Managing difficult catheterisation in nurse‐led catheterisation services: Does guidewire‐assisted urethral catheterisation make a difference?

The use of guidewires is well established in medical practice, but relatively new in nurse‐led catheterisation services (NCS). We investigate the incidence of difficult urethral catheterisation and whether guidewire‐assisted catheterisation reduces disrupted patient care. A retrospective Audit (September 2016‐August 2017) recorded incidence and management of difficult catheterisation in two NCS. In NCS‐A, nurses were familiar with improvised guidewire‐assisted catheterisation, whereas in NCS‐B nurses were not enabled and had to refer patients to urologists when they encountered problems. From September 2017 to August 2018, a National Institute for Health and Care Excellence (NICE)‐approved urethral catheterisation device with integrated guidewire (Urethrotech UCD) was used in NCS‐B for difficult urethral catheterisation. User and patient satisfaction was evaluated prospectively. Of 540 men attending NCS‐A for trial without catheter (TWOC), 31% (169/540) were recatheterized, of whom 4%(6/169) required a guidewire‐catheterisation technique to manage difficult catheterisation without problems. This was also done in 45 of 146 men attending for long‐term catheter change with known history of difficult catheter change. Of 1002 men attending NCS‐B for TWOC, 23% (226/1002) were recatheterized. This was difficult in 25% (57/226), of which 40% (23/57) suffered complications with bleeding from repeated catheterisation attempts and 10 men had to be admitted for specialist interventions to manage retention and catheterisation‐associated urethral injury. During the prospective audit, 945 men attended the TWOC‐clinic of NCS‐B. In 11% (13/120), the UCD was used for failed Foley‐catheterisation without complications. Patients and users were very satisfied because the difficult recatheterisation episode was managed successfully without patient harm and care delay. Difficult urethral catheterisation is a frequent occurrence in NCS with significant risk of urethral trauma. Catheterisation‐associated urethral injury can be prevented with guidewire‐assisted urethral catheterisation techniques. The NICE‐approved UCD with integrated guidewire was easy to use with high user and patient satisfaction avoiding patient care delay and is supporting nurses to manage difficult urethral catheterisation safely making efficient use of specialist resources.     

Effect of Aggregation on the Hydrodynamic Properties of Bovine Serum Albumin

Purpose

To systematically analyze shape and size of soluble irreversible aggregates and the effect of aggregate formation on viscosity.

Methods

Online light scattering, refractive index and viscosity detectors attached to HPLC (Viscotek®) were used to study aggregation, molecular weight and intrinsic viscosity of bovine serum albumin (BSA). Irreversible aggregates were generated by heat stress. Bulk viscosity was measured by an oscillating piston viscometer.

Results

As BSA was heated at a higher concentration or for a longer time, the relative contribution, molecular weight and intrinsic viscosity of aggregate species increased. Molecular shape was evaluated from intrinsic viscosity values, and aggregates were estimated to be more asymmetric than monomer species. The presence of aggregates resulted in an increase in bulk viscosity when relative contribution of very high molecular weight species exceeded 10%.

Conclusions

For model system and conditions studied, generation of higher order aggregate species was concluded to be associated with an increase in molecular asymmetry. Elevated viscosity in the presence of aggregated species points to molecular asymmetry being a critical parameter affecting solution viscosity of BSA.

     

Xenovaccinotherapy for colorectal cancer.

The objectives of this phase I-II trial were to assess the toxicity, immunological and clinical responses induced in 37 patients with stage IV colorectal cancer by the subcutaneous administration of a xenogenic polyantigenic vaccine (XPV) prepared from disrupted murine melanoma (B16) and carcinoma (LLC) cells. An inducing course of vaccinotherapy consisted of 10 immunizations (5 at weekly and 5 at fortnight intervals). Twenty-four hours later each of first 5 vaccinations the patient was subcutaneously given a low dose of the recombinant interleukin-2 (IL-2). A consolidating course of vaccinotherapy consisted of monthly vaccinations. No grade III or IV toxicities, but also laboratory and clinical signs of developing systemic autoimmune disorders were noted in any XPV-treated patient. A significant increase in cell-mediated immunoreactivity to both LLC and B16 antigens (Ags) occurred in the patients after inducing vaccinations, as determined by delayed-type hypersensitivity (DTH) skin reactions, as well as by blood lymphocyte proliferation responses. Vaccinations also led to increased cell-mediated reactivity to murine non-tumor, spleen cell (SC)-associated Ags. This reactivity, however, was not as significant as that to tumor-associated antigens (TAAs). XPV was also found to capable of generating IgG antibody-mediated responses. With immunotherapy concentrations of both interferon-gamma (IFN-gamma) and interleukin-4 (IL-4) detectably elevated in patients' sera, suggesting intensification of T helper 1-/T helper 2-mediated responses in the XPV-treated patients. The average survival of the XPV-treated patients was noticeably superior than was that of the clinically comparable control patients (17 vs 7 months). Collectively the results suggest that xenogenic TAAs are safe to use, able to induce measurable cellular and humoral immune responses, and may be clinically effective in certain colorectal cancer patients.     

Evaluation of real time polymerase chain reaction targeting mpb64 gene for diagnosis of extrapulmonary tuberculosis

BackgroundPaucibacillary nature of extrapulmonary tuberculosis (EPTB) has paved way for molecular methods increasingly being used for diagnosis. We undertook a study for evaluation of sensitivity and specificity of real-time polymerase chain reaction (RT-PCR) targeting mpb64 gene for diagnosis of EPTB.MethodsA total of 152 clinical samples from suspected cases of EPTB were included in this study. All samples were extracted using spin column based commercial DNA extraction kit and were subjected to RT-PCR targeting mpb64 and IS6110. Smear and culture was also done for samples whenever quantity was sufficient. Cytology report was noted from hospital information system. Receiver operating characteristic (ROC) curve analysis was done for determining cut-off Ct value for mpb64 RT-PCR. Melt curve analysis was done for samples whose cycle threshold (Ct) value was more than 37. The sensitivity and specificity of the mpb64 RT-PCR was calculated using a composite gold standard i.e., positive for one or more of the following: microscopy (including fine needle aspiration cytology (FNAC), acid-fast bacilli positivity), culture and IS6110 RT-PCR.ResultsOut of the 152 samples, 72 (47.4%) were positive for tuberculosis by composite gold standard. Samples consisted of ascitic fluid (12), CSF (35), pus (23), lymph node aspirate (35), pleural fluid (37), synovial fluid (4), urine (1), pericardial fluid (1) and tissue bits (4). Microscopy (AFB smear including lymph node aspirate) was done for 124 samples of which 43 (34.7%) were positive. Culture results were available for 79 samples, 25 (31.6%) of which were positive and 42 (27.6%) of the 152 samples were positive by IS6110 PCR. Based on ROC and melt curve analysis, mpb64 RT-PCR was able to detect 38 (52.8%) of the 72 positive samples. In comparison to IS6110 RT PCR, 4 additional cases were detected by mpb64 RT-PCR. Compared to composite gold standard mpb64 showed overall sensitivity of 52.8%.ConclusionThe mpb64 RT-PCR is highly specific or MTB and can be used as a supplemental test for diagnosis of EPTB along with other diagnostic tests. However the overall sensitivity of mpb64 RT-PCR is too low to be used as an independent test for diagnosis of EPTB. Combining the results of IS6110 RT PCR and mpb64 RT PCR improved the overall sensitivity and hence mpb64 can be used as an additional target for diagnosis of EPTB.     

Psoriasis: Targeting Therapy Towards the Inflammatory Cascade

Alopecia areata is an unpredictable hair-loss condition. As there is no cure for alopecia areata and no effective conventional therapy, a substantial number of alopecia areata patients resort to complementary and alternative medical remedies and therapies (CAM). This review on the application of CAM in alopecia areata addresses two pertinent aspects. First, it provides a current overview of the published medical literature on CAM used in alopecia areata, and alopecia areata-related studies. Second, it presents a thorough assessment of the considerations and limitations of the use of CAM for the treatment of alopecia areata. A systematic MEDLINE search yielded 13 studies of the clinical use of CAM in the management of alopecia areata, all belonging to one of the five main categories of CAM. Methodological quality was analyzed using objective assessment scores (Wilson and Lawrence scores). Unfortunately, no study was of sufficient internal validity to provide robust evidence of the benefit of CAM. This might be attributable to several specific disease characteristics of alopecia areata, which require an especially solid trial design to properly assess the therapeutic effects of CAM. The review concludes with some recommendations for improving the quality of trials incorporating CAM in the treatment of alopecia areata