Evaluation of Xpert MTB/RIF Ultra for the Diagnosis of Extrapulmonary Tuberculosis: A Retrospective Analysis in Saudi Arabia.

The incidence of extrapulmonary tuberculosis (EPTB) in low- and middle-income countries, as well as, high-income countries has increased over the last two decades. The acid-fast bacillus (AFB) smear test is easy to perform and cost-effective with a quick turnaround time but the test has low sensitivity. Culture remains the gold standard for detecting TB; however, it has low sensitivity and slow bacterial growth patterns, as it may take up to 6 to 8 weeks to grow. Therefore, a rapid detection tool is crucial for the early initiation of treatment and ensuring an improved therapeutic outcome. Here, the Xpert Ultra system was developed as a nucleic acid amplification technique to accelerate the detection of MTB in paucibacillary clinical samples and endorsed by the World Health Organization. From March 2020 to August 2021, Xpert Ultra was evaluated for its sensitivity and specificity against EPTB and compared with those of the routinely used Xpert, culture, and AFB tests in 845 clinical samples in Saudi Arabia. The results indicate the overall sensitivity and specificity of Xpert Ultra to be 91% and 95%, respectively, compared with the Xpert (82% and 99%, respectively) and AFB smear (18% and 100%, respectively) tests. The results also indicated that despite the low microbial loads that were categorized as trace, very low, or low on Xpert Ultra, yet, complete detection was achieved with some sample types (i.e., 100% detection). Consequently, Xpert Ultra has great potential to replace conventional diagnostic approaches as a standard detection method for EPTB.

The diagnostic impact of implementing a molecular-based algorithm to standard mycobacterial screening at a reference laboratory with an intermediate prevalence for non-respiratory samples.

Rapid, reliable results can be given by molecular, direct detection and identification of the Mycobacterium tuberculosis (MTB/Mtb) complex from clinical samples. The Xpert MTB/RIF assay is an assay that has been availablefor more than a decade for identification of Mycobacterium tuberculosis and resistance to rifampicin. However, there is minimal evidence on its clinical usefulness in paucibacillary, non-respiratory samples. The Xpert MTB/RIF assay clinical utility index, its diagnostic characteristics and the number required to diagnose 2935 non-respiratory specimens submitted for routine mycobacterial work-up in a reference laboratory in an intermediate prevalence setting per specimen form were evaluated. The Xpert MTB/RIF assay showed a variable clinical utility index and number required to diagnose (NND) depending on the type of specimen, which was moderate in tissue biopsies (NND = 1.8) and excellent in pus and urine samples, compared to acid-fast microscopy and culture as a gold standard technique (NND = 1.1 and 1.2). Microscopy, on the other hand, consistently showed a weak to fair index of clinical usefulness in all specimen forms, with in NND of 2.3-12.5. The NND for detecting tuberculous infection in the cerebrospinal fluid by the Xpert MTB/RIF assay was noted to be 1.2, with a moderate clinical utility index of 0.8. The evidence presented indicates that the overall appropriate diagnostic utility of the Xpert MTB/RIF assay is clinically successful in most non-respiratory samples. To check the cost-effectiveness and prognostic effect of integrating this completely automated molecular-based assay into the routine testing algorithm for non-respiratory mycobacterial specimens, further data must be collected.

The VITOM® exoscope in oculoplastic surgery: the 5 year Coventry experience.

BACKGROUND: Intraoperative imaging is a desirable tool in oculoplastic surgery; however, there are few modalities which allow surgeons to capture and edit the images in real time without compromising the sterility of the surgical field. We describe the set-up of the VITOM® exoscope system based on our 5 years' experience of using it as an effective intraoperative video imaging and teaching modality for extraocular surgery. METHODS: The VITOM® is a specially designed exoscope mounted onto a versatile mechanical arm. It is attached to a high definition (HD) digital camera displayed on the HD video monitor of a standard endoscopy stack. This technology has been utilised in other surgical subspecialties, but there is no documented use within extraocular surgery. RESULTS: The exoscope was simple to set-up and allowed real-time recording and editing with an HD image display system. The theatre team were able to view the precise surgical steps, contributing to improved theatre flow. Trainees reported that the VITOM® images significantly improved their visualisation and understanding of key surgical anatomy and steps. CONCLUSIONS: Our experience showed that the VITOM® exoscope is an excellent intraoperative video imaging and teaching aid, as it allows real-time capture and editing of open surgery and seems to improve theatre flow. With newer models using 3D stereoscopic vision, it could be further evaluated as a heads-up viewing system within extraocular and oculoplastic surgery.

The enlarged extraocular muscle: to relax, reflect or refer?

PurposeExtraocular muscle enlargement (EOME) is most commonly associated with thyroid eye disease, but there are other causes. We report our outcomes of investigating and managing non-thyroid-related EOME (NTR-EOME).MethodsRetrospective consecutive case series. Sixteen patients identified by clinical features and orbital imaging. Patient demographics, radiological features, and adjuvant tests including biopsy and final diagnosis were recorded.ResultsMean age at presentation 59.3 years (range 24-89 years). Mean follow-up 3.2 years (range 3 months to 5.5 years). Superior rectus (SR) was most commonly involved muscle (8/16 cases) followed by lateral rectus (4/16). Of the 16 cases, 14 were associated with underlying systemic neoplasia (5 lymphoma, 5 metastatic carcinoma, and 4 presumed paraneoplastic syndrome). All SR enlargement was associated with underlying neoplasia. All patients underwent orbital imaging followed by systemic imaging based on clinical index of suspicion (14/16 patients (13 full body CT (FBCT), 1 mammography)). Positive systemic radiological findings were detected in 12/14 cases. Of the remaining 2 patients, 1 underwent full body positron emission tomography-computed tomography (FBPET-CT), which detected thyroid carcinoma, and the second patient underwent FBCT for staging following orbital biopsy showing lymphoma. Four patients (25%) died within 3 years of follow-up due to disseminated systemic malignancy.ConclusionsAll cases of NTR-EOME should be viewed with a high level of clinical suspicion for systemic neoplasia, especially when the SR is involved. FBCT can help to identify a primary systemic cause. FBPET-CT is best reserved for cases negative on FBCT or for staging and monitoring systemic disease. NTR-EOME can be associated with significant mortality (25%), hence warrants prompt and thorough systemic investigation.

Potential of carboxymethyl cellulose coating and low dose gamma irradiation to maintain storage quality, inhibit fungal growth and extend shelf-life of cherry fruit.

Carboxymethyl cellulose (CMC) coatings alone and in combination with gamma irradiation was tested for maintaining the storage quality, inhibiting fungal incidence and extending shelf-life of cherry fruit. Two commercial cherry varieties viz. Misri and Double after harvest at commercial maturity were coated with CMC at levels 0.5-1.0 % w/v and gamma irradiated at 1.2 kGy. The treated fruit including control was stored under ambient (temperature 25 ± 2 °C, RH 70 %) and refrigerated (temperature 3 ± 1 °C, RH 80 %) conditions for evaluation of various physico-chemical parameters. Fruits were evaluated after every 3 and 7 days under ambient and refrigerated conditions. CMC coating alone at levels 0.5 and 0.75 % w/v was not found effective with respect to mold growth inhibition under either of the two conditions. Individual treatment of CMC coating at 1.0 % w/v and 1.2 kGy irradiation proved helpful in delaying the onset of mold growth up to 5 and 8 days of ambient storage. During post-refrigerated storage at 25 ± 2 °C, RH 70 %, irradiation alone at 1.2 kGy gave further 4 days extension in shelf-life of cherry varieties following 28 days of refrigeration. All combinatory treatments of CMC coating and irradiation proved beneficial in maintaining the storage quality as well as delaying the decaying of cherry fruit during post-refrigerated storage at 25 ± 2 °C, RH 70 % but, combination of CMC at 1.0 % w/v and 1.2 kGy irradiation was found significantly (p ≤ 0.05) superior to all other treatments in maintaining the storage quality and delaying the decaying of cherry fruit. The above combinatory treatment besides maintaining storage quality resulted in extension of 6 days in shelf life of cherry varieties during post-refrigerated storage at 25 ± 2 °C, RH 80 % following 28 days of refrigeration. Above Combination treatment gave a maximum of 2.3 and 1.5 log reduction in yeast and mold count of cherry fruits after 9 and 28 days of ambient and refrigerated storage, thereby ensuring consumer safety.

Production and characterization of novel self-assembling biosurfactants from Aspergillus flavus.

AIM: This work was conducted to produce, purify and characterize biosurfactants from Aspergillus flavus AF612 isolated from citrus fruit. METHODS AND RESULTS: Biosurfactant named 'Uzmaq' was isolated from A. flavus AF612. The chemical characterization of the biosurfactant was conducted. Biosurfactant Uzmaq produced by A. flavus, was composed of methoxy phenyl oxime glycosides. Two molecular forms of the biosurfactant, Uzmaq-A and Uzmaq-B were isolated. Biological properties (antifungal activity) were evaluated. The fractions of the biosurfactant were isolated and their surface properties were analysed. Uzmaq-A and Uzmaq-B had critical micelle concentration (CMC) around 170 and 80 mg l(-1) , and lowered surface tension of water up to 20 and 25 m Nm(-1) respectively. The biosurfactants were stable at pH 3-12 and temperature up to 80°C. Growth and biosurfactant production kinetics were also analysed. CONCLUSION: Novel biosurfactant Uzmaq was produced from A. flavus, which was composed of methoxy phenyl oxime glycosides. The surface activity of Uzmaq was better than the maximum values of synthetic chemical surfactants. The biosurfactant showed antifungal activity and self-assembling properties. SIGNIFICANCE AND IMPACT OF THE STUDY: Aspergillus flavus AF612 can be used for commercial production of Uzmaq that may be employed for controlled drug release applications and bioremediation.

Upper lid entropion post ptosis correction: is tarsal buckling the cause?

PURPOSE: To report two cases of the rare complication of entropion following involutional ptosis surgery and its successful management. METHODS: Clinical findings and management of the patients are presented. RESULTS: Case 1: An 89-year-old female underwent aponeurosis advancement surgery for left involutional ptosis. Post-operatively she achieved good lid height, but had developed entropion of the upper lid which resulted in a persistent corneal epithelial defect. The patient underwent repeat surgery during which the aponeurosis was found to be inserted into the lower part of middle one third of tarsus with the tarsus itself being extremely thin. The aponeurosis was reinserted into upper third of tarsus, followed by greyline split with anterior lamellar repositioning. Post-operatively the patient achieved good lid height with correction of the entropion.Case 2: A 70-year-old male who had previously undergone bilateral brow lift and ptosis correction two years ago, was referred with right upper lid entropion. During surgery the aponeurosis was found to be inserted into the lower part of middle one third of tarsus, with a very thin tarsus. This patient was also managed by reinserting aponeurosis into upper third of tarsus with grey line split and anterior lamellar repositioning following which he achieved good lid height and correction of the entropion. COMMENT: Entropion has rarely been reported as a complication of ptosis surgery. This case series highlights the importance of taking special care when advancing the aponeurosis, in cases where the tarsus is thin, as it may result in vertical buckling of the tarsus.

Effect of rituximab on peripheral blood stem cell mobilization and engraftment kinetics in non-Hodgkin's lymphoma patients.

Rituximab is used for in vivo tumor cell purging for non-Hodgkin's lymphoma (NHL) patients prior to autologous peripheral blood stem cell transplantation (PBSCT). However, its effects on PBSC mobilization and function are poorly understood. We compared the mobilization characteristics and engraftment kinetics of 13 NHL patients receiving and 34 NHL patients not receiving rituximab 6 months before PBSC mobilization. In the rituximab group, there was a significantly longer time to neutrophil engraftment (P=0.0466), a trend toward the need for BM harvest to supplement low-yield PBSC collections (31 vs 9%, P=0.08) and a significantly increased rate of bacteremia episodes (62 vs 26%, P=0.025). Median progression-free survival (PFS) and overall survival (OS) were significantly longer in the rituximab compared to the nonrituximab patients (P=0.049 and 0.042, respectively). However, patients in the nonrituximab group were at high risk for recurrence and expected to have shorter survival. Rituximab used within 6 months prior to collection may have a detrimental effect on PBSC mobilization and engraftment. However, rituximab is a major therapeutic breakthrough for NHL treatment and this negative effect may be offset by improved survival. Further studies are warranted in larger populations to determine the impact of rituximab on engraftment, PFS and OS.