Is HRCT reliable in determining disease activity in pulmonary tuberculosis?

Aims and Objectives The purpose of our study is to [1] determine the activity of disease based on the HRCT findings (2) to define indications for the use of HRCT in evaluation of Pulmonary TB and (3) to determine whether additional information provided by HRCT alters clinical management of the disease. Materials and Methods The present study was carried out at Shree Sayajirao General Hospital (SSGH), Baroda, Gujarat, India from January 2002 to December 2002. Twenty five patients with sputum positive post-primary pulmonary TB were studied prospectively with chest radiographs and HRCT. The diagnosis of active TB was based on detection of acid-fast bacilli in sputum. None of the patients in our study population was HIV positive. All patients underwent x-ray chest and HRCT chest (Philips Tomoscan, Best, Netherlands). The pattern, extent and severity of HRCT findings were recorded and compared with the plain x-ray findings. The gathered information and investigations were subjected to statistical analysis. Results Our study population consisted of sputum positive (AFB positive) 25 patients, 22 of them were newly diagnosed/suspected post-primary tuberculosis (GROUP 1) and 3 of them had taken six months of AKT (GROUP 2). Our study included 22 males and 3 females with average age of 38 years (range, 14-65 years.) In total chest radiographic signs of active tuberculosis were seen in twelve (48%) patients. HRCT showed evidences of active tuberculosis in all 22 patients of newly diagnosed tuberculosis; and in 2 out of 3 patients with prior history of AKT. Thus, total of 24 (96%) patients had evidence of active pulmonary TB on HRCT. One patient with prior history of AKT showed evidence of pulmonary Koch′s sequel. Conclusion Although chest radiography remains the foremost imaging technique in the evaluation of pulmonary TB, HRCT can be useful in certain circumstances and can provide important information in the diagnosis and management of the disease. HRCT is helpful in the distinction of active form inactive TB. HRCT is better than plain chest radiograph in identification of extent of pulmonary TB, especially subtle areas of consolidation, cavitation, bronchogenic and miliary spread. HRCT is recommended when the radiographic findings are normal or inconclusive and tuberculosis is suspected clinically for the confirmation of diagnosis and determination of activity.

Activation pattern during his pacing: how close are we to normal physiology?

Background

His bundle pacing aims to mimic the activation pattern of normal conduction to maintain ventricular synchrony. However, selective His capture can be challenging, and the activation sequence during His pacing may not replicate normal conduction.

Purpose

Compare the right ventricular (RV) and left ventricular (LV) activation pattern in sinus rhythm and His bundle pacing.

Methods

Baseline LV and RV map was created in sinus rhythm using Rhythmia mapping system (Boston Scientific Corporation) in canine animal model. Medtronic 3830 lead was placed near the bundle of His under fluoroscopic, intracardiac echocardiogram, and electroanatomic guidance. Conduction system capture was confirmed by observing a QRS duration <120ms and an isoelectric segment between pacing artifact and QRS on surface ECG. Repeat LV and RV activation map was obtained during His pacing. Average QRS, HV and pacing to V intervals were calculated with standard deviation.

Results

Mapping was performed successfully in four animals. At baseline, the average QRS duration was 44±2.6ms and HV interval was 32±4.2ms. Earliest site of myocardial activation was in the mid-septal LV region. The earliest RV myocardial activation was also at the septum closer to the apex, but later than the LV (Figure1A). With His pacing, the average QRS duration was 70±17.0ms and the average stim to V interval was 31±8.7ms. During His pacing, the earliest site of activation was in the RV septum, with an activation pattern from base to apex in both the RV and LV.

Conclusion

Unlike normal physiology, the activation pattern during conduction system pacing is from base to apex with earliest site in the RV.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Mayo Clinic

Cognitive behavior therapy in patients with binge eating disorder

Introduction

With the growing epidemic of obesity many treatments are aimed at reducing weight like diets, exercise, pharmacotherapy and bariatric surgery. All of these can reduce weight at least for a period; however none of them adequately address the behavior of binge eating/eating disorder.

Aim

assessed the role of Cognitive Behavior therapy in reducing disordered eating behavior.

Method

The subjects were enrolled in 12 weeks CBT. They were all obese and had a score of > 20 on the BES. They completed a BDI, MBSRQ, and BES before and after the groups. Their weight was recorded before and after the 12 weeks. 79 patients were enrolled in groups over a period of 3 years. Of those 56 patients completed the groups and questionnaires. Most groups consisted of 6–8 patients.

Discussion

70% of patients had psychiatric symptoms psychotropic medications like antidepressants. More than 70% felt their eating habits were more in control and felt more informed about themselves since attending CBT groups. All of the patients who stayed and attended groups felt that the connection helped them sustain better eating habits. 67% of patients had lost 4–30 lbs during the 12 weeks of CBT, none had gained weight.

Conclusion

CBT helps the patient reduce disordered eating behaviors by understanding the cause of their self sabotage. CBT addresses the core of the problem i.e. disordered behavior as opposed to its consequences (viz. obesity and its multiple medical comorbidities); while affecting weight indirectly.

Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections

BACKGROUND

Consistent compliance with evidence-based guidelines is challenging yet critical to patient safety. We conducted a qualitative study to explore the underlying causes for non-compliance with evidence-based guidelines aimed at preventing four types of healthcare-associated infections in the surgical intensive care unit (SICU) setting.

METHODS

Twenty semistructured interviews were conducted with attending physicians (3), residents (2), nurses (6), quality improvement coordinators (3), infection control practitioners (2), respiratory therapists (2) and pharmacists (2) in two SICUs. Using a grounded theory approach, we performed thematic analyses of the interviews.

RESULTS

The concept of systems ambiguity to explain non-compliance with evidence-based guidelines emerged from the data. Ambiguities hindering consistent compliance were related to tasks, responsibilities, methods, expectations and exceptions. Strategies reported to reduce ambiguity included clarification of expectations from care providers with respect to guideline compliance through education, use of visual cues to indicate the status of patients with respect to a particular guideline, development of tools that provide an overview of information critical for guideline compliance, use of standardised orders, clarification of roles of care providers and use of decision-support tools.

CONCLUSIONS

The concept of systems ambiguity is useful to understand causes of non-compliance with evidence-based guidelines aimed at reducing healthcare-associated infections. Multi-faceted interventions are needed to reduce different ambiguity types, hence to improve guideline compliance.

Vitamin D and cancer

Vitamin D, a fat-soluble prohormone is synthesized in response to sunlight. Experimental evidence suggests that vitamin D may reduce the risk of cancer through regulation of cellular proliferation and differentiation as well as inhibition of angiogenesis. These anticancer properties have been attributed primarily to 1,25-dihydroxyvitamin D [1,25(OH) 2 D] (calcitriol), the hormonal form of vitamin D. Extensive research has shown that cells, including cancer cells, express specific receptors (VDR) for 1,25-dihydroxyvitamin D. When bound to the VDR, 1,25-dihydroxyvitamin D regulates> 60 genes that exert prodifferentiating, antiproliferative and antimetastatic effects on cells, including effects on cell cycle. The amount of exposure to the sun has been found to correlate inversely with cancer mortality and survival in numerous epidemiological studies. An inverse relationship between solar ultraviolet-B (UV-B) exposure and non-skin cancer mortality has long been reported. Several ecological studies suggest that sunlight may protect against prostate, colon, rectal, female breast and ovarian cancer, all diseases that contribute to a substantially higher proportion of cancer mortality in the western industrialized world. Some analytical studies also suggest a protective association between circulating vitamin D in blood, which is largely derived from sunlight, or dietary vitamin D. Paricalcitol (calcitriol analogue) is as effective as 1,25-dihydroxyvitamin D in transactivating the prostatic VDR and in inhibiting the growth of prostate cancer cell lines and primary cultures of prostate cancer cells in vitro. Promising preclinical evaluations of calcitriol and analogues have appeared in prostate cancer animal models.

"Imaging features of extramedullary plasmacytoma of skull base with multiple myeloma"- a rare case

Imaging features of extramedullary plasmacytoma of skull base with multiple myeloma is reported in a 65 year old woman patient presented with multiple cranial nerve palsies. Contrast Enhanced CT revealed a large homogeneously enhancing mass in the left parapharyngeal region with extension in left petrous apex, left cavernous sinus and upper two cervical vertebrae. An extramedullary plasmacytoma associated with multiple myeloma was diagnosed after biopsy from the mass and laboratory investigations.

Studies on the leaching of fluoride in tea infusions

In order to assess the levels of fluoride ingestion through intake of tea, studies were conducted with four different brands of tea leaves commonly available in the Indian market. Four most prevalent methods for the preparation of tea with various contact times (2,4,6,8 and 10 min) of tea leaves with water show that: (a) leaching of fluoride is least in case of leaf tea as compared to powdered tea (F levels increasing with decreasing grain size); (b) leaching of fluoride reaches a maximum after a contact of about 6 min; (c) there is no difference between levels of fluoride with or without addition of milk in the English style where tea leaves are not boiled, while for the Indian style, addition of milk and subsequent boiling resulted in reduction of fluoride levels and (d) ingestion of fluoride per cup of tea ranged from 1.55 mg/l to 3.21 mg/l amounting to an intake per day per person of fluoride between 0.3 to 1.9 mg.

Complement-independent lysis of human red blood cells by cold hemagglutinins

Hemolysis mediated by human antibodies is generally ascribed to the attack of red blood cells (RBC) by complement. We here extend earlier in vitro observations which indicate that potent cold agglutinins can directly cause lysis of RBC without the participation of complement. We have noted that EDTA plasma taken from patients with cold agglutinin disease is frequently reddish if the plasma is not immediately separated from the cells at 37 degrees C. Moreover, eluates prepared in such cases from plasma or heat-inactivated serum (30 min at 56 degrees C) by absorption (at 4-20 degrees C) and elution (at 37 degrees C) are usually contaminated with hemoglobin, and a large number of RBC used for absorption is lost during the procedure. To characterize this phenomenon further, we examined the effect of different hemagglutinating antibodies in vitro on normal RBC in the absence of complement. Hemolysis (5-17%) of RBC only occurred after treating the cells with potent antibodies at low temperatures (0-20 degrees C). This hemolysis increased 2- to 3-fold when the RBC were treated with an enzyme and decreased with rising temperature. Unlike cells hemolyzed by complement activation, no C5b-9 complexes could be detected on RBC damaged by this mechanism.

Carboxamidomethyl esters as reactive substrates for alpha-chymotrypsin. Orientational effects of hydrogen-bonding interactions

Effects of hydrogen-bonding interactions of amide groups on reactivity of esters to alpha-chymotrypsin were studied. Of the methyl esters studied, only that from acetyl-L-phenylalanine has k3 rate-limiting. In methyl beta-phenylpropionates an alpha-acetamido substituent increased k2 greater than 550 times, k3 approximately 5 times; an alpha-acetylclycyloxy substituent increased k2 approximately 2 times, k3 approximately 6 times, both in comparison with the alpha-acetoxy esters. Essentially all carboxamidomethyl esters studied have k3 rate-limiting; reactivity to hydroxide is only 4 times that of methyl esters. In alpha-substituted beta-phenylpropionates, carboxamido-methyl esters show k2 values greater than 110 times greater than 280 times, greater than 26 times, and 7 times the k2 values of the methyl esters for the alpha substituents, acetoxy, acetylglycyloxy, hydroxy, and hydrogen, respectively. In esters of alpha-acetamido acids, carboxamidomethyl esters show k2 values 44 times, greater than 110 times, greater than 12 times, and approximately 33 times the k2 values of the methyl esters of glycine, alanine, leucine, and phenylalanine, respectively. Cyanomethyl esters also had k3 rate-limiting. Hydrogen-bonding to the enzyme of either an alpha-acetamido group or a carboxamidomethyl group combined with bonding of the beta-aryl group, orients the hydrolyzing groups properly, increasing k2. Hydrogen-bonding of both alpha-acetamido and carboxamido-methyl groups is effective to a lesser degree. The amide group appears to have small effects on Ks as hydrogen bonding is balanced by desolvation. It is proposed that desolvation during bonding increases k2 and Ks.

Low serum triiodothyronine in patients with anorexia nervosa

Patients with anorexia nervosa can demonstrate clinical and/or laboratory findings suggestive of reduced thyroid hormone secretion. In this study, the thyroxine (T4) and triiodothyronine (T3) serum concentrations, and thyrotropin (TSH) response to intravenous administration of thyrotropin releasing hormone (TRH) were determined in 6 patients (aged 9 to 15 yr) with anorexia nervosa and the results compared to those found in a group of 15 normal subjects. The mean basal TSH concentration and mean maximum increase in TSH after TRH were comparable to those in the normal subjects. The mean T4 concentration (7.2 mug/100 ml) in the anorexia nerovsa group was slightly but significantly lower than in the normal group (9.5 mug/100 ml). Five of the 6 patients had serum T3 concentrations below the lower limits of normal and the mean T3 concentrations (49.7 ng/100 ml) was significantly lower than in the normal group (106 ng/100 ml). The extremely low serum levels of T3 in these patients with anorexia nervosa suggest that peripheral conversion of T4 to T3 is impaired during chronic starvation.