Obligatory Investigation Research Articles

The cytological pattern of cervical smears of a series of Saudi women in one gynecologic center.

Cervical intraepithelial neoplasia (CIN) is a type of abnormal cervical epithelial development that can lead to cervical malignancy. Thus, the purpose of this study was to examine the cytological pattern of cervical smears from a group of Saudi women who visited a single gynecologic center. From May 2020 to May 2021, 300 women were referred to the cytopathology laboratory and their cytological materials were collected. Because of gynecologic concerns, the women in the study were referred for Pap smears. As part of the obligatory investigations in conjunction with the clinical assessment, a Pap smear is requested. CIN of various grades was found in 11% of the women. High-grade Squamous Intraepithelial Lesions (HSIL) were the most detected modifications, followed by Atypical Squamous Cells of Undetermined Significance (ASUS) and Low-grade Squamous Intraepithelial Lesions (LSIL), accounting for 36.4%, 33.3%, and 30.3%, respectively. In 23.7% of the women, inflammatory cell infiltrations were found. Infection with Candida Albicans was identified in 2.3% of the women. In 15.8% of the patients, cytological evidence of bacterial infection was found. The prevalence of CIN has been growing in Saudi Arabia in recent years, implying a probable involvement in the spread of HPV. Most CIN cases associated with middle age point to HPV infection at a younger age. There is no link between estrogen and/or progesterone levels and CIN.

Detection of Atypical Salmonella Infantis Phenotypes in Broiler Environmental Samples.

In numerous countries, strict and targeted measures concerning Salmonella monitoring and control are implemented and high quality of surveillance is ensured by obligatory investigation of samples from the primary production level of animals according to EN/ISO standards. Here, 2 phenotypic characteristics of Salmonella exhibited on compulsory media are crucial, namely, motility demonstrated on modified semisolid Rappaport Vassiliadis agar (MSRV), and production of hydrogen sulfide (H2S) on xylose lysine deoxycholate agar (XLD). In the present study, we describe the detection of Salmonella Infantis variants found in broiler environmental samples with major alterations in their growth characteristics on MSRV, XLD, and brilliant green-phenol red-agar (BPLS). The variants proved to be non-motile on MSRV and displayed non-confirming colony appearances on the previously mentioned selective agars. The growth spectrum comprised pinhead sized yellow colonies with small black centers, but also pinpoint sized colorless colonies, both colony types of regular shape. Our work contributes to highlight the finding of S. Infantis variants which possess more than one phenotypic deviation from the "typical" growth characteristics and by this limit the detection power of the actual obligatory used media. IMPORTANCE Salmonellosis caused by non-typhoidal Salmonella serovars is the second most frequently reported zoonotic disease in humans in the EU. The transmission of these agents is mainly via contaminated food of animal origin. In this context, poultry products are the main source of infection. Therefore, continuous and standardized surveillance of the prevalence of such Salmonella serovars at the primary production level is essential. Our findings show the phenotypic heterogeneity of the serovar Infantis and provide growth characteristics of atypical variants. Such variants pass unnoticed official screening methods, resulting in incorrect identification and being underrepresented in epidemiological surveillance programs.

Swelling of sulfate-bearing soil: A case study of A1 highway pavement failure

Lime stabilization is one of the most commonly used methods for improving weak road subgrades, but it becomes very problematic in sulfate-bearing soils. This article presents results of a case study in which the sulfate attack was the most probable reason for a significant deformation of a highway pavement founded on lime-stabilized Doggerian clay. Macroscopic analysis revealed partial degradation of the concrete structure, a larger extent of stabilization than designed, and large gypsum crystals in the native soil. Chemical tests indicated a very high content of sulfates in the soil (> 10,000 mg/kg of SO4) and in the groundwater (> 3,000 mg/l of SO42-). The maximum free swelling strain (εvolmax = 3–6%) and the swelling pressure (pcmax = 56 kPa) of the clay, determined in the Wasiliew apparatus and the oedometer tests, were not large enough to be considered as the only cause of the pavement damage. Sand-cement and clay-lime mixtures, which simulated stabilized soil layers in the road profile, were observed for several months in oedometric tests, under various loading conditions. The swelling of Sa-Cem was negligible, but the Cl-Lim mixtures turned out to be much more expansive than the natural soil (εvolmax up to 21%, pcmax = 230 kPa) with a much longer duration of volume increase. The samples were flooded with distilled water or hard groundwater to clarify whether the constant access of the material to sulfates is important in the swelling process, but the results were unequivocal. X-ray diffraction revealed that the addition of lime resulted in the formation of secondary minerals: butlerite, portlandite, and ettringite. The presence and swelling of ettringite in the stabilized sub-base soil layers was eventually agreed to be the most probable reason for the pavement deformation. These results indicate the need to introduce an obligatory investigation of the level of sulfates in clayey subbase soils subject to lime stabilization.

Fluorodeoxyglucose Positron Emission Tomography Imaging in Pneumocystis jiroveci Pneumonia.

Fever or pyrexia of unknown origin (PUO) is commonly defined as body temperature higher than 38.3°C on several occasions for a period of at least 3 weeks with uncertain diagnosis after initial routine obligatory investigations. In most cases of PUO, there is an uncommon presentation of a common disease which includes infection, noninfectious inflammatory diseases, malignancy, and miscellaneous causes. We present an interesting case of a 48-year-old man with PUO, who is a known case of multiple myeloma on immunosuppressive therapy, where 18F-fluorodeoxyglucose positron emission tomography-computed tomography was able to detect occult cause of infective etiology.

Reporting and Investigation of Unmanned Aircraft Systems (UAS) Accidents and Serious Incidents. Regulatory Perspective

Naturally, the ever-growing number of drone operations conducted worldwide carries with it an increase in the number of safety-related incidents and occurrences. The reporting and subsequent investigation of unmanned aircraft system (UAS) accidents and serious incidents seems like a proven solution towards improving operational safety. Such procedures also stem from the fact that UAS are of recognized as aircraft – and aircraft accidents and serious incidents are subject to obligatory investigation. From a technical perspective, a key issue concerns discrepancies in the investigation process as there are significant differences between manned and unmanned aviation operations. From a regulatory perspective, one key question is to what extent should it be obligatory to conduct independent technical investigation of occurrences involving UAS? Such occurrences are not only accidents and serious incidents that involve both UAS and manned aircraft, where “traditional” rules of conducting a full and independent technical investigation apply – the majority occurrences involve only UAS that were either destroyed, damaged or acted as a hazard to third parties. The method of study comprised of content analysis of existing legislation. Current doctrines were confronted with existing regulations, documents, materials, safety reports and statistics. Results of the study shows that the extension of regulations created for manned aviation accident reporting and investigation may not be enough, and certain improvements are necessary, e.g. to standardize the reporting of occurrences and the criteria to conduct a formal accidents and serious incidents investigation. It is also reasonable to take actions aimed at raising awareness among UAS users of the need to report accidents and serious incidents, as well as engage them in the investigative process. The lack of standardization in this field has resulted in the lack of data that is “good enough” to indicate the main causes and factors that contribute to UAS accidents.

Retrospective analysis of 1,641 cases of classic fever of unknown origin

BackgroundFever of unknown origin (FUO) is commonly defined as fever higher than 38.3 °C on several occasions during at least 3 weeks with uncertain diagnosis after a number of obligatory investigations. It is a special type of fever and a common disease in internal medicine. However, due to its complex etiology, lack of characteristic clinical manifestations, and insufficient laboratory examination indicators, it often baffles clinicians in diagnosis. We herein present a study of the etiological factors and clinical features of classic fever of unknown origin (FUO) to provide help for related clinical diagnosis and treatment.MethodsA total of 1,641 cases of patients with classic FUO hospitalized in West China Hospital of Sichuan University between January 1, 2011 and December 31, 2017, were collected, and the etiological factors of classic FUO were analyzed. A special effort was made to explore and screen the laboratory indicators related to infectious diseases, and the above data were compared with the clinical features of tuberculosis and lymphoma, which are difficult to diagnose.ResultsAmong the 1,641 patients, 1,504 were finally diagnosed through various types of examination or diagnostic methods, and the diagnosis rate was 91.65%. Among all the causes of the 1,641 cases of FUO, 48.69% [799] were infectious diseases, of which tuberculosis was the most common, accounting for 19.50% [320]. Connective tissue diseases were responsible for 19.26% [316] of cases, of which adult-onset Still’s disease (AOSD) was the most common, comprising 89 (5.42%) of the cases; 16.94% [278] were neoplastic diseases, and lymphoma (143, 8.71%) cases, was the most common malignant tumor; 6.76% [111] were other diseases; and in 8.35% [137] of cases, the cause was unclear. Through comparative analysis of tuberculosis and lymphoma, no significant differences were found between the symptoms, signs, and non-specific routine examination results of the two diseases. The diagnosis of these diseases was more dependent on tuberculosis-related examinations and pathological examinations.ConclusionsInfectious diseases are the principal cause of classic FUO, in which tuberculosis accounts for a large proportion. Non-infectious diseases that cause FUO are mainly connective tissue diseases and malignant tumors. Of the various causes of classic FUO, tuberculosis and lymphoma are relatively difficult to diagnose. In most cases, the causes of classic FUO can be ascertained.

Carcinoma of colon: A rare cause of fever of unknown origin

Fever of unknown origin (FUO) was originally defined as a body temperature greater than 38.3°C on several occasions longer than 3 weeks, with a diagnosis that remains unclear after 7 days of obligatory investigation. Only a few types of solid tumors have been associated with FUO. We described 2 patients who had recurrent fever but no other specific gastrointestinal symptoms where carcinoma of the colon was the only identifiable cause. In the first case, a mass arising from the sigmoid colon was found without any nodal metastasis, and the fever was resolved after three days of the surgical resection. In the second case, advanced adenocarcinoma was found in the ascending colon together with liver cirrhosis. Although it was not possible to surgically remove this tumor, prolonged fever in the patient was most likely due to the carcinoma. These cases indicate that clinicians should consider carcinoma of the colon in the differential diagnosis of patients with FUO.

A Prospective Multicenter Study on Fever of Unknown Origin

We conducted a prospective study to update our knowledge of fever of unknown origin (FUO) and to explore the utility of a structured diagnostic protocol. From December 2003 to July 2005, 73 patients with FUO were recruited from 1 university hospital (n = 40) and 5 community hospitals (n = 33) in the same region in The Netherlands. FUO was defined as a febrile illness of >3 weeks' duration, a temperature of >38.3 degrees C on several occasions, without a diagnosis after standardized history-taking, physical examination, and certain obligatory investigations. Immunocompromised patients were excluded. A structured diagnostic protocol was used. Patients from the university hospital were characterized by more secondary referrals and a higher percentage of periodic fever than those referred to community hospitals. Infection was the cause in 16%, a neoplasm in 7%, noninfectious inflammatory diseases in 22%, miscellaneous causes in 4%, and in 51%, the cause of fever was not found (no differences between university and community hospitals). There were no differences regarding the number and type of investigations between university and community hospitals. Significant predictors for reaching a diagnosis included continuous fever; fever present for <180 days; elevated erythrocyte sedimentation rate, C-reactive protein, or lactate dehydrogenase; leukopenia; thrombocytosis; abnormal chest computed tomography (CT); and abnormal F-fluorodeoxyglucose positron emission tomography (FDG-PET). For future FUO studies, inclusion of outpatients and the use of a set of obligated investigations instead of a time-related criterion are recommended. Except for tests from the obligatory part of our protocol and cryoglobulins in an early stage, followed by FDG-PET, and in a later stage by abdominal and chest CT, temporal artery biopsy in patients aged 55 years or older, and possibly bone marrow biopsy, other tests should not be used as screening investigations.

Pyrexia of unknown origin

<h2>Abstract</h2> Fever of unknown origin (FUO) is now often defined as a fever higher than 38.3°C on several occasions during at least 3 weeks with uncertain diagnosis after several obligatory tests. Infection accounts for about one-third of cases of FUO, followed by neoplasm and non-infectious inflammatory diseases. No diagnosis is reached in 25–35% of cases. In patients with periodic fever, this percentage is higher. A diagnostic algorithm is proposed in which the most important steps are history-taking, physical examination and obligatory investigations in a search for potentially diagnostic clues (PDCs). First, factitious fever and drug fever should be excluded. Further diagnostic procedures should be guided by a list of most probable diagnoses. In patients without useful PDCs, certain diagnostic procedures, divided into first-stage and second-stage investigations, should be performed. If no diagnosis is reached and the clinical condition is stable, waiting for new PDCs is recommended. In patients with recurrent fever, diagnosis should comprise only a search for PDCs matching known recurrent syndromes. Scintigraphic methods such as gallium-67 citrate-labelled leucocytes and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) are often used in patients with FUO. Because of the favourable characteristics of FDG-PET, conventional scintigraphic techniques may be replaced by FDG-PET in institutions where it is available. If undiagnosed fever persists, supportive treatment with non-steroidal anti-inflammatory drugs can be helpful. Most patients with undiagnosed FUO have benign self-limiting or recurrent fever. Other therapeutic trials should be considered only in patients who deteriorate.

Ultrasound scan-guided core sampling for diagnosis versus freehand FNAC of the thyroid gland

Freehand fine needle aspiration cytology (FNAC) is an obligatory investigation of the thyroid nodule. Between 5.0-43.1% of FNAC samples are reported as being initially unsatisfactory. In our unit, thyroid freehand FNAs are performed with a small needle (21 or 23G). Non-dominant nodules as part of multinodular goitres, difficult to palpate nodules or nodules with previously unsatisfactory freehand FNACs are sampled under ultrasound scan (USS) guidance with the larger 20G cutting core sampling technique. We aimed to compare the satisfactory sampling rate and safety of the two different methods. Cytology forms were reviewed for 262 freehand FNACs and USS-guided core samples, performed in our unit over a two-year interval (1 July 1999 to 30 June 2001). Ultrasound-guided core samples for cytology were unsatisfactory (AC0-1) in 19/121 (15.6%) of the cases, compared with 66/141 (46.8%) of freehand FNACs (p value = < 0.0001). Ten out of eleven patients (91%) had a satisfactory USS-guided core after an unsatisfactory freehand FNA; 7/15 patients (46.7%) had satisfactory repeat freehand FNACs following an initial unsatisfactory freehand FNAC (p value = 0.0191). There were no complications as a result of either freehand FNAC or USS-guided core sampling. USS-guided cores provided more satisfactory samples for assessment than freehand FNACs. The USS-guided technique is safe despite the use of the larger cuffing needle. The USS-guided core sampling was also a useful tool for repeat thyroid nodule sampling after an unsatisfactory freehand FNAC.

Fever of unknown origin (FUO). II. Diagnostic procedures in a prospective multicenter study of 167 patients. The Netherlands FUO Study Group.

From January 1992 until January 1994, we used a standardized diagnostic protocol for the 167 immunocompetent patients with fever of unknown origin (FUO) admitted on the internal medicine wards in all 8 university hospitals in the Netherlands. This protocol consisted of a standardized coded history and standardized physical examination for all 167 patients. A number of additional obligatory investigations had to be performed in the first week of admission for all patients, and all potentially diagnostic clues (PDCs) thus retrieved had to be registered. In the presence of PDCs, specific investigations had to be performed based on the differential diagnosis. In the absence of PDCs or in the presence of only misleading PDCs, patients underwent a screening 2-staged diagnostic protocol. In 162 (97%) patients, PDCs were present after 1 week of admission. In 61 patients these PDCs were all misleading. The likelihood of reaching a diagnosis in patients with PDCs was not significantly higher than that in patients without PDCs, probably because of the high proportion of misleading PDCs. The likelihood of establishing a diagnosis was significantly lower (< 10%) only for patients with recurrent fever, normal erythrocyte sedimentation rate (ESR), and normal hemoglobin. All other PDCs were not significantly different in patients with a diagnosis compared with patients without a diagnosis. The screening 2-staged diagnostic protocol proved useful in 10 of 43 patients in whom it was used. The screening value of immunologic and microbiologic serology and endocrine investigations was nil; these investigations probably should be performed only when PDCs for the disease searched for are present. Scintigraphic techniques, echocardiography, and other imaging procedures were never helpful in our population in the absence of PDCs. Many patients with FUO had nonspecific anemia and disturbed liver chemistry. In the presence of these findings alone, without other more specific PDCs, the likelihood of reaching a diagnosis with help of bone marrow aspiration was nil, and with help of liver biopsy, it was low. Enteric biopsy was never helpful. If lymphadenopathy was confined to the cervical or inguinal region (with negative chest X-ray and abdominal ultrasound), lymph node biopsy was not helpful, in contrast to patients having generalized lymphadenopathy, in whom the technique had a yield of 79%. As shown in this study, the search for PDCs remains an important tool for establishing the diagnosis in patients with FUO, although in many cases these PDCs appear to be misleading. Directed diagnostic workup--using the PDCs retrieved by repeated, meticulous history taking and physical examination--remains the most efficient and intellectually satisfactory way to solve the problem of FUO in the individual patient. A standard protocol in patients with FUO in whom the obligatory investigations, as used by us, do not lead to the diagnosis can be limited to the tests that proved to be of some use as screening procedure: temporal biopsy in patients older than 55 years; fundoscopy; serology (Western blot) for Yersinia enterocolitica; serum for cryoglobulin at an early stage of the diagnostic process; and bone biopsy, liver biopsy, abdominal computed tomography (CT), and chest CT at a later stage. Repeating a thorough history-taking, physical examination, and obligatory investigations and waiting for PDCs to appear probably is better than ordering more screening investigations in the hope that something abnormal will come up. Supportive treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) can be helpful at this stage. Only rarely do patients deteriorate while using NSAIDs without presenting new PDCs. In these rare patients, further diagnostic workup should be performed or a therapeutic trial with, for example, antibiotics, steroids, or antituberculous agents started.