CSF or middle ear effusion? Diagnostical dilemmas in a patient with temporal bone meningioma: A case report.

Introduction: Cerebrospinal fluid (CSF) fistulas are a rare phenomenon, that can lead to life-threatening complications if left untreated. Presenting as rhinorrhea or otorrhea, they can be difficult to diagnose due to admixture of other bodily fluids. Typically, CSF fistulas develop after trauma, but in rare instances, they can be diagnosed in patients with a neoplastic lesion. Objective: To discuss several steps in diagnosing CSF fistulas. Patient: A fifty-year-old female with an intra-osseous temporal bone meningioma. Interventions: For diagnosing CSF admixture in fluids, two tests are looked into: beta-2 transferrin (ß2T) and beta-trace protein (ßTP) testing. Conclusion: Testing for ßTP is a highly sensitive, quick and non-invasive method to assess CSF admixture in middle ear effusion. Because of its lower cost, faster results and easy sample collection, ßTP testing has in our clinic replaced ß2T testing. The current case illustrates a rare etiology of a CSF fistula, where ß2T testing presumably showed false-negative results and ßTP testing showed true-positive results.

Further evidence of misclassification of the injury deaths in South Africa: When will the barriers to accurate injury death statistics be removed?

BACKGROUND: Contrary to the World Health Organization's internationally recommended medical certificate of cause of death, the South African (SA) death notification form (DNF) does not allow for the reporting of the manner of death to permit accurate coding of external causes of injury deaths. OBJECTIVES: To describe the injury cause-of-death profile from forensic pathology records collected for the National Cause-of-Death Validation (NCoDV) Project and compare it with profiles from other sources of injury mortality data. In particular, the recording of firearm use in homicides is compared between sources. METHODS: The NCoDV Project was a cross-sectional study of deaths that occurred during a fixed period in 2017 and 2018, from a nationally representative sample of 27 health subdistricts in SA. Trained fieldworkers scanned forensic records for all deaths investigated at the forensic mortuaries serving the sampled subdistricts during the study period. Forensic practitioners reviewed the records and completed a medical certificate of cause of death for each decedent. Causes of death were coded to the International Statistical Classification of Diseases, 10th revision (ICD-10), using Iris automated coding software. Cause-specific mortality fractions for injury deaths were compared with Injury Mortality Survey 2017 (IMS 2017) and Statistics South Africa 2017 (Stats SA 2017) datasets. The cause profile for all firearm-related deaths was compared between the three datasets. RESULTS: A total of 5 315 records were available for analysis. Males accounted for 77.6% of cases, and most decedents were aged between 25 and 44 years. Homicide was the leading cause of death (34.7%), followed by transport injuries (32.6%) and suicide (14.7%). This injury cause profile was similar to IMS 2017 but differed markedly from the official statistics, which showed markedly lower proportions of these three causes (15.0%, 11.6% and 0.7%, respectively), and a much higher proportion of other unintentional causes. Investigation of firearm-related deaths revealed that most were homicides in NCoDV 2017/18 (88.5%) and IMS 2017 (93.1%), while in the Stats SA 2017 data, 98.7% of firearm deaths were classified as accidental. Approximately 7% of firearm-related deaths were suicides in NCoDV 2017/18 and IMS 2017, with only 0.3% in Stats SA 2017. CONCLUSION: The official cause-of-death data for injuries in SA in 2017 differed substantially from findings from the NCoDV 2017/18 study and IMS 2017. Accurate data sources would ensure that public health interventions are designed to reduce the high injury burden. Inclusion of the manner of death on the DNF, as is recommended internationally, is critically important to enable more accurate, reliable and valid reporting of the injury profile.

Ureaplasma-Driven Neonatal Neuroinflammation: Novel Insights from an Ovine Model.

Ureaplasma species (spp.) are considered commensals of the adult genitourinary tract, but have been associated with chorioamnionitis, preterm birth, and invasive infections in neonates, including meningitis. Data on mechanisms involved in Ureaplasma-driven neuroinflammation are scarce. The present study addressed brain inflammatory responses in preterm lambs exposed to Ureaplasma parvum (UP) in utero. 7 days after intra-amniotic injection of UP (n = 10) or saline (n = 11), lambs were surgically delivered at gestational day 128-129. Expression of inflammatory markers was assessed in different brain regions using qRT-PCR and in cerebrospinal fluid (CSF) by multiplex immunoassay. CSF was analyzed for UP presence using ureB-based real-time PCR, and MRI scans documented cerebral white matter area and cortical folding. Cerebral tissue levels of atypical chemokine receptor (ACKR) 3, caspases 1-like, 2, 7, and C-X-C chemokine receptor (CXCR) 4 mRNA, as well as CSF interleukin-8 protein concentrations were significantly increased in UP-exposed lambs. UP presence in CSF was confirmed in one animal. Cortical folding and white matter area did not differ among groups. The present study confirms a role of caspases and the transmembrane receptors ACKR3 and CXCR4 in Ureaplasma-driven neuroinflammation. Enhanced caspase 1-like, 2, and 7 expression may reflect cell death. Increased ACKR3 and CXCR4 expression has been associated with inflammatory central nervous system (CNS) diseases and impaired blood-brain barrier function. According to these data and previous in vitro findings from our group, we speculate that Ureaplasma-induced caspase and receptor responses affect CNS barrier properties and thus facilitate neuroinflammation.

Postmortem Fetal Temperature Estimation with Magnetic Resonance Imaging: Apparent Diffusion Coefficient Measurements in the Vitreous Body and Cerebrospinal Fluid.

OBJECTIVES: Magnetic resonance imaging (MRI) is increasingly used in postmortem fetal imaging. Several factors influence the quality of MRI in this setting, such as small size, autolytic and maceration changes, and temperature. Knowing the fetal temperature at the time of scanning can improve the MRI interpretation. Temperature can be calculated using diffusion-weighted imaging with measurements of the apparent diffusion coefficient (ADC) in the cerebrospinal fluid (CSF). However, this is complicated by small ventricle size and hemorrhage and, therefore, may be unreliable in postmortem imaging. The current study evaluated the feasibility and reliability of using the ADC for temperature measurements of the vitreous body compared to that of CSF. MATERIALS AND METHODS: Two lambs were scanned postmortem at five different time points over 28 hours. Furthermore, 10 stillborn fetuses were scanned once, at 4 to 62 hours after birth. The temperature was measured with a digital thermometer and calculated using the ADCs of the vitreous body (lambs and fetuses) and CSF (fetuses). RESULTS: There was an excellent correlation between measured and calculated temperatures in vitreous bodies of lambs (r = 0.997, P < 0.001) and fetuses (r = 0.970, P < 0.001). The correlation between measured and calculated temperatures in the CSF was poor (r = 0.522, P = 0.122). CONCLUSION: The calculation of the temperature based on the ADC of the vitreous body is feasible and reliable for postmortem fetal imaging.

Postmortem Diffusion-Weighted Magnetic Resonance Imaging of the Brain in Perinatal Death: An Animal Control Study to Detect the Influence of Postmortem Interval.

OBJECTIVES: Diffusion-weighted imaging may be useful as part of a postmortem magnetic resonance imaging protocol. However, apart from the effect of temperature on apparent diffusion coefficient (ADC), normal postmortem ADC changes can influence the interpretation. Therefore, this study was conducted to evaluate the correlation between normal ADC changes and postmortem intervals (PMIs) and develop a reference standard for postmortem changes after temperature correction. MATERIALS AND METHODS: Six premature lambs were scanned at different PMIs. ADC values were measured at different parenchymal locations. Correlation and linear regression between ADC values and PMI were analyzed for all locations, both uncorrected and corrected for temperature. RESULTS: All locations showed a significant negative correlation between the PMI and ADC value, with (R2 = 0.581-0.837, P < 0.001) and without (R2 = 0.183-0.555, P < 0.001-0.018) temperature correction. CONCLUSIONS: The postmortem interval is negatively correlated with ADC values in the brain. A correlation coefficient for the PMI can be calculated after temperature correction to predict ADC changes. However, further research is required to evaluate its clinical application in humans.

Structured diabetes self-management education and glycaemic control in low- and middle-income countries: A systematic review.

AIM: To determine the association between structured diabetes self-management education (DSME) and glycaemic control in persons living with diabetes (PLD) in low- and middle-income countries (LMICs). METHODS: PubMed, Embase and Cochrane databases were searched up to June 2020 for intervention studies on the effect of structured DSME on glycaemic control in PLD in LMICs (PROSPERO registration CRD42020164857). The primary outcome was reduction in glycated haemoglobin. Included studies were assessed for risk of bias (RoB) with the Cochrane RoB tool for randomised trials. Findings were summarized in a narrative synthesis. RESULTS: Out of 154 abstracts retrieved and screened for eligibility, nine studies with a total of 1389 participants were included in the review. The structured DSME interventions were culturally tailored and were delivered in-person. They were associated with reductions in glycated haemoglobin in all studies: mean/median reduction ranged between 0.5% and 2.6% relative to baseline. CONCLUSIONS: There is a dearth of literature on the association between structured DSME and glycaemic control among PLD in LMICs. The evidence available suggests that in LMICs; particularly in sub-Saharan Africa, structured DSME is associated with reduction in glycated haemoglobin. We recommend further intervention studies on the effects of structured DSME in LMICs.

Respiratory presentations to acute services at a tertiary hospital in South Africa.

BACKGROUND: Respiratory diseases account for >10% of the global burden of disease when measured in disability-adjusted life-years. The burden of chronic respiratory diseases (CRDs) increases as the world's population ages, with a much greater increase in low- to middle-income countries. OBJECTIVES: To characterise and quantify the reasons for acute respiratory presentations to the acute care services at a tertiary hospital in Cape Town, South Africa. METHODS: A cross-sectional descriptive study was conducted. Casualty registers and electronic record databases were reviewed to determine the diagnoses of consecutive patients attending the casualty unit from May 2019 to January 2020. RESULTS: A total of 1 053 individual patients presented with a primary respiratory diagnosis. Fewer than 10% of admissions were from outside the Cape Town metropole, while >60% were from the subdistrict immediately adjacent to the hospital. Of all patients, 8.3% were readmitted at least once within the 9-month study period. Six hundred and forty-three (61.1%) of the patients presented with non-CRDs. The main reasons for presentation in these patients were pulmonary tuberculosis (PTB) (n=224; 21.3%), other infections including lower respiratory tract infections, pneumonia and bronchitis (n=272; 25.8%), and cancer (n=140; 13.3%). Haemoptysis was seen in 9.8% of all patients, mainly explained by post-tuberculosis lung disease (PTLD) (37.9%) and PTB (36.9%). Of the patients, 410 (38.9%) had an underlying CRD, with chronic pulmonary obstructive disease (COPD) being the most common (n=192; 18.2%), followed by PTLD (n=88; 8.5%) and asthma (n=52; 5.1%). CONCLUSIONS: Over a 9-month period, acute respiratory presentations to a tertiary hospital were mainly for primary/secondary level of care indications, highlighting disparity in accessing tertiary services. COPD and PTLD predominated among CRDs, while infections and cancers were common. A high readmission rate was found for several diseases, suggesting the potential for targeted interventions to prevent both admissions and readmissions and reduce acute hospital utilisation costs.

Ultrasound to Evaluate Neonatal Spinal Dysraphism: A First-Line Alternative to CT and MRI.

The embryologic development of the spinal cord is a remarkably complex process. Spinal abnormalities can occur in isolation or be part of a clinical syndrome commonly summarized as spinal dysraphism. Proper evaluation of spinal malformations with imaging is required for early diagnosis prior to counseling and selection of postnatal treatment options. The preferred imaging modality of the spine in newborns up to 3 months of age are ultrasound (US) and magnetic resonance imaging (MRI). The diagnostic workup should preferably start with the safe, minimal invasive (no need for sedation), cost-effective, and bedside US as a screening procedure. On the other hand, need for sedation, thermal instability of infants, and high cost make the use of spinal MRI impracticable for screening purposes. US is also a well-established imaging modality to investigate the spinal cord and canal during pregnancy. It is critical to follow a strict protocol in an attempt to precisely identify all imaging findings, one should be familiar with the normal ultrasonographic appearance of bony and soft tissue structures in the various planes and one should be able to correlate the abnormal findings with spinal cord embryology as it aids in identifying the etiology. US should be considered as a first-line imaging for neonates suspected of spinal anomalies. In this article, we discuss up-to-date US technique of the spine, the most frequently encountered neonatal spinal malformations seen with US and correlate these findings with the relevant embryologic processes.

Dual-energy CT of the brain and intracranial vessels.

OBJECTIVE: The purpose of this review is to summarize the principles and applications of dual-energy CT in evaluation of the brain and the intracranial blood vessels. CONCLUSION: One major advantage of dual-energy CT is the capability of material differentiation. In general, this property can be applied to bone removal in CT angiography for easier and faster postprocessing. In neuroradiology, material decomposition allows detection of hemorrhage on contrast-enhanced CT scans and facilitates the search for the underlying pathologic mechanism of hematomas. The combination of low radiation dose and advantageous spectral information (blood vs contrast) from these datasets justifies broad clinical implementation of dual-energy CT in neuroradiology.

Norms for the Wingate anaerobic test with comparison to another similar test.

This study was undertaken in order to develop norms for the Wingate test for physically active young men and women, and also to compare mean power measures obtained from the Wingate test with those obtained from another similar cycle ergometer test. A total of 112 males and 74 females aged 18 to 28 years comprised the subject pool. Data collected from the Wingate test included mean power for 30 s, peak power for 5 s, and a percent fatigue index. Data from the second test (Katch test) included mean power for both 30 s and 40 s. Percentile norms and descriptive statistics were generated as were multiple regression equations for prediction of mean power between the two different tests. Correlations between the two tests ranged from .66 to .87. Comparisons among data derived from this study and those reported for other athletic groups are also given.

Gender comparisons in anaerobic power and anaerobic capacity tests.

The purpose of the study was to compare anaerobic power and anaerobic capacity test scores between young active men and women. Three performance measures of anaerobic power and two of anaerobic capacity were administered to a sample comprising 52 male and 50 female college students (means age = 21.4 yrs). Results indicated significant differences between men and women in body height, weight and per cent fat, in fat free mass (FFM), anaerobic power, and anaerobic capacity when recorded as gross work completed and relative to body weight. However, these differences are reduced when data is adjusted for body weight and further reduced when corrected for FFM. The study found no significant differences between men and women in either anaerobic power or anaerobic capacity when values were given relative to FFM.

Physiological and anthropometric parameters that describe a rugby union team.

The purpose of this study was to describe the anthropometric and physiological parameters that apply to a USA amateur rugby union club team. Fifteen players who were members of the club's first team were evaluated for body composition, muscular strength, power and endurance, flexibility, anaerobic power, anaerobic capacity, and cardio-respiratory function shortly after completion of the regular season. Means for some of the variables measured include: age, 29 yr; height, 180 cm; weight, 84 kg; lean body weight, 74 kg; body fat, 12%, endurance sit-ups, 50/min; vertical jump height, 51 cm; anaerobic power output, 132 m.kg.s-1 (1.32 kw); anaerobic capacity, 2247 m.kp/40s (22.5 kJ); maximum heart rate, 186 beats/min; maximum ventilation, 175 l/min-1; maximum respiratory quotient 1.23; and maximum oxygen uptake, 56.6 ml.kg-1 min-1. In comparison with other rugby players studied these players had higher maximum oxygen uptake values, were similar in endurance sit-up and vertical jump ability, exhibited less upper body strength, and the forwards had lower body fat percentages. They were generally within the range of scores found to describe the aerobic and anaerobic fitness, and body composition of other élite amateur and professional intermittent sport athletes.

A survey of health-fitness evaluation centers.

Twenty-three medically oriented private health-fitness evaluation centers in the United States were surveyed to determine the types of tests available, protocols used, the availability of exercise prescriptions, qualifications of employees, and facility use. All centers administered an electrocardiogram exercise tolerance test, but great variability existed with regard to the number and type of other tests given and services available. Questions in the survey explored the availability of cardiovascular, pulmonary function, musculoskeletal, body composition, and lifestyle evaluations. Some centers were restricted to testing solely for cardiovascular function, while others were complete wellness centers. The centers had a range of 8 to 325 patrons per month, and in general, they tested more men than women.

Fifty years of training and competition in the marathon: Wally Hayward, age 70--a physiological profile.

A 70-year-old South African long-distance runner, holder of his age group's marathon record and former Olympic marathon runner, was studied to determine the effects of 52 years of regular training on functional capacity and health. Maximal treadmill exercise testing revealed no ischaemic ECG abnormalities and an excellent functional capacity (58,6 ml/kg/min). Submaximal testing showed that the subject ran at approximately 86% of maximum aerobic capacity when completing the marathon in his record time. The subject was very lean (13,6% fat) for his age. Muscles contained 82% slow-twitch fibres. Pulmonary function and blood chemical values were within normal limits. Although total cholesterol was somewhat high (247 mg/dl), high-density lipoprotein cholesterol was elevated (53 mg/dl). Twenty-four-hour Holter monitoring revealed no significant ventricular ectopic activity although frequent premature atrial contractions were noted. M-mode echocardiography revealed a normal heart with moderately hypertrophied left ventricular wall thickness. Radionuclide cine angiography showed a normal ejection fraction at rest (69%), followed by a slight drop at maximal exercise (62%). Left ventricular regional wall motion was considered normal at both rest and exercise. He had no significant orthopaedic abnormalities but showed normal flexibility and well-balanced muscular strength. Thickened heel pads were also noted. These results appear to indicate a beneficial effect of habitual physical activity upon the retention of functional capacity with ageing.