Prospective external validation of IOTA methods for classifying adnexal masses and retrospective assessment of two-step strategy using benign descriptors and ADNEX: a Portuguese multicenter study.

OBJECTIVE: This study aimed to externally and prospectively validate the International Ovarian Tumor Analysis (IOTA) Simple Rules (SRs), Logistic Regression model 2 (LR2) and Assessment of Different NEoplasias in the adneXa (ADNEX) in a Portuguese population, comparing them with operator subjective assessment (SA), Risk-of-Malignancy Index (RMI), as well as with each other. This study also aimed to retrospectively validate IOTA two-step strategy, using modified benign descriptors (MBDs) followed by the application of ADNEX in cases where MBDs were not applicable (MBDs + ADNEX). METHODS: In this multicenter diagnostic accuracy study, conducted between January 2016 and December 2021, three tertiary referral centers prospectively included consecutive patients with ultrasound diagnosis of at least one adnexal tumor who underwent surgery. All ultrasound assessments were performed by level II or III sonologists with IOTA certification. Patient clinical data and serum cancer antigen (CA125) levels were collected from the hospital databases. Each adnexal mass was classified as benign or malignant using SA, RMI, IOTA SRs, LR2 and ADNEX (with and without CA125). The reference standard was histopathological diagnosis. In the second phase, all adnexal tumors were retrospectively classified using the two-step strategy (MBDs + ADNEX). The sensitivity, specificity, positive (PPV) and negative predictive value (NPV), positive (LR+) and negative likelihood ratio (LR-) as well as overall accuracy were determined for SA, RMI, IOTA SRs, LR2, ADNEX and two-step strategy (MBDs + ADNEX). Receiver-operator characteristic curves were constructed and corresponding areas under the curve (AUC) determined for RMI, LR2 and ADNEX and two-step strategy (MBDs + ADNEX). The ADNEX calibration plots were constructed and estimated by LOESS smoother. RESULTS: Of the 571 included patients, 428 had benign disease, 42 borderline ovarian tumors, 93 primary invasive adnexal cancers and 8 metastatic tumors in adnexa (malignancy prevalence: 25.0%). The operator SA had an overall sensitivity of 97.9% and a specificity of 83.6% for distinguishing between benign and malignant lesions. RMI showed high specificity (95.6%) but very low sensitivity (58.7%), with an AUC of 0.913. The IOTA SRs were applicable in 80.0% of patients, with a sensitivity of 94.8% and a specificity of 98.6%. LR2 revealed a sensitivity of 84.6%, a specificity of 86.9% and an AUC of 0.939, at the malignancy risk cut-off of 10%. At the same cut-off, ADNEX with and without CA125 had a sensitivity of 95.8% and 98.6%, respectively, and a specificity of 82.5% and 79.7%, respectively. The AUC of ADNEX with vs. without CA125 was 0.962 vs. 0.960. The ADNEX model provided heterogeneous results in distinguishing between benign and different subtypes of malignancy, with the highest AUC (0.991) for discriminating benign masses from primary adnexal cancer stage II-IV, and the lowest AUC (0.696) for distinguishing primary adnexal cancer stage I and metastatic lesion in adnexa. The ADNEX calibration plots suggested an underestimation of the predicted risk in relation with the observed proportion of malignancies. The MBDs were applicable in 26.3% of cases (150/571 tumors, none of which were malignant). Similar to the ADNEX model applied in all patients, the two-step strategy using ADNEX in the second step only, with and without CA125, had an AUC of 0.964 and 0.961, respectively. CONCLUSIONS: Our results showed a good to excellent performance of the IOTA methods in the studied Portuguese population, outperforming RMI. ADNEX was superior in accuracy, but interpretation of its ability to distinguish malignant subtypes was fundamentally limited not only by sample size but also by large differences in the prevalence of tumor subtypes. The IOTA MBDs have been shown to be reliable in identifying benign disease. The two-step strategy based on the application of MBDs, followed by the ADNEX model if MBDs are not applicable, has proven to be suitable for daily practice circumventing the need to use electronic support in all patients. This article is protected by copyright. All rights reserved.

A survey of pathology specimens associated with impacted teeth over a 21-year period.

BACKGROUND: To compare the histologic diagnosis of lesions associated with impacted teeth from a South African population with literature data. MATERIAL AND METHODS: A retrospective cross-sectional survey of tissue specimens associated with impacted teeth that were analyzed in the Department of Oral Pathology (University of the Witwatersrand, South Africa) between 1996 and 2016. Patient age, gender, impacted tooth location and the histologic diagnosis were recorded for statistical analysis. RESULTS: Odontogenic pathology was diagnosed in 389 (95.6%) specimens while dental follicle comprised 4.4% of tissue submissions. The mean age was 25.3 ±15.2 years with a male predilection (M:F=1.8:1). The 11-20 year age group was mostly affected and the overall frequency of odontogenic lesions reduced significantly with an increase in age (p=0.01). Dentigerous cyst (56.5%) and ameloblastoma (14%) were most commonly diagnosed. CONCLUSIONS: This is the first African epidemiologic survey of histologic specimens associated with impacted teeth and shows striking differences in the ratio of pathologic to non-pathologic diagnoses compared to other populations. Locally aggressive odontogenic lesions appear to develop one to two decades earlier in patients from developing countries.

A Deadly Combination - HIV and Diabetes Mellitus: Where are we now?

BACKGROUND:The combination of HIV infection and diabetes mellitus (DM) represents a collision of two chronic conditions. Both HIV and DM increase the risk of developing tuberculosis (TB). Health resources in developing countries are already under strain as a result of the TB epidemic and poor diabetic control would further worsen this epidemic. Optimal diabetic control provides one avenue of curbing the TB epidemic in developing countries.OBJECTIVES:To establish if there is a difference in blood pressure; lipid and glycaemic control and complications between HIV-infected and uninfected diabetic patients; and to compare characteristics among HIV-infected diabetic patients between those with optimal and sub- optimal glycaemic control.METHODS:This was a retrospective chart review of all patients who visited the Edendale Hospital diabetic clinic; Pietermaritzburg; from 1 October 2012 to 30 September 2013.RESULTS:There were statistically significant differences noted in the following parameters between HIV-infected and uninfected diabetic patients: (i) mean HbA1c% (11.08% v. 10.14%; respectively); (ii) nephropathy defined by proteinuria (25.66% v. 15.43%); (iii) neuropathy (48.68% v. 42.10%); and (iv) Kidney Disease Outcomes Quality Initiative (KDOQI) stage =2 chronic kidney disease (30.87% v. 41.67%). There were no significant differences noted in the percentage of patients achieving the following target parameters between the two cohorts: (i) blood pressure (42.11% v. 35.62%); (ii) total cholesterol (36.84% v. 34.67%); and (iii) triglycerides (42.76% v. 40.19%). Within the HIV-infected diabetic cohort 85.23% displayed suboptimal glycaemic control. A significant percentage of HIV-infected diabetic patients on antiretroviral (ARV) therapy (89.36%) had suboptimal glycaemic control. HIV-infected female diabetic patients showed a significant increased waist circumference when compared with their HIV-uninfected counterparts.CONCLUSION:HIV-infected diabetic patients had significantly poorer blood sugar control and a higher incidence of neuropathy and nephropathy (when defined by overt proteinuria). There was a non-significant difference noted between the HIV-infected and uninfected diabetic patients with regard to blood pressure and lipid control. The majority of HIV-infected patients on ARVs failed to achieve target glycaemic control. Obesity remains a global challenge; as noted in both the HIV-infected and uninfected diabetic patients

A note on the solutions of some nonlinear equations arising in third-grade fluid flows: an exact approach.

In this communication, we utilize some basic symmetry reductions to transform the governing nonlinear partial differential equations arising in the study of third-grade fluid flows into ordinary differential equations. We obtain some simple closed-form steady-state solutions of these reduced equations. Our solutions are valid for the whole domain [0,∞) and also satisfy the physical boundary conditions. We also present the numerical solutions for some of the underlying equations. The graphs corresponding to the essential physical parameters of the flow are presented and discussed.

Cotton-type and joint invariants for linear elliptic systems.

Cotton-type invariants for a subclass of a system of two linear elliptic equations, obtainable from a complex base linear elliptic equation, are derived both by spliting of the corresponding complex Cotton invariants of the base complex equation and from the Laplace-type invariants of the system of linear hyperbolic equations equivalent to the system of linear elliptic equations via linear complex transformations of the independent variables. It is shown that Cotton-type invariants derived from these two approaches are identical. Furthermore, Cotton-type and joint invariants for a general system of two linear elliptic equations are also obtained from the Laplace-type and joint invariants for a system of two linear hyperbolic equations equivalent to the system of linear elliptic equations by complex changes of the independent variables. Examples are presented to illustrate the results.

Evaluation of Ki-67 and cyclin D1 expression in odontogenic keratocysts and orthokeratinised jaw cysts.

INTRODUCTION: Orthokeratinised jaw cyst (OJC) is an entity distinct from odontogenic keratocyst (OKC) that has not been fully characterised at the molecular level. AIM: To compare the proliferative activity of the epithelial linings of OKC and OJC immunohistochemically, using Ki-67 and cyclin D1 as markers of cellular proliferation and activity. METHODS: The total numbers of positively stained cells per 10 consecutive lengths of a light microscope calibration ruler were counted in each case (OKC, n = 15; OJC, n = 15) and the composite data were statistically compared. RESULTS AND CONCLUSIONS: OJC showed significantly fewer Ki-67 and cyclin D1 positive cells than OKC, a finding consistent with the clinically more indolent behaviour of the OJC. Ki-67 expression was mainly detected in the suprabasal cell layers in OKC. Expression of Ki-67 was more uniform in OJC and notably without a significant predilection for the supra-basal compartment. The accumulation of Ki-67 positive cells supra-basally in OKC raises the possibility that a process of asymmetrical cell division may be operational in OKC. Expression of Ki-67 and cyclin D1 differed significantly quantitatively and by distribution pattern in OKC and OJC respectively thereby suggesting that the presence of cyclin D1 protein in OKC and OJC may not necessarily reflect production of this molecule by cycling cells.

Oral submucous fibrosis--a potentially malignant condition of growing concern.

Oral submucous fibrosis (OSF) is a premalignant condition that primarily affects the oral cavity. The clinical hallmark of this disease is the development of progressive trismus. The latter is a direct consequence of loss of the normal fibro-elasticity of the oral mucosa and replacement of the fibromuscular connective tissue by the deposition of dense collagen. This change in the oral mucosa is aetiologically linked to the areca nut chewing habit where the development of OSF results from the interaction of the mucosa with the chemical constituents of areca. Areca nuts are used as a masticatory substance either alone, in a self-prepared quid or in various commercial preparations known as paan masala and gutka. The habitual usage of these products is rapidly increasing and oral health professionals globally are likely to encounter patients with this disease. The potentially malignant nature of OSF is well documented and habitual areca nut chewing even in the absence of tobacco is an independent risk factor for oral cancer. Public health education against the areca nut chewing habit is essential to eradicate the deleterious effects of this habit on oral health.

A 20-year retrospective study of oral and maxillofacial histopathology in a South African paediatric population sample.

INTRODUCTION: The characterisation of oral and maxillofacial (OMF) histopathology found in children has not yet been reported from South Africa. AIMS AND OBJECTIVES: This study aims to evaluate the spectrum of OMF histopathological diagnoses encountered in a sample of South African children. METHODS: A retrospective study was designed to analyse the clinico-pathologic data, as obtained from OMF histopathology reports, at the University of the Witwatersrand's Division of Oral Pathology over a 20-year period. RESULTS AND CONCLUSIONS: A total of 1,258 OMF biopsies from children < or = 16 years of age with histologically confirmed disease were recorded, accounting for 6,5% of the total number of OMF biopsies received during this period. Pathology involving the jaw bones formed the largest category of all OMF pathologies and was predominated by odontogenic cysts and tumours. The remaining pathology, in decreasing order of frequency; involved the oral/perioral soft tissues, salivary glands and oral mucosa. Malignant neoplasms comprised 4,1% of the total number of cases with Burkitt's lymphoma emerging as the most common malignancy. Although the smallest number of biopsy specimens was obtained from children younger than 5-years of age, the likelihood of a malignant diagnosis in this age group was substantially higher than in older children.

Knowledge; Attitudes and Practices Regarding Iodine among Patients with Hyperthyroidism in the Free State; South Africa

Objectives: To gather baseline information on the knowledge; attitudes and practices regarding iodine and iodised salt among patients with hyperthyroidism in the Free State. Subjects and Setting: The study was part of a large cohort study that included the first 96 patients aged 13 years or older diagnosed withhyperthyroidism and referred to Universitas Academic Hospital in Bloemfontein; South Africa during 2005. Methods: The patients were interviewed in their language using a structured validated questionnaire. Descriptive statistics were used for data analysis. Results: The majority of the patients (86.9) did not know what iodine was. Similarly; a higher percentage of patients (76.7) were unaware of the most important or main source of iodine in the food of South Africans. Regarding knowledge of the most important harmful effect on the health of children if they did not get enough iodine; almost all of the patients (89.1) did not know what it was. Ninety-five per cent of salt was obtained from the local shops; and only 36.1of the patients read the labelling on the package during purchase. A very small proportion of patients (1.6) stored salt in closed containers and away from sunlight; while about half of them (49.2) stored salt in open containers without lids; 36.1stored it in rigid plastic containers with holes at the top; and 13.1stored it in the open plastic bags in which the salt was bought. Conclusions: Patients with hyperthyroidism lacked knowledge of iodine; as well as of the storage of iodised salt; and this could have contributed to the persisting endemic goitre reported in previous studies. An aggressive awareness programme; targeting policy makers and the public; is recommended to ensure sustainable elimination of iodine deficiency disorders in South Africa

The squamous variant of eccrine porocarcinoma: a clinicopathological study of 21 cases.

AIM: Squamous differentiation in eccrine porocarcinoma (EPC) is an unusual phenomenon that has rarely been reported in the literature. This study describes the clinical and pathological findings in a series of 21 cases of EPC showing extensive squamous differentiation. METHODS: The H&E-stained sections, epithelial membrane antigen and carcinoembryonic antigen immunohistochemical stains were reviewed for each case. The following variables were examined: age, gender, race, site and size of the EPC. The prevalence of other cutaneous lesions and/or underlying systemic disease was also documented. RESULTS: There was an almost equal gender distribution. Mean age was 61.5 years and the average tumour size was 46.5 mm. An inordinately large number (10/21, 48%) of EPCs occurred in black patients. The tumours were located at various sites with the extremities predominating (10/19, 53%). Seven patients developed other sun-induced skin tumours, three patients were renal transplant recipients, and two patients were HIV-positive, one of whom also suffered from albinism. Six of the 11 patients in whom follow-up was available had an adverse outcome: local recurrence developed in one patient, one patient developed nodal metastases, and one patient experienced both local recurrence and nodal metastases, and of the three patients who died of disease, two developed distant metastases. CONCLUSION: The findings suggest a possible role for ultraviolet radiation and chronic immunosuppression in the induction of malignant squamous differentiation in a subset of EPCs. Further reports on this histological variant of EPC are required to determine whether a pathogenetic link does indeed exist or whether these tumours simply represent a unique variant of squamous cell carcinoma with divergent acrosyringial differentiation.

Altered E-cadherin/beta-catenin expression in oral squamous carcinoma with and without nodal metastasis.

OBJECTIVES: The aim of this study was to investigate the potential use of E-cadherin, a tumour-suppressor gene product involved in establishing cell-cell adhesion and one of its associated proteins, beta-catenin, as markers of nodal metastasis in oral squamous cell carcinoma (OSCC). MATERIALS AND METHODS: Thirty invasive OSCCs in patients with (n = 19) and without (n = 11) nodal metastases, as confirmed on histopathologic examination of the resected regional lymph nodes (n = 30), were examined for E-cadherin and beta-catenin expression by immunohistochemistry. RESULTS: There was a highly significant association (P < 0.0001) between E-cadherin and beta-catenin expression and tumour differentiation by conventional Broders' grading of the whole tumour. Irrespective of the nodal status and invasive tumour front (ITF) grading score, however, loss of expression was recorded at the ITF in 28 (93%) of 30 tumours and 22 (73%) of 30 tumours stained for E-cadherin and beta-catenin respectively. CONCLUSION: The results of this study suggest an association between loss of expression of E-cadherin and beta-catenin and a lower degree of differentiation; however, their use as markers of nodal metastasis in OSCC appears unreliable.

Stavudine, lamivudine and nevirapine combination therapy for treatment of HIV infection and AIDS in adults.

BACKGROUND: A favourable regimen for people infected with HIV/AIDS is one that provides optimal efficacy, durability of antiretroviral activity, tolerability, and has low adverse effects and drug-drug interactions. The combination of the non-nucleoside reverse transcriptase inhibitor nevirapine (NVP), and two nucleoside reverse transcriptase inhibitors, stavudine (d4T) and lamivudine (3TC), is widely used as first-line therapy, especially in low-resource countries. Analysis of the efficacy, durability and tolerability of the regimen is thus important to clinicians, consumers and policy-makers living in both rich and poor countries. OBJECTIVES: To examine the efficacy of the stavudine, lamivudine and nevirapine regimen for the treatment of HIV infection and AIDS in adults. SEARCH STRATEGY: We used the comprehensive search strategy developed specifically by the Cochrane HIV/AIDS Review Group to identify HIV/AIDS randomised controlled trials, and searched the following electronic databases: MEDLINE (searched July 2004); Embase (searched October 2004); and CENTRAL (July 2004). This search was supplemented with a search of AIDSearch (April 2005) to identify relevant conference abstracts, as well as searching reference lists of all eligible articles. The search was not limited by language or publication status. SELECTION CRITERIA: Randomised controlled trials of the stavudine, lamivudine and nevirapine regimen, compared with any other regimens for treating HIV/AIDS, in antiretroviral treatment-naive or antiretroviral treatment-experienced adults. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the methodological quality of the trials and extracted data. MAIN RESULTS: Our search resulted in 1,148 records, of which two studies described trials that met our inclusion criteria. One trial was a small single-centre Australian trial of 70 antiretroviral-naive participants, while the other trial was a large, multicentre trial, conducted in 14 countries, of 1,216 antiretroviral-naive participants. In both trials over 60% of participants were male. As the therapeutic combinations compared in both trials were not identical, it was not possible to conduct a meta-analysis to increase the power of the results. The main findings, therefore, are from the much larger trial, which was of a high quality. This trial found that there was no statistically significant difference in the efficacy (measured by treatment failure) between nevirapine and efavirenz (EFZ), when used in combination with 3TC and d4T (RR = 1.16; 95%CI: 0.95, 1.41). There was no statistically significant difference between once daily or twice-daily dosing of NVP, when used in combination with 3TC and d4T (RR = 1.00; 95%CI: 0.83; 1.21). It also showed that, compared with NVP plus EFZ, 3TC and d4T, a once-daily dosing of NVP, in combination with 3TC and d4T, performs better in averting treatment failure (RR = 0.82; 95%CI: 0.67, 1.00) than does twice-daily dosing of NVP with 3TC and d4T (RR = 0.82; 95%CI: 0.69; 0.97). Frequency of toxicity was higher in participants receiving NVP, compared with EFZ. AUTHORS' CONCLUSIONS: The combination of nevirapine, 3TC and d4T is as efficacious as a combination of efavirenz, 3TC and d4T. Once-daily NVP with twice-daily 3TC and d4T is as efficacious as twice-daily NVP, 3TC and d4T. However, toxicity may be increased in the once-daily NVP regime. Additional trials of sufficient duration are required to provide better evidence for the use of this combination as a first line therapy. Ideally, trials should use standardised assessment measures especially with respect to measuring viral load, so that results can be compared and combined in meta-analyses.

Is there a need for elderly forensic psychiatric services?

The population of the elderly in most developed nations is on the increase. Furthermore, the prevalence of mental disorder amongst elderly offenders is high. The true extent of 'elderly' crime is unknown because much of it goes undetected and unreported. This leads to a failure to detect mental illness in such offenders. Court diversion schemes may improve recognition of mental illness but these schemes usually tend to deal with the more severe crimes. This may result in an overestimation of the amount of serious crime committed by the elderly and a failure to detect mental illness amongst those who commit less serious crimes. Efforts to service this hidden morbidity call for multi-agency collaboration. Improved detection and reporting of crimes is essential if mental health difficulties in the elderly are not to go unnoticed. The needs of elderly mentally-disordered offenders are complex and fall within the expertise of old age and forensic psychiatry, without being adequately met by either one. Therefore, consideration should be given to the development of a tertiary specialist forensic old-age psychiatry service.

TORCH agents in pregnant Saudi women.

OBJECTIVE: To determine the seroprevalence rates of IgG to common TORCH agents in pregnant Saudi women using indirect enzyme-linked immunosorbent assay. SUBJECTS AND METHODS: A total of 926 samples of sera were tested for antibodies to TORCH agents known to cause serious congenital infections: Toxoplasma gondii, rubella, cytomegalovirus (CMV), herpes simplex viruses (HSV-1 and HSV-2), varicella zoster virus (VZV) and human immunodeficiency virus (HIV-1 and HIV-2). RESULTS: Toxoplasma IgG antibodies were detected in 35.6%, CMV total IgG antibodies were found in 92.1%, rubella IgG antibodies in 93.3%, HSV-1 IgG antibodies in 90.9%, HSV-2 IgG in 27.1%, and VZV IgG antibodies in 74.4%. A 0% seroprevalence rate for HIV-1 and -2 was found. CONCLUSION: Pregnant Saudi women commonly have IgG antibodies to rubella, CMV, HSV-1 and -2, VZV, and T. gondii. Serological evidence of HIV infection was not observed.

Comparison of urine with urethral swabs for the detection of Chlamydia trachomatis in men attending an STD clinic.

Urethral swabs and first-catch urine specimens for the detection of Chlamydia trachomatis were collected from 370 black men with urethritis who attended a sexually transmitted disease (STD) clinic in Pretoria. An enzyme immunoassay (EIA) for C. trachomatis was carried out on all urethral swabs and urine specimens. Chlamydial culture and a direct immunofluorescent antibody (DFA) test (Imagen, Dako, UK) were also carried out on urethral swabs; DFA was used for confirmation of urine EIA positives. Based on culture and/or DFA, C. trachomatis was detected in 96 (26%) urethral swab specimens. The sensitivity of urine EIA investigation was 94% and the specificity 99%, compared with those of urethral swab EIA which were 97% and 99% respectively. The positive and negative predictive values for urine were 96% and 98% compared with 96% and 99% respectively for urethral swabs. Urine examination was therefore sensitive and specific compared with urethral swab examination in these STD patients. In view of this, the advantage of urine as an alternative to urethral swabs for C. trachomatis detection is that sampling is non-invasive and non-traumatic.

The impact of endemic schistosomiasis on acute viral hepatitis.

One hundred forty-four of 166 adults with acute viral hepatitis (AVH) admitted to an Egyptian fever hospital were followed for 12 months. The hepatitis B surface antigen (HBsAg) carrier rate in 95 with hepatitis B virus (HBV) hepatitis decreased from 53% at three months to 13% at 12 months. At 12 months, 22% of the male patients had persistent HBsAg compared with only 7% of the female patients. The HBsAg carrier rate was 25% at 12 months in those with schistosomiasis compared with 9% in those with only acute HBV infection. Splenomegaly persisted in those with palpable spleens at the initial examination and others developed splenomegaly. The prevalence of splenomegaly increased from 11% on admission to 20% at 12 months in those with only AVH, and from 40% to 69% in those with concomitant schistosomiasis. Patients with concomitant schistosomiasis had higher mean values for liver function test results and a greater proportion had abnormal liver function test results during hospitalization and follow-up than those with AVH only. Concomitant schistosomiasis increased the prevalence and prolonged splenomegaly and morbidity due to AVH. Both male sex and concomitant schistosomiasis prolonged the HBsAg carrier state. We propose that AVH frequently converts uncomplicated intestinal schistosomiasis to hepatosplenic schistosomiasis.