available.

The value of comparative radiographs in the diagnosis of extremity fractures in children by doctors in the emergency department

No abstract available.

Paediatric doctors’ error rate in detection of paediatric elbow injuries in Rahima Moosa Mother and Child Hospital

No abstract available

Computerised tomography findings in lymphobronchial tuberculosis: A comparison between infants and older children

No abstract available.

Pilot Educational Intervention and Feasibility Assessment of Breast Ultrasound in Rural South Africa

Purpose

Breast cancer is the leading cause of cancer death in women worldwide, with high mortality in low- and middle-income countries because of a lack of detection, diagnosis, and treatment. With mammography unavailable, ultrasound offers an alternative for downstaging. The literature reports successful training in various domains, but a focus on the breast is novel. We assessed the feasibility (knowledge acquisition, perceived usefulness, and self-efficacy) of breast ultrasound training for nonphysician providers.

Methods

Training was implemented for 12 providers at Hlokomela Clinic in Hoedspruit, South Africa, over 3 weeks. Didactic presentations and example cases were followed by a presurvey and test (n = 12). All providers received hands-on training with nurses as models; five providers trained with patients. A post-test (n = 12) assessed knowledge acquisition and a postsurvey (n = 10) assessed perceived program usefulness and provider self-efficacy.

Results

The pre- to post-test averages improved by 68% in total and in four competencies (foundational knowledge, descriptive categories, benign v malignant, and lesion identification). On the postsurvey, providers expressed that ultrasound could significantly influence breast cancer detection (9.1 out of 10), treatment (7.9 out of 10), and survival (8.7 out of 10) in their community and endorsed moderate confidence in their scanning (6.3 out of 10) and interpreting abilities (5.6 out of 10).

Conclusion

Our research supports the feasibility of breast ultrasound training as part of a breast education program in low- and middle-income countries. Pre- and post-test results and observed proficiency indicate that training nonphysician providers is achievable; postsurvey responses indicate program acceptance, community-based ownership, and provider self-efficacy with ultrasound. Future work may show that breast ultrasound is viable for early detection where mammography is unavailable.

Entropy Evolution in the Magnetic Phases of Partially Frustrated CePdAl

In the heavy-fermion metal CePdAl, long-range antiferromagnetic order coexists with geometric frustration of one-third of the Ce moments. At low temperatures, the Kondo effect tends to screen the frustrated moments. We use magnetic fields B to suppress the Kondo screening and study the magnetic phase diagram and the evolution of the entropy with B employing thermodynamic probes. We estimate the frustration by introducing a definition of the frustration parameter based on the enhanced entropy, a fundamental feature of frustrated systems. In the field range where the Kondo screening is suppressed, the liberated moments tend to maximize the magnetic entropy and strongly enhance the frustration. Based on our experiments, this field range may be a promising candidate to search for a quantum spin liquid.

The Standard Spending Assessment as a Measure of Spending Needs in Nonmetropolitan Districts

Central government assistance to local government in England is based on the Standard Spending Assessment (SSA), which is intended to reflect the spending needs of each local council. This paper is an evaluation of the methodology used in calculating SSA, with particular reference to the district-level service clement of the All Other Services block of SSA. This element accounts for the vast majority of SSA for nonmetropolitan district councils. The first section of the paper is concerned with the overall structure of the SSA methodology, and the second section is an examination of some of the details of how it was implemented. Barrow-in-Furness is used as an illustrative example. In the conclusion some specific problems are high-lighted and some potential improvements are suggested.

Complete Genome Sequence of Alkaliphilus metalliredigens Strain QYMF, an Alkaliphilic and Metal-Reducing Bacterium Isolated from Borax-Contaminated Leachate Ponds

Alkaliphilus metalliredigens strain QYMF is an anaerobic, alkaliphilic, and metal-reducing bacterium associated with phylum Firmicutes QYMF was isolated from alkaline borax leachate ponds. The genome sequence will help elucidate the role of metal-reducing microorganisms under alkaline environments, a capability that is not commonly observed in metal respiring-microorganisms.

Complete genome sequence of the Antarctic Halorubrum lacusprofundi type strain ACAM 34

Halorubrum lacusprofundi is an extreme halophile within the archaeal phylum Euryarchaeota. The type strain ACAM 34 was isolated from Deep Lake, Antarctica. H. lacusprofundi is of phylogenetic interest because it is distantly related to the haloarchaea that have previously been sequenced. It is also of interest because of its psychrotolerance. We report here the complete genome sequence of H. lacusprofundi type strain ACAM 34 and its annotation. This genome is part of a 2006 Joint Genome Institute Community Sequencing Program project to sequence genomes of diverse Archaea.

Digital platform for improving non-radiologists' and radiologists' interpretation of chest radiographs for suspected tuberculosis - a method for supporting task-shifting in developing countries

BACKGROUND

Shifting X-ray interpretation to non-radiologists can help to address radiologist shortages in developing countries.

OBJECTIVE

To determine the change in accuracy of non-radiologists and radiologists for the radiographic diagnosis of paediatric tuberculosis after a short skill-development course.

MATERIALS AND METHODS

Participants interpreted 15 paediatric chest radiographs before and after a 30-minute course using three possible responses: (1) diagnostic for tuberculosis, (2) abnormal but inconclusive for diagnosis of tuberculosis and (3) normal. We compared proportions of correct diagnoses, sensitivity, and specificity, before and after the course.

RESULTS

We included 256 participants comprising 229 non-radiologists (134 radiographers, 32 paediatricians, 39 Médecins Sans Frontières clinicians and 24 physicians including paediatricians) and 27 radiologists. Mean change proportions of correct diagnosis ranged from -27% to 53% for individuals and 9% to 20% for groups. All groups showed a statistically significant improvement. Mean change in diagnostic sensitivity ranged from -38% to 100% for individuals and from 16% to 41% for groups. All groups showed a statistically significant improvement. Mean change in specificity ranged from -57% to 57% for individuals and from -15% to -4% for groups. The decrease was statistically significant for physicians, paediatricians and radiographers.

CONCLUSION

The course resulted in increased correct diagnoses and improved sensitivity at the expense of specificity.

'I felt a little bubbly in my tummy': eliciting pre-schoolers' accounts of their health visit using a computer-assisted interview method

BACKGROUND

In the health care services, children's rights to participate in all matters that concern them are considered important. However, in practice this can be challenging with young children. In My Shoes (IMS) is a computer-assisted interview tool developed to help children talk about their experiences. The aim of the study was to evaluate the IMS' ability to elicit pre-schoolers' subjective experiences and accurate accounts of a routine health visit as well as the children's engagement in the interview process.

METHODS

Interviews were conducted with 23 children aged 4-5 years, 2-4 weeks after their health visit. The interviews were transcribed verbatim and analysed using a method inspired by Content Analysis to evaluate IMS's ability to elicit accounts about subjective experiences. Accurate accounts were assessed by comparing the transcribed interviews with the filmed visits at the child health centre. The children's engagement was defined by the completion and length of the interviews, and the children's interaction with the software.

RESULTS

All children gave accounts about their subjective experiences, such as their emotional state during the visit, available toys or rewards they received. All children related to the correct event, they all named at least one person who was present and 87% correctly named at least one examination procedure. The majority of children (91%) completed the interview, which lasted 17-39 min (M = 24), and 96% interacted with the IMS software.

CONCLUSIONS

IMS was feasible to help children describe their health care experiences, in both detail and depth. The children interacted with the software and maintained their interest for an extended period of time.

Protein corona acts as a protective shield against Fe3O4-PEG inflammation and ROS-induced toxicity in human macrophages

Protein corona (PC) is the main biological entity of initial cell interaction and can define the toxicological response to Fe3O4 nanoparticles (IONP). Polymer coating to IONP, polyethilenglycol (PEG) and polyvinylpyrrolidone (PVP), is a widely accepted strategy to prevent toxicity and avoid excessive protein binding. The aim of this study was to assess the role of PC as a potential protector for ROS-induced cytotoxicity and pro-inflammatory response in THP-1 macrophages (exposed to three different IONP: bare, PVP or PEG coated). Cells were exposed to either IONP in RPMI-1640 media or IONP with a preformed human PC. All three IONP showed cytotoxic effects, which in the presence of PC was abolished. IONP-PEG exposure significantly increased ROS, mitochondrial dysfunction and pro-inflammatory cytokines release (IL-1β and TNF-α). PC presence on IONP-PEG promoted a decrease in ROS and prevented cytokine secretion. Also, presence of PC reduced cell uptake for IONP-bare, but had no influence on IONP-PVP or IONP-PEG. Hence, the reduction in IONP-PEG cytotoxicity can be attributed to PC shielding against ROS generation and pro-inflammatory response and not a differential uptake in THP-1 macrophages. The presence of the PC as a structural element of NP biological entity provides in vivo-relevant conditions for nanosafety testing.

Complete genome sequence of the phenanthrene-degrading soil bacterium Delftia acidovorans Cs1-4

Polycyclic aromatic hydrocarbons (PAH) are ubiquitous environmental pollutants and microbial biodegradation is an important means of remediation of PAH-contaminated soil. Delftia acidovorans Cs1-4 (formerly Delftia sp. Cs1-4) was isolated by using phenanthrene as the sole carbon source from PAH contaminated soil in Wisconsin. Its full genome sequence was determined to gain insights into a mechanisms underlying biodegradation of PAH. Three genomic libraries were constructed and sequenced: an Illumina GAii shotgun library (916,416,493 reads), a 454 Titanium standard library (770,171 reads) and one paired-end 454 library (average insert size of 8 kb, 508,092 reads). The initial assembly contained 40 contigs in two scaffolds. The 454 Titanium standard data and the 454 paired end data were assembled together and the consensus sequences were computationally shredded into 2 kb overlapping shreds. Illumina sequencing data was assembled, and the consensus sequence was computationally shredded into 1.5 kb overlapping shreds. Gaps between contigs were closed by editing in Consed, by PCR and by Bubble PCR primer walks. A total of 182 additional reactions were needed to close gaps and to raise the quality of the finished sequence. The final assembly is based on 253.3 Mb of 454 draft data (averaging 38.4 X coverage) and 590.2 Mb of Illumina draft data (averaging 89.4 X coverage). The genome of strain Cs1-4 consists of a single circular chromosome of 6,685,842 bp (66.7 %G+C) containing 6,028 predicted genes; 5,931 of these genes were protein-encoding and 4,425 gene products were assigned to a putative function. Genes encoding phenanthrene degradation were localized to a 232 kb genomic island (termed the phn island), which contained near its 3' end a bacteriophage P4-like integrase, an enzyme often associated with chromosomal integration of mobile genetic elements. Other biodegradation pathways reconstructed from the genome sequence included: benzoate (by the acetyl-CoA pathway), styrene, nicotinic acid (by the maleamate pathway) and the pesticides Dicamba and Fenitrothion. Determination of the complete genome sequence of D. acidovorans Cs1-4 has provided new insights the microbial mechanisms of PAH biodegradation that may shape the process in the environment.

Stroke Recurrence and its Prevention in Patients with Patent Foramen Ovale

BACKGROUND

It is unclear whether medical or invasive (surgical or catheter interventional) treatment is preferable to prevent recurrence of cerebral ischemia in patients with patent foramen ovale (PFO) as the suspected cause of stroke and what the role of concomitant risk factors is in stroke recurrence.

METHODS

Over a period of ten years, 124 patients (mean age 51 +/- 15 years) with cryptogenic cerebral ischemia and PFO were included into the study and prospectively followed over a mean of 52 +/- 32 months. Of these, 83 were treated medically, 34 underwent transcatheter closure, and seven had surgical closure of the foramen. Of the medically treated patients, 11 stopped medication during follow-up. Recurrent ischemic events and risk factors for recurrence were analyzed.

RESULTS

Annual stroke recurrence rates were generally low and comparable in catheter and medically treated patients, and in patients who had stopped medication (2.9%/2.1%2.2%/year). Patients suffering from recurrence after transcatheter closure (n = 2) both had residual shunts. No stroke recurrence was observed in the few surgically treated patients. An atrial septal aneurysm was not a predictor of recurrent or multiple strokes (p > 0.05, OR = 0.31, and OR = 0.74). Large shunts and a history of previous ischemic events were considerably more frequent in patients with recurrent strokes (p < 0.05, OR = 5.0, and OR = 4.4). Pulmonary embolism and case fatality rates were significantly higher in patients with stroke recurrence (p < 0.001, and p < 0.01).

CONCLUSIONS

The absolute risk of recurrent cerebrovascular events in patients with PFO receiving medical or catheter interventional therapy is low. The small group of untreated patients had a comparably low rate of stroke recurrences. Previous ischemic events and shunt size were risk factors in this observational study. Given conflicting findings across multiple studies, enrollment into a randomized controlled trial would be the optimal choice.

On the formation of the porous structure in nanostructured a-Si coatings deposited by dc magnetron sputtering at oblique angles

The formation of the porous structure in dc magnetron sputtered amorphous silicon thin films at low temperatures is studied when using helium and/or argon as the processing gas. In each case, a-Si thin films were simultaneously grown at two different locations in the reactor which led to the assembly of different porous structures. The set of four fabricated samples has been analyzed at the microstructural level to elucidate the characteristics of the porous structure under the different deposition conditions. With the help of a growth model, we conclude that the chemical nature of the sputter gas not only affects the sputtering mechanism of Si atoms from the target and their subsequent transport in the gaseous/plasma phase towards the film, but also the pore formation mechanism and dynamics. When Ar is used, pores emerge as a direct result of the shadowing processes of Si atoms, in agreement with Thornton's structure zone model. The introduction of He produces, in addition to the shadowing effects, a new process where a degree of mobility results in the coarsening of small pores. Our results also highlight the influence of the composition of sputtering gas and tilt angles (for oblique angle deposition) on the formation of open and/or occluded porosity.

Genome sequence of the Thermotoga thermarum type strain (LA3(T)) from an African solfataric spring

Thermotoga thermarum Windberger et al. 1989 is a member to the genomically well characterized genus Thermotoga in the phylum 'Thermotogae'. T. thermarum is of interest for its origin from a continental solfataric spring vs. predominantly marine oil reservoirs of other members of the genus. The genome of strain LA3T also provides fresh data for the phylogenomic positioning of the (hyper-)thermophilic bacteria. T. thermarum strain LA3(T) is the fourth sequenced genome of a type strain from the genus Thermotoga, and the sixth in the family Thermotogaceae to be formally described in a publication. Phylogenetic analyses do not reveal significant discrepancies between the current classification of the group, 16S rRNA gene data and whole-genome sequences. Nevertheless, T. thermarum significantly differs from other Thermotoga species regarding its iron-sulfur cluster synthesis, as it contains only a minimal set of the necessary proteins. Here we describe the features of this organism, together with the complete genome sequence and annotation. The 2,039,943 bp long chromosome with its 2,015 protein-coding and 51 RNA genes is a part of the Genomic Encyclopedia of Bacteria and Archaea project.

Immune reconstitution inflammatory syndrome Kaposi sarcoma in the liver manifesting as acute obstructive hepatitis: another potential role for montelukast?

Immune reconstitution inflammatory syndrome has been described in Kaposi sarcoma, but does not usually manifest as acute hepatitis. We describe a case of rapid obstructive jaundice after initiation of antiretroviral therapy, in which the liver biopsy confirmed hepatic Kaposi sarcoma, and the clinical course was altered by the addition of montelukast.

Complete genome sequence of Anabaena variabilis ATCC 29413

Anabaena variabilis ATCC 29413 is a filamentous, heterocyst-forming cyanobacterium that has served as a model organism, with an extensive literature extending over 40 years. The strain has three distinct nitrogenases that function under different environmental conditions and is capable of photoautotrophic growth in the light and true heterotrophic growth in the dark using fructose as both carbon and energy source. While this strain was first isolated in 1964 in Mississippi and named Anabaena flos-aquae MSU A-37, it clusters phylogenetically with cyanobacteria of the genus Nostoc. The strain is a moderate thermophile, growing well at approximately 40(°) C. Here we provide some additional characteristics of the strain, and an analysis of the complete genome sequence.

Long-term oncological results after 400 skin-sparing mastectomies

OBJECTIVE OF THE STUDY

Skin-sparing mastectomies (SSM) have gained acceptance among teams performing immediate breast reconstruction because this technique provides the best cosmetic outcome. Nevertheless, in France, concerns have been raised that limited skin excision during mastectomy could result in an increased risk of local recurrence especially in invasive breast cancer; many surgeons continue to have reservations regarding the oncologic safety of this operation. This is a retrospective, long-term follow-up study of 400 patients operated and followed by two oncoplastic surgeons.

PATIENTS AND METHODS

A total of 400 patients with breast cancer underwent SSM with immediate breast reconstruction from January 1, 1992 to December 31, 2002. The American Joint Committee on Cancer pathological staging was Stage 0 (41.5%), Stage I (33.25%), Stage II (16%), Stage III (7.5%), while 1.75% were non-stageable.

RESULTS

With a mean follow-up period of 88 months (range: 13-215 months), the locoregional recurrence rate was 3.5%, the rate of distant metastases was 13.5%, and 83% of patients have remained free of recurrent disease.

CONCLUSION

This study provides encouraging results suggesting that skin-sparing mastectomy is a safe and reliable option for the management of selected cases of women with invasive or in situ breast cancer.

Genome sequence of the chemoheterotrophic soil bacterium Saccharomonospora cyanea type strain (NA-134(T))

Saccharomonospora cyanea Runmao et al. 1988 is a member of the genus Saccharomonospora in the family Pseudonocardiaceae that is moderately well characterized at the genome level thus far. Members of the genus Saccharomonospora are of interest because they originate from diverse habitats, such as soil, leaf litter, manure, compost, surface of peat, moist, over-heated grain, and ocean sediment, where they probably play a role in the primary degradation of plant material by attacking hemicellulose. Species of the genus Saccharomonospora are usually Gram-positive, non-acid fast, and are classified among the actinomycetes. S. cyanea is characterized by a dark blue (= cyan blue) aerial mycelium. After S. viridis, S. azurea, and S. marina, S. cyanea is only the fourth member in the genus for which a completely sequenced (non-contiguous finished draft status) type strain genome will be published. Here we describe the features of this organism, together with the draft genome sequence, and annotation. The 5,408,301 bp long chromosome with its 5,139 protein-coding and 57 RNA genes was sequenced as part of the DOE funded Community Sequencing Program (CSP) 2010 at the Joint Genome Institute (JGI).

Reversible khat-induced hepatitis: two case reports and review of the literature

Recreational chewing of Catha edulis (khat) leaves is part of the ethnic culture of Somali, Yemeni and other East African societies for its stimulant properties. With increasing emigration, khat use has become common in these ethnic groups once they move to other areas such as Europe and the USA; one-third of the UK Somali population report khat use within the last month. Cathinone, the active component of the khat leaves, is controlled under the UK Misuse of Drugs Act, but the use of the khat plant and its leaves remains not subject to control in the UK. There have been several previous reports of acute hepatitis related to chronic use of khat leading to acute liver failure, and resulting in transplantation or death. We report two cases with severe acute khat-related hepatitis that resolved on cessation of khat use initially, but relapsed with further use, reinforcing the importance of permanent khat cessation to prevent progression to liver failure. With reference to the current literature, we also consider the difficult diagnosis of this disorder, then go on to consider the pathophysiology, mechanisms of liver injury and potential future areas of research.

Bronchoscopic assessment of airway involvement in children presenting with clinically significant airway obstruction due to tuberculosis

INTRODUCTION

The incidence of complicated lymph node disease in tuberculosis (TB) in children less than 15 years of age varies from 8% to 38%. There are few published studies on the bronchoscopic appearance and severity of airway obstruction caused by lymph node involvement of the airways resulting from Mycobacterium tuberculosis (MTB). The primary aim of the study was to describe the flexible bronchoscopic findings of lymph node involvement of the airways caused by MTB in children with severe airway obstruction. The secondary aim was to compare the degree of airway involvement in HIV negative to HIV positive children as well the airway involvement caused by drug susceptible and drug resistant MTB.

PATIENTS AND METHODS

All children between 1 month and 13 years of age presenting with clinical and radiological signs of significant airway obstruction suspected of being the result of MTB infection were studied. In addition to routine examination for MTB disease a flexible bronchoscope and bronchoalveolar lavage (BAL) for MTB culture were performed on all the children.

RESULTS

Two hundred fifty children (16% HIV positive) were studied. Median age was 14 months and the median weight 8.5 kg. MTB was cultured from 78% (n = 194) of children with the BAL positive in 44%. The BAL culture yield was significantly higher in children with radiological evidence of pneumonia when compared to children with airway involvement alone (P = 0.004). The bronchial tree was obstructed on the right in 85% (n = 212), the left in 66% (n = 164), and both sides in 53% (n = 132) of cases. The commonest sites of obstruction were bronchus intermedius (72%) and left main bronchus (62%). Drug resistance was present in 16% (n = 28). There was no difference in the site or severity of obstruction when comparing drug susceptible to drug resistant cases or HIV positive to HIV negative children.

CONCLUSIONS

Bronchus intermedius and left main bronchus were the commonest sites of airway obstruction. The MTB culture yield from BAL was higher in children with pneumonia when compared to those with airway involvement alone. HIV positive or children with drug resistant TB did not have more severe airway obstruction.