Ultrasound accuracy for brachial plexus pathology.

AIM: To determine (a) the accuracy of ultrasound in detecting brachial plexus pathology and (b) outline the advantages and limitations of ultrasound compared to MRI for imaging the brachial plexus. MATERIAL AND METHODS: cases with clinically suspected brachial plexus pathology were evaluated first by ultrasound, followed by MRI. Patients with prior brachial plexus imaging were excluded. The final diagnosis was based on a combination of ultrasound, MRI, clinical follow-up, and surgical findings. The accuracy of the ultrasound was assessed by comparing the ultrasound and the final diagnoses. The mean clinical follow-up time following ultrasound was 1.8 ± 1.4 years. RESULTS: Ninety-two (64%) of the 143 cases had normal brachial plexus ultrasound and MRI examinations. Fifty-one (36%) of 143 cases had brachial plexus pathology on MRI, comprising post-radiation fibrosis (n=25, 49%), nerve sheath tumor (n=11, 21%), traumatic injury (n=7, 14%), inflammatory polyneuropathy (n=4, 8%), malignant infiltration (n=2, 4%), desmoid fibromatosis (n=1,2%), and neuralgic amyotrophy (n=1, 2%). Overall diagnostic accuracy of ultrasound for brachial plexus pathology was 98% (140/143), with three discordant cases (neuralgic amyotrophy n=1, inflammatory neuropathy n=1, postradiation fibrosis n=1) regarded as normal on ultrasound assessment. Sensitivity, specificity, and positive and negative predictive value of ultrasound for identifying brachial plexus pathology were 94%, 100%, 100%, and 97%, respectively. CONCLUSION: Ultrasound identifies brachial plexus pathology with high accuracy and specificity, showing comparable diagnostic efficacy to MRI. Ultrasound can serve as an effective first-line imaging investigation for suspected brachial plexus pathology.

Ultrasound-guided lymph node sampling: accuracy of FNAC, end-cutting (Franseen), and side-cutting (Temno) needle biopsy techniques.

AIM: To compare technical success, diagnostic accuracy, and histological yield of fine-needle aspiration cytology (FNAC), side-cutting (Temno) needle biopsy, and end-cutting (Franseen) needle biopsy for ultrasound-guided sampling of groin and axillary lymph nodes. MATERIALS AND METHODS: A total of 270 abnormal groin and axillary nodes were sampled using one of the three techniques. Nodes with a maximum length of <2.5 cm underwent FNAC or Franseen biopsy, while nodes >2.5 cm underwent Temno biopsy. Mean size of nodes sampled by FNAC (21.2 mm) and Franseen (19.7 mm) were similar while nodes sampled by Temno were larger (34.4 mm, p<0.0001). RESULTS: Technical success rates of FNAC (82/93, 88%), Franseen (105/111, 95%), and Temno (59/66, 89%) biopsies were similar (p>0.05 for all). Lymphoid tissue yield by FNAC (mean total area 1.51 mm2) was less than that by Franseen (7.14 mm2, p=0.002) or Temno biopsy (19.44 mm2, p<0.0001). Diagnostic accuracy for malignancy was lower for FNAC (22/30, 73%) than Franseen (25/26, 96%, p=0.02) or Temno biopsy (32/32, 100%, p=0.002). For malignant nodes, determining the likely organ of origin was also lower for FNAC (7/30, 23%) than Franseen (19/26, 73%, p=0.0002) or Temno biopsy (29/32, 91%, p<0.0001), with a similar pattern observed in the identification of lymphoma. CONCLUSION: For similarly sized nodes, Franseen biopsy provided more lymphoid material, a higher diagnostic accuracy for malignancy including lymphoma, and better identification of the likely organ of origin than FNAC. Routine use of Franseen biopsy is advocated rather than FNAC for percutaneous sampling of lymph nodes not suitable for side-cutting needle biopsy.

Prognostic implication of the neoadjuvant rectal score and other biomarkers of clinical outcome in Hong Kong Chinese patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy.

BACKGROUND: Neoadjuvant chemoradiotherapy is a standard treatment for locally advanced rectal cancer, for which pathological complete response is typically used as a surrogate survival endpoint. Neoadjuvant rectal score is a new biomarker that has been shown to correlate with survival. The main objectives of this study were to investigate factors contributing to pathological complete response, to validate the prognostic significance of neoadjuvant rectal score, and to investigate factors associated with a lower neoadjuvant rectal score in a cohort of Hong Kong Chinese. METHODS: Data of patients with locally advanced rectal cancer who received neoadjuvant chemoradiotherapy from August 2006 to October 2018 were retrieved from hospital records and retrospectively analysed. RESULTS: Of 193 patients who had optimal response to neoadjuvant chemoradiotherapy and surgery, tumour down-staging was the only independent prognostic factor that predicted pathological complete response (P<0.0001). Neoadjuvant rectal score was associated with overall survival (hazard ratio [HR]=1.042, 95% confidence interval [CI]=1.021-1.064; P<0.0001), disease-free survival (HR=1.042, 95% CI=1.022-1.062; P<0.0001), locoregional recurrence-free survival (HR=1.070, 95% CI=1.039-1.102; P<0.0001) and distant recurrence-free survival (HR=1.034, 95% CI=1.012-1.056; P=0.002). Patients who had pathological complete response were associated with a lower neoadjuvant rectal score (P<0.0001), but pathological complete response was not associated with survival. For patients with intermediate neoadjuvant rectal scores, late recurrences beyond 72 months from diagnosis were observed. CONCLUSION: Neoadjuvant rectal score is an independent prognostic marker of survival and disease recurrence in a cohort of Hong Kong Chinese patients who received neoadjuvant chemoradiotherapy for locally advanced rectal cancer.

Five years of national policies: progress towards tackling obesity in England.

Obesity is a major burden on the health system in England and the rest of the UK. Obesity prevalence is high in adults and children and most of the UK population are consuming more energy than required, and not meeting other dietary recommendations, including those for saturated fat, free sugars, fibre, oily fish and fruit and vegetables. Over the past 5 years, a number of cross-government policies, both promoting voluntary action and legislative, have been put in place to tackle diet-related health and obesity. The food environment is complex with many influencing factors, some of which act through individual automatic choices. Other factors such as accessibility, advertising, promotion and nudging drive increased food and drink purchases. With continual changes in the food environment favouring fast-food outlets and meal delivery companies alongside the adverse impact of the COVID-19 pandemic on diets and physical activity levels, further governmental action is likely needed to deliver sustained improvements to diet and health.

Acupuncture for the treatment of hiccups following stroke: a systematic review and meta-analysis.

OBJECTIVES: To assess the effectiveness and safety of acupuncture for hiccups following stroke. METHODS: Medline, Embase, CENTRAL, CINAHL, and four Chinese medical databases were searched from their inception to 1 June 2015. The dataset included randomised controlled trials (RCTs) with no language restrictions that compared acupuncture as an adjunct to medical treatment (effectiveness) or acupuncture versus medical treatment (comparative effectiveness) in stroke patients with hiccups. The Cochrane risk of bias tool was used to assess the methodological quality of the trials. RESULTS: Out of 436 potentially relevant studies, five met the inclusion criteria. When acupuncture was compared with other interventions (as sole or adjunctive treatment), meta-analysis revealed a significant difference in favour of cessation of hiccups within a specified time period (CHWST) following intervention when used as an adjunct (risk ratio (RR) 1.59, 95% CI 1.16 to 2.19, I2=0%), but not when used alone (RR 1.40, 95% CI 0.79 to 2.47, I2=65%, ie, high heterogeneity). No safety information was reported in these studies. CONCLUSIONS: Our systematic review and meta-analysis suggests that acupuncture may be an effective treatment for patients suffering from hiccups following stroke when used as an adjunct to medical treatment. However, due to the limited number of RCTs and poor methodology quality, we cannot reach a definitive conclusion, hence further large, rigorously designed trials are needed.

Developing a scalable training model in global mental health: pilot study of a video-assisted training Program for Generalist Clinicians in Rural Nepal.

BACKGROUND: In low- and middle-income countries, mental health training often includes sending few generalist clinicians to specialist-led programs for several weeks. Our objective is to develop and test a video-assisted training model addressing the shortcomings of traditional programs that affect scalability: failing to train all clinicians, disrupting clinical services, and depending on specialists. METHODS: We implemented the program -video lectures and on-site skills training- for all clinicians at a rural Nepali hospital. We used Wilcoxon signed-rank tests to evaluate pre- and post-test change in knowledge (diagnostic criteria, differential diagnosis, and appropriate treatment). We used a series of 'Yes' or 'No' questions to assess attitudes about mental illness, and utilized exact McNemar's test to analyze the proportions of participants who held a specific belief before and after the training. We assessed acceptability and feasibility through key informant interviews and structured feedback. RESULTS: For each topic except depression, there was a statistically significant increase (Δ) in median scores on knowledge questionnaires: Acute Stress Reaction (Δ = 20, p = 0.03), Depression (Δ = 11, p = 0.12), Grief (Δ = 40, p < 0.01), Psychosis (Δ = 22, p = 0.01), and post-traumatic stress disorder (Δ = 20, p = 0.01). The training received high ratings; key informants shared examples and views about the training's positive impact and complementary nature of the program's components. CONCLUSION: Video lectures and on-site skills training can address the limitations of a conventional training model while being acceptable, feasible, and impactful toward improving knowledge and attitudes of the participants.

Genomic characterisation of the severe acute respiratory syndrome coronavirus of Amoy Gardens outbreak in Hong Kong.

Severe acute respiratory syndrome (SARS) is a global health concern. In Hong Kong, two major outbreaks, one hospital based and the other in the Amoy Gardens apartments, were identified. The frequency of diarrhoea, admission to intensive care, and mortality differed significantly between the two outbreaks. We did genomic sequencing for viral isolates from five Amoy Gardens patients. The virus sequence was identical in four of these five patients. The sequence data from one hospital case and the four identical community cases had only three nucleotide differences. Alterations in the SARS coronavirus genome are unlikely to have caused the distinctive clinical features of the Amoy Gardens patients, and these results highlight the importance of non-viral genomic factors in this outbreak.

Bone mineral density in children with thalassaemia major: determining factors and effects of bone marrow transplantation.

Osteoporosis and osteopenia affect up to half of patients with thalassaemia major (TM). We investigate the effects of acquired factors and BMT on bone mineral density (BMD) in these patients. In all, 53 patients on regular transfusion (BT group) and 33 patients at 5.7+/-1.9 years post transplant (BMT group) were recruited. BMD was measured by dual energy X-ray absorptiometry. Serum concentrations of osteocalcin, bone-specific alkaline phosphatase (ALP), beta-crossLap and urinary cross-linking deoxypyridinoline (DPD) were measured by chemiluminescence and enzyme immunoassay, respectively. Severe BMD deficit (Z-score <-2.5) at spine and hip were noted in 62 and 35% of BT group. Serum osteocalcin (beta=-0.463; P=0.006) was predictive of spine BMD, whereas age (beta=-0.843; P=0.007) and urine DPD (beta=-0.439; P=0.037) were associated with hip BMD in BT group. Among BMT patients, post transplant duration (beta=0.450; P=0.009) and serum bone-specific ALP (beta=-0.495; P=0.013) were associated with spine BMD. Severe BMD deficit was less common among BMT than BT patients (6 vs 35%; P=0.036). The mean (s.d.) osteocalcin levels in BMT and BT groups were 96.4 (72.7) microg and 68.9 (40.3) microg/l, respectively (P=0.037). In conclusion, severe BMD deficit is common in Chinese TM patients and BMT may reverse BMD deficit in these patients.

Acquired deficiency and urinary excretion of antithrombin III in nephrotic syndrome.

The published data concerning changes of antithrombin III (ATIII) in nephrotic syndrome (NS) are contradictory. While increased ATIII activity has been reported by some investigators, decreased concentration has been shown by others and normal values by yet another group of authors. We determined plasma and urine concentrations of ATIII in a group of 20 patients with NS using an immunologic assay. In addition, plasma ATIII activity was determined. The results were compared with those obtained in a group of normal volunteers. Plasma concentration and activity of ATIII were both greatly reduced in the patients with NS. In addition, substantial quantities of ATIII were recovered in the urine of all tested patients. The present study, therefore, substantiates the low plasma concentrations of ATIII and its urinary losses in NS. In addition, a parallel reduction in plasma ATIII activity is demonstrated providing functional evidence of acquired ATIII deficiency in this condition.

Impaired intestinal absorption of vitamin D3 in azotemic rats.

Changes in vitamin D metabolism and their effect on calcium and bone metabolism in uremia have been extensively studied. However, the possible effect of uremia on intestinal absorption of vitamin D has not been investigated. We determined the rate of intestinal absorption of vitamin D3 in uremic and normal rats using a well-defined in vivo perfusion technique under identical experimental conditions. The rate of jejunal absorption of vitamin D3 in uremic animals (5.09 +/- 1.87 pmol/100 cm/h) was significantly less (p less than 0.001) than that found in the control animals (11.5 +/- 1.6 pmol/100 cm/h). While the underlying mechanism(s) of the observed reduction in vitamin D absorption in uremia is not known, its recognition adds another dimension to the previously recognized abnormalities of vitamin D metabolism in uremia.

Effect of hemodialysis on contact group of coagulation factors, platelets, and leukocytes.

Earlier reports have suggested possible activation and consumption of factor XII during hemodialysis. To investigate this possibility, a series of in vivo and in vitro experiments were conducted using different dialysis membranes and two different dialysates (acetate and bicarbonate). Factors XII and XI activities, factor XII concentration, and high-molecular-weight kininogen were measured. In addition, platelet count, white blood cell count, and hematocrit were monitored. Contrary to the previous reports, no discernible consumption of factor XII, factor XI, or high-molecular-weight kininogen was found irrespective of the type of membrane or the composition of the dialysate used. Transient leukopenia was noted with cellulosic membranes, whereas none occurred with polyacrylonitrile dialyzers. The composition of dialysate did not affect the white blood cell count during dialysis.

Urinary excretion and deficiency of prothrombin in nephrotic syndrome.

Plasma and urinary prothrombin concentration and plasma prothrombin activity were measured in a group of 17 patients with the nephrotic syndrome. An immunologic assay using a monospecific antibody against human prothrombin was employed in the measurement of prothrombin concentration in the plasma and urine. Prothrombin-deficient plasma was used as the substrate in the measurement of plasma prothrombin activity. A control group consisting of five normal volunteers was included for comparison. Both the activity and concentration of prothrombin were significantly lower in the nephrotic group as compared with the control group. Significant quantities of immunoreactive prothrombin were detected in the urine of the majority of nephrotic patients. This study has provided unequivocal evidence of urinary excretion and acquired deficiency of prothrombin in the nephrotic syndrome.

Impact of an ACE inhibitor and calcium antagonist on microalbuminuria and lipid subfractions in type 2 diabetes: a randomised, multi-centre pilot study.

BACKGROUND: Microalbuminuria (MA) is associated with increased cardiovascular risk and lipid abnormalities in people with type 2 diabetes. ACE inhibitors and calcium channel blockers (CCBs) reduce MA and are neutral on total cholesterol and triglycerides. The effect of ACE inhibitors and CCBs on lipid subfractions such as Lp(a), apolipoprotein (apo) A1, apo B, and others, however, is unclear. The current study tests the hypothesis that a fixed-dose combination of an ACE inhibitor, benazepril (B) with the dihydropyridine CCB, amlodipine (A), will further reduce arterial pressure and reduce atherogenic lipid fractions compared to either agent alone. DESIGN: A multicentre, randomised, open-label, parallel group design was used to study 27 participants with type 2 diabetes. Measurements for total cholesterol, high- and low-density lipoprotein (HDL and LDL), triglycerides, apo A1, apo B, Lp(a), MA, arterial pressure and creatinine clearance were obtained at baseline and at 12-week intervals during the 36 week study. RESULTS: Arterial pressure was significantly reduced at 36 weeks in all three groups (P = 0.0078 for A, P = 0.0039 for B, and P = 0.0313 for A+B). MA was lowered in all groups with relatively greater reductions in the B (P < 0.05) and A+B groups (P < 0.03) vs A. An increase in mean HDL-cholesterol from baseline was noted in the B and A+B groups; P < 0.05), but not in the A group. A trend was also observed between the rise in HDL-cholesterol and the reduction in MA in the B and A+B groups. Additionally, only the B group exhibited a decrease in the median value of Lp(a) (P < 0.05). CONCLUSION: These data support the concept that ACE inhibition with B reduces the atherogenic profile by decreasing Lp(a) and increasing HDL-cholesterol, the latter being correlated with reductions in MA. While A+B exhibited similar trends in lipid subfractions and MA as B, this group had the greatest reduction in systolic blood pressure of the three groups. Thus, use of A+B offers the benefits of a decreased atherogenic profile with a higher probably of achieving goal blood pressure as recommended by national guidelines.

Coagulation abnormalities in patients with end-stage renal disease treated with hemodialysis.

Plasma levels of various blood coagulation factors, antithrombin III and plasminogen were measured in 18 patients with end-stage renal disease treated by longterm hemodialysis. The results were compared with those obtained in a group of normal volunteers. Factors XII, IX and II activities were significantly reduced; factors VIII, VII and X levels were increased; and factors XI and V activities and high molecular weight kininogen concentration were comparable to the control group. Antithrombin III activity and concentration were significantly reduced. The mean plasma fibrinogen concentration was normal although levels above and below normal limits were noted in a few patients. Similarly the mean platelet count was normal, although mild thrombocytopenia occurred in several patients and thrombocytosis in one. In conclusion, the present study confirms published results about factor VIII and AT-III, and provides new information on changes of other coagulation factors in uremia treated by long-term hemodialysis.

[Improvement in urinary tract infections rates in a department of internal medicine]. / Proyecto de mejora en prevención de infecciones del tracto urinario asociadas a sondaje vesical.

OBJECTIVE: To evaluate the impact on the urinary tract infections (UTI) rates of an intervention implemented in the Department of Internal Medicine of the Hospital Universitario Insular de Gran Canaria. MATERIAL AND METHODS: Infection control practitioners implemented a three phase project, each lasting two months, focusing on surveillance and feed-back, between 2009 and 2011. During phases 1 and 2, the 2004 Centers for Disease Control and Prevention (CDC)-diagnostic criteria for nosocomial infections were followed, and only rates of infections were calculated. For phase 3, the criteria published in 2009 were used, and rates of infections plus processes rates were obtained. The cumulative incidence of UTI in the three periods was compared using a chi-square for trends test. RESULTS: The total number of catheter days, as well as the cumulative incidence of UTI dropped from phase 1 to 3. Nevertheless, in phase 2 the mean urinary catheter days increased. We detected a decrease in the UTI rates and urinary catheter days mean after introducing an electronic reminder in the patient electronic charts. CONCLUSIONS: A multidisciplinary approach, including surveillance, reminders, and feed-back, has proved useful in controlling UTI rates in our hospital.

Periorificial and acral dermatitis in a newborn having milk intolerance.

A 2-week-old infant born at 36-week gestation developed diarrhea and metabolic acidosis when he was put on formula feeding. He was treated for sepsis and was screened for metabolic diseases. Blood and cerebrospinal fluid cultures were clear. The diarrhea and metabolic acidosis settled but recurred when formula feeding was resumed. He developed a florid erythematous rash involving the palms, feet, perioral and perineal regions. Zinc deficiency was confirmed and zinc replacement resulted in prompt resolution of the skin rash. The patient was put on Pepti-Junior and remained well. This case illustrates that zinc deficiency must be sought and treated in an infant with a typical rash involving the palms, feet and body orifices.

Detection of circulating fetal nucleic acids: a review of methods and applications.

The discovery of cell-free circulating fetal nucleic acids in maternal plasma has opened up new possibilities in non-invasive prenatal diagnosis. The rapid advancement of this field in the past decade is catalysed by the discovery of new classes of fetal nucleic acid markers and technological developments in nucleic acid detection and amplification. In this review, some of the more significant recent developments in this field will be discussed, including the detection of single molecule, chromosomal aneuploidies, single nucleotide variations and placental microRNAs in maternal plasma.