Staging of lung cancer in a tertiary care setting in Sri Lanka, using TNM 7th edition. A comparison against TNM6.

BACKGROUND: Lung cancer is a leading cause of cancer-related mortality in Sri Lanka and throughout the world. The latest staging system for lung cancer is the tumor node metastasis (TNM) 7th edition in which there are major changes to the previous version. The objective of our study was to find out the implications of TNM7th edition on lung cancer staging in a resource limited setting, and to compare it with the previous TNM 6th edition. METHODS: Patients with histologically proven lung cancer consecutively presented to respiratory unit of Teaching Hospital Kandy, Sri Lanka were recruited to the study over a period of one year from April 2010 to March 2011. They were staged using CT, ultrasound scan of abdomen, bronchoscopy and CT spine and brain when necessary. Staging was done using TNM 7 as well as TNM6. Surgical or non-surgical treatment arms were decided on staging and the number of patients in each treatment arm was compared between the two staging systems. RESULTS: Out of 62 patients, thirty four patients (54%) had metastatic disease and 19 (30%) of them had pleural effusions (M1a), while 15 (24%) had distant metastasis (M1b). When compared to TNM6 there was no difference in the number of patients in T1 category, but the number in T2 was higher in TNM7 (25 Vs 20). Similarly the number in T3 group was higher in TNM7 (11 Vs 5) and the number in M category was doubled (34 Vs 17 [Chi-6.46, p = 0.011]) compared to TNM 6. The number of patients suitable for surgery were 17(27.5%) in TNM 7 and 18(29%) [Chi-0.02, p = 0.88] in TNM6. CONCLUSIONS: This study shows that a significant proportion of patients were having advanced disease with distant metastasis on presentation. The number of patients falling to stage IV is significantly higher when staged with TNM7 but there was no significant difference in the number of patients undergoing surgery when TNM 7 was used compared to TNM6.

Predictors of the development of myocarditis or acute renal failure in patients with leptospirosis: an observational study.

BACKGROUND: Leptospirosis has a varied clinical presentation with complications like myocarditis and acute renal failure. There are many predictors of severity and mortality including clinical and laboratory parameters. Early detection and treatment can reduce complications. Therefore recognizing the early predictors of the complications of leptospirosis is important in patient management. This study was aimed at determining the clinical and laboratory predictors of myocarditis or acute renal failure. METHODS: This was a prospective descriptive study carried out in the Teaching Hospital, Kandy, from 1st July 2007 to 31st July 2008. Patients with clinical features compatible with leptospirosis case definition were confirmed using the Microscopic Agglutination Test (MAT). Clinical features and laboratory measures done on admission were recorded. Patients were observed for the development of acute renal failure or myocarditis. Chi-square statistics, Fisher's exact test and Mann-Whitney U test were used to compare patients with and without complications. A logistic regression model was used to select final predictor variables. RESULTS: Sixty two confirmed leptospirosis patients were included in the study. Seven patients (11.3%) developed acute renal failure and five (8.1%) developed myocarditis while three (4.8%) had both acute renal failure and myocarditis. Conjunctival suffusion - 40 (64.5%), muscle tenderness - 28 (45.1%), oliguria - 20 (32.2%), jaundice - 12 (19.3%), hepatomegaly - 10 (16.1%), arrhythmias (irregular radial pulse) - 8 (12.9%), chest pain - 6 (9.7%), bleeding - 5 (8.1%), and shortness of breath (SOB) 4 (6.4%) were the common clinical features present among the patients. Out of these, only oliguria {odds ratio (OR) = 4.14 and 95% confidence interval (CI) 1.003-17.261}, jaundice (OR = 5.13 and 95% CI 1.149-28.003), and arrhythmias (OR = 5.774 and 95% CI 1.001-34.692), were predictors of myocarditis or acute renal failure and none of the laboratory measures could predict the two complications. CONCLUSIONS: This study shows that out of clinical and laboratory variables, only oliguria, jaundice and arrhythmia are strong predictors of development of acute renal failure or myocarditis in patients with leptospirosis presented to Teaching Hospital of Kandy, Sri Lanka.

Evaluation of surveillance case definition in the diagnosis of leptospirosis, using the Microscopic Agglutination Test: a validation study.

BACKGROUND: Leptospirosis is endemic in both urban and rural areas of Sri Lanka and there had been many out breaks in the recent past. This study was aimed at validating the leptospirosis surveillance case definition, using the Microscopic Agglutination Test (MAT). METHODS: The study population consisted of patients with undiagnosed acute febrile illness who were admitted to the medical wards of the Teaching Hospital Kandy, from 1st July 2007 to 31st July 2008. The subjects were screened to diagnose leptospirosis according to the leptospirosis case definition. MAT was performed on blood samples taken from each patient on the 7th day of fever. Leptospirosis case definition was evaluated in regard to sensitivity, specificity and predictive values, using a MAT titre >or= 1:800 for confirming leptospirosis. RESULTS: A total of 123 patients were initially recruited of which 73 had clinical features compatible with the surveillance case definition. Out of the 73 only 57 had a positive MAT result (true positives) leaving 16 as false positives. Out of the 50 who didn't have clinical features compatible with the case definition 45 had a negative MAT as well (true negatives), therefore 5 were false negatives. Total number of MAT positives was 62 out of 123. According to these results the test sensitivity was 91.94%, specificity 73.77%, positive predictive value and negative predictive values were 78.08% and 90% respectively. Diagnostic accuracy of the test was 82.93%. CONCLUSION: This study confirms that the surveillance case definition has a very high sensitivity and negative predictive value with an average specificity in diagnosing leptospirosis, based on a MAT titre of >or= 1: 800.