Selective transperineal prostate biopsy for fluoroquinolone-resistance patients reduces sepsis and cost

Background:Urosepsis is a recognized complication of transrectal ultrasound-guided prostate biopsy (TRUS-Bx). Pre-biopsy rectal swabs have been used to identify patients with microorganisms in the rectal flora resistant to the conventionally used empirical prophylaxis. The transperineal route of biopsy (TP-Bx) has a lower complication risk but comes at an increased cost.Materials and methods:Retrospective cohort study including patients undergoing prostate biopsies between October/2015 and April/2018. The intervention cohort, a rectal swab was performed, the result of which dictated the biopsy route; TRUS-Bx against TP-Bx. TP-Bx for patients with fluoroquinolone resistance or extended-spectrum β-lactamase. The control cohort underwent TRUS without a rectal swab receiving empirical antibiotics—oral ciprofloxacin and intravenous gentamicin.Results:Total 1000 patients were included in which 500 underwent a swab, 14 (2.8%) developed post-TRUS biopsy infective complications with 3 having positive bacteremia (0.6%); 500 had no swab, 47 (9.4%) developed post-TRUS biopsy infective complications with 22 (4.4%, p < 0.05) having positive bacteremia. Three patients (0.6%) of patients who underwent swab developed urinary tract infection symptoms whilst 12 (2.4%) had urinary tract infection in the control group. In those patients that underwent a swab, 14 required hospitalization with mean length of stay of 2.5 days versus 43 patients of the control with 3.6 days. Cost analysis concluded savings of this strategy was £18,711.Conclusions:We have demonstrated a protocol that reserves template biopsies for higher risk patients and can significantly reduce sepsis and other infectious complication rates whilst also proving to be a cost-efficient strategy. We recommend that units not utilizing rectal swabs to uncover the fluoroquinolone resistance rate by introducing them. We advocate units that already utilize rectal swabs, to introduce transperineal biopsy for their higher risk patients.     

Development of a composite indicator to prioritize districts for implementation of human immunodeficiency virus programmes in Maharashtra,India

A key recommendation of the National AIDS Control Programme‐IV of India was to develop new strategies for geo‐prioritization of the human immunodeficiency virus (HIV) epidemic. We conducted this study to categorize the districts in Maharashtra (India) based on a multidimensional framework for geo‐prioritization of services. Programmatic data on trends of HIV prevalence, coverage of marginalized populations and vulnerability factors were included. A composite indicator based on these was developed, and the cumulative score was calculated for each district. HIV prevalence among general population has declined steadily from 0.60% in 2007 to 0.33% in 2017. The programme coverage was stable but inadequate for men who have sex with men (MSM). The coverage for female sex workers (FSWs) was inadequate and reduced over time. Nine districts were categorized as high priority, 13 as moderate priority and 11 were classified as low‐priority districts based on burden and vulnerability for HIV. The high‐priority districts were Pune, Solapur and Yavatmal for FSW interventions and Pune, Thane and Latur for MSM interventions. This multidimensional indicator is based on existing programmatic data, dynamic and can be made state‐specific. It is useful to categorize and prioritize districts for allocation of resources and geo‐prioritization of services in resource limited settings.     

Adolescent mother -- an unprepared child

The World Health Organization considers adolescence to be the period between 10 and 20 years during which individuals undergo significant psychosexual and psychosocial development. The needs an well-being of people, especially girls, in this age group in India, however, are neglected. Almost 25% of India's population is comprised of girls below 20 years of age. Adolescent pregnancies make up 10-15% of the total and may be largely attributed to early marriage, but these girls are prepared neither physically nor emotionally for pregnancy and motherhood. Adolescents who marry between aged 15-19 will nonetheless bear on average 6-7 children over the course of their lives. In fact, 80% of women's time between the ages 15 and 35 is spent either being pregnant or nursing offspring. Sections discuss nutritional deprivation and poor fetal growth, obstetric risks, and maternal and infant mortality, literacy and school dropouts, and psychosocial aspects of adolescent pregnancy and motherhood. Intervention programs could aim to increase total food intake, prevent against iron deficiency anemia, provide education and health care for girls aged 10-15, promote the use of contraception, register marriages and provide family life education, and involve boys in the education process. While the marriage age needs to be increased, this change should not be legislated. Change must instead result from education syllabi at the school level.     

Mandibular invasion in oral cancers

Mandibular resection for oral cancers has significant aesthetic and functional sequelae. A reliable preoperative predictor of mandibular invasion is required to guide the need for and extent of mandibular resection. An orthopantomogram of the mandible is an accurate, reliable, cost-effective predictor of bony involvement except for central arch lesions. The feasibility of outer table rim mandibulectomy alone in patients with floor of mouth tumors needs to be examined carefully. Received: 11 December 1998 / Accepted: 7 October 1999     

Gene-targeted inhibition of transactivation of human immunodeficiency virus type-1 (HIV-1)-LTR by antisense oligonucleotides

We have used an in vitro approach to study the efficiency of antisense oligonucleotides in inhibiting LTR-(HIV-1)-directed CAT expression catalyzed by tat protein, the functional protein of the transactivator gene. We selected the target sequence localized near the 5 end of the tat mRNA. The following conclusions can be drawn from the data presented here: a) Antisense oligonucleotides modified by conjugation of cholesterol at the 3 end have a severalfold higher inhibitory response, b) inhibitory response is dependent on the mode of introducing oligonucleotides, and c) the inhibition by antisense oligonucleotides is sequence specific and directed towards the targeted region. This approach could be useful for targeting functional regions of regulatory gene products and designing gene-targeted inhibitors of virus replication.Dedicated to Professor Klaus Ring on his 60th birthday.     

Nutrition and immunology: from the clinic to cellular biology and back again

Diet and immunity have been known to be linked to each other for centuries. In the last 30 years systematic studies have confirmed that nutrient deficiencies impair immune response and lead to frequent severe infections resulting in increased mortality, especially in children. Protein-energy malnutrition results in reduced number and functions of T-cells, phagocytic cells and secretory immunoglobulin A antibody response. In addition, levels of many complement components are reduced. Similar findings have been reported for moderate deficiencies of individual nutrients such as trace minerals and vitamins, particularly Zn, Fe, Se, vitamins A, B6, C and E. For example, Zn deficiency is associated with profound impairment of cell-mediated immunity such as lymphocyte stimulation response, decreased CD4+:CD8+ cells, and decreased chemotaxis of phagocytes. In addition, the level of thymulin, which is a Zn-dependent hormone, is markedly decreased. The use of nutrient supplements, singly or in combination, stimulates immune response and may result in fewer infections, particularly in the elderly, low-birth-weight infants and malnourished critically-ill patients in hospitals. The interactions between nutrition and the immune system are of clinical, practical and public health importance.     

Unemployment, depression, and health: a look at the African-American community

OBJECTIVES: While the unemployment rate of African-American people is more than twice that of the white population, the research on the impact of unemployment on the health of this population is scarce. This study analysed the impact of unemployment on depression and well being among African-American people, and the factors associated with well being. METHODS: Logistic and multiple regression models were used to analyse panel data collected in the National Survey of Families and Households 1987-1992. African-American (1369) and white (6660) respondents were analysed separately. Outcome variables included an index of depression and self reported health status. MAIN FINDINGS: Differences between employment and unemployment groups were less significant for African-Americans than for the white population in predicting depression and well being. Health enhancing factors such as education and wealth were significantly associated with better health and lower depression indices among the white population but not consistently so among African-Americans. Satisfaction with personal relationships was the strongest predictor of well being for both groups. CONCLUSION: Research should focus on the special needs and circumstances of African-Americans, because protective factors may not have the same impact in different groups of the population.     

Laparoscopic management of benign solid and cystic lesions of the liver

OBJECTIVE: The authors present their experience in the laparoscopic management of benign liver disease. The aim of the study is to analyze technical feasibility and evaluate immediate and long-term outcome. SUMMARY BACKGROUND DATA: Indications for the laparoscopic management of varied abdominal conditions have evolved. Although the minimally invasive treatment of liver cysts has been reported, the laparoscopic approach to other liver lesions remains undefined. METHODS: Between September 1990 and October 1997, 43 patients underwent laparoscopic liver surgery. There were two groups of benign lesions: cysts (n = 31) and solid tumors (n = 12). Indications were solitary giant liver cysts (n = 16), polycystic liver disease (n = 9), hydatid cyst (n = 6), focal nodular hyperplasia (n = 3), and adenoma (n = 9). Only solid tumors, hydatid cysts, and patients with polycystic disease and large dominant cysts located in anterior liver segments were included. All giant solitary liver cysts were considered for laparoscopy. Patients with cholangitis, cirrhosis, and significant cardiac disease were excluded. Data were collected prospectively. RESULTS: The procedures were completed laparoscopically in 40 patients. Median size was 4 cm for solid nodules and 14 cm for solitary liver cysts. Conversion occurred in three patients (7%), for bleeding (n = 2) and impingement of a solid tumor on the inferior vena cava (n = 1). The median operative time was 179 minutes. All solitary liver cysts were fenestrated in less than 1 hour. There were no deaths. Complications occurred in 6 cases (14.1%). Two hemorrhagic and two infectious complications were noted after management of hydatid cysts. There were no complications after resection of solid tumors. Three patients received transfusions (7%). The median length of stay was 4.7 days. Median follow-up was 30 months. There was no recurrence of solitary liver or hydatid cysts. One patient with polycystic disease had symptomatic recurrent cysts at 6 months requiring laparotomy. CONCLUSION: Laparoscopic liver surgery can be accomplished safely in selected patients with small benign solid tumors located in the anterior liver segments and giant solitary cysts. The laparoscopic management of polycystic liver disease should be reserved for patients with a limited number of large, anteriorly located cysts. Hydatid disease is best treated through an open approach.     

The lateral pectoral flap

The lateral pectoral flap is a new pedicled flap based on the superficial thoracic artery which arises from the subscapular artery and courses along the lateral border of pectoralis major. The flap consists of skin, subcutaneous tissue and the underlying pectoral epimysium. It has been used successfully to resurface contralateral soft tissue defects over the fingers, thumb and dorsum of the hand in eight cases. The advantages of this flap are that it provides reliable soft tissue cover to the hand, which can be kept in an elevated position resting comfortably on the contralateral pectoral region with the forearm and arm aligned conveniently in the cross-chest position. It does not interfere with clothing and dressing the lower part of the body in contrast to the groin, hypogastric or lower abdominal flaps, and it allows early ambulation. Primary closure of the donor site in the majority of cases is an added benefit.     

"False inhibition" of demand pacemaker due to leakage of fluid into the pacemaker lead socket

"False inhibition" of a demand pacemaker usually occurs with a microfracture of the lead system resulting in a galvanic potential at the site of the fracture or with sensing of myopotential with exercise. An increase in the slope of the leading half edge of the pulse contour is generally considered diagnostic of lead fracture. We report the case of a patient in whom "false inhibition" at rest and an increase in the slope of the leading half edge of the pulse contour were caused by leakage of fluid into the pacemaker lead socket.