C-reactive Protein (CRP) as a Single Biomarker for Diagnosis of Neonatal Sepsis: A Comprehensive Meta-analysis.

Neonatal sepsis (NS) is a life-threatening disorder and an important cause of morbidity and mortality in neonates. Blood culture, the gold standard for diagnosis of neonatal sepsis is costly, not available at all centres and test result not readily available. CRP is low cost diagnostic test for neonatal sepsis which is possible to perform at all centres and test result is easily available. We aimed to evaluate the usefulness of C-reactive protein (CRP) measurement to identify neonatal sepsis. We conducted this meta-analysis to investigate the diagnostic accuracy of the CRP in neonatal sepsis. The literature was searched in PUBMED, Cochrane Library, Google scholar and other Medical Databases using set search criteria. Each included study was evaluated by quality assessment of diagnostic accuracy studies (QUADAS) tool. Four investigators independently extracted the data and study characteristics, and disagreements, if any, were resolved by consensus. Meta-disc software was used to calculate the pooled sensitivity, specificity and summary diagnostic odds ratio (SDOR), I² or Cochrane Q to test heterogeneity. False positive report probability (FPRP) was calculated to confirm the significance of the results. Eleven studies (1557 neonates) were included in this meta-analysis. The pooled sensitivity and specificity of CRP were 71% and 86% respectively, which had moderate accuracy in the diagnosis of NS. The pooled diagnostic odds ratio (DOR) and area under curve (AUC) was 19.10 and 0.8535 (Q*=0.7845), respectively. The diagnostic threshold analysis showed that there was no threshold effect. Meta-analysis showed that CRP had a moderate accuracy (AUC=0.8535) for the diagnosis of NS. CRP is a helpful biomarker for diagnosis of NS. However, we should combine the results with clinical symptoms and signs, laboratory and microbial results.

Fatty acid binding proteins 4 and 5 in overweight prepubertal boys: effect of nutritional counselling and supplementation with an encapsulated fruit and vegetable juice concentrate.

Elevated fatty acid binding proteins (FABP) may play a role in obesity and co-morbidities. The role of nutritional interventions in modulating these levels remains unclear. The aim of this post hoc study was to determine the effect of overweight (OW) on FABP4 and FABP5 in boys in relation to indices of adiposity, insulin resistance and inflammation, and to investigate the effects of a 6-month supplementation with an encapsulated fruit and vegetable juice concentrate (FVJC) plus nutritional counselling (NC) on FABP levels. A post hoc analysis of a double-blind, randomised, placebo-controlled study of children recruited from the general paediatric population was performed. A total of thirty age-matched prepubertal boys (nine lean and twenty-one OW; aged 6-10 years) were studied. Patients received NC by a registered dietitian and were randomised to FVJC or placebo capsules for 6 months. FABP4, FABP5, glucose, insulin, homeostasis model assessment-insulin resistance (HOMA-IR), glucose-induced acute insulin response (AIR), lipid-corrected ß-carotene (LCßC), adiponectin, leptin, high-sensitivity C-reactive protein (hs-CRP), IL-6 and body composition by dual-energy X-ray absorptiometry were determined before and after the intervention. FABP were higher (P < 0·01) in the OW v. lean boys and correlated directly with HOMA-IR, abdominal fat mass (AFM), hs-CRP, IL-6, and LCßC (P < 0·05 for all). FABP4 was associated with adiponectin and AIR (P < 0·05). FVJC plus NC reduced FABP4, HOMA-IR and AFM (P < 0·05 for all) but not FABP5. OW boys showed elevated FABP4 and FABP5, but only FABP4 was lowered by the FVJC supplement.

Estimation of dynamic time activity curves from dynamic cardiac SPECT imaging.

Whole-heart coronary flow reserve (CFR) may be useful as an early predictor of cardiovascular disease or heart failure. Here we propose a simple method to extract the time-activity curve, an essential component needed for estimating the CFR, for a small number of compartments in the body, such as normal myocardium, blood pool, and ischemic myocardial regions, from SPECT data acquired with conventional cameras using slow rotation. We evaluated the method using a realistic simulation of (99m)Tc-teboroxime imaging. Uptake of (99m)Tc-teboroxime based on data from the literature were modeled. Data were simulated using the anatomically-realistic 3D NCAT phantom and an analytic projection code that realistically models attenuation, scatter, and the collimator-detector response. The proposed method was then applied to estimate time activity curves (TACs) for a set of 3D volumes of interest (VOIs) directly from the projections. We evaluated the accuracy and precision of estimated TACs and studied the effects of the presence of perfusion defects that were and were not modeled in the estimation procedure.The method produced good estimates of the myocardial and blood-pool TACS organ VOIs, with average weighted absolute biases of less than 5% for the myocardium and 10% for the blood pool when the true organ boundaries were known and the activity distributions in the organs were uniform. In the presence of unknown perfusion defects, the myocardial TAC was still estimated well (average weighted absolute bias <10%) when the total reduction in myocardial uptake (product of defect extent and severity) was ≤ 5%. This indicates that the method was robust to modest model mismatch such as the presence of moderate perfusion defects and uptake nonuniformities. With larger defects where the defect VOI was included in the estimation procedure, the estimated normal myocardial and defect TACs were accurate (average weighted absolute bias ≈ 5% for a defect with 25% extent and 100% severity).

Nitrogen level and physiological basis of yield of mungbean at varying plant population in High Ganges River Flood Plain soil of Bangladesh.

A field experiment was conducted at the Regional Agricultural Research Station of Bangladesh Agricultural Research Institute, Jessore during early kharif season of 2009 and 2010 to observe the effect of nitrogen on the physiological basis of yield of mungbean at varying plant population. In the experiment, four nitrogen levels (N0, N40, N60 and N80 kg ha(-1)) were assigned in the main plots and three plant population (P30, P35 and P40 m(-2)) in the sub plots. The results revealed that mungbean showed better growth in N60 and N80 kg ha(-1) representing higher values of CGR, TDM, LAI and plant height while N40 exhibited intermediate growth. Again, growth of mungbean was better in higher plant population (35-40 m(-2)) representing higher values of growth parameters. Seed yield of mungbean was obtained the highest (1908 kg ha(-1)) associated with the highest No. of pods plant(-1) (29.98), seeds pod(-1) (10.41) and 1000-seed weight (37.70 g) in N40 kg ha(-1). Further, seed yield of mungbean was the highest (1919 kg ha(-1)) in plant population of 40 m(-2). In interaction, seed yield was the highest (1963 kg ha(-1)) in N40 kg ha(-1) with plant population of 40 m(-2). The effect of applied nitrogen on the seed yield of mungbean can be explained 78% (R2 = 0.78) by this function (Y = 1540.70+16.069x-0.173x2). The optimum nitrogen level was 46 kg ha(-1) by using the developed functional model and then the predicted seed yield of mungbean would be 1944 kg ha(-1).

Metabolic effects of oral versus transdermal 17ß-estradiol (E2): a randomized clinical trial in girls with Turner syndrome.

CONTEXT: The long-term effects of pure 17ß-estradiol (E2) depending on route of administration have not been well characterized. OBJECTIVE: Our objective was to assess metabolic effects of oral vs transdermal (TD) 17ß-E2 replacement using estrogen concentration-based dosing in girls with Turner syndrome (TS). PATIENTS: Forty girls with TS, mean age 16.7 ± 1.7 years, were recruited. DESIGN: Subjects were randomized to 17ß-E2 orally or TD. Doses were titrated using mean E2 concentrations of normally menstruating girls as therapeutic target. E2, estrone (E1), and E1 sulfate (E1S) were measured by liquid chromatography tandem mass spectrometry and a recombinant cell bioassay; metabolites were measured, and dual-energy x-ray absorptiometry scan and indirect calorimetry were performed. MAIN OUTCOME: Changes in body composition and lipid oxidation were evaluated. RESULTS: E2 concentrations were titrated to normal range in both groups; mean oral dose was 2 mg, and TD dose was 0.1 mg. After 6 and 12 months, fat-free mass and percent fat mass, bone mineral density accrual, lipid oxidation, and resting energy expenditure rates were similar between groups. IGF-1 concentrations were lower on oral 17ß-E2, but suppression of gonadotropins was comparable with no significant changes in lipids, glucose, osteocalcin, or highly sensitive C-reactive protein between groups. However, E1, E1S, SHBG, and bioestrogen concentrations were significantly higher in the oral group. CONCLUSIONS: When E2 concentrations are titrated to the normal range, the route of delivery of 17ß-E2 does not affect differentially body composition, lipid oxidation, and lipid concentrations in hypogonadal girls with TS. However, total estrogen exposure (E1, E1S, and total bioestrogen) is significantly higher after oral 17ß-E2. TD 17ß-E2 results in a more physiological estrogen milieu than oral 17ß-E2 administration in girls with TS.

Sex variability in pediatric leukemia survival: large cohort evidence.

Purpose. Sex disparities in pediatric leukemia have been previously reported, and male children continue to present with poorer survival. However, the observed disparities are not fully understood. This current study sought to examine disparities in survival by the sex, and to determine if tumor prognostic factors impact on these disparities. Patients and Methods. We used the Surveillance Epidemiology and End Results dataset of pediatric leukemia patients (ages 0-19 years) diagnosed in the United States from 1973 to 2006. There were 15,215 patients of whom 8,622 (65.7%) were boys and 6,593 (43.3%) were girls. The Kaplan-Meier survival estimates, log rank test, and Cox proportional hazard methods were used to assess the data. Results. The overall (both sexes) five-year survival rate was 67.9%. Girls had a survival rate of 70.1%, while the rate was 66.3% in boys. Girls had a significant 14% decreased risk of dying relative to boys, hazard ratio (HR) = 0.86, 99% CI = 0.80-0.93. There were significant differences between boys and girls with respect to tumor cell type, race, age at diagnosis, year of diagnosis, and number of primaries, P < 0.001. After controlling for these factors, the sex differences in survival persisted, with girls still less likely to die from leukemia compared to boys, adjusted HR (AHR) = 0.85, 99% CI = 0.72-1.00, P < 0.01. Conclusion. In a large population-based pediatric leukemia study, boys continued to show poorer survival. These disparities were not completely explained by treatment received, tumor prognostic or socio-demographic factors.

Burn injury in Bangladesh: electrical injury a major contributor.

Electrical injury is a major cause of burn injury and significant cause of mortality, morbidity and disability. To explore the proportional incidence of thermal and electrical burn injuries in Bangladesh, a population-based cross sectional survey was conducted between January and December 2003. Nationally representative data was collected from 171,366 rural and urban households, comprising of a total population of 819,429.The study was designed to describe the proportional incidence of thermal, electrical and chemical cause of burn in Bangladesh. Electrical injury constituted about one third of the total burn injuries. Among the total 1,999 injuries about 31% were due to electrical injuries, about 26% were due to flame, about 25% were due to hot liquid, over 16% by hot object, about 2% by chemical and less than 1% were due to explosives. The incidence of death rate was 3.97 per 100,000 populations per year. Thermal burn was found as the major cause of death due to burn injures and constituted 58% of the total deaths due to burn. Electrical injuries caused 42% of the deaths. It was estimated that more than 5,600 people die due to burn and electrical injuries every year in Bangladesh considering the incidence rate of 3.97 per 100,000 populations per year in the 150 million population. Electrical injury including lightning constitute about one third of the burn related mortality, morbidity and disabilities. Rural people and children are the more vulnerable group. Electrical injury needs to be included as a special component in a burn prevention strategy, particularly in rural Bangladesh.

A hot, swollen joint in a cirrhotic patient.

Septic arthritis in the elderly carries a high mortality. Underlying risk factors, such as diabetes, malignancy, chronic renal failure, rheumatoid arthritis, hepatobiliary disease and AIDS, should be assessed. Rare causative organisms are occasionally encountered. Here, we describe a case of an 80-year-old diabetic patient with liver cirrhosis who developed Klebsiella pneumoniae septic arthritis, which is a rare cause of joint infection. We postulate that this case supports the notion that the patient's knee effusion seeded during a primary K pneumoniae bacteraemia of intestinal origin and related to liver cirrhosis.

Vascular surgery is an unattractive career option for current basic surgical trainees: a regional perspective.

INTRODUCTION: The workload of vascular services will substantially increase in the foreseeable future with the recent changes in surgical training presenting a challenge to training and recruitment in vascular surgery. This study aimed to determine the current feelings towards vascular surgery as a career choice from basic surgical trainees (BSTs) within a single region. MATERIALS AND METHODS: BSTs from a single region were questioned. Probable career specialty choice was ascertained, as were suggestions for changes to the career pathway of a vascular surgeon to make it a more attractive career choice. RESULTS: Seventy-seven of 110 BSTs returned the questionnaire. Of the 77, 52 had previous experience of a vascular firm. Ten BSTs had been on a pure vascular firm as an SHO and 52 had been on a general surgical firm. No BST specified vascular surgery as their ultimate career choice. Career choices included general surgery (n = 30), orthopaedics (n = 17), plastic surgery (n = 9) and urology (n = 5). Thirty-three BSTs would not be tempted at all to a career in vascular surgery. Changes in the career structure that would result in BSTs contemplating a career in vascular surgery included the inclusion of endovascular surgery (n = 13), no compulsion to undertake a period of research (n = 5), pure vascular training (n = 2), more general surgical training (n = 2) and less onerous on-calls when older (n = 2). CONCLUSIONS: The lack of trainees wishing to become vascular surgeons is of grave concern. Increasing the endovascular capabilities of vascular surgeons as well as altering the stance on research may have an increasingly positive role in recruitment.

The effect of addressing demand for as well as supply of emergency obstetric care in Dinajpur, Bangladesh.

PURPOSE: The Dinajpur SafeMother Initiative (DSI) was designed to test the impact of several interventions on use of obstetric services in government health facilities in Northwestern Bangladesh during 1998-2001. INTERVENTION: Facility-based interventions included upgrading health facilities. The sub-district hospitals or Upazila Health Centers (UHCs) had earlier been upgraded to provide basic emergency obstetric care (BEmOC). This project undertook activities designed to improved the quality of care in the facilities which included team-building among providers, case reviews and a stakeholders' committee. CARE introduced a community mobilization intervention, which included birth planning, community support systems for funding, transportation, blood donation etc. for care of women with complications. METHODS: The intervention area received all interventions. The only intervention in the comparison area was the upgrading of the health facilities to provide basic EmOC. There were no interventions in the control area. RESULTS: Met need increased by 13% in comparison area but nearly 24% in intervention area. There was no substantial change in the control area. At the end of the project, knowledge of obstetric danger signs was much greater in intervention area than in the other 2 areas. CONCLUSION: We conclude, therefore, that the best results are achieved through a combination of facility improvement, quality of care activities and targeted community mobilization activities.

Use of the CRABEL Score for improving surgical case-note quality.

INTRODUCTION: Quality assurance of medical record keeping in general surgery is facilitated by use of the CRABEL Score. Critical appraisal and constant feedback to staff plays an important part in improving case-note quality. MATERIALS AND METHODS: For each case-note audit, a house officer reviewed two sets of case notes for each of six consultant surgeons. Scores were awarded according to initial clerking, subsequent entries, consent, and discharge summary. Overall scores were derived by subtracting deductions for omissions in each category from a starting score of 100. A larger number of points deducted due to absent data leads to a lower overall score and indicates poorer quality case notes. After four audits, a clerking proforma specifically designed to address some of the common areas of weakness identified in our record keeping was introduced and a further audit was performed in March 2004 to assess its impact. RESULTS: The mean score was lowest in the September 2001 audit and improved over the next two audits. However, there was a small reduction in September 2003 compared to September 2002. When the individual sections of the score were looked at separately, the greatest contribution to a poor score comes from the 'subsequent entries' section since there are five entries scored individually leading to a cumulative effect on the overall score. Within both the 'initial clerking' and 'subsequent entries' sections, early audits showed poor performance across a range of areas but consistent poor implementation of the guidelines was seen in a small number of specific areas as record keeping improved. The quality of medical notes improved over the first three cycles but the improvement was not maintained subsequently. DISCUSSION: The CRABEL score has been shown to be a useful, reproducible and easy-to-perform objective assessment of the quality of medical record keeping. Repeated audit cycles have ensured that case-note quality remains a high priority and have also led to the development of standardised admission documentation. Introduction of the latter has led to a measurable improvement in medical record keeping.

Axillary artery transection following anterior shoulder dislocation: classical presentation and current concepts.

Injury to the axillary artery following anterior shoulder dislocation is a very rare occurrence. This review serves to illustrate the now classical case of an elderly gentleman with a recurrent dislocation, transection of the axillary artery and its invariable association with a severe brachial plexus lesion, which is the most important determinant of long-term disability. It also highlights the pathognomic triad of anterior shoulder dislocation, expanding axillary haematoma and diminished peripheral pulse, to highlight awareness of this important injury. The literature on this injury has been reviewed and recommendations for the immediate and early post-operative investigation and management have been brought up to date in line with current thinking.

A case report on Klinefelter syndrome.

An 18 year old boy presented with small genitalia, failure of eruption of secondary sex hairs, female like voice with eunachoid body habitus, bilateral gynecomastia, infantile external genitalia, small testes and poorly developed musculature. He was diagnosed as a case of 47XXY Klinefelter syndrome on the basis of hormone assay and karyotyping. He has given androgen replacement therapy with the aim to relieve symptoms of androgen deficiency, to reproduce physiological levels of plasma testosterone and to prevent long term consequences of androgen deficiency.

Audit of rabies post-exposure prophylaxis in England and Wales in 1990 and 2000.

The objectives were to compare rabies post-exposure prophylaxis issued by the Public Health Laboratory Service (PHLS) in 1990 and in 2000, to evaluate their appropriateness, and to make recommendations for future issue of rabies post-exposure prophylaxis in England and Wales. The method was to review all rabies vaccine and immunoglobulin issues by PHLS in 1990 and 2000 with evaluation against Department of Health recommendations. The PHLS issued prophylaxis to 656 people in 1990 and 295 people in 2000. The fall is attributable to control measures in Western Europe leading to a lower risk of exposure in countries in the region. Vaccine was still issued for exposures in countries with a category of 'no risk' (15 individuals) including rabies immunoglobulin in six cases. Immunoglobulin was frequently not issued for exposures in high-risk countries but the reasons were not always evident from the information provided; in many cases treatment had probably been started abroad. Delay before contacting the PHLS fell between 1990 and 2000 (p = 0.003). Dogs continue to be the most common animal exposure reported, and their rabies status is generally unknown. The most frequent site of bite was the leg. Prophylaxis was issued for exposure to some animals which have never been known to transmit rabies. Successful control measures in Europe have reduced the need for rabies prophylaxis in UK residents who travel abroad. More detailed information should be collected in future on aspects such as pre-exposure vaccination and treatment started abroad to facilitate future audit of appropriateness of treatment. A repeat audit should be carried out to evaluate the impact of a death from European Bat Lyssavirus 2 infection in a UK bat handler in November 2002.

Tuberous sclerosis.

Tuberous sclerosis - also called tuberous sclerosis complex (TSC) - is a rare, multi-system genetic disorder affecting cellular differentiation & proliferation, which results in hamartoma formation in many organs. The classic triad of clinical features comprises mental retardation, epilepsy & skin lesion, but these three features are not always present. Mrs. Jahanara Khatun, a 30 years old lady presented with maculo-papular skin lesions over the face, neck, shoulder since her six years of age, a lump in the right lumber region for four years, pain in the right lumber region associated with passage of blood clot in urine for 15 days. Her family history was very characteristic. One of her elder brother had developed same type of skin lesions. Again her 13 years old daughter had developed same type of skin lesions since seven years of age & she was mentally retarded. Clinical examination revealed normal mentation, pin head sized yellowish red translucent discrete waxy papules situated in the face, neck, shoulder. A large tender firm irregular mass in the right lumber region, which was ballotable & moved with respiration. USG revealed bilateral retroperitoneal masses with the involvement of right kidney & formation of renal artery aneurysm. The patient undergone right sided nephrectomy & histopathology of the specimen showed features suggestive of renal angiomyolipoma. The patient was diagnosed as a case of definite tuberous sclerosis complex as she had two major feature of revised diagnostic criteria - facial angiofibromas & renal angiomyolipoma.

Underlying sleep pathology may cause chronic high fatigue in shift-workers.

About 20-25% of the population in primary healthcare settings complains of chronic fatigue but this symptom has been under-emphasized compared with sleepiness in clinical practice. Shift-workers are particularly vulnerable because of various fatigue-related personal and public morbidity and mortality. The goal of this cross-sectional study was to explore if fatigue severity could be used as an independent predictive tool to identify underlying sleep pathology. The 21 most-fatigued (study group) and 23 least-fatigued (control) miners were selected on the basis of the Fatigue Severity Scale (FSS), which was administered to 195 subjects in an underground mine in Timmins, a town in northern Ontario. The two groups were matched for age, gender, and body mass index (BMI). Mean FSS score for the most-fatigued subjects was 4.9 +/- 0.5 and the least-fatigued was 2.2 +/- 0.5 (P < 0.0001). The subjects from each group were studied polysomnographically to identify sleep disorders. The polysomnographic data in 15 of 21 (71.4%) of the most-fatigued subjects displayed significant sleep pathology compared with only three of 23 (13.0%) in the least-fatigued subjects. Based on Fisher's exact test, the difference between the two groups was highly significant (P < 0.0001). Also, in the total subject pool (n = 195), the correlation between subjective fatigue and sleepiness was not very strong (Pearson's r = 0.45), suggesting that these two symptoms can be independent phenomena. It is concluded that chronic high fatigue can be an independent manifestation of underlying sleep pathology, which warrants independent subjective and objective assessment.

Malabsorption in the elderly. 1: Examination, history and investigation.

Malabsorption in elderly patients has varied presentations, and can be overlooked. A high index of clinical suspicion is required. This, the first of two articles, discusses the principal causes, clinical features and initial investigations of malabsorption in the elderly.

Malabsorption in the elderly. II: Treatment and further investigations.

After the initial assessment of elderly patients suspected of having malabsorption, as discussed in the first of this pair of articles, more specific investigations may be necessary. These are described in this article, together with the main treatment options that are available.