Diagnostic Investigations Research Articles

Norwegian society of rheumatology recommendations on diagnosis and treatment of patients with Polymyalgia Rheumatica: a narrative review

BackgroundTo provide evidence-based, up-to-date recommendations for physicians in primary and specialist healthcare setting in diagnosing and treating patients with polymyalgia rheumatica (PMR).MethodsThe PMR working group conducted a narrative review of the available evidence in the field and wrote the draft guidelines. These guidelines were discussed and revised according to the standard operating procedures within the Norwegian Society of Rheumatology. The European Alliance of Associations for Rheumatology (EULAR) and American College of Rheumatology (ACR) recommendations for the management of PMR, the British Society for Rheumatology (BSR) guidelines for the management for PMR, the treat-to-target recommendations in giant cell arteritis and PMR and the 2023 recommendations for early referral of individuals with suspected polymyalgia rheumatica were used in particular for purpose of harmonization.ResultsA total of 10 recommendations have been formulated covering initial diagnostic investigations, comorbidity assessment, imaging, specialist referral criteria, treatment involving glucocorticoids and steroid-sparing agents and follow-up care.ConclusionNorwegian recommendations for diagnostics and treatment to improve management and outcome in patients with PMR were developed.

OA24 Extended oligoarthritis with proximal muscle weakness and antinuclear antibody positivity associated with a novel genetic variant of uncertain significance in lipopolysaccharide-responsive and beige-like anchor protein (LRBA) gene

Abstract Introduction LRBA deficiency is associated with recurrent infections and immune dysregulation, particularly autoimmune cytopenias, enteropathy and intestitial lung disease, and in a few cases chronic polyarthritis and uveitis. Case description A girl presented at three years old with history of not walking for two months with no history of trauma or fever. Examination revealed arthritis in her ankles and knees. Ultrasound showed synovial thickening in both knees and small effusion to hips. There was no evidence of uveitis at presentation. Her bloods showed raised C-Reactive Protein (CRP) 33 mg/L and Erythrocyte Sedimentation rate (ESR) 45 mm/h. Anti-nuclear and anti-centromere antibodies were positive. Diagnosis was made of oligoarticular JIA and she was treated with intra-articular steroids in both knees and ankles and was started on oral prednisolone, weekly oral methotrexate. On subsequent clinic review, she had started to walk with mild restriction to internal rotation of hips and difficulty in getting up from sitting. She was started on regular hydrotherapy, physiotherapy and occupational therapy. From five to 11 years old, she had four flares of uveitis, treated with prednisolone eye drops; and two flares of arthritis, treated with steroids. Her methotrexate was changed to subcutaneous and at eight years of age she was also started on subcutaneous adalimumab fortnightly. Due to prolonged proximal muscle weakness, abnormal gait and chronic pain in leg joints without clinical or radiological evidence of synovitis during clinic reviews, she underwent thorough neurological work up which was inconclusive for myopathies. Her creatinine kinase levels, thyroid profile, MRI brain and spine were normal. Genetic work up showed two variants in the LRBA gene, one pathogenic and the other was variant of uncertain significance (VUS). Her CTLA4 expression was normal by flow cytometry. Discussion Three case reports have previously associated homozygous LRBA deficiency with polyarthritis. Compound heterozygous LRBA deficiency may present with various phenotypes including autoimmune disease affecting multiple organs, immune cytopenia and immune dysregulations including CTLA-4 expression. This report potentially widens the clinical spectrum of LRBA deficiency and given that it is a novel variant, prompts us to screen for this gene mutation in patients with JIA where remission is challenging and there is a need for continuous immunosuppressive or immune-modulatory therapy. Three case reports have previously associated homozygous LRBA deficiency with polyarthritis. Compound heterozygous LRBA deficiency may present with various phenotypes including autoimmune disease affecting multiple organs, immune cytopenia and immune dysregulations including CTLA-4 expression. This report potentially widens the clinical spectrum of LRBA deficiency and given that it is a novel variant, prompts us to screen for this gene mutation in patients with JIA where remission is challenging and there is a need for continuous immunosuppressive or immune-modulatory therapy. Three case reports have previously associated homozygous LRBA deficiency with polyarthritis. Compound heterozygous LRBA deficiency may present with various phenotypes including autoimmune disease affecting multiple organs, immune cytopenia and immune dysregulations including CTLA-4 expression. This report potentially widens the clinical spectrum of LRBA deficiency and given that it is a novel variant, prompts us to screen for this gene mutation in patients with JIA where remission is challenging and there is a need for continuous immunosuppressive or immune-modulatory therapy. Key learning points • There is no single diagnostic investigation for JIA as the aetiology is complex and there are currently no specific clinical guidelines of when to consider genetic testing in patients with JIA. With the mainstreaming of genetic services and improved access to cheaper, advanced next-generation sequencing, we should consider looking into monogenic conditions that mimic JIA. • The case illustrates the challenges of determining whether VUS are pathogenic in causing arthritis, or just incidental findings. Compound heterozygous LRBA may present within a spectrum of clinical features, further analysis with CTLA4 expression by flow cytometry and genetic analysis of siblings and parents will be helpful. • Compound heterozygous LRBA variation has different clinical manifestation which needs personalised treatment. Treatment with abatacept (a soluble CTLA4 immunoglobulin fusion protein) which is reported in a case series of LRBA deficiency. Risks of continuous immunosuppressive treatment need to be balanced with more definitive hematopoietic stem cell transplantation (HSCT) previously used to achieved complete remission in LRBA deficiency.

Long-term outcomes and prognostic factors in dogs with meningoencephalitis of unknown origin and suspected necrotic lesions on magnetic resonance imaging: 37 cases (2007-2020).

To describe the long-term outcomes, overall survival, progression-free survival, and prognostic factors in dogs with necrotizing encephalitis (NE). 37 client-owned dogs clinically diagnosed with NE. All dogs underwent MRI and CSF analysis. Cox proportional hazards regression was used to examine factors related to the risk of relapse and death, including signalment, history, diagnostic investigation results, and treatments before the first relapse. The medians of the overall and progression-free survival times were 639 days (IQR, 342 to 1,482 days) and 233 days (IQR, 111 to 775 days), respectively. Overall survival was highly correlated with progression-free survival. Four dogs (11%) died or were euthanized within 3 months of diagnosis. Relapse within 6 months was associated with a shorter overall survival. However, no prognostic factors for overall survival were found. The category of patients with presenting clinical signs that lasted 29 days to 6 months (OR, 3.26; 95% CI, 1.35 to 7.90) was associated with a higher risk of relapse. Seizures were presented in 75.7% of dogs, with a recurrence rate of 100%. This report provides comprehensive follow-up information for dogs with NE, revealing a fair prognosis and low early mortality rate. Seizure is a very common clinical sign with a high recurrence rate.

Effectiveness of paediatric asthma hubs: a clinical pilot study

BackgroundChildren and young people (CYP) with asthma in the UK are at higher risk of poor outcomes compared with other high-income European countries due to factors including poor access to high-quality asthma reviews, diagnostic testing and inconsistent postattack reviews. The Leicester Integrated Care Board funded the first UK pilot asthma hub for CYP, to investigate the feasibility and effectiveness of hubs, in providing postattack reviews along with providing asthma education, the opportunity to carry out diagnostic lung function tests and optimise treatment.MethodsClinical pilot study including CYP aged 4–17 years referred to the hub with uncontrolled asthma or postattack from November 2021 to April 2022. CYP received a structured clinical assessment including National Institute for Health and Care Excellence (NICE) first-line diagnostic investigations for asthma including spirometry, bronchodilator reversibility (BDR) and fraction of exhaled nitric oxide (FeNO).ResultsOf 312 CYP referred (mean age 8.6±3.2 years; 42% women), 266 (85.3%) attended their appointment. Median time from referral to review was 2 days (IQR 1–3). Three CYP (1.1%) were severely unwell at review and required further hospital treatment. In the 231 CYP who completed first-line tests, asthma was confirmed for 73 (31.6%) based on NICE diagnostic criteria for CYP. Twenty-two per cent of children with normal baseline spirometry had ≥12% BDR.ConclusionPaediatric asthma hubs are a feasible model of care to deliver CYP postasthma attack reviews and identify high-risk patients requiring further treatment. Spirometry, BDR and FeNO testing allowed diagnostic confirmation in a significant proportion of CYP.

MÚLTIPLOS ABSCESSOS ESPLÊNICOS EM PACIENTE COM CIRROSE HEPÁTICA NO AMAZONAS

A 38-year-old male patient with a diagnosis of liver cirrhosis for 5 years, irregularly treated with lactulose and furosemide, presented with fever, confusion, fatigue, jaundice, and ventilator-dependent pleuritic pain when seeking medical attention. Upon examination, he was lucid but exhibited slowed thinking, a sleep-wake cycle inversion, and flapping. The physical examination revealed edema in the lower limbs, jaundice, and pain in the left subcostal region. Due to the presence of decompensated cirrhosis, monitoring and diagnostic investigation for possible etiologies were initiated. Laboratory tests, ECG, chest X-ray, and echocardiogram were performed. A computed tomography (CT) scan revealed splenomegaly with regular contours and heterogeneous attenuation coefficients, showing hypodense, non-enhancing collections occupying the entire upper half, as well as a left pleural effusion and signs of chronic liver disease and portal hypertension. A transverse incision was made, revealing splenomegaly with the presence of thick fluid collections in the upper pole of the spleen, consistent with a diagnosis of splenic abscess. The patient progressed to hypovolemic shock and underwent reoperation after 72 hours for active bleeding control. Ciprofloxacin and clindamycin were administered for 28 days. The patient improved well after discharge from the ICU, with clinical and laboratory improvement. Follow-up was conducted with amoxicillin 250 mg for two years, and he continues outpatient follow-up with a gastroenterologist. Splenic abscess (SA) usually arises from endocarditis or other forms of hematogenous transmission, such as pneumonias, gastrointestinal perforations, or arteriovenous malformations. Although not always present, risk factors for the development of endocarditis include immunosuppression, diabetes mellitus, trauma, or microorganisms. Diagnosis is based on clinical findings and imaging studies (ultrasound and CT). Treatment depends on the number, size, and location of the abscesses. Antibiotic therapy can drastically reduce mortality associated with this condition, and percutaneous drainage has been successful. However, in some cases, splenectomy is necessary. Splenic abscess is a rare condition, and its early diagnosis requires a high degree of suspicion, and there is still no best approach for treatment.

Relative contribution of imaging techniques for the contemporary diagnosis of infective endocarditis: a single-center experience

Abstract Introduction In developed countries, the incidence of infective endocarditis (IE) is up to 6 cases per 100,000 individuals and in-hospital mortality rates are reported to reach 30%. The diagnostic recommendations for IE have been revised in the new ESC guidelines emphasizing the use of transesophageal echocardiography (TEE) and advanced imaging techniques (computed tomography [CT], magnetic resonance [MR], positron emission tomography [PET] and white blood cell scintigraphy [WBC-SPECT]). Aims This research aims to investigate the practical applicability of established clinical guidelines in a real-world population with suspected IE. Methods We reviewed the hospital database from 06/2021 to 06/2023 using the international classification of disease codification (ICD-10) for IE. Only patients admitted to Cardiology or Cardiac Surgery departments were included. Diagnosis of IE was defined according to the modified Duke criteria. Firstly, we identified individuals in whom diagnosis was performed by clinical presentation, blood cultures and transthoracic echocardiogram (TTE). Subsequently, we identified those who required further imaging diagnostic investigation. Results A total of 63 patients were included [mean age 64 ±14 years; 76% male (n=48)]. Native IE was diagnosed in 53 (84%) patients, prosthetic IE in 7 (11%) and cardiac implantable electronic devices-related IE in 3 (5%). A total of 26 (41%) patients had at least one predisposing risk factor, 48 (76%) presented with fever, 24 (38%) suffered an embolic event and 1 (2%) had an immunological phenomenon. Out of 49 positive blood cultures (78%), typical microorganisms consistent with IE were isolated in 25 (78%) of samples: 13 (34%) staphylococcus aureus, 10 (26%) oral streptococci, 9 (24%) enterococcus faecalis, 5 (13%) streptococcus gallolyticus and 1 (3%) HACEK group. Overall, in 22 (34%) patients, a definitive diagnosis of IE was established by means of clinical presentation, blood cultures and TTE. In the remaining, TEE was performed in 86% (n=36). Of those, a definite diagnosis was established in 52% (n=22). Brain and whole-body imaging upgraded the diagnosis from possible to definite in 3 (5%) patients. In the one patient in which a comprehensive clinical evaluation including TTE and TEE rejected IE, the diagnosis was ultimately established by means of PET. The median time from admission to the definite/possible diagnosis of IE was 6 (IQR 2-17) days. A total of 47 (75%) patients underwent surgery, with the most frequent indications being heart failure 46% (n=21) and uncontrolled infection 28% (n=13). Time from diagnosis to surgery was 10 (2-19) days, hospital length of stay was 45 (35-70) days and in-hospital mortality 21%. Conclusion Clinical presentation, blood cultures and TTE plus TEE established the definite or possible diagnosis of IE in most patients with suspected IE. Advanced imaging techniques allowed the establishment of definite diagnosis in only 6% of patients.

Osteosarcoma with Pathological Fracture: A Rare Case Report

Introduction: Osteosarcoma is a primary malignant bone tumor originating from stem cells and is characterized by the proliferation of tumor cells that directly form immature bone or bone-like tissue. Osteosarcoma represents only 3% to 5% of all spinal malignancies. The aim of study is to discuss the importance of diagnostic investigation for a relatively rare case of spinal osteosarcoma. Case presentation: A 49 years old female came to the Emergency Unit, with a chief complaint of bilateral weakness of lower extremities for 1 year and worsening in 2 weeks. Upon examination, the initial diagnosis was mistaken for a spinal canal stenosis because metastatic bone disease from previous history of malignant melanoma. Subsequently, a decompression with stabilization fusion and biopsy is performed. Primary osteosarcoma was confirmed from histopathology results. Further chemotherapy is planned referring to confirmed primary osteosarcoma on histopathology. Discussion: Spinal osteosarcoma is very rare. Osteosarcoma occurs most frequently in the appendicular skeleton, especially the distal femur and proximal tibial metaphysis, which account for 90% of all cases. Primary osteosarcomas of the vertebral column are uncommon and occur dominantly in the vertebral body. Biopsy remains the gold standard of care for diagnosis. Conclusion: The performance of MRI and pathologic evaluation with immunohistochemistry is particularly important for the differential diagnosis of soft tissue tumors. Histopathologic analysis also plays an important role in differentiating from metastatic bone disease. An aggressive treatment plan and long-term follow-up are mandatory in managing this case. Keywords: osteosarcoma, spinal osteosarcoma, spinal canal stenosis, malignancy, pathological fracture, rare case.

Clinical Characteristics and Outcomes in Tracheobronchopathia Osteochondroplastica: A Scoping Review

Background and Objective: Tracheobronchopathia osteochondroplastica (TBOCP) is a rare, benign condition characterised by the presence of multiple bony and cartilaginous nodules in the tracheal and bronchial submucosa. Its etiology remains unknown, and clinical presentations and management vary. Methods: We conducted a scoping review to evaluate clinical and radiological characteristics, diagnostic investigations and prognostic outcomes of TBOCP in adults by exploring Pubmed and SCOPUS databases. Results: From the search results of 675 studies, 98 were included in this scoping review. TBOCP has a myriad of presenting symptoms and clinical severity but is notably an asthma mimic, displaying an obstructive pattern on spirometry. Bronchoscopic tools were the most common interventional diagnostic or management tool. Conclusion: While the etiology of TBOCP remains unknown, clinicians are alerted to its varied presentations and classical histopathological and gross morphological appearance.

Dairy cows inoculated with highly pathogenic avian influenza virus H5N1.

Highly pathogenic avian influenza (HPAI) H5N1 hemagglutinin clade 2.3.4.4b was detected in the United States in 2021. These HPAI viruses caused mortality events in poultry, wild birds, and wild mammals. On March 25, 2024, HPAI H5N1 clade 2.3.4.4b was confirmed in a dairy cow in Texas in response to a multi-state investigation into milk production losses.1 Over 200 positive herds were identified in 14 U.S. states. The case description included reduced feed intake and rumen motility in lactating cows, decreased milk production, and thick yellow milk.2,3 The diagnostic investigation revealed viral RNA in milk and mammary tissue with alveolar epithelial degeneration and necrosis and positive immunoreactivity of glandular epithelium. A single transmission event, likely from birds, was followed by limited local transmission and onward horizontal transmission of H5N1 clade 2.3.4.4b genotype B3.13.4 We sought to experimentally reproduce infection with genotype B3.13 in Holstein yearling heifers and lactating cows. Heifers were inoculated by aerosol respiratory route and cows by intramammary route. Clinical disease was mild in heifers, but infection was confirmed by virus detection, lesions, and seroconversion. Clinical disease in lactating cows included decreased rumen motility, changes to milk appearance, and production losses. Infection was confirmed by high levels of viral RNA detected in milk, virus isolation, lesions in mammary tissue, and seroconversion. This study provides the foundation to investigate additional routes of infection, pathogenesis, transmission, and intervention strategies.

Circulatory collapse requiring mechanical circulatory support in a child with autoimmune adrenal insufficiency: a case report

BackgroundWe report a rare case of new onset autoimmune adrenal insufficiency in childhood, presenting with severe shock requiring mechanical circulatory support. In the current era of readily available imaging, laboratory and other diagnostic investigations, medical history and careful physical exam can often provide valuable diagnostic information for timely therapy.Case presentationA 7-year-old boy with a history of mild intermittent asthma, presented with severe cardiogenic shock requiring extracorporeal membrane oxygenation (ECMO). Bronzing of his entire body was noted on physical exam. Stress dose hydrocortisone was given for suspected adrenal insufficiency. After weaning from ECMO and extensive rehabilitation, the patient recovered and was discharged home.ConclusionPrimary adrenal insufficiency (PAI) should be considered in the context of physical exam and laboratory findings, even in the presence of circulatory shock.

Sarcomatoid mesothelioma presenting as a mediastinal mass: A case report

Sarcomatoid mesothelioma (SM) is a subtype of mesothelioma, a deadly cancer strongly related to asbestos exposure. Herein, we present the case of a 50-year-old female who presented with back pain and non-specific symptoms for approximately 9 months. The diagnostic investigation revealed a large, centrally necrotic mass in the thorax that appeared to arise from the mediastinum and surrounded vital structures, including the superior vena cava. A biopsy of the thoracic mass revealed SM. The patient developed hematemesis, and emergent endoscopy revealed a gastric ulcer composed of malignant SM cells, a rare finding in pleural mesothelioma. Her disease was too advanced for surgical resection and conventional therapy. She tragically died weeks after diagnosis. The findings of this report highlight the varied presentation of SM to underscore the importance of early diagnosis and treatment of patients in improving overall survival.

Characteristics and prognosis of patients with cardiac sarcoidosis presenting with atrioventricular block and ventricular arrhythmias

Cardiac sarcoidosis (CS) may initially present with life-threatening arrhythmias such as atrioventricular block (AVB) and ventricular arrhythmia (VA), including ventricular tachycardia and ventricular fibrillation. Diagnosing CS is challenging due to subtle or absent findings in routine tests and the low sensitivity of the definitive diagnostic tool, endomyocardial biopsy. CS can also mimic other cardiac conditions such as dilated cardiomyopathy or arrhythmogenic right ventricular cardiomyopathy, and it may occur without any systemic involvement. Consequently, delays in presentation, accurate diagnosis, and initiation of appropriate treatment are frequent. Greater awareness of the condition could improve outcomes for patients with CS. Non-invasive advanced imaging techniques, such as 18F-fluorodeoxyglucose positron emission tomography and cardiac magnetic resonance imaging are essential for diagnosis, although they may not be accessible in all clinical settings. Management of arrhythmias in CS involves conventional therapies in the utilization of antiarrhythmics and non-pharmacological therapy (e.g., implantable devices), but with notable divergences in the use of immunosuppression and a preference for implantable cardioverter defibrillators over permanent pacemakers. This narrative review aimed to outline the clinical features of patients with CS presenting with AVB or VA and examine diagnostic investigations, imaging techniques, treatment approaches, and prognosis based on current research and international guidelines.

Utility of ultra-portable ultrasound devices for the risk-stratification of thyroid dysfunctions in an emergency setting.

We previously showed that the rapid TSH (rTSH) screening is able to detect a high prevalence of thyroid diseases in patients presenting to the Emergency department (ED), with a 7% prevalence of undiagnosed thyroid dysfunctions. The purpose of the present study is to implement our diagnostic flow-chart for thyroid dysfunctions in the ED with a rapid point-of-care thyroid ultrasound (rPOCUS). rPOCUS was performed by an app-based mobile ultrasound device (Lumify® by Philips Healthcare) in patients with suppressed rTSH undergoing urgent procedures requiring iodinate contrast media. Our results suggest that rPOCUS is cost- and time-effective for the management of patients with a newly diagnosed hyperthyroidism requiring urgent iodinated contrast media or amiodarone administration. Moreover, this handled US scanner avoided rTSH measurement in patients found to have a normal thyroid gland, and detected some incidental findings (nodules, heterogeneous echotexture), which would lead to further diagnostic investigations. We demonstrate, for the first time, that rPOCUS greatly improves the management of patients attending the ED, including the prompt characterization and correct treatment of hyperthyroidism, and the prevention of iodine-induced thyrotoxicosis.

12465 Unraveling The Enigma: A Multifaceted Presentation Of Hormonal Dysregulation In A 37-year-old Woman

Abstract Disclosure: S.Y. Rizvi: None. N. Ahmad: None. Title: Unraveling the Enigma: A Multifaceted Presentation of Hormonal Dysregulation in a 37-Year-Old Woman Background: Leydig cell tumors (LCTs) are rare gonadal tumors, arising from the interstitial cells of the testis or, less commonly, the ovary, 0.1%. These tumors are known for their potential to produce androgens, leading to virilization symptoms such as hirsutism. While LCTs are typically benign, they can occasionally exhibit malignant features. Accurate diagnosis and appropriate management are crucial to prevent complications and ensure favorable outcomes. Clinical Case: A 37-year-old, G3P3A0 woman, presented to our endocrinology clinic for a follow-up visit following the removal of a malignant thyroid nodule. During the visit, her endocrinologist noted elevated testosterone levels and worsening hirsutism. She reported mild abdominal pressure but denied other symptoms. She also complained of pain in the lower abdomen, although physical examination findings were limited due to type II obesity. Diagnostic investigations revealed a history of imaging studies, including CT scans and pelvic ultrasounds, demonstrating various findings such as a fibroid uterus, ovarian abnormalities, and a heterogeneous mass in the left adnexa. Laboratory evaluations over time showed fluctuations in androgen levels, with notable values including DHEA-sulfate (137.5 ug/dL), total testosterone (309.6 NG/dL), and free testosterone (12.85 NG/dL). Tumor markers, including CA 19-9= 16 U/mL, CA 125= 23.3 U/mL, CEA = 1.7 NG/mL, and HCG, were unremarkable. Gynae/Oncology was consulted, and she underwent surgical exploration with laparoscopic left oophorectomy. It revealed a Leydig cell tumor without overt malignant features, as confirmed by histopathological examination and immunohistochemical analysis. Her testosterone improved since oophorectomy. Patient undergoes frequent post-op follow up of her testosterone, free+total lc/MS to monitor for hyperandrogenism. Conclusion: This case highlights the importance of considering Leydig cell tumors in the differential diagnosis of hirsutism, particularly in the presence of elevated androgen levels. Multidisciplinary collaboration involving endocrinologists, gynecologists, oncologists, radiologists, and pathologists is essential for accurate diagnosis and optimal management. Surgical resection remains the cornerstone of treatment for Leydig cell tumors, with careful histopathological evaluation necessary to assess for potential malignancy. Long-term follow-up is warranted to monitor for recurrence or metastasis, although the prognosis for benign Leydig cell tumors is generally favorable. Patients with large body habitus may present challenges in physical examination, necessitating reliance on imaging and laboratory studies for diagnostic evaluation. Keywords: hirsutism, testosterone, ovary Presentation: 6/2/2024

Serratia marcescens outbreak at a neonatal intensive care unit in an acute care tertiary hospital in Singapore

To report the epidemiological, diagnostic, and genetic investigation of an outbreak of neonatal patients infected or colonized with Serratia marcescens (S. marcescens) including the infection control interventions. Outbreak investigation report. 28-bedded neonatal unit in an acute care tertiary hospital in Singapore divided into three areas: two negative-pressure airborne infection isolation rooms with a shared anteroom, 10 neonatal intensive care unit (NICU) beds, and 16 high dependency beds. A total of five neonates were involved in this outbreak. Screening of in-flight patients and their immediate environment for S. marcescens to determine probable environmental sources, whole genome sequencing (WGS) analysis of resulting isolates to determine clone-relatedness and possible transmission patterns. Implementation of infection control interventions included prompt isolation of cases, enhanced equipment and environmental disinfection, use of alcohol-based hand rub as the preferred hand hygiene mode, enhanced infection prevention orientation for parents, review of practices, audits, and immediate feedback on non-compliance. Five neonates infected or colonized with S. marcescens were involved in this outbreak. Four were infection cases whilst one identified through contact tracing. Three NICU sinks and the milk preparation room sink were tested positive for S. marcescens. WGS confirmed clonality of strains from two NICU sinks, and milk preparation room sink with that of the five neonates. Multiprong strategy was required to contain this outbreak. WGS analysis showed association of biofilms in sinks with the outbreak.

An investigation of scattered light integrating collector technology for rapid blood culture sensitivity testing.

Introduction. Sepsis rates are increasing, with Gram-negative organisms representing a large proportion of bloodstream infections. Rapid antibiotic administration, alongside diagnostic investigations, is required for the effective management of these patients.Gap statement. Current diagnostics take ~48 h for a final report; therefore, rapid diagnostics are required.Aim. This study investigated a novel antibiotic sensitivity method, the scattered light integrating collector (SLIC), combined with a rapid identification method using matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) technology to determine if an accurate identification and susceptibility result can be provided within 4 h of a positive blood culture report.Methodology. A total of 47 blood cultures containing Gram-negative bacteria from 46 patients were processed using the MALDI-TOF Biotyper Sepsityper for identification directly from the blood and the SLIC instrument for susceptibility testing. All organisms were also tested using the current standard workflow used in the host laboratory. Categorical agreement (CA), major errors (MaEs) and very major errors (VMEs) were determined.Results. SLIC produced susceptibility results with a 71.9% CA, 30.6% MaE and 17.5% VME. The median difference in time to the final result was 44.14 (43 : 05-45 : 15) h earlier compared to the current method.Conclusion. We conclude that SLIC was unable to consistently provide sufficiently accurate antibiotic susceptibility results compared to the current standard method.

Breast Cancer: The Psychological Impact of Diagnosis, Treatment, and Remission.

Breast cancer affects millions of people worldwide. With physical manifestations being the predominant feature of management, healthcare professionals can overlook the psychological toll that the disease can have on the patients and their support network. This literature review examines the vast multi-factorial approach that must be taken when managing breast cancer patients from initial screening to diagnostic investigations, treatment, and remission. A literature search in PubMed from January 2000 to April 2024 was executed. Data sets in the studies filtered during the literature search were collected and analysed, looking not only at the data itself but also the entirety of the study. This included its limitations and possible biases.From screening, the possibility of cancer as a diagnosis can trigger mixed emotions including fear, depression, and anxiety. During diagnostic, patients may find themselves subject to fear of negative body image evaluation and fear of judgment. Medical professionals must be prepared to support the patient when they experience these feelings. The treatment stages can be the most difficult for the patient as side effects and complications of treatment can impact their lives in numerous ways, making management challenging. These include pain, sexual dysfunction, and alopecia. Overall, the analysis of the selected literature showed areas in clinical practice that can be optimised when providing psychological support for a patient's cancer diagnosis, management, and treatment. Being able to counsel prior to the presentation of these, and ideally prevent unnecessary cases of these can substantially increase a patient's quality of life during treatment. This literature review hopes to identify and promote awareness and further implementation of support systems by healthcare professionals.

Clinical impact of whole-body MRI in staging and surveillance of patients with myxoid liposarcoma: a 14-year single-centre retrospective study.

To assess the clinical impact of regular whole-body magnetic resonance imaging (WBMRI) surveillance in myxoid liposarcoma patients. This was a retrospective cohort study of myxoid liposarcoma patients who underwent at least one WBMRI at our institution between October 2006 and December 2020. The effect of WBMRI on clinical management, namely treatment modification or additional diagnostic investigations was studied. A standardised WBMRI surveillance protocol was instituted in 2015. We compared patient outcomes for the metastatic patients who had and had not received regular WBMRI surveillance and performed survival analysis for both subgroups. Of the 56 patients (60.7% male, median age: 48.1 years) who underwent 345 WBMRI, 17 (30.3%) had metastases, and 168 WBMRI were performed in this group. The median imaging follow-up for the entire cohort was 35 months; the metastatic group had a median follow-up of 42 months. WBMRI changed the clinical management in 13 (76.5%) metastatic patients, with 33 instances of treatment modification. Thirty-five lesions were labelled 'indeterminate,' 16 (45.7%) had additional investigations/interventions, and 4 (11.4%) were confirmed to be metastatic. Twenty-one metastatic lesions were missed initially on WBMRI and confirmed on subsequent WBMRI, of which 5 (23.8%) were clinically significant. The 5-year survival since the detection of metastasis was better in the regular surveillance subgroup (85.7% vs. 45%), but this was not statistically significant (p = 0.068). Five patients (8.9%) developed their first metastasis more than 5 years after diagnosing the primary lesion. Regular WBMRI surveillance of myxoid liposarcoma patients considerably impacts clinical management by frequently influencing treatment decisions. WBMRI has been recently recommended as an imaging option for the staging and surveillance of myxoid liposarcoma patients. Our study highlights the impact of regular WBMRI surveillance on the clinical management of these patients and how it affects their survival.

Effect of a Single-Session Mindfulness-Based Swinging Technique (MBST) Intervention on Emotional Distress in Cancer Patients Undergoing PET-CT Scan: A Randomized Controlled Trial.

Introduction: Undergoing complex diagnostic investigation of positron emission tomography-computed tomography (PET-CT) scans is associated with high levels of distress, fear, and anxiety in oncological patients. This study evaluated the effects of a single 20-min session of an innovative mindfulness-based swinging technique (MBST) intervention on emotional distress in cancer patients scheduled for PET-CT scans. Material and Methods: Adult cancer patients undergoing PET-CT scans (n = 57) were assigned to the intervention group (n = 27) or the control group (n = 30). The emotion thermometer (ET) was used to measure distress, anxiety, depression, anger, and need for help at baseline and after the PET-CT scan. Participants in the intervention group received a 5-min psycho-education followed by listening to an audio recording of the MBST intervention just before their PET-CT scan. The session included mindfulness-based visualization, imaginary swinging activity, and synchronized breathing. The control group participants received brief 5-min counseling. Results: There was a statistically significant reduction in distress (p < 0.001), anxiety (p < 0.001), depression (p < 0.001), anger (p = 0.002), and need for help (p < 0.001) in the intervention group compared with the control group. Safety: None of the participants reported adverse events caused by the MBST intervention. The intervention was well accepted by the participants. However, n = 3 participants could not complete the intervention due to mind wandering, inability to focus, difficulty complying with the guided instructions, falling asleep, and physical discomfort unrelated to the intervention. Conclusion: The findings suggest the potential role of MBST intervention in mitigating emotional distress in patients undergoing complex diagnostic imaging procedures. Integrating this with conventional care in nuclear medicine settings can provide patient-centered care that addresses their unmet requirements. There is a need for further validation with a larger sample size. Clinical Trial Registration Number: CTRI/2023/04/051243 (Registered prospectively on 03/04/2023).

Reviving the poppy seed test for the diagnosis of colovesical fistula: A case report from a single rural center experience.

The poppy seed test is a valuable, cost-effective, and sensitive initial diagnostic investigation to identify the presence of colovesical fistula, particularly for clinicians in remote or rural areas with lack of access to specialist radiologic, endoscopic, surgical, or urological support. The poppy seed test therefore may act as a bridge toward the commencement of appropriate referral pathways for the management of colovesical fistula. The diagnosis of colovesical fistula is resource intensive, often requiring a combination of radiological investigation and endoscopy. The poppy seed test is a non-invasive and cost-effective alternative that has been demonstrated to identify presence of colovesical fistula with high sensitivity. There is however a noticeable paucity of recommendations for the poppy seed test in the diagnostic approach to colovesical fistula due to significant advancements in alternative radiologic and endoscopic technologies. Despite this, in resource-challenged areas with lack of specialist support, the poppy seed test is a cost-effective, accessible and safe test that can be performed to confirm the presence of colovesical fistula. We report a case of a 79-year-old man with a past history of colorectal cancer managed surgically with adjuvant chemoradiotherapy who develops noisy micturition, pneumaturia, and fecaluria 22 years after treatment. Given the suspicion of colovesical fistula, computed tomography imaging and cystoscopy were performed which was unable to demonstrate an overt fistula. The poppy seed test was utilized and demonstrated presence of poppy seeds in the urine, confirming the presence of a fistula. The patient was referred to a specialist surgical center for consideration of further management. The poppy seed test is a valuable initial diagnostic investigation for clinicians in remote or rural areas with lack of access to specialist radiologic, endoscopic, surgical, or urological support in confirming the presence of a colovesical fistula and initiating referral pathways for the management of this condition.