SMaRT-PCR: sampling using masks and RT-PCR, a non-invasive diagnostic tool for paediatric pulmonary TB.

Key challenges in paediatric TB diagnosis are invasive sampling and poor sensitivity of standard methods. This study demonstrates the diagnostic potential of non-invasive sampling of bioaerosols from children using SMaRT-PCR, comprising mask sampling combined with reverse transcriptase-polymerase chain reaction (RT-PCR) for TB.Exhaled bioaerosols were captured on modified N-95 masks in a 10-min talk-cough-breathe process from 51 children (30 with TB confirmed using standard sampling methods and 21 without TB) aged 2-15 years. All mask samples were tested using in-house RT-PCR for 16s and rpoB RNA transcripts. Additional mask samples from children with TB were tested using Xpert® MTB/RIF (n = 3) and Xpert® MTB/RIF Ultra (n = 27).SMaRT-PCR sensitivity for detecting TB among treatment-naïve children was 96% if 16s or rpoB was present, and 75% if both genes were present, comparable to standard methods (71%) in the same cohort. Specificity was better for both genes, at 95%, than 85% for a single gene detection. Mask sampling with Xpert MTB/RIF or Ultra had a sensitivity of only 13%.This is the first study to provide evidence for testing bioaerosols as a promising alternative for detecting paediatric TB. Sampling is non-invasive and simple, with the potential for point-of-care applications. This pilot study also suggests that RNA transcript-based detection may improve TB diagnostic sensitivity in children; however, further investigation is required to establish its adaptability in clinical settings..

Case-control study of vitamin D status and adult multidrug-resistant pulmonary TB.

BACKGROUND: India has the highest prevalence of multidrug-resistant TB (MDR-TB) globally. Vitamin D deficiency is potentially an important risk factor for MDR-TB.METHODS: We conducted a case-control study of 90 newly diagnosed adult MDR-TB cases, 180 household controls and 82 non-household controls in Mumbai, India. Serum 25-hydroxyvitamin D (25(OH)D), anthropometry, clinical status and history, dietary data and sociodemographic data were collected from each participant. Interferon-gamma release assay (IGRA) was also performed in controls to assess latent TB. Multivariable regression was performed to estimate associations between 25(OH)D vs. case status and IGRA positivity.RESULTS: Mean participant age was 33.8 ± 12.0 years; 72.8% had 25(OH)D <20 ng/ml. Mean 25(OH)D was significantly (P < 0.05) lower in cases (12.5 ± 7.9) than both household (17.5 ± 11.2) and non-household controls (16.4 ± 9.1). In multivariable models, 25(OH)D concentration was inversely associated with MDR-TB case status among cases and household controls (OR 0.95 per 1 ng/ml, 95% CI 0.92-0.99; P = 0.015), and among cases and non-household controls (OR 0.94 per 1 ng/ml, 95% CI 0.89-1.00; P = 0.033); 53.6% of controls were IGRA-positive. 25(OH)D status was not associated with IGRA positivity.CONCLUSION: Vitamin D status was independently associated with MDR-TB case status. Research should evaluate the effectiveness of vitamin D supplementation in prevention and adjunctive treatment of MDR-TB.

endoscope-i: an innovation in mobile endoscopic technology transforming the delivery of patient care in otolaryngology.

INTRODUCTION: Digital and mobile device technology in healthcare is a growing market. The introduction of the endoscope-i, the world's first endoscopic mobile imaging system, allows the acquisition of high definition images of the ear, nose and throat (ENT). The system combines the e-i Pro camera app with a bespoke engineered endoscope-i adaptor which fits securely onto the iPhone or iPod touch. Endoscopic examination forms a salient aspect of the ENT work-up. The endoscope-i therefore provides a mobile and compact alternative to the existing bulky endoscopic systems currently in use which often restrict the clinician to the clinic setting. Areas covered: This article gives a detailed overview of the endoscope-i system together with its applications. A review and comparison of alternative devices on the market offering smartphone adapted endoscopic viewing systems is also presented. Expert commentary: The endoscope-i fulfils unmet needs by providing a compact, highly portable, simple to use endoscopic viewing system which is cost-effective and which makes use of smartphone technology most clinicians have in their pocket. The system allows real-time feedback to the patient and has the potential to transform the way that healthcare is delivered in ENT as well as having applications further afield.

Acute unilateral sensorineural hearing loss associated with anabolic steroids and polycythaemia: case report.

BACKGROUND: Unilateral sudden sensorineural hearing loss due to an infarct in the vertebrobasilar system has been widely reported. Most patients have a background of traditional coronary risk factors related to these cerebrovascular episodes. CASE REPORT: A 32-year-old male, a regular user of anabolic steroids, presented to the emergency department with unilateral sensorineural hearing loss and symptoms suggestive of an infarct of the anterior inferior cerebellar artery but in the absence of risk factors for ischaemic stroke. RESULTS: Magnetic resonance imaging confirmed the presence of infarction in the region supplied by the anterior inferior cerebellar artery. Polycythaemia was found on haematological analysis, which we believe was secondary to the use of anabolic steroids. The patient was commenced on aspirin as per the stroke management protocol. There was resolution of neurological symptomatology six weeks after the episode, but no improvement in hearing. CONCLUSION: To our knowledge, this is the first case report of unilateral sensorineural hearing loss secondary to the use of anabolic steroids causing polycythaemia. This cause should be considered in the differential diagnosis of patients presenting with sensorineural hearing loss, especially in young males, when no other risk factors can be identified.

Cochlear implantation in the mouse via the round window: effects of array insertion.

Animal models are the only means of assessing the effects of cochlear implantation (CI) at a cellular and molecular level. The range of naturally occurring and genetically-modified mouse strains which mimic human deafness provide excellent opportunities for auditory research. To date, there are very few studies of CI in mice. The main aims of this study were to develop a reproducible and viable technique to enable long term CI in the mouse and to assess the response of the mouse cochlea to implantation as a means of evaluating the success of the procedure. Electrode array implantation via the round window was performed in C57Bl/6 mice aged 3 and 6 months. The contralateral cochlea acted as a control. Auditory brainstem responses (ABR) were recorded prior to and following CI. Analysis showed greater threshold shifts in the implanted ear compared to the control ear post-implantation, but substantial preservation of hearing. There were no cases in which implantation caused a profound hearing loss across all frequencies. Cone beam computerised tomography and light microscopy confirmed correct placement of the electrode array within the scala tympani. Cochleae were prepared for histological examination. Initial analysis revealed encapsulation of the implant in tissue with morphological characteristics suggestive of fibrosis. Our results show that mouse CI via the round window offers a model for exploring tissue responses to implantation.

Improved detection of focal cortical lesions using 7T magnetisation transfer imaging in patients with multiple sclerosis.

BACKGROUND: Cortical lesions account for a larger proportion of brain demyelination than white matter (WM) lesions. They are often missed on conventional MRI. Recently studies improved the detection of cortical lesions using 7T T2(⁎), 7T MPRAGE and 3T DIR but it seems that we are still able to detect only "the tip of the iceberg". In this study we report for the first time the systematic use of high resolution MTR in MS and compare MTR lesion detection with 7T MPRAGE, 7T T2(⁎) and 3T 3D DIR. OBJECTIVES: We report the use of high resolution, fast, magnetisation transfer imaging (MTI) at 7T in MS focusing on the detection of cortical lesions. SUBJECTS AND METHODS: Eighteen patients with MS were scanned (Expanded Disability Status Scale score: 3.0, mean age: 48 years, mean disease duration: 7.25 years). The scans were compared to nine healthy control subjects (mean age 36.5 years). DATA ACQUISITION: We acquired 7T MPRAGE images, 7T MTR maps, 7T T2(⁎)and 3T 3D DIR. The WM was segmented from the MPRAGE and removed to obtain only the cortical grey matter ribbon (cGMR) mask. The mask was then applied to the different modalities (MPRAGE, MTR, DIR, T2(⁎)w) previously registered onto the MPRAGE volume. The analysis of the cGMR was performed by two observers blinded to the disease state. RESULTS: In patients with MS 365 lesions in total were detected with 7T MTR (mean 20.28 lesions per patient), 289 lesions were detected with 7T MPRAGE (mean 16.06 lesions) and 231 lesions were detected with 7T T2(⁎) (mean 12.83 lesions). In the 8 MS subjects who had 3T 3D DIR acquired on the same day, a total of 136 lesions (mean 17 lesions per patient) were detected as opposed to 171 lesions with 7T MTR, 147 lesions were detected with 7T MPRAGE and 126 lesions with 7T T2(⁎) in the same patients. CONCLUSION: We found that 7T MTR, in less than 10min scanning time, was able to detect cortical lesions. In this study we found that 7T MTR was better in detecting intracortical lesions in comparison with 7T T2(⁎), 7T MPRAGE, and 3T 3D DIR. since only a very few intracortical lesions were detected in healthy controls in our blind assessment, it is likely that the lesions detected represent focal grey matter demyelination. High resolution MT imaging has especially revealed cortical changes that have not been recognised by other MR sequences. MTR maps were noisier than MPRAGE, T2(⁎) and DIR, but also better in localising cortical lesions. As MTR is more pathologically specific than other sequences in detecting tissue myelination, it raises the possibility that high resolution MTR will be able to demonstrate cortical remyelination in vivo.

Variation in temperature during composting of food and vegetable waste.

Composting is one of the suitable method for disposal of organic waste and convert it in to organic fertilizer. For effective composting, role of temperature within the composting heap is important. Variation of temperature in the composting heap is the indicator of type of microbial biomass present during the composting. Present study was conducted to find out the minimum volume of waste for effective composting. The present study was conducted in two phases. The first phase of study was conducted to monitor the temperature variation in different volume of composting heap and second phase of study was conducted to study the leachate production in food and vegetable waste. The results of the present study revealed that minimum 80 and 100 kg of food and vegetable waste required maintaining the thermophilic and mesophilic stage. To attain the thermophilic stage the minimum volume should be around 0.5 m3 and minimum height 0.6m. Leachate was produced at initial stage of degradation and it was more in vegetable waste compared to food waste.

Observation of the binary coalescence and equilibration of micrometer-sized droplets of aqueous aerosol in a single-beam gradient-force optical trap.

The binary coalescence of aqueous droplets has been observed in a single-beam gradient-force optical trap. By measuring the time-dependent intensity for elastic scattering of light from the trapping laser, the dynamics of binary coalescence have been examined and the time scale for equilibration of a composite droplet to ambient conditions has been determined. These data are required for modeling the agglomeration of aqueous droplets in dense sprays and atmospheric aerosol. Elastic-light scattering from optically trapped particles has not been used previously to study the time-resolved dynamics of mixing. It is shown to offer a unique opportunity to characterize the binary coalescence of aqueous droplets with radii from 1 to 6 µm. The study of this size regime, which cannot be achieved by conventional imaging methods, is critical for understanding the interactions of droplets in the environment of dense sprays.

The dragon and the tiger: realties in the control of tuberculosis.

India and China are two Asian super-powers with developing economies carried on the shoulders of their booming populations. This growth can only be sustained by nurturing their "human resource". However increasing reports of insufficient public health (PH) initiatives in India when compared to the aggressive PH system of China may prove to be the Achilles' heels for India. This review compares the PH system in India and China for combating Tuberculosis (TB), the disease responsible for maximum mortality and morbidity by a single infectious agent. While China has acknowledged the disease load and thereafter has methodically improved its reporting, detection, diagnosis and treatment, India is still in denial of the imminent health risk. The Indian PH system still considers TB as a "facultative" disease for which the required control measures are already in place and functioning. Globally, India and China recorded the highest Multi-Drug Resistant TB (MDR) cases notified in 2010 (64000 and 63000, respectively). Additionally non-government sources reported extremely high proportions of MDR in India. Here we have compared the medical, social and economic approaches of the two nations towards better management and control of TB. Does India have lessons to learn from China?

Mycobacterium tuberculosis "Beijing" epidemics: a race against mutations?

Multi Drug Resistant Tuberculosis Beijing strains exhibit different drug-resistance mutations (DRM) in different locations. By comparing DRM in Beijing reported from Tuberculosis endemic and epidemic locations, we propose that DRM selected in a population cannot tolerate biologically available drugs in different populations resulting in further evolution through novel DRM.

SU-E-T-428: Class Solution for Prostate High Dose Rate Brachytherapy with Inverse Planning Simulated Annealing.

PURPOSE: To develop and validate a class solution for inverse planning simulated annealing (IPSA) with CT based prostate high dose rate brachytherapy (HDR). METHODS: Between November 2008 and November 2011, our institution treated 40 prostate cancer patients with HDR in 7 Gy fractions followed by external beam radiotherapy. The HDR treatments were planned with Nucletron Oncentra using manual graphical optimization (GO). Plans were optimized to the following clinical goals: = 95% of prostate volume received 7 Gy, < 1 cc of rectum received 5.6 Gy, < 0.1 cc of rectum received 6.3 Gy, and < 0.01 cc of urethra received 8.75 Gy. New plans were manually customized using IPSA (MC-IPSA) for each patient to match prostate coverage by the prescription dose to within ± 1% of the GO plans while meeting the rectal and urethral dose constraints. An IPSA class solution (CS-IPSA) was created from the mean MC-IPSA parameters. New plans were developed for each of these 40 patients using only CS-IPSA with no further optimization. Additionally, plans were created on an independent dataset of 30 different patients using only CS-IPSA with no further optimization. RESULTS: Plans were optimized in about 30 minutes using GO, MC-IPSA took an average of 14.1 ± 6.5 minutes, and CS-IPSA optimizationwas < 1 minute. There was no significant difference (p > 0.05) among the optimization methods for all clinical goals over the 40 CS-IPSA source patients. There was no significant difference (p > 0.05) between the source and the independent datasets for all clinical goals when using CS-IPSA with no further optimization. CONCLUSION: A prostate HDR IPSA class solution was developed and validated on a source and an independent dataset. The IPSA class solution yields plans comparable to custom manual IPSA and graphical optimization while saving considerable time.

TU-E-BRA-10: Personalized Utility Function for Radiotherapy Based on Pulmonary Ventilation of Locally Advanced Lung Cancer Patients.

PURPOSE: To develop tailor-made utility functions based on each patient's pulmonary function distribution so that personalized organ-function-based treatment plan is obtained for locally advanced lung cancer patients. METHODS: Five locally advanced lung cancer patients were retrospectively evaluated in the study. Fractional regional ventilation was obtained by performing subtraction of spatially matched and corrected 4DCT images. Histogram of the fraction ventilation values was generated for each patient. The cumulative distribution function (CDF), which represented an inverse relationship with the desired dose to each voxel for function preservation, showed potential as personalized utility function. In order to spare the majority of the volume with pulmonary function, a more aggressive utility function was defined as a piece-wise linear function based on the most frequent fractional ventilation value (peak of the histogram). This utility function was used in the objective function during treatment planning. Conventional objectives and constraints were maintained during the planning process. RESULTS: Both conventional plan and personalized functional plan were classified as satisfactory plans by physician based on conventional dose and dose-volume metrics. However, functional plan successfully spared high ventilation volume based on each patient's unique condition. When spatial function information was included to collect function dose/dose-volume metrics, significant reduction of fV20, fV30 and mean lung dose was achieved by function-based personalized plan with p-value < 0.01. CONCLUSIONS: Organ-function-based radiotherapy has been presented to incorporate patient's pulmonary function in hopes of reducing the risk of complications. Current methods utilize the function information in the same fashion across patients. We took one step further to not only incorporate heterogeneous pulmonary function during treatment planning but also generate personalized utility function based on the function distribution of each patient. AAPM Research Seed Funding Initiative.

Development and validation of a symptom questionnaire for recording outcomes in adult lacrimal surgery.

BACKGROUND: A symptom-based questionnaire (the `Lac-Q` questionnaire) for adult patients undergoing lacrimal drainage surgery was developed. The questionnaire yields a numerical score that can be used to assess severity of symptoms. METHODOLOGY: In this study, the questionnaire was evaluated in 17 consecutive patients undergoing 22 dacryocystorhinostomy (DCR) procedures. The questionnaire was administered pre- and postoperatively. The pathology encountered at operation was recorded. The success of surgery was judged by patient satisfaction, endoscopic evaluation of DCR stomal patency, and objective lacrimal drainage testing using the functional endoscopic dye test (FEDT). In a further group of 12 pre-operative cases, the questionnaire was repeated after 4-6 weeks but before surgery, to assess test-retest reliability in the absence of clinical change. RESULTS: The Lac-Q questionnaire was based on two broad categories of eye-specific scores and social impact scores. A numerical score, the `Lac-Q` score, was generated pre- and postoperatively. When compared to pre-operative scores, the reduction in Lac-Q scores postoperatively was significant. Postoperative scores also correlated well with objective lacrimal drainage testing using the FEDT. Analysis of symptom scores shows that the questionnaire was reliable with regard to content validity, internal consistency, test-retest reliability, and responsiveness to clinical change. CONCLUSIONS: We conclude that the Lac-Q questionnaire is a useful clinical tool to evaluate outcomes after adult lacrimal surgery.

Use of propranolol to treat multicentric airway haemangioma.

OBJECTIVE: To report our experience of using propranolol to treat an infantile airway haemangioma. METHODS: A five-week-old girl presented with upper airway obstruction. Having started systemic steroids, concurrent propranolol therapy was commenced. Propranolol was given with close monitoring of the blood pressure, pulse and capillary glucose level. The dose of propranolol was gradually increased to 2 mg/kg total daily dose, with simultaneous reduction and withdrawal of steroids. RESULTS: Prior to propranolol treatment, laryngotracheobronchoscopy revealed an extensive haemangioma extending from the posterior pharyngeal wall to the subglottis. Following initiation of propranolol, a dramatic reduction in tumour bulk was seen on repeated laryngotracheobronchoscopy within 10 days of treatment. Eight months on, the patient remained asymptomatic on propranolol, with no endoscopic evidence of disease apart from mild telangiectasia. CONCLUSION: Haemangiomas of the airway can cause obstruction which may potentially be life-threatening. This case demonstrates the potential of propranolol to become a valuable therapeutic option in such clinical situations.

Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest.

BACKGROUND: Tension and bilateral pneumothorax can cause or contribute to death following trauma. A surgical incision (thoracostomy) or needle decompression through the chest wall rapidly treats these conditions. Resuscitation of patients in traumatic cardiac arrest focuses on treating common and reversible life-threatening conditions. A study was undertaken to observe the practice, findings and outcome of chest decompression when performed as part of the resuscitation strategy of these patients by air ambulance crews. METHODS: Patients in prehospital traumatic cardiac arrest were identified over a 39-month period from an air ambulance database. The use of thoracostomy or needle decompression was identified together with indications, findings and outcome. Primary outcome was return of cardiac output by arrival at hospital. RESULTS: 18 of 37 cases underwent chest decompression (17 thoracostomy, 1 needle decompression). Four patients had a return of cardiac output (3 tension pneumothorax, 1 bilateral pneumothorax). Six further cases were positive for intrathoracic injury. In 2 cases the injuries identified were incompatible with life and resuscitation efforts were consequently ceased. CONCLUSIONS: Chest decompression in traumatic cardiac arrest identifies and treats a high proportion of potentially life-ending injuries and should be considered as part of the resuscitation effort of patients in traumatic cardiac arrest. In a proportion of patients, non-survivable injuries are identified which guide resuscitation efforts.

The management of soft tissue sarcoma.

SUMMARY: Soft tissue sarcomas are a rare group of mesenchymal tumours that display cardinal signs, which can raise suspicion to their diagnosis. Management in a sarcoma treatment centre by its multidisciplinary team has improved outcome. Good local disease control with limb salvage and adjuvant radiotherapy has considerably reduced the morbidity of previous limb amputation. By the early involvement of a plastic surgeon, tissue reconstruction is optimised and wound complications reduced. This article looks at the contemporary management of soft tissue sarcoma and, in particular, its relevance to the plastic surgeon today.