Evaluation of Host Serum Protein Biomarkers of Tuberculosis in sub-Saharan Africa.

Accurate and affordable point-of-care diagnostics for tuberculosis (TB) are needed. Host serum protein signatures have been derived for use in primary care settings, however validation of these in secondary care settings is lacking. We evaluated serum protein biomarkers discovered in primary care cohorts from Africa reapplied to patients from secondary care. In this nested case-control study, concentrations of 22 proteins were quantified in sera from 292 patients from Malawi and South Africa who presented predominantly to secondary care. Recruitment was based upon intention of local clinicians to test for TB. The case definition for TB was culture positivity for Mycobacterium tuberculosis; and for other diseases (OD) a confirmed alternative diagnosis. Equal numbers of TB and OD patients were selected. Within each group, there were equal numbers with and without HIV and from each site. Patients were split into training and test sets for biosignature discovery. A nine-protein signature to distinguish TB from OD was discovered comprising fibrinogen, alpha-2-macroglobulin, CRP, MMP-9, transthyretin, complement factor H, IFN-gamma, IP-10, and TNF-alpha. This signature had an area under the receiver operating characteristic curve in the training set of 90% (95% CI 86-95%), and, after adjusting the cut-off for increased sensitivity, a sensitivity and specificity in the test set of 92% (95% CI 80-98%) and 71% (95% CI 56-84%), respectively. The best single biomarker was complement factor H [area under the receiver operating characteristic curve 70% (95% CI 64-76%)]. Biosignatures consisting of host serum proteins may function as point-of-care screening tests for TB in African hospitals. Complement factor H is identified as a new biomarker for such signatures.

Xpert Xpress Flu/RSV: Validation and impact evaluation at a large UK hospital trust.

Despite vaccination programs and antivirals, influenza remains a prominent cause of morbidity and mortality. The Xpert Xpress Flu/respiratory syncytial virus (RSV) test is a leading influenza point-of-care test, but its evaluation has been limited to nasopharyngeal samples. In addition, the clinical impacts of Xpress Flu/RSV have not yet been quantified. We evaluated the performance of Xpress Flu/RSV at three locations in a UK Hospital Trust against an existing laboratory assay. Multiple upper respiratory tract sample types were included. In addition, we calculated time saved by Xpert, and the associations between Xpert use and rates of early patient isolation and antiviral prescription as recorded at the time of the laboratory result being telephoned out. A total of 642 patients were included in the diagnostic performance analysis. There were 177 laboratory-confirmed cases of influenza A, 7 influenza B and 86 RSV. For influenza A, sensitivity and specificity were 96.6% (95% confidence interval [CI]: 92.8%-98.8%) and 98.1% (CI: 96.4%-99.1%), respectively. This was sustained across all locations and sample types. The negative predictive value was 98.7% (CI: 97.2%-99.4%). The median amount of time saved was 27.1 h. Xpert use was associated with sixfold higher rates of isolation and threefold higher rates of antiviral prescribing by the time the laboratory result was available. Sensitivity for RSV was lower at 86.0% (95% CI: 76.9%-92.6%). Xpert Xpress Flu/RSV reliably detects influenza A infection and has significant clinical impacts. Cartridge optimization is required to enable accurate multiplexing, including from a range of sample types.

Parasite community structure as a predictor of host population structure: An example using Callorhinchus capensis.

This paper describes the parasite community structure of the Cape elephant fish or St Joseph shark (Callorhinchus capensis) caught off the West and South Coast of South Africa between 2010 and 2015. These data were used to build species accumulation curves (SAC) and calculate biodiversity indices including rarefied species richness, Shannon Weiner's diversity index, Simpson's index and Pielou's J index. The biodiversity indices were correlated with the host's biological data to determine how these affected the parasite community structure and provide insight into the host's population structure. The parasites identified in C. capensis (n = 259) include a cestode (Gyrocotyle plana), two monogeneans (Callorhynchicotyle callorhynchi and Callorhinchicola multitesticulatus), an isopod (Anilocra capensis) and a leech (Branchellion sp.). Gyrocotyle plana was the most prevalent at 71.43% and the monogenean C. callorhynchi had the highest mean abundance (1.55 ±â€¯0.45 parasites.fish-1) and the highest mean infection intensity (4.79 ±â€¯0.66 parasites.infected fish-1). The SAC and biodiversity measures indicate a uniform parasite community across the sampled host population, suggesting a highly interactive shark community with no evidence for population structure. These results show that parasite community structure can be used to infer their host's population structure.

Endovascular stent-associated infection with Staphylococcus lugdunensis.

An elderly woman presented febrile 5 days after stenting of multiple coronary arteries. Echocardiography showed a thickening of the aortic root, raising the possibility of stent infection. Four  of four blood culture bottles grew Staphylococcus lugdunensis and repeat echo showed an aortic root abscess. Despite appropriate antibiotic treatment, the patient died. A 24-year-old man with a ventricular septal defect presented febrile 4 weeks after stenting of an aortic coarctation. Initial transoesophageal echo found no vegetations around the stent or elsewhere. Four of six blood culture bottles grew S lugdunensis. Following an episode of hypoxia, the imaging was repeated and a new large vegetation was seen on the pulmonary valve with two thin-walled cavities in the lungs on a CT pulmonary angiogram. The patient was treated with a long course of appropriate antibiotic therapy and discharged from hospital 6 weeks later.

Simple sling for hand infection.

In the absence of a Bradford sling, I constructed a simple sling to elevate an infected hand from medical equipment that was readily available on the ward. The results were so successful and the experience so comfortable for the patient that the technique should be explained and made clear for other doctors. In this particular case, a serious side effect was avoided namely infection of nearby indwelling metalwork. The patient contacted us afterwards to say how well he felt, he had been looked after and how comfortable the equipment had been to use during his stay in hospital.

Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome--how I do it.

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a well-described condition involving mechanical compression of the third part of the duodenum by the SMA and the aorta, resulting in proximal obstruction. DISCUSSION: Although there are a handful of case reports describing various techniques of laparoscopic duodenojejunostomy, a technique that involves creating the anastomosis in the infracolic compartment provides a more dependent stoma for the patient. CONCLUSION: This is a safe, effective, and relatively simple procedure for the experienced minimally invasive surgeon.