Adrenal Incidentaloma: Prevalence and Referral Patterns From Routine Practice in a Large UK University Teaching Hospital.

CONTEXT: Adrenal incidentalomas (AIs) are increasingly being identified during unrelated imaging. Unlike AI clinical management, data on referral patterns in routine practice are lacking. OBJECTIVE: This work aimed to identify factors associated with AI referral. METHODS: We linked data from imaging reports and outpatient bookings from a large UK teaching hospital. We examined (i) AI prevalence and (ii) pattern of referral to endocrinology, stratified by age, imaging modality, scan anatomical site, requesting clinical specialty, and temporal trends. Using key radiology phrases to identify scans reporting potential AI, we identified 4097 individuals from 479 945 scan reports (2015-2019). Main outcome measures included prevalence of AI and referral rates. RESULTS: Overall, AI lesions were identified in 1.2% of scans. They were more prevalent in abdomen computed tomography and magnetic resonance imaging scans (3.0% and 0.6%, respectively). Scans performed increased 7.7% year-on-year from 2015 to 2019, with a more pronounced increase in the number with AI lesions (14.7% per year).Only 394 of 4097 patients (9.6%) had a documented endocrinology referral code within 90 days, with medical (11.8%) more likely to refer than surgical (7.2%) specialties (P < .001). Despite prevalence increasing with age, older patients were less likely to be referred (P < .001). CONCLUSION: While overall AI prevalence appeared low, scan numbers are large and rising; the number with identified AI are increasing still further. The poor AI referral rates, even in centers such as ours where dedicated AI multidisciplinary team meetings and digital management systems are used, highlights the need for new streamlined, clinically effective systems and processes to appropriately manage the AI workload.

Challenges faced in establishing a dedicated 250 bed COVID-19 intensive care unit in a temporary structure.

An Intensive Care Unit (ICU) is an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency. While this availability of trained manpower and specialized equipment makes it possible to care for critically ill patients, it also presents singular challenges in the form of man and material management, design concerns, budgetary concerns, and protocolization of treatment. Consequently, the establishment of an ICU requires rigorous design and planning, a process that can take months to years. However, the Coronavirus disease-19 (COVID-19) epidemic has required the significant capacity building to accommodate the increased number of critically ill patients. At the peak of the pandemic, many countries were forced to resort to the building of temporary structures to house critically ill patients, to help tide over the crisis. This narrative review describes the challenges and lessons learned while establishing a 250 bedded ICU in a temporary structure and achieving functionality within a period of a fortnight.

Recurrent central nervous system tuberculoma with tubercular meningitis: Swerving from asymptomatic disease to severe form.

Tuberculosis (TB) is known for its varied presentation and complications, the most dreaded complication being central nervous system (CNS) TB which includes tuberculoma. We present a case report of an asymptomatic recurrent case of CNS tuberculoma requiring multiple surgeries and prolonged critical care management.

Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness.

INTRODUCTION: Adrenal incidentalomas are lesions that are incidentally identified while scanning for other conditions. While most are benign and hormonally non-functional, around 20% are malignant and/or hormonally active, requiring prompt intervention. Malignant lesions can be aggressive and life-threatening, while hormonally active tumours cause various endocrine disorders, with significant morbidity and mortality. Despite this, management of patients with adrenal incidentalomas is variable, with no robust evidence base. This project aimed to establish more effective and timely management of these patients. METHODS: We developed a web-based, electronic Adrenal Incidentaloma Management System (eAIMS), which incorporated the evidence-based and National Health Service-aligned 2016 European guidelines. The system captures key clinical, biochemical and radiological information necessary for adrenal incidentaloma patient management and generates a pre-populated outcome letter, saving clinical and administrative time while ensuring timely management plans with enhanced safety. Furthermore, we developed a prioritisation strategy, with members of the multidisciplinary team, which prioritised high-risk individuals for detailed discussion and management. Patient focus groups informed process-mapping and multidisciplinary team process re-design and patient information leaflet development. The project was partnered by University Hospital of South Manchester to maximise generalisability. RESULTS: Implementation of eAIMS, along with improvements in the prioritisation strategy, resulted in a 49% reduction in staff hands-on time, as well as a 78% reduction in the time from adrenal incidentaloma identification to multidisciplinary team decision. A health economic analysis identified a 28% reduction in costs. CONCLUSIONS: The system's in-built data validation and the automatic generation of the multidisciplinary team outcome letter improved patient safety through a reduction in transcription errors. We are currently developing the next stage of the programme to proactively identify all new adrenal incidentaloma cases.

A high-throughput screen for the identification of compounds that inhibit nematode gene expression by targeting spliced leader trans-splicing.

Infections with parasitic nematodes are among the most significant of the neglected tropical diseases affecting about a billion people living mainly in tropical regions with low economic activity. The most effective current strategy to control nematode infections involves large scale treatment programs with anthelmintic drugs. This strategy is at risk from the emergence of drug resistant parasites. Parasitic nematodes also affect livestock, which are treated with the same limited group of anthelmintic drugs. Livestock parasites resistant to single drugs, and even multi-drug resistant parasites, are appearing in many areas. There is therefore a pressing need for new anthelmintic drugs. Here we use the nematode Caenorhabditis elegans as a model for parasitic nematodes and demonstrate that sinefungin, a competitive inhibitor of methyltransferases, causes a delay in development and reduced fecundity, and inhibits spliced leader trans-splicing. Spliced leader trans-splicing is an essential step in gene expression that does not occur in the hosts of parasitic nematodes, and is therefore a potential target for new anthelmintic drugs. We have exploited the ability of sinefungin to inhibit spliced leader trans-splicing to adapt a green fluorescent protein based reporter gene assay that monitors spliced leader trans-splicing for high-throughput screening for new anthelmintic compounds. We have established a protocol for robust high-throughput screening, combining mechanical dispensing of living C. elegans into 384- or 1536- well plates with addition of compounds using an acoustic liquid dispenser, and the detection of the inhibition of SL trans-splicing using a microplate reader. We have tested this protocol in a first pilot screen and envisage that this assay will be a valuable tool in the search for new anthelmintic drugs.

Renal arteriovenous malformation mimicking hydronephrosis-hidden danger.

Renal arteriovenous malformations (AVMs) are rare, with an incidence of approximately 0.04%. Diagnosis is often challenging due to mimics of AVMs. We report a case of renal AVM mimicking hydronephrosis on ultrasound and unenhanced computed tomography (CT). A 24-year-old female with background of recurrent urinary tract infections (UTIs) presented to the Accident and Emergency department with 1 day history of bilateral flank pain, dysuria, rigors and pyrexia. Urine dipstick showed microscopic haematuria and blood tests showed mild neutrophilia. Dilated right renal pelvis was seen on ultrasound. Unenhanced CT of the urinary tract demonstrated right hydronephrosis with no evidence of calculi. Subsequent Uro-radiology meeting discussion concluded that renal pelvis might be pus-filled and recommended an urgent nephrostomy. However, ultrasound Doppler scan performed at the time of the planned nephrostomy demonstrated colour flow within dilated renal pelvis suggestive of an AVM. Nephrostomy was abandoned and subsequent CT angiogram confirmed a large congenital AVM. The patient was referred for embolization.Colour flow ultrasound imaging is a simple and quick technique to diagnose AVMs. However, as in our case, when colour flow Doppler imaging was not used at the initial ultrasound, the opportunity to obtain an accurate diagnosis was missed. If the subsequently planned nephrostomy had taken place, this may have led to potentially serious outcomes. We suggest that colour flow imaging should be used prior to nephrostomy insertion to differentiate hydronephrosis from vascular abnormalities.

Interventional radiology in the management of malignant biliary obstruction.

Malignant biliary obstruction is commonly due to pancreatic carcinoma, cholangiocarcinoma and metastatic disease which are often inoperable at presentation and carry a poor prognosis. Percutaneous biliary drainage and stenting provides a safe and effective method of palliation in such patients, thereby improving their quality of life. It may also be an adjunct to surgical management by improving hepatic and, indirectly, renal function before resection of the tumor.

Left ventricular lateral annulus and left atrial free-wall velocity time integral indicate thromboembolism in patients with rheumatic atrial fibrillation.

BACKGROUND: Low wall motion and stasis increase the likelihood of clot formation. We hypothesized that tissue Doppler indices of left atrial (LA) motion are reduced in the presence of LA thrombi and may be predictive for clot formation in patients with atrial fibrillation (AF). METHODS: We did an observational study for 3 years in 118 patients with rheumatic mitral valve disease in chronic AF who had not received anticoagulation, with (Group 1, n = 36) and without (Group 2, n = 82) thromboembolism. Pulsed tissue Doppler systolic velocities and velocity time integrals (VTIs) were measured in all four chambers. A mean LA VTI was calculated. LA strain during ventricular systole was calculated using VTI and distance between two LA locations. RESULTS: Logistic regression analysis showed that, after adjusting for age, gender, diabetes, hypertension, LA size, and left ventricular (LV) ejection fraction, mean LA VTI [Odds ratio (OR) 0.69, 95%CI (0.56-0.86, P = 0.03)] and lateral mitral annulus VTI [OR 0.15 (0.04-0.56, P = 0.03)] were associated with clot formation. The addition of these two parameters to the conventional risk factors increased the ability to predict thromboembolism (Nagelkerke R² = 0.32-0.50, P = 0.01; area under the curve 0.83 by receiver operating characteristic analysis, P = 0.01). LA strain also had potential to indicate clot formation (0.9 ± 13.8 vs. -8.2 ± 15.1%, group 1 vs. 2, respectively, P = 0.01). CONCLUSION: Patients with chronic AF and thromboembolism have reduced LA and LV motion independently of LA size and LV ejection fraction. Tissue Doppler parameters may have potential to predict clot formation in these patients.

Stearidonic acid-enriched soybean oil increased the omega-3 index, an emerging cardiovascular risk marker.

A plant source of omega-3 fatty acid (FA) that can raise tissue eicosapentaenoic acid (EPA) and/or docosahexaenoic acid (DHA) is needed. A soybean oil (SBO) containing approximately 20% stearidonic acid [SDA; the delta-6 desaturase product of alpha-linolenic acid (ALA)] derived from genetically modified soybeans is under development. This study compared the effects of EPA to SDA-SBO on erythrocyte EPA+DHA levels (the omega-3 index). Overweight healthy volunteers (n=45) were randomized to SDA-SBO (24 ml/day providing approximately 3.7 g SDA) or to regular SBO (control group) without or with EPA ethyl esters (approximately 1 g/day) for 16 weeks. Serum lipids, blood pressure, heart rate, platelet function and safety laboratory tests were measured along with the omega-3 index. A per-protocol analysis was conducted on 33 subjects (11 per group). Compared to baseline, average omega-3 index levels increased 19.5% in the SDA group and 25.4% in the EPA group (p<0.05 for both, vs. control). DHA did not change in any group. Relative to EPA, SDA increased RBC EPA with about 17% efficiency. No other clinical endpoints were affected by SDA or EPA treatment (vs. control). In conclusion, SDA-enriched SBO significantly raised the omega-3 index. Since EPA supplementation has been shown to raise the omega-3 index and to lower risk for cardiac events, SDA-SBO may be a viable plant-based alternative for providing meaningful intakes of cardioprotective omega-3 FAs.

Stearidonic acid increases the red blood cell and heart eicosapentaenoic acid content in dogs.

Plant sources of omega-3 fatty acids (FA) are needed that can materially raise tissue levels of long-chain omega-3 FA [i.e., eicosapentaenoic acid (EPA; 20:5n-3) and docosahexaenoic acid (DHA; 20:6n-3)]. Stearidonic acid (SDA; 18:4n-3) is the delta-6 desaturase product of alpha-linolenic acid (ALA; 18:3n-3), and when fed to humans, increases red blood cell (RBC) content of EPA to a greater extent than does ALA. This study was undertaken to determine the dose-dependence and time course of the increase in the EPA and DHA content of the heart and RBC in dogs. Adult male Beagles were fed 21, 64, or 193 mg/kg of SDA in in their food daily for up to 12 weeks. Positive and negative controls were given EPA (43 mg/kg) or high oleic acid sunflower oil, respectively. The baseline EPA content of RBC was 0.38 +/- 0.03% which increased (P<0.01) in a dose-dependent manner, with the high dose of SDA and EPA achieving levels of 1.33 +/- 0.26 and 1.55. +/- 0.28%, respectively. In the heart, the content of EPA rose from 0.06 +/- 0.01 to 1.24 +/- 0.22% in the EPA group and to 0.81 +/- 0.32% in the high SDA group (both P<0.01). In both tissues, DHA did not change. Compared to dietary EPA, SDA was 20-23% as efficient in raising tissue EPA levels. In conclusion, SDA supplementation increased the EPA content of RBC and heart and may have utility as a plant-based source of omega-3 FA.

Composition of grain and forage from corn rootworm-protected corn event MON 863 is equivalent to that of conventional corn (Zea mays l.).

Insect-protected corn hybrids containing event MON 863 protect corn plants against feeding damage from corn rootworm (Diabrotica), a major North American insect pest. Corn event MON 863 contains a gene that expresses an amino acid sequence variant of the wild-type Cry3Bb1 insecticidal protein from Bacillus thuringiensis. The purpose of this study was to compare the composition of corn containing event MON 863 with that of conventional nontransgenic corn. Compositional analyses were conducted to measure proximates, fiber, amino acids, fatty acids, minerals, folic acid, thiamin, riboflavin, vitamin E, antinutrients, and certain secondary metabolites in grain and proximates and fiber content in forage collected from a total of eight field sites in the U.S. and Argentina. Compositional analyses demonstrated that the grain and forage of event MON 863 are comparable in their nutritional content to the control corn hybrid and conventional corn. These comparisons, together with the history of the safe use of corn as a common component of animal feed and human food, support the conclusion that corn event MON 863 is compositionally equivalent to, and as safe and nutritious as, conventional corn hybrids grown commercially today.