Ganga and Yamuna Rivers: Through the Lens of the National Green Tribunal

Despite the country’s extensive environmental jurisprudence and many historic rulings in which the courts have rescued worsening environmental situations, river (Ganga and Yamuna) water does not match the mandated minimum “bathing quality.” Rivers like the Ganga and Yamuna, which flow through numerous states and towns, would be in a different situation. Without strict monitoring and enforcement of the measures, no action plan can work. Punishment of defaulters can serve as deterrence while also instilling fear in other non-compliant enterprises. In comparison to environmental legislation, the NGT Act allows for substantially harsher fines and penalties. River rejuvenation plans must be carefully monitored to ensure that they do not suffer the same fate. Making action plans will not improve river water quality unless they are implemented with sincerity and consistency, as well as continuous monitoring and severe enforcement.

Prescribing Patterns for Long-Acting Inhaled Bronchodilators Among Rural Adults With Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) is prevalent in rural areas of the USA. Long-acting inhaled bronchodilators (LABDs) are a key tool in COPD management and are underutilized. The purpose of this study was to determine whether rates of prescriptions for LABD differed by payer among patients with COPD in a rural healthcare network.

Methods

In analysis 1, a random sample of patients with spirometry- and symptom-confirmed COPD over April 1, 2017 to December 31, 2019 was identified. Patient characteristics, including payer status, extracted from medical records were compared for those who did and did not have any prescriptions for LABD during the study window. In analysis 2, patients with one or more COPD-related hospitalizations during the same time period were identified and similar comparisons were made by LABD prescription status.

Results

Among a random sample of patients with spirometry-confirmed COPD, 93.0% had been prescribed LABD during the study window with no difference in proportion by payer. Among the 461 patients with a COPD-related hospitalization, 388 (84.2%) had been prescribed LABD, again with no difference in prescriptions by payer. Those with a COPD-related hospitalization who had been prescribed LABD were younger, had lower body mass index, were more likely to be current smokers and had higher rates of hospitalizations for COPD during the study period than those not prescribed LABD.

Conclusion

While disparities in LABD utilization may occur due to cost or other barriers to filling prescriptions, in our study, prescriptions for LABD were common and did not differ by payer status.

A Behavioral Lifestyle Intervention to Improve Frailty in Overweight or Obese Older Adults with Type 2 Diabetes: A Feasibility Study

BACKGROUND

Older adults with Type 2 diabetes (T2D) are more likely to be frail, which increases the risk for disability and mortality.

OBJECTIVES

To determine the feasibility of a behavioral lifestyle intervention, enhanced with mobile health technology for self-monitoring of diet and activity, to improve frailty in overweight/obese older adults (≥65 years) diagnosed with T2D.

DESIGN, SETTING, AND PARTICIPANTS

Single arm, 6-month study of a behavioral lifestyle intervention in 20 overweight/obese (BMI>25) older adults (≥ 65 years) with self-reported T2D diagnosis who owned a smartphone. A Fitbit tracker was provided to all participants for self-monitoring of diet and physical activity. Our primary outcome of feasibility was measured by session attendance, adherence to Fitbit usage to self-monitor diet and physical activity, and study retention. Secondary outcomes included the preliminary efficacy of the intervention on frailty, physical function, quality of life, and T2D-related outcomes.

RESULTS

Eighteen participants completed the study. The mean age was 71.5 (SD ± 5.3) years, 56% were female, and half were Hispanic. At baseline, 13 (72%) were pre-frail, 4 (22%) were frail, and 1 (6%) were non-frail. At follow-up, frailty scores improved significantly from 1.61 ± 1.15 to 0.94 ± 0.94 (p=0.01) and bodyweight improved from 205.66 ± 45.52 lbs. to 198.33 ± 43.6 lbs. (p=<0.001).

CONCLUSION

This study provides evidence for the feasibility of a behavioral lifestyle intervention in overweight/obese older adults with T2D and preliminary results support its potential efficacy in improving frailty score.

Habit Mimics the Illness: EVALI During the Era of the COVID-19 Pandemic

Globally, health care providers have been challenged to provide adequate care during the coronavirus disease-2019 (COVID-19) pandemic. Due to the ever changing and rapidly evolving nature of the novel coronavirus, there is increased public anxiety and knowledge gaps that have created major dilemmas in health care delivery. In this environment, there is tremendous pressure on clinicians to diagnose each and every case of COVID-19. This has led to a situation in which clinicians are primed to suspect all respiratory illness is due to COVID-19 infection until proven otherwise. Because of this, providers may misdiagnose patients who have illnesses that are distinct from COVID-19 but present in a similar manner. In the current article, we present the case of e-cigarette- and vaping-associated acute lung injury (EVALI) mimicking pneumonia secondary to the novel coronavirus. It is unknown if vaping puts patients at higher risk of respiratory failure if coinfected with COVID-19. Therefore, exposure history in patients presenting with pneumonia-like syndrome is important. Physicians should be aware of the overlap between these conditions and should pay particular attention during history taking to distinguish EVALI from COVID-19 pneumonia.

Acute myocardial infarction in several mental illness: a nationwide analysis of prevalence, management strategies and outcomes

Background

Severe mental illness (SMI) is associated with an increased risk of cardiovascular disease and mortality. However, it is unclear whether SMI patients are just as likely to receive guideline-recommended therapy for AMI as those without mental illness.

Purpose

To examine national-level estimates of the prevalence, management strategies and in-hospital clinical outcomes of SMI patients presenting with AMI.

Methods

All AMI hospitalisations from the United States National Inpatient Sample were included, stratified by mental health status in to 5 groups: no-SMI, Schizophrenia, “Other non-organic psychoses” (ONOP), Bipolar Disorder and Major Depression. Multivariable logistic regression modelling was performed to examine the association between SMI subtypes and receipt of invasive management and subsequent in-hospital clinical outcomes, expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI).

Results

Out of 6,968,777 AMI hospitalisations between 2004 and 2014, a total of 439,544 (6.5%) had an SMI diagnosis. The prevalence of SMI amongst the ACS population doubled over the study period (from 4.5% in 2004 to 9.5% in 2014), primarily due to an increase in Major Depression and Bipolar Disorder diagnoses. All SMI subtypes were less likely to receive coronary angiography and PCI, with the Schizophrenia group being at least odds of either procedure (aOR 0.46 95% CI 0.45, 0.48 and aOR 0.57 95% CI 0.55, 0.59, respectively). Although patients with Schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared to those without SMI, only Schizophrenia patients were associated with increased odds of mortality (aOR 1.10 95% CI 1.04, 1.16), while ONOP were the only group at increased odds of stroke (aOR 1.53 95% CI 1.42,1.65) following multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared to those without SMI (aOR 1.11 95% CI 1.04,1.17).

Conclusion

Patients with SMI are less likely to receive invasive management for AMI, with women and schizophrenia diagnosis being the strongest predictors of conservative management. Schizophrenia and “other non-organic psychoses” are the only SMI subtypes associated with adverse clinical outcomes after AMI. A multidisciplinary approach between psychiatrists and cardiologists could improve outcomes of this high-risk population.

Odds of management and clinical outcomes

Funding Acknowledgement

Type of funding source: None

Pulmonary blastomycosis in rural Upstate New York: A case series and review of literature

In a rural medical center in Upstate New York, we observed an increase in pulmonary blastomycosis cases. Herein, we highlight the increased prevalence of blastomycosis in our region, and our experience with the diagnostic dilemma resulting in delayed diagnosis. This delay may have resulted in an increased mortality. A high index of suspicion may help hasten the diagnosis in an otherwise nonendemic area. A single-center retrospective case series of all patients diagnosed with culture-proven blastomycosis is reported at the Bassett Medical Center from 2007 to 2019. Eight cases of confirmed pulmonary blastomycosis were identified. All patients resided in a rural area along the Susquehanna River Basin. Only one case had a travel history to an endemic state. Males accounted for 100% of cases. There was a 50% mortality rate from acute respiratory distress syndrome. Bronchoalveolar lavage (BAL) reliably made the diagnosis. About 40% of patients had a false-negative blastomycosis serology. There was an average delay of 2.5 months from presentation to correct diagnosis due to a lack of consideration for blastomycosis. BAL resulted in a correct diagnosis, while serology was not reliable to exclude the diagnosis. Physicians should include blastomycosis in the diagnostic differential cases of nonresolving pneumonia in Upstate New York, an area not previously considered as endemic. Bronchoalveolar remains the evaluation method of choice if blastomycosis is suspected.

WITHDRAWN: Diagnostic accuracy of folate receptor-positive circulating tumor cells detected by ligand-targeted polymerase chain reaction in patients with non-small-cell lung cancer: A meta-analysis

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Incidence and Risk of Thyroid Dysfunction in Advanced or Metastatic Non-small Cell Lung Cancer Patients Treated with Pembrolizumab: A Meta-analysis

Thyroid dysfunction is one of the major side effects associated with Pembrolizumab in the treatment of advanced or metastatic non-small cell lung cancer (NSCLC). We performed a systematic review and meta-analysis of randomized clinical trials to determine its overall incidence. A literature search was conducted using the electronic database engines PubMed and Google Scholar from inception to March 2019. Eligible studies were prospective randomized clinical trials with advanced or metastatic NSCLC. The pooled incidence, risk ratio (RR), and 95% confidence interval (CI) of thyroid dysfunction were calculated using the random-effect model. Given the possibility of a between-study variance, we used the random-effect model rather than the fixed-effect model.

A total of four studies, including 1603 patients, were selected for analysis. Among patients receiving Pembrolizumab, the overall incidence of all-grade thyroid dysfunction was 19.8% (95% CI: 16.6-23.3%). Pembrolizumab was associated with a significantly increased risk of thyroid dysfunction of all grades, with a relative risk of 3.9 (95% CI: 2.08-7.42%, p= 0.084) in comparison with the controls. Therefore, there is a significant increase in developing thyroid dysfunction in advanced or metastatic NSCLC patients treated with Pembrolizumab.

P6535Atrial fibrillation and its impact in hospitalised cancer patients

Background

Atrial fibrillation (AF) is associated with increased morbidity and mortality. However, its impact on outcomes of cancer patients is largely unknown. We sought to determine the prevalence and effect of AF on in-hospital outcomes of patients admitted with AF in the United States.

Methods

We obtained and analyzed data from Nationwide Inpatient Sample (NIS 2002- 2014). The study population included all adults (>18 years old) with the discharge diagnosis of cancer and the associated secondary diagnosis of AF. The associations of AF with in-hospital complications, procedures, discharge outcomes, and mortality, were analyzed after adjusting for potential confounders using logistic regression analyses.

Results

During the study period, 12,410,290 patients were admitted with cancer; of which, 1,013,735 (8.2%) had AF. Patients with AF were likely to be male (51.1% vs 42.7%), white (86.3% vs 73.6%), and had significantly higher rates comorbidities including hypertension (59.6% vs 44.6%), diabetes (20.9% vs 15.8%), heart failure (23.8% vs 4.5%), and stroke (1.3% vs 0.7%). Similarly, in-hospital complications (including infections, venous thromboembolism, gastrointestinal bleeding, myocardial infarction) and hospital procedures (including cardiac catheterization, intubation, blood transfusion, percutaneous coronary intervention) were found at a significantly higher rate in cancer patients with AF compared to without AF (p-value for all <0.0001). After adjusting for all confounding factors, cancer patients in the AF group had higher odds of in-hospital death (odds ratio, 1.26; 95% confidence interval, 1.23–1.28; P<0.0001). The presence of AF conferred on average three days of extra inpatient stay in patients with cancer. Mortality in the cancer patients admitted with a concomitant diagnosis of AF has gradually increased from 7.2% to 9.7% over the 13-year study period.

Table 1. Multivariate model showing Atrial fibrillation as an independent risk factor of inpatient mortality in cancer patients Unadjusted univariate model Multivariate model adjusted for age, sex, race and potential confounders* Odds ratio (95% confidence interval P-value Odds ratio (95% confidence interval P-value Discharged alive Reference Reference In-hospital mortality 2.08 (2.07, 2.10) <0.0001 1.26 (1.23, 1.28) <0.0001 *Confounders adjusted for include all clinical comorbidities and in-hospital complications and procedures.

Conclusions

In patients with cancer, AF confers significant in-hospital burden by increasing the hospital stay by 3 days. AF is also associated with significantly higher rates of in-hospital procedures and complications in cancer patients and is an independent risk factor of in-hospital mortality.

Acknowledgement/Funding

None

Severe Hyponatremia Due to Cisplatin-induced Syndrome of Inappropriate Secretion of Antidiuretic Hormone

We report a rare case of severe hyponatremia due to cisplatin-induced syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in a 74-year-old male with a history of squamous cell carcinoma of the tongue who presented with a five days history of worsening confusion. He was found to have severe hyponatremia. His clinical and laboratory findings were consistent with hyponatremia due to SIADH. He was treated with fluid restriction and salt tablets after which his serum sodium markedly improved. Drugs including diuretics, antidepressants, antipsychotics are well known to cause hyponatremia. Cisplatin is a very common antineoplastic drug for solid tumors. Clinicians need to have prompt recognition of this rare side effect of cisplatin to prevent life-threatening hyponatremia.

Systemic Air Embolism Following Computed Tomography-Guided Lung Biopsy

A 61-year-old male with a history of poorly differentiated squamous cell carcinoma of tongue who completed chemo-radiation was found to have bilateral lung nodules on follow-up positron emission tomography (PET) scan. He underwent computed tomography (CT)-guided lung biopsy. Sequential chest scans done during the procedure showed air-fluid level in the left ventricle, suggestive of air embolism. He was hemodynamically stable during the procedure, however at the end of the procedure he developed right-sided face and arm weakness with aphasia. Emergent CT scans including angiography of head and neck were done which did not show any bleed and was also negative for any air in intracranial vasculature. Patient was treated with 100% oxygen. His neurological symptoms resolved in 30 minutes and he was subsequently admitted to intensive care unit (ICU) for further management. Six hours later, repeat CT of chest was done which showed resolution of air embolism.

A Rare Case of Necrotizing Sarcoid Granulomatosis Involving Liver

Sarcoidosis is a multi-system inflammatory disease, characterized by formation of non-caseating epithelioid granulomas. It usually involves lungs, lymph nodes, skin, joints, eyes and uncommonly liver. Necrotizing sarcoid granuloma is a rare entity. We are presenting a case of necrotizing sarcoid granuloma of liver which is extremely rare.

A case of Avascular Necrosis in a patient with Adrenocortical Carcinoma and Disseminated Metastasis

28 years old, male patient was diagnosed with Metastatic Adrenocortical Carcinoma after extensive investigation. Patient's primary concern was only his right hip and right shoulder pain. On imaging investigations, the patient was diagnosed with Avascular Necrosis of the right hip joint. Further laboratory work-up for avascular necrosis showed Primary Hypercortisolism and eventually patient was found to have Adrenocortical Carcinoma base on CT and bone scan results, Avascular Necrosis usually presents with pain in the affected area, mostly involving shoulder, knee or hip joint. Among many of the causes of Avascular necrosis, one rare cause is hormone secreting Adreno cortical Carcinoma, a rare and a highly malignant tumour. Patients can present with Cushing's syndrome or can have atypical presentation like this patient. This patient did not have any symptoms related to malignancy such as loss of appetite and weight loss.

Glucose-6-phosphate dehydrogenase inhibition attenuates acute lung injury through reduction in NADPH oxidase-derived reactive oxygen species

Acute lung injury (ALI) is a heterogeneous disease with the hallmarks of alveolar capillary membrane injury, increased pulmonary oedema and pulmonary inflammation. The most common direct aetiological factor for ALI is usually parenchymal lung infection or haemorrhage. Reactive oxygen species (ROS) generated by nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX2) are thought to play an important role in the pathophysiology of ALI. Glucose-6-phosphate dehydrogenase (G6PD) plays an important role both in production of ROS as well as their removal through the supply of NADPH. However, how G6PD modulation affects NOX2-mediated ROS in the airway epithelial cells (AECs) during acute lung injury has not been explored previously. Therefore, we investigated the effect of G6PD inhibitor, 6-aminonicotinamide on G6PD activity, NOX2 expression, ROS production and enzymatic anti-oxidants in AECs in a mouse model of ALI induced by lipopolysaccharide (LPS). ALI led to increased G6PD activity in the AECs with concomitant elevation of NOX2, ROS, SOD1 and nitrotyrosine. G6PD inhibitor led to reduction of LPS-induced airway inflammation, bronchoalveolar lavage fluid protein concentration as well as NOX2-derived ROS and subsequent oxidative stress. Conversely, ALI led to decreased glutathione reductase activity in AECs, which was normalized by G6PD inhibitor. These data show that activation of G6PD is associated with enhancement of oxidative inflammation in during ALI. Therefore, inhibition of G6PD might be a beneficial strategy during ALI to limit oxidative damage and ameliorate airway inflammation.

A case of hypotriploid chromosome in a patient with acute lymphoblastic leukaemia

TA 58-61, XXXX, hypotriploid chromosome was detected in the cytogenetics report of a 28 years old female patient, known case of B-cell Acute Lymphoblastic Leukaemia. On admission, the patient had normal physical examination findings and mental status, except history of fever spikes and generalized bone pains. The patient was admitted for induction of chemotherapy. Bone Marrow/Trephine biopsy report showed diffuse infiltration with blast cells with overall cellularity around 80-85% and suppressed normal haematopoiesis. Hypotriploid chromosome number in patients with B-cell Acute Lymphoblastic Leukaemia is a unique finding which, according to WHO classification of ALL, is an important prognostic factor itself and these cases have a favourable prognosis. There are only a few medical reports published about cases with similar presentations in Pakistan. Therefore, this case is very unique and further work should be done for better understanding of similar presentations and to find out more about its epidemiology.

Intracellular Cargo Transport by Kinesin-3 Motors

Intracellular transport along microtubules enables cellular cargoes to efficiently reach the extremities of large, eukaryotic cells. While it would take more than 200 years for a small vesicle to diffuse from the cell body to the growing tip of a one-meter long axon, transport by a kinesin allows delivery in one week. It is clear from this example that the evolution of intracellular transport was tightly linked to the development of complex and macroscopic life forms. The human genome encodes 45 kinesins, 8 of those belonging to the family of kinesin-3 organelle transporters that are known to transport a variety of cargoes towards the plus end of microtubules. However, their mode of action, their tertiary structure, and regulation are controversial. In this review, we summarize the latest developments in our understanding of these fascinating molecular motors.

Pyomyositis of the pectineus muscle in an adolescent male

The 'irritable hip' continues to pose a challenge for clinicians. Even with predictive clinical algorithms, decision making can be difficult. Emergency treatment is required if septic arthritis is suspected. Other differential diagnoses such as transient synovitis, pyomyositis of the pelvic girdle muscles and osteomyelitis must be considered in order to help guide appropriate investigations and allow early treatment. We report the case of a 13-year-old boy presenting to our institution with an acutely painful left hip but still able to weight bear. Despite a fever and raised inflammatory markers, the clinical examination did not correspond to that of an infected hip joint. Urgent magnetic resonance imaging (MRI) confirmed pyomyositis of the pectineus muscle. To our knowledge, this is the first reported case in the literature. The child was treated with seven days of intravenous antibiotics. There was a good clinical response as well as normalisation of the C-reactive protein level and white cell count. The patient was discharged home with a further week of oral antibiotics. Follow-up MRI at two weeks demonstrated a dramatic reduction in the inflammation of the pectineus. At the clinic follow-up appointment, the child was asymptomatic and back to normal function. Pyomyositis is typically found in tropical areas but its rates in temperate climates have been rising. It usually affects large groups of muscles such as the quadriceps and gluteal muscles. MRI is the gold standard investigation. If diagnosed early, the condition can be treated successfully with intravenous antibiotics alone. Given the widespread availability of MRI, we recommend its increased use to distinguish between pyomyositis and other paediatric hip pathologies.

A case report of acute myelogenous leukemia with Turner Syndrome

Turner Syndrome was diagnosed in a 45 years old female, known case of Acute Myeloid Leukaemia (AML) with maturation, on Bone Marrow biopsy. She presented with blurred vision, vertigo, exertional dyspnoea and insomnia. She did not show the typical features of Turner syndrome, but her cytogenetis confirmed the diagnosis. Bone marrow biopsy showed diffuse infiltration of blast cells with cellularity around 80-85% and haematopoietic suppression. Karyotype analysis showed: 45 X, -X, t (8; 21) (q22; q22) [According to The International System for Human Cytogenetic Nomenclature (ISCN)]. Turner syndrome is caused by partial or complete absence of second X chromosome in a female. It is known to have Cardiovascular and Reproductive complications but it is rare to find haematologic malignancies. There are few similar reported cases of AML associated with Turner syndrome, therefore this is a unique case presented to Jinnah Postgraduate Medical Center, Karachi, Pakistan and further research should be done to identify more similar cases to explore the prognostic significance of this association.

Accuracy of conventional digital palpation and ultrasound of the cricothyroid membrane in obese women in labour

Success of cricothyroidotomy depends on accurate identification of anatomical neck landmarks. Anaesthetists palpated the cricothyroid membrane of 28 obese and 28 non-obese women in labour (cut-off BMI 30 kg.m(-2) ) and marked the entry point for device insertion with an ultraviolet invisible pen. Ultrasonography was used to mark the midpoint of the cricothyroid membrane and the distance between the two marks was measured. The median (IQR [range]) distance between the two marks was significantly greater in the obese than the non-obese patients (5 (2-9.5 [0-34]) mm vs 1.8 (0.1-6 [0-15]) mm, respectively; p = 0.02). The cricothyroid membrane was accurately identified with digital palpation in only 39% (11/28) of obese compared with 71% (20/28) of non-obese patients (p = 0.03). Increased neck circumference in obese patients was significantly associated with inaccuracy in locating the cricothyroid membrane. Percutaneous identification of the cricothyroid membrane in obese women in labour was poor. Pre-procedural ultrasound may help improved the identification of neck landmarks for cricothyroidotomy.

Lateral epicondylitis

Lateral epicondylitis, or ’tennis elbow’, is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments.

Cite this article: Bone Joint J 2013;95-B:1158–64.

A case of sebaceous carcinoma arising in a benign cystic teratoma of the ovary and review of the literature

Objective:

To present an extremely rare case of sebaceous carcinoma arising in a mature cystic teratoma of the ovary.

Clinical presentation and intervention:

A 66-year-old woman presented with abdominal discomfort and a pelvic mass. Abdominal and pelvic ultrasound, as well as CT scan, revealed a 27 cm complex right pelvic mass, which was diagnosed histologically as a sebaceous carcinoma arising in a mature cystic teratoma. The patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy, peritoneal washings, appendicectomy and infracolic omentectomy.

Conclusion:

This case adds to the rare reports in the literature of sebaceous carcinoma occurring in a mature cystic teratoma. The clinical behaviour and optimal management of this entity are not well established. The patient has been well for 32 months following surgery with no evidence of recurrent disease clinically.

Video-assisted structured teaching to improve aseptic technique during neuraxial block

BACKGROUND

Teaching epidural catheter insertion tends to focus on developing manual dexterity rather than improving aseptic technique which usually remains poor despite increasing experience. The aim of this study was to compare epidural aseptic technique performance, by novice operators after a targeted teaching intervention, with operators taught aseptic technique before the intervention was initiated.

METHODS

Starting July 2008, two groups of second-year anaesthesia residents (pre- and post-teaching intervention) performing their 4-month obstetric anaesthesia rotation in a university affiliated centre were videotaped three to four times while performing epidural procedures. Trained blinded independent examiners reviewed the procedures. The primary outcome was a comparison of aseptic technique performance scores (0-30 points) graded on a scale task-specific checklist.

RESULTS

A total of 86 sessions by 29 residents were included in the study analysis. The intraclass correlation coefficient for inter-rater reliability for the aseptic technique was 0.90. The median aseptic technique scores for the rotation period were significantly higher in the post-intervention group [27.58, inter-quartile range (IQR) 22.33-29.50 vs 16.56, IQR 13.33-22.00]. Similar results were demonstrated when scores were analysed for low, moderate, and high levels of experience throughout the rotation.

CONCLUSIONS

Procedure-specific aseptic technique teaching, aided by video assessment and video demonstration, helped significantly improve aseptic practice by novice trainees. Future studies should consider looking at retention over longer periods of time in more senior residents.

Clinical utility of ¹⁸F FDG-PET/CT in the detection of bone marrow disease in Hodgkin's lymphoma

OBJECTIVE

The aim of the study was to evaluate the potential role of fludeoxyglucose (FDG)-positron emission tomography (PET)/CT in the detection of bone/bone marrow disease in patients with Hodgkin's lymphoma (HL).

METHODS

We retrospectively reviewed ((18)F)-FDG-PET/CT scans of 122 newly diagnosed, biopsy-proven cases of HL performed between November 2009 and June 2010. All the patients were staged before treatment by both PET/CT and bone marrow biopsy (BMB). Patients were subdivided into three groups based on the findings of FDG-PET/CT. Group A consisted of patients showing diffuse FDG uptake, Group B consisted of patients showing unifocal FDG uptake and Group C patients showed multifocal FDG-avid foci on PET/CT scans. Bone marrow results were also reviewed and considered positive if lymphomatous involvement was detected on bone marrow trephine biopsy. BMB results were correlated with FDG-PET/CT findings.

RESULTS

There were 122 patients in total-81 (66.4%) were male and 41 (33.6%) were female. The age range was from 6 years to 78 years (mean 35.70 years). PET/CT was reported as negative for bone/bone marrow involvement in 85 (69.7%) patients, while the remaining 37 showed abnormal FDG uptake. The sensitivity of FDG-PET/CT was calculated to be 100%, the specificity was 76.57%, the negative predictive value was 76.57%, the positive predictive value was 29.72% and the diagnostic accuracy was 78.62%.

CONCLUSION

(18)F-FDG-PET/CT and BMB are complementary in the evaluation of bone marrow disease.

How we do it: 'tonsillectomy mat', scored rubber sheet to fix the Draffin's rods

Slipping of the Driffin's rod from the operating table is problematic during tonsillectomy. We describe a technique to overcome this problem by using a 'tonsillectomy mat'.

HIV and other sexually transmitted infections among men, transgenders and women selling sex in two cities in Pakistan: a cross-sectional prevalence survey

OBJECTIVES

The extent and possibilities of spread of the HIV epidemic are not fully understood in Pakistan. A survey was conducted among men, women and transgender populations selling sex in Rawalpindi (Punjab) and Abbottabad (North West Frontier Province) in order to inform evidence-based programme planning.

METHODS

A cross-sectional survey was performed with participants recruited through respondent-driven sampling. Male and transgender sex workers were analysed in three gender groups; women were analysed as one group. Behavioural surveys were conducted and clinical specimens collected. Laboratory tests looked for evidence of acute infection (gonorrhoea, Chlamydia, syphilis, Trichomonas) and infection over the lifetime (HIV, herpes simplex virus-2, syphilis). Predictors of infection were explored using univariable and multivariable logistic regression.

RESULTS

The prevalence of HIV was low in 917 male and transgender sex workers and absent in 533 female sex workers in the study. High levels of current sexually transmitted infections were found, predominantly among transgender sex workers. Risk behaviours were common and knowledge of HIV was extremely low. Multivariable analysis found a large number of factors associated with higher levels of infection, including experience of forced first sex. Protection against risk was low, but those sex workers who reported using condoms at last sex had lower rates of infection.

CONCLUSIONS

The HIV epidemic is currently in its early stages among people who sell sex, but there may be potential for a much greater spread given the levels of other sexually transmitted infections found and the concomitant low levels of both protective knowledge and risk-reducing behaviours. Action is needed now to avert an epidemic. Framing interventions by upholding the recognition and protection of human rights is vital.