Initial experiences of cataract & lens surgery in 1269 patients in outpatient clean rooms using a portable laminar air flow device.

BACKGROUND: In 2020, routine cataract surgery was halted in most countries due to the COVID-19 pandemic in order to reduce transmission. With a consequent lack of theatre space, we developed a safe cataract pathway in outpatient department clean rooms to minimize patient exposure and time spent in hospital using a sterile laminar air flow device. We describe our initial experiences of restarting elective cataract surgery in the UK outpatient setting, outside of the operating theatre environment. METHODS: This was a prospective consecutive study of our clinical practice. A sterile air zone unit, the Toul Meditech Operio Mobile device, was used to create a sterile surgical site in three separate outpatient clean rooms from May 2020 to December 2021 in different geographical locations within Herefordshire, UK. Observations of the time spent in the department and a formal patient satisfaction survey were carried out for the initial 100 patients. All patients were followed up to assess development of post-operative complications. RESULTS: 1269 patients were included in the study. No patients sustained post-operative infection (n = 0/1269, 0%). For the initial 100 patients, the average time spent within the department was 74.3 min (unilateral cases, range 45-115 min) and 93.1 min (bilateral, 55-135 min). Patient satisfaction was high. CONCLUSION: Initial results demonstrate a safe, efficient and effective cataract surgery pathway with high patient satisfaction by converting outpatient clean rooms into ophthalmic operating theatres using the Toul Meditech Operio Mobile.

Evaluation of the effect of extended refrigerated storage of serum and plasma specimens on syphilis serologic test results.

The effect of extended refrigerated storage of 14 serum and plasma specimens on 5 syphilis serologic tests was evaluated for 16 weeks. Higher stability of nontreponemal and treponemal antibodies in serum was recorded compared to plasma. Described work may provide insights on refrigerated specimens' stability and suitability for syphilis tests.

Development of a novel magnetic particle-based agglutination immunoassay for anticardiolipin antibody detection in syphilis.

OBJECTIVES: Serological tests of non-treponemal and treponemal types are the most frequently used for syphilis diagnosis. Treponemal tests are available in wide variety of assay formats; however, limited advances have been made for the improvement of conventional non-treponemal tests. The objective of this work was to develop a novel non-treponemal magnetic particle-based agglutination assay (NT-MAA) and evaluate its feasibility for syphilis testing. METHODS: Cardiolipin was modified and coupled to magnetic microbeads. Serum diluted in phosphate-buffered saline was mixed with cardiolipin-coupled beads and incubated in a round bottom microplate for 90-120 min followed by visual inspection. A panel of reported syphilis (n=127) and non-reactive (n=244) specimens was prepared to evaluate the NT-MAA performance in comparison to conventional rapid plasma reagin (RPR). Treponema pallidum particle agglutination (TP-PA) assay and enzyme immunoassay (EIA) were included. Analytical sensitivity and reproducibility of NT-MAA were also determined. RESULTS: The non-treponemal NT-MAA and RPR showed sensitivity of 90.6% and 88.2% and specificity of 96.7% and 100%, respectively. The treponemal TP-PA and EIA yielded sensitivity of 100% and 99.2%, respectively, and 100% specificity by both assays. The per cent agreement between NT-MAA and RPR was 97% (kappa=0.931, 95% CI 0.891 to 0.971). Analytical sensitivity determined with IgM anticardiolipin antibody (ACA) was 2.6 µg/mL for both NT-MAA and RPR, while IgG ACA yielded 0.9 µg/mL and 1.7 µg/mL for NT-MAA and RPR, respectively. Qualitative results of intra-assay and interassay reproducibility revealed 100% consistency for NT-MAA. CONCLUSION: Preliminary evaluation of the novel NT-MAA validated proof of concept using laboratory-characterised syphilis sera and demonstrated performance comparable to RPR. Further validation of NT-MAA using additional specimens with better clinical staging may broaden the scope of developed test for syphilis diagnosis.

Laboratory Evaluation of a Commercially Available Rapid Syphilis Test.

Serological diagnosis of syphilis depends on assays that detect treponemal and nontreponemal antibodies. Laboratory certification and trained personnel are needed to perform most of these tests, while high costs and long turnaround time can hinder treatment initiation or linkage to care. A rapid treponemal syphilis test (RST) that is simple to perform, accessible, and inexpensive would be ideal. The Syphilis Health Check (SHC) assay is the only Food and Drug Administration (FDA)-cleared and Clinical Laboratory Improvement Amendments (CLIA)-waived RST in the United States. In this study, 1,406 archived human serum samples were tested using SHC and traditional treponemal and nontreponemal assays. Rapid test results were compared with treponemal data alone and with a laboratory test panel consensus defined as being reactive by both treponemal and nontreponemal assays for a given specimen, or nonreactive by both types of assays. The sensitivity and specificity of the SHC assay compared with treponemal tests alone were 88.7% (95% confidence interval [CI], 86.2 to 90.0%) and 93.1% (95% CI, 90.0 to 94.9%), respectively, while comparison with the laboratory test panel consensus showed 95.7% (95% CI, 93.6 to 97.2%) sensitivity and 93.2% (95% CI, 91.0 to 95.1%) specificity. The data were further stratified based on age, sex, pregnancy, and HIV status. The sensitivity and specificity of the SHC assay ranged from 66.7% (95% CI, 46.0 to 83.5%) to 91.7% (95% CI, 87.7 to 94.7%) and 88% (95% CI, 68.8 to 97.5%) to 100% (95% CI, 47.8 to 100%), respectively, across groups compared to traditional treponemal assays, generally increasing for all groups except the HIV-positive (HIV+) population when factoring in the laboratory test panel consensus. These data contribute to current knowledge of the SHC assay performance for distinct populations and may guide use in various settings.

Differentiation of mucinous from non-mucinous pancreatic cyst fluid using dual-stained, 1 dimensional polyacrylamide gel electrophoresis.

BACKGROUND: Pancreatic cysts are being increasingly identified in patients. Mucinous cysts have malignant potential whereas non-mucinous cysts do not. Distinguishing potentially malignant cysts from harmless ones by the characterization of cyst fluid contents remains a difficult problem. This study was undertaken to determine whether cyst fluid mucin glycoprotein analysis could differentiate mucinous from non-mucinous pancreatic cysts. METHODS: Cyst fluid from 28 patients who underwent resection of a pancreatic cyst was used for the study. In each case the type of cyst was histologically identified. One dimensional SDS polyacrylamide gel electrophoresis (1D-SDS PAGE) was performed on cyst fluid samples. For the detection of the separated proteins, we employed a novel dual staining technique. The gel was first stained with periodic acid Schiff (PAS), a mucin histochemical stain followed by a secondary protein staining with Simply Blue Safestain (Invitrogen). RESULTS: Visual scoring (based on the presence of mucins) gave a sensitivity of 95%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 88% for prediction of mucinous histology. CONCLUSIONS: One dimensional SDS polyacrylamide gel electrophoresis of pancreatic cyst fluid, followed by mucin (PAS) and protein (Simply Blue Safestain) staining, provides a means of concentrating and visualizing mucins, which allows the accurate differentiation of mucinous from non-mucinous histology in pancreatic cysts.

Histologic and imaging features of mural nodules in mucinous pancreatic cysts.

BACKGROUND & AIMS: Mural nodules predict malignancy within pancreatic cysts, but it is not clear whether endoscopic ultrasound (EUS) and computed tomography (CT) accurately identify nodules. We assessed images and the histology of mural nodules in branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) and mucinous cystic neoplasms (MCNs) and identified criteria to distinguish mural nodules from mucus. METHODS: We reviewed pathology specimens and EUS and CT images from consecutive patients with resected BD-IPMNs or MCNs. A blinded interobserver study of the EUS images was then conducted to identify features that distinguished nodules from mucus. After education about these features, the raters interpreted the EUS images again. RESULTS: On the basis of histologic analysis, 22 of 57 cases had epithelial nodules. Cancer or high-grade dysplasia was found in 23% of cysts with nodules versus 3% without nodules (P = .02). On the basis of reports, EUS detected epithelial nodules with 75% sensitivity and 83% specificity, whereas these values were 24% and 100%, respectively, for CT. Mucus accounted for 65% of intracystic lesions detected by EUS and was often diagnosed by using change in body position and fine-needle aspiration. Interobserver analysis identified 3 features that were detected by EUS (echogenicity, edge, and rim) that distinguished mucus from epithelial nodules. The diagnostic accuracy of the raters improved from a mean of 57% to 79% after education about these features (P = .004); accuracy was 90% when all 3 features of mucus were present. CONCLUSIONS: Malignancy is associated with epithelial nodules in BD-IPMNs and MCNs, but most echogenic lesions detected in cysts by EUS are mucus. Knowledge of features that discriminate mucus from mural nodules improves the diagnostic accuracy of EUS.

EUS-guided FNA diagnostic yield of malignancy in solid pancreatic masses: a benchmark for quality performance measurement.

BACKGROUND: The diagnostic yield of EUS-guided FNA (EUS-FNA) of solid pancreatic masses is a potential benchmark for EUS-FNA quality, because the majority of EUS-FNA of solid pancreatic masses should be diagnostic for malignancy. OBJECTIVES: To determine the cytologic diagnostic rate of malignancy in EUS-FNA of solid pancreatic masses and to determine if variability exists among endoscopists and centers. DESIGN: Multicenter retrospective study. PATIENTS: EUS centers provided cytology reports for all EUS-FNAs of solid, noncystic, >or=10-mm-diameter, solid pancreatic masses during a 1-year period. MAIN OUTCOME MEASUREMENT: Cytology diagnostic of pancreatic malignancy. RESULTS: A total of 1075 patients underwent EUS-FNA at 21 centers (81% academic) with 41 endoscopists. The median number of EUS-FNA of solid pancreatic masses performed during the year per center was 46 (range, 4-177) and per endoscopist was 19 (range, 1-97). The mean mass dimensions were 32 x 27 mm, with 73% located in the head. The mean number of passes was 3.5. Of the centers, 90% used immediate cytologic evaluation. The overall diagnostic rate of malignancy was 71%, 95% confidence interval 0.69%-0.74%, with 5% suspicious for malignancy, 6% atypical cells, and 18% negative for malignancy. The median diagnostic rate per center was 78% (range, 39%-93%; 1st quartile, 61%) and per endoscopist was 75% (range, 0%-100%; 1st quartile, 52%). LIMITATIONS: Retrospective study, participation bias, and varying chronic pancreatitis prevalence. CONCLUSIONS: (1) EUS-FNA cytology was diagnostic of malignancy in 71% of solid pancreatic masses and (2) endoscopists with a final cytologic diagnosis rate of malignancy for EUS-FNA of solid masses that was less than 52% were in the lowest quartile and should evaluate reasons for their low yield.

Applications of the Colorado Visible Human Project in gastroenterology.

Several applications of the University of Colorado Visible Human project have recently been developed in clinical gastroenterology, including a textbook of endoscopic ultrasound anatomy, an internet-based journal, articles on internet web-sites, and simulators. Details surrounding some of these projects are described.

Gastrointestinal, pancreatic, and hepatic cancer during pregnancy.

Pregnancy affects the clinical presentation, evaluation, treatment, and prognosis of patients with gastrointestinal cancer. Pregnant patients may present with advanced gastrointestinal cancer as a result of delayed diagnosis, in part because of difficulty differentiating signs and symptoms of cancer from signs and symptoms of normal pregnancy. The approach to cancer surgery and chemotherapy must be modified in pregnant patients to minimize fetal and maternal risks. Because of these factors, women who develop gastrointestinal cancers during pregnancy seem to have a poor prognosis. This article focuses on cancers of the colon, stomach, pancreas, and liver that occur during pregnancy.

Cetuximab, a monoclonal antibody targeting the epidermal growth factor receptor, in combination with gemcitabine for advanced pancreatic cancer: a multicenter phase II Trial.

PURPOSE: To determine the response rate, time to disease progression, survival duration and rate, and toxicity with the combination of cetuximab and gemcitabine in patients with epidermal growth factor receptor (EGFR)-expressing advanced pancreatic cancer. PATIENTS AND METHODS: Patients with measurable locally advanced or metastatic pancreatic cancer who had never received chemotherapy for their advanced disease and had immunohistochemical evidence of EGFR expression were eligible for the multicenter phase II trial. Patients were treated with cetuximab at an initial dose of 400 mg/m(2), followed by 250 mg/m(2) weekly for 7 weeks. Gemcitabine was administered at 1,000 mg/m(2) for 7 weeks, followed by 1 week of rest. In subsequent cycles, cetuximab was administered weekly, and gemcitabine was administered weekly for 3 weeks every 4 weeks. RESULTS: Sixty-one patients were screened for EGFR expression, 58 patients (95%) had at least 1+ staining, and 41 were enrolled onto the trial. Five patients (12.2%) achieved a partial response, and 26 (63.4%) had stable disease. The median time to disease progression was 3.8 months, and the median overall survival duration was 7.1 months. One-year progression-free survival and overall survival rates were 12% and 31.7%, respectively. The most frequently reported grade 3 or 4 adverse events were neutropenia (39.0%), asthenia (22.0%), abdominal pain (22.0%), and thrombocytopenia (17.1%). CONCLUSION: Cetuximab in combination with gemcitabine showed promising activity against advanced pancreatic cancer. Further clinical investigation is warranted.

Assessment of gastrointestinal function and response to megesterol acetate in subjects with gastrointestinal cancers and weight loss.

BACKGROUND: Cancer-associated anorexia/cachexia syndrome (CACS) is common in advanced gastrointestinal malignancies and felt to be due primarily to cytokine-induced appetite suppression. Therapy with an appetite stimulant (megesterol acetate) is commonly employed, but results are sometimes disappointing. We hypothesize that CACS not only suppresses appetite but also interferes with gastrointestinal function. METHODS: We conducted a prospective study in which 21 subjects with advanced gastrointestinal cancer and weight loss had digestive function. Patients were assessed using an indirect stable isotope method, and nutritional parameters were determined following which patients were treated with megesterol acetate for 4 weeks. Nutritional parameters were then reassessed, weight change determined, and the results were correlated with digestive function results obtained at the initiation of the study. RESULTS: Abnormal gastrointestinal function based on the stable isotope test was common (86% of patients). The majority of the abnormal function appeared to be due to abnormal pancreatic function testing, in which 17/21 subjects recorded low results. Initial albumin, prealbumin, and carotene values were also frequently abnormal (55-65% of patients). Megesterol acetate therapy resulted in a weight gain in most (75%) patients, although serum albumin fell modestly in the group (average decrease of 0.2 mg/dl). However, prealbumin levels rose in 70% and carotene levels rose in 55%. The degree of weight gain was negatively correlated with previous self-reported weight loss ( r=-0.53, p<0.05), and positively correlated ( p<0.05) with pretherapy carotene ( r=0.58), prealbumin ( r=0.61) and the pancreatic function (digestive) phase of the digestive function test ( r=0.41). CONCLUSION: These data suggest that abnormal digestive function is commonly seen in subjects with CACS and advanced gastrointestinal cancer, and that both pretherapy digestive function and nutritional status can predict or possibly influence the outcome of hormonal appetite stimulation therapy.

Validating methods of urine collection: a pilot study.

In this pilot study of 21 adults, direct collection versus cotton-ball collection of urine was studied. Results showed the use of cotton balls for collecting urine is a safe and effective method for measuring antioxidants and markers of oxidative stress for clinical and research use.