Percentage Of Total Cases Research Articles

Molecular rapid diagnostic testing for bloodstream infections: Nanopore targeted sequencing with pathogen-specific primers

Nanopore sequencing, known for real-time analysis, shows promise for rapid clinical infection diagnosis but lacks effective assays for bloodstream infections (BSIs). We prospectively assessed the performance of a novel nanopore targeted sequencing (NTS) assay in identifying pathogens and predicting antibiotic resistance in BSIs, analyzing 387 blood samples from December 2021 to April 2023. The positivity rate for NTS (69.5%, 269/387) nearly matches that of metagenomic next-generation sequencing (mNGS) (74.7%, 289/387; p=0.128) and surpasses the positivity rate of conventional blood culture (BC) (33.9%, 131/387; p<0.01). Frequent pathogens detected by NTS included Klebsiella pneumoniae (n=54), Pseudomonas aeruginosa (n=36), Escherichia coli (n=36), Enterococcus faecium(n=30), Acinetobacter baumannii(n=26), Staphylococcus aureus(n=23), and Human cytomegalovirus (n=37). Against a composite BSI diagnostic standard, NTS demonstrated a sensitivity and specificity of 84.0% (95% CI 79.5%-87.7%) and 90.1% (95% CI 81.7%-88.5%), respectively. The concordance between NTS and mNGS results (the percentage of total cases where both either detected BSI-related pathogens or were both negative) was 90.2% (359/387), whereas the consistency between NTS and BC was only 60.2% (233/387). In 80.6% (50/62) of the samples with identical pathogens identified by both NTS tests and BCs, the genotypic resistance identified by NTS correlated with culture-confirmed phenotypic resistance. Using NTS, 95% of samples can be tested and analyzed in approximately 7h, allowing for early patient diagnosis. NTS is rapid, sensitive, and efficient for detecting BSIs and drug-resistant genes, making it a potential preferred diagnostic tool for early infection identification in critically ill patients.

Complete and incomplete lower motor neuron facial palsy in post-COVID-19 mucormycosis

Purpose:To study facial nerve palsy (FNP) in post-COVID-19-mucormycosis patients and its ocular complications, report different presentations of FNP in such patients, and propose its etiopathogenesis based on presentation and clinico-radiologic localization.Methods:A prospective cohort study was carried out in patients of post-COVID-19-mucormycosis who presented at our tertiary center, over a period of 3 months. Motor and sensory examination of the facial nerve was done to diagnose FNP and localize the lesion clinically. Slit-lamp examination was done for grading corneal involvement. MRI brain, orbit, and paranasal sinuses (PNS) with contrast were studied to find involvement along the facial nerve. It was assessed whether this site of lesion corresponded with clinical localization. Data were analyzed using the percentage of total cases and Fisher’s test.Results:A total of 300 patients with post-COVID-19 mucormycosis were examined, of which 30 (10%) patients were found to have FNP. All were lower motor neuron (LMN) type and were associated with corneal complications. The most common site clinically was distal to the chorda tympani (66.66%) and radiologically was infratemporal (IT) fossa (63.4%). The clinical localization significantly correlated with the radiological findings (P = 0.012). Twenty percent of patients showed incomplete involvement of facial musclesConclusion:FNP was found to be of LMN type. The most common site of insult was IT fossa. There was a good clinico-radiological correspondence of lesions. Isolated lesions were also found along the peripheral nerve course, presenting as incomplete facial palsy. Recognition of FNP in post-COVID-19 mucormycosis, in all its variable forms, is important to manage corneal complications.

Acute Febrile Encephalopathy in Children: Etiology, Clinical Presentation and Outcome

Background: Fever and altered sensorium constitute a medical emergency in children. Early recognition, accurate diagnosis and timely management may help in reducing the morbidity and mortality in acute febrile encephalopathy (AFE). AIM: To study etiology, clinical presentation and outcome in children presenting with acute febrile encephalopathy. Methods: This prospective observational cohort study was conducted in a tertiary care center over the duration of one year (2016 to 2017).consecutive patients (age group of one month to 12 years) presenting with fever of ≤ 2 weeks duration and altered mental status were enrolled. The clinical features were noted and patients were followed up through the duration of hospital stay (wards &amp; intensive care unit). Etiology and clinical features were listed as percentage of total cases. Risk factors for mortality were determined using chi-square test. Results: 120 children were enrolled. Besides fever and altered sensorium, convulsions (70%) and meningeal signs (38.3%) were common clinical features. Tubercular meningitis (33.3%) was the most common cause followed by viral encephalitis (24.2%), bacterial meningitis (9.2%) and cerebral malaria (5.8%). Mortality was 16.7% with neuro-morbidity seen in 45% of the cases. Longer duration of hospital stay (≥ 28 days), longer duration of PICU stay (&gt; 14 days), longer duration of mechanical ventilation (≥ 7 days) and low Glasgow coma score (GCS&lt; 8) were risk factors associated with higher mortality. Conclusion: Infectious causes were the commonest cause of AFE. AFE has a high rate of neuro-morbidity. Early identification of high risk factors may help to reduce the mortality. Corresponding Author : Milind S. Tullu, Professor Additional, Department of Pediatrics, Seth Gordhandas Sunderdas Medical College &amp; King Edward Memorial Hospital, Mumbai 400012, Maharashtra, India.

Current State of Cytologic-Histologic Correlation Implementation for North American and International Laboratories: Results of the College of American Pathologists Cytopathology Committee Laboratory Practices in Gynecologic Cytology Survey.

The College of American Pathologists (CAP) updated the Laboratory Accreditation Program Cytopathology Checklist to assist laboratories in meeting and exceeding the Clinical Laboratory Improvement Amendments standards for gynecologic cytologic-histologic correlation (CHC). To survey the current CHC practices. Data were analyzed from a survey developed by the committee and distributed to participants in the CAP Gynecologic Cytopathology PAP Education Program mailing. Worldwide, CHC practice is nearly universally adopted, with an overall rate of 87.0% (568 of 653). CHC material was highly accessible. CHC was commonly performed real time/concurrently at the time the corresponding surgical pathology was reviewed. Investigation of CHC discordances varied with North American laboratories usually having a single pathologist review all discrepant histology and cytology slides to determine the reason for discordance, while international laboratories have a second pathologist review histology slides to determine the reason for discordance. The cause of CHC discordance was primarily sampling issues. The more common statistical metrics for CHC monitoring were the total percentage of cases that correlated with subsequent biopsies, screening error rate by cytotechnologist, and interpretative error rate by cytotechnologist. Many laboratories have adopted and implemented the CHC guidelines with identifiable differences in practices between North American and international laboratories. We identify the commonalities and differences between North American and international institutional practices including where CHC is performed, how CHC cases are identified and their accessibility, when CHC is performed, who investigates discordances, what discordances are identified, and how the findings affect quality improvement.

Study of Profile of Mucormycosis During the Second Wave of COVID-19 in a Tertiary Care Hospital.

Introduction and aimMucormycosis is a lethal opportunistic infection caused by filamentous fungi of the family Mucoraceae (black fungus). There has been a sudden increase in the incidence of these cases during the second wave of the COVID-19 pandemic due to the immunocompromised state caused by the disease and its treatment. Early diagnosis and appropriate medical management are essential to reduce disease morbidity and mortality. Through this study, we aim to study the clinical features, risk factors, laboratory investigations, and radiological findings of patients with mucormycosis as well as evaluate the clinical outcomes in each case.Methods and materialsThis was a prospective study that included only confirmed mucormycosis cases admitted in Tata Main Hospital (TMH) from April 2021 to July 2021. A case of mucormycosis was defined as the one in which clinical and radiological features were consistent with mucormycosis and fungus was demonstrated in the tissue by potassium hydroxide (KOH) mount/culture/histopathological examination (HPE). Data relating to epidemiology, risk factors, clinico-radiological features, and outcomes were analyzed and expressed as a percentage of total cases.ResultsOf the total 15 cases, three patients (33.3%) had active COVID-19 infection, eight (53.3%) were in the post-COVID-19 state, two (13.4%) had COVID-19 like illness and two (13.4%) patients did not have COVID-19 in the recent past. There was male predominance with the male to female ratio being 2.75:1. The commonest associated co-morbid condition was diabetes mellitus (13 patients, 86.7%). Amongst the myriad manifestations, periorbital swelling was the commonest symptom (11 patients, 73.3%). Among neurological manifestations, involvement of cranial nerves was found in nine (60%) patients with the third cranial nerve being the most commonly affected nerve (eight patients, 53.3%). Cavernous sinus thrombosis (CST) was found in one (6.7%) patient. Diagnostic nasal endoscopy (DNE) revealed eschar at various sites in 13 patients (86.7%). Central retinal artery occlusion (CRAO) was found bilaterally in one patient (6.7%) while two patients (13.3%) had CRAO on the left. Radiologically, the most commonly involved sinuses were maxillary and ethmoidal (eight patients, 53.3%). Bilateral sinus involvement was more common (46.7%) than unilateral sinus involvement. The average length of stay (LOS) was 17.5±7.8 days. The overall mortality was 40%. Five (33.3%) patients developed secondary bacterial infections. All patients received medical therapy with intravenous amphotericin B. In addition, seven (46.7%) patients underwent functional endoscopic sinus surgery (FESS) with debridement of which, five (71.4%) patients survived and made a good recovery. One patient (6.7%) with pulmonary mucormycosis underwent lobectomy.ConclusionNew-onset headache, black nasal discharge, periorbital swelling, retro-orbital pain, visual diminution, restriction of eye movements should prompt an immediate search for mucormycosis especially in the background of history of diabetes mellitus in patient with recent or current COVID-19 disease. Radio-imaging with computerized tomography and magnetic resonance imaging are complementary to clinical evaluation in assessing the disease extent and diagnosis of complications. Prompt diagnosis is essential due to the angio-invasive nature of the mucor and requires aggressive anti-fungal therapy and debridement of the devitalized tissue.

COVID-19 associated rhino-orbital-cerebral mucormycosis: An observational study from Eastern India, with special emphasis on neurological spectrum

Aims: 1Describe the epidemiology and determine risk factors for COVID-19 associated mucormycosis. 2Elaborate the clinical spectrum of Rhino-Orbital-Cerebral Mucormycosis (ROCM), pattern of neuroaxis involvement and it's radiological correlates. MethodsObservational study. Consecutive, confirmed cases of mucormycosis (N = 55) were included. A case of mucormycosis was defined as one who had clinical and radiological features consistent with mucormycosis along with demonstration of the fungus in tissue via KOH mount/culture/histopathological examination (HPE). Data pertaining to epidemiology, risk factors, clinico-radiological features were analysed using percentage of total cases. ResultsMiddle aged, diabetic males with recent COVID-19 infection were most affected. New onset upper jaw toothache was a striking observation in several cases. Among neurological manifestations headache, proptosis, vision loss, extraocular movement restriction; cavernous sinus, meningeal and parenchymal involvement were common. Stroke in ROCM followed a definitive pattern with watershed infarction. ConclusionsNew onset upper jaw toothache and loosening of teeth should prompt an immediate search for mucormycosis in backdrop of diabetic patients with recent COVID-19 disease, aiding earlier diagnosis and treatment initiation. Neuroaxis involvement was characterized by a multitude of features pertaining to involvement of optic nerve, extraocular muscles, meninges, brain parenchyma and internal carotid artery.

Potential risk of medial cortex perforation due to peg position of morphometric tibial component in unicompartmental knee arthroplasty: a computer simulation study.

The purpose of this study is to evaluate the risk of medial tibial cortical perforation in unicompartmental knee arthroplasty (UKA) due to peg positions on the tibial tray of the Persona Partial Knee (PPK). Preoperative CT images of 60 patients and 60 osteoarthritic knees (30 male and 30 female patients) were used. A tibial multiplanar reconstruction (MPR) image was reconstructed in preoperative planning software, and the implant was placed in a virtual osteotomy plane. In addition to PPK, Zimmer Unicompartmental Knee (ZUK) and TRIBRID (TBD) were used for evaluation. The horizontal distances from the medial tibial cortex to the anterior and posterior pegs (APCD/PPCD, respectively) were measured under neutral, 3-degree varus, 3-degree valgus and 2mm distal positions. The differences between implants under the same positions and between positions using the same implants were compared. The percentage of total cases with APCD/PPCD of less than 3mm and the perforation risk rate were calculated. The APCD of PPK was significantly shorter at all positions except for the varus position of TBD. The PPCD of PPK was significantly shorter at all positions compared to ZUK and TBD. There were no cases with an APCD of less than 3mm. Except for varus positions, the perforation risk rate of PPCD was significantly higher for PPK than the other two implants. The posterior pegs of the PPK are located more medially than the other two implants, which may result in perforation of the medial tibial cortex during implantation. Surgeons should consider the risk involved in the type of implant used.

Health equity and burden of childhood asthma - related to air pollution in Barcelona

BackgroundAir pollution is one of the major health risk factors in urban populations. Air pollution has been associated with asthma in children. Air pollution has also been suggested to be distributed unequally within the cities, something that can lead to urban health inequalities. AimWe aimed to estimate the number of childhood asthma cases attributable to three main air pollutants; Nitrogen dioxide (NO2), Particulate Matter (PM 2.5), and Black Carbon (BC) in the city of Barcelona, Spain. We also aimed to describe the distribution of those impacts depending on the social deprivation index in Barcelona. MethodsWe estimated the number of childhood asthma cases in Barcelona by applying a quantitative Health Impact Assessment (HIA) approach. Air pollution (NO2, PM2.5, and BC) exposure assessment was estimated using a land-use regression model. Two scenarios were assessed and compared the current levels of air pollution with 1) achieving the World Health Organization (WHO) guideline on exposure levels for NO2 and PM2.5 (scenario 1); and 2) achieving the minimum reported levels in a previously published meta-analysis (scenario 2), from where we also obtained the exposure-response functions. The relative risk and population attributable fraction (PAF) for each scenario and pollutant were estimated. Using the asthma incidence rate in Spain the expected number of asthma cases in Barcelona attributable to NO2, PM2.5, and BC for each scenario was estimated. ResultsThe annual average levels of NO2, PM2.5, and BC at census levels were 56 μg/m3, 17.11 μg/m3, and 2.88 μg/m3, respectively. The number of asthma cases attributable to NO2 and PM2.5 (percentage of total cases) estimated in scenario 1 was 454 (18%) and 478 (19%) respectively. For scenario 2, the estimated number of cases attributable to NO2, PM2.5, and BC were 1230 (48%), 992 (39%) and 789 (31%) respectively. Although NO2 and BC showed differences between asthma cases and areas with different deprivation index, only BC differences were statistically significant between less and more deprived areas. ConclusionsThis study estimated that up to 1230 (48%) of asthma cases in Barcelona could be attributable to air pollution each year. This study also found that in Barcelona, less socially deprived groups could be more affected by asthma-related to air pollution than those more socially deprived.

HEMS Guidelines Utilization

Introduction Debates exist on the benefits of Helicopter EMS (HEMS) with safety, cost, and outcome implications often cited. The decision to utilize HEMS is a complex process that involves many considerations. Professional associations and agencies have published guidelines to assist providers with decision making for the utilization of helicopter transport. Study Objective The goal of this project is to determine if requests for HEMS align with recently published utilization guidelines. Methods A retrospective chart review was performed during a six month period. Reviewers versed in Wisconsin HEMS Utilization, NAEMSP, and CAMTS guidelines determined if criteria were met for each transport. Charts were categorized according to whether they did or did not follow the criteria for each set of recommendations. Percentage of total cases was calculated for each group and compared between groups. Results 514 charts were reviewed, 439 of which consisted of completed patient transports. 42.8% of transports were for trauma, 9.3% STEMI, 8.0% stroke, 4.1% sepsis, and 35.8% for other medical conditions. Pediatric patients comprised 15.9% of all HEMS transports and met the trauma, sepsis, and other medical condition subgroup criteria 20.2%, 11.1%, and 19.1% of the time, respectively. CAMTS, NAEMSP, and WI HEMS guidelines satisfied 85.4%, 83.4%, and 53.1% of requests, respectively. There were statistically significant differences when comparing rates meeting criteria between WI HEMS and CAMTS and between WI HEMS and NAEMSP guidelines (p-value < 0.0001). This was true in all subgroups except STEMI, which did not show significant difference among the three guidelines. There was no difference between rates for CAMTS and NAEMSP guidelines in any group. Conclusion We detected a significant difference between the number of cases meeting Wisconsin HEMS utilization versus NAEMSP guidelines, and between Wisconsin HEMS utilization and CAMTS guidelines in all subgroups except STEMI patients. No statistically significant difference existed between the NAEMSP guidelines and the CAMTS guidelines. Further study is required to examine the lack of agreement between guidelines to clearly identify patients that should be transported by HEMS. Debates exist on the benefits of Helicopter EMS (HEMS) with safety, cost, and outcome implications often cited. The decision to utilize HEMS is a complex process that involves many considerations. Professional associations and agencies have published guidelines to assist providers with decision making for the utilization of helicopter transport. The goal of this project is to determine if requests for HEMS align with recently published utilization guidelines. A retrospective chart review was performed during a six month period. Reviewers versed in Wisconsin HEMS Utilization, NAEMSP, and CAMTS guidelines determined if criteria were met for each transport. Charts were categorized according to whether they did or did not follow the criteria for each set of recommendations. Percentage of total cases was calculated for each group and compared between groups. 514 charts were reviewed, 439 of which consisted of completed patient transports. 42.8% of transports were for trauma, 9.3% STEMI, 8.0% stroke, 4.1% sepsis, and 35.8% for other medical conditions. Pediatric patients comprised 15.9% of all HEMS transports and met the trauma, sepsis, and other medical condition subgroup criteria 20.2%, 11.1%, and 19.1% of the time, respectively. CAMTS, NAEMSP, and WI HEMS guidelines satisfied 85.4%, 83.4%, and 53.1% of requests, respectively. There were statistically significant differences when comparing rates meeting criteria between WI HEMS and CAMTS and between WI HEMS and NAEMSP guidelines (p-value < 0.0001). This was true in all subgroups except STEMI, which did not show significant difference among the three guidelines. There was no difference between rates for CAMTS and NAEMSP guidelines in any group. We detected a significant difference between the number of cases meeting Wisconsin HEMS utilization versus NAEMSP guidelines, and between Wisconsin HEMS utilization and CAMTS guidelines in all subgroups except STEMI patients. No statistically significant difference existed between the NAEMSP guidelines and the CAMTS guidelines. Further study is required to examine the lack of agreement between guidelines to clearly identify patients that should be transported by HEMS.

Complications of Distal Biceps Tendon Repair: A Meta-analysis of Single-Incision Versus Double-Incision Surgical Technique.

Background:Anatomic reinsertion of the distal biceps is critical for restoring flexion and supination strength. Single- and double-incision surgical techniques have been reported, analyzing complications and outcomes measures. Which technique results in superior clinical outcomes and the lowest associated complications remains unclear.Hypothesis:We hypothesized that rerupture rates would be similar between the 2 techniques, while nerve complications would be higher for the single-incision technique and heterotopic ossification would be more frequent with the double-incision technique.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:A systematic review was conducted using the PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SPORTSDiscus, and the Cochrane Central Register of Controlled Trials databases to identify articles reporting distal biceps ruptures up to August 2013. We included English-language articles on adult patients with a minimum of 3 cases reporting single- and double-incision techniques. Frequencies of each complication as a percentage of total cases were calculated. Fisher exact tests were used to test the association between frequencies for each repair method, with P < .05 considered statistically significant. Odds ratios with 95% CIs were also computed.Results:A total of 87 articles met the inclusion criteria. Lateral antebrachial cutaneous nerve neurapraxia was the most common complication in the single-incision group, occurring in 77 of 785 cases (9.8%). Heterotopic ossification was the most common complication in the double-incision group, occurring in 36 of 498 cases (7.2%).Conclusion:The overall frequency of reported complications is higher for single-incision distal biceps repair than for double-incision repair. The frequencies of rerupture and nerve complications are both higher for single-incision repairs while the frequency of heterotopic ossification is higher for double-incision repairs. These findings can help surgeons make better-informed decisions about surgical technique and provide their patients with detailed information about expected outcomes and possible complications.

Pediatric surgery – a changing field: national trends in pediatric surgical practice

BackgroundOver the last decade, our institution has experienced a relative increase in the number of mundane cases, such as appendectomy and incision and drainage of abscess, versus index (complex) cases. We sought to determine if this trend is present at the national level. MethodsA retrospective review of surgical case volume at 36 freestanding children's hospitals was performed between January 2004 and December 2013 using the Pediatric Health Information System (PHIS) database. Procedures were classified as “mundane” or “index”, and 10 procedures of each type were selected for analysis. Results were reported as a percentage of total cases. Statistical analysis of linear trends was performed with the Mann-Kendall test. ResultsOverall, index procedures had a significant downward trend (p<0.01), whereas mundane procedures had a significant upward trend (p<0.01). Individually, 5 mundane procedures had significant upward trends, and 3 had downward trends. Five index procedures had significant downward trends, and none had an upward trend. ConclusionThe field of pediatric surgery is undergoing change with mundane procedures constituting an increasing proportion of the surgical caseload, while complex procedures are proportionately decreasing. These trends may be useful to inform decisions regarding future pediatric surgery workforce planning.

Addition of EUS-FNA and On-site Cytology to EUS-FNB Increases Procedure Time but Not Diagnostic Accuracy

Purpose: The diagnostic accuracy of EUS-FNA in non-pancreatic lesions is poor relative to pancreas adenocarcinoma; accuracy is improved with EUS-FNB. As histology is often needed in these lesions, it may be possible to forgo initial EUS-FNA and rapid on-site cytology evaluation (ROSE). The goal of this study was to compare the diagnostic accuracy of EUS-FNB alone with a conventional sampling algorithm of EUS-FNA with ROSE followed by EUS-FNB in non-pancreas adenocarcinoma lesions. Methods: Retrospective cohort study of subjects who underwent EUS sampling of non-pancreatic adenocarcinoma lesions over a 28-month time period (2/2011-5/2013) since introduction of new core biopsy needle (Echotip Procore, Cook Endoscopy, USA). Lesions included lymphadenopathy or retroperitoneal/mediastinal mass (LRMM), subepithelial mass (SEM), non-adenocarcinoma pancreas, or gastrointestinal wall thickening. Two cohorts were compared: EUS-FNB without EUS-FNA or ROSE (EUS-FNB group) and EUS-FNA with ROSE and if needed, EUS-FNB (EUS-FNA/B group). The primary outcome of this study was to compare diagnostic accuracy, defined as the percentage of total cases where an accurate cytologic or histologic diagnosis was achieved. The secondary outcome was total procedure time. Results: Over the study period, there were 96 lesions (43 in EUS-FNB, 53 in EUS-FNA/B groups). In the EUS-FNB cohort, SEM was the most common indication (48.8%) followed by LRMM (20.0%). In the cohort of EUS-FNA/B patients, LRMM (50.9%) was the most common indication followed by SEM (26.4%). Mean lesion size was similar between EUS-FNB and EUS-FNA/B groups (23.8 mm vs. 27.6mm; p=0.35). In the EUS-FNA/B group, a median of a 4±1.4 EUS-FNA passes were performed prior to either procedure termination or EUS-FNB. A diagnosis was obtained by EUS-FNA alone in nine patients (17.0%). Overall diagnostic accuracy was similar between the EUS-FNB and EUS-FNA/B groups (83.7% vs. 84.9%; p=NS; Table 1). In the subgroup of SEM lesions, diagnostic accuracy remained similar in the EUS-FNB and EUS-FNA/B groups (81.0% and 70.6%; p=0.7). In cases where only a single needle size was used, diagnostic accuracy was numerically greater when a 19-gauge needle was used compared to 22-gauge or 25-gauge needles (Table 2). EUS-FNB procedures were significantly shorter than those in the EUS-FNA/B group (58.4 min vs. 73.5 min; p<0.0001).Table 1: Diagnostic accuracyTable 2: Diagnostic accuracy of needle sizes (EUS-FNB only)Conclusion: EUS-FNB without ROSE has a high diagnostic accuracy in lesions where histology is likely needed. Addition of EUS-FNA and ROSE is associated with increased time and resource utilization but does not improve diagnostic accuracy. This data suggests EUS-FNB without ROSE may be the optimal technique for lesions other than pancreas adenocarcinoma. Disclosure - Dr. Keswani - Consultant, Cook Medical Dr. Komanduri - Consultant, Cook Medical.

The endemisation of schistosomiasis in Porto de Galinhas, Pernambuco, Brazil, 10 years after the first epidemic outbreak

In 2000, after heavy rains and floods in Porto de Galinhas, Pernambuco, Brazil, an outbreak of schistosomiasis was recorded, of which 62.2% (412 cases) were of the acute clinical form. Between 2001-2009, occasional findings of Biomphalaria snails parasitised by Schistosoma mansoni indicated that disease transmission was still occurring. This motivated a new epidemiological survey between August-December 2010 to provide an update of the occurrence of this health hazard and to investigate the process of disease endemisation at this locality. This survey gathered parasitological, clinical and malacological data. The results of this survey, compared with data from the year 2000 survey, showed the following: (i) over these 10 years, there were declines in the total percentage of cases and the percentage of acute forms, (ii) the acute clinical form now represents 23.3% in contrast with the 62.2% detected in 2000 and (iii) the current prevalence of schistosomiasis is 15.7%, while in 2000 32.1% of the individuals were diagnosed as parasitised. Today, the chronic clinical form represents 76.7% of the total number of cases diagnosed, thus showing that over the 10-year period the occurrences of clinical forms became inverted. These findings, together with visual observation of insalubrious environmental conditions, indicate that schistosomiasis has become endemic in Porto de Galinhas.

Abstract P283: Operator Variation in Coronary Angioplasty and Stenting

Background: Post COURAGE trial the treatment of coronary artery disease has become a complex decision process, with many physicians advocating initial revascularization only for medical failures and high risk subgroups. The decision of whether to use Drug Eluting or Bare Metal Stents has also drawn wide attention and has changed practice. We examined the extent of variability with its implications for quality, utilization and health care costs on physician driven interventions compared to the UHC and national comparison benchmarks. Methods: The practice patterns of 11 interventional cardiologists in 2009 were reviewed relative to patient treatment and outcomes for determinants of variation in revascularization practice. Associations were evaluated by Chi square for significance and Pearson's correlation coefficients were calculated. Results: There were 1,977 PCI (44.6%) performed on 4,428 patients undergoing cardiac catheterization. PCI as a percentage of total cases varied widely by physician from 22.8% to 58.8%. The use of Bare Metal Stents ranged from 12.7% to 61.4% of cases [25.2% mean; benchmarks 18.4%, 21.8%]; Drug Eluting Stent use varied from 38.6% to 87.3% by operator [74.8% mean]. The number of stents placed/patient was significantly less for Bare Metal Stent cases (1.19-2.0 mean 1.9; benchmarks 1.6, 1.54) than for Drug Eluting Stent cases (1.46-2.92 mean 2.20; benchmarks 1.99,2.18). There was no significant correlation between the number of stents placed and 30 day readmission. There was no significant correlation between cath lab operator volume and conversion rate to angioplasty or to the number of stents placed. Conclusions: There is wide variation in revascularization practice that is physician associated. DES stent use has declined from a high of 90% to about 75% with procedures requiring multiple stents favoring the use of DES. Higher PCI revascularization rates and more extensive revascularization were not associated with a short term increase in adverse outcomes, LOS, or readmissions. The long-term outcomes and cost of more aggressive revascularization with PCI are unknown and will merit further investigation.

Total case of dog bites to humans and seasonal patterns of the bites

Dog bites are poorly understood and often underestimated public health problem as it causes huge medico-social problem as these attacks result in millions of injuries and thousands of deaths all over the world due to risk of rabies transmission. Approximately 1 in 20 dogs bite a human being during the dogs’ lifetime. The present study estimated average annual dog bites to humans and indicate seasonal pattern of the bite in Addis Ababa in the year 2008 and 2009. All data on total, stray and owned dog bites to humans are obtained from human rabies post exposure treatment record of the Zoonoses Diseases Research Team in the Ethiopian Health and Nutrition Research Institute. The data used are all dog bite cases in Addis Ababa of the year 2008 and 2009. A seasonal pattern of dog bites are also analyzed from the same data in the study period. Average annual or seasonal dog bites are expressed as a percentage of total cases, or as a mean ± SD and one-way analysis of variance (ANOVA) was applied for seasonal pattern of dog bites. The X2 test was used to determine the statistical significance between stray and owned dog bites. The average value for dog bites was 1097 ± 0.37/year for stray and 400 ± 1.06/year for owned dogs. In both years injuries caused by stray dogs was higher and significantly differed from injuries caused by owned dogs (t= 33.04, p=0.000). The highest average value of total dog bites was observed in the autumn months in 2008 (146.67 ± 0.89) as well in the autumn months for the two years together 281.67 ± 1.71). Mean of bites are significantly different between seasons in both years together (F=13.95, p=0.000).

Abstract P4-08-05: Delineation of HER2 Gene Status in Korean Breast Cancers by Standardized Immunohistochemistry (IHC) and Silver In Situ Hybridization (SISH): Comparison of Local IHC Result with Central IHC and SISH Results

Abstract Background: Amplification of the human epidermal growth factor receptor 2 (HER2) gene and concomitant protein overexpression are present in 20-25% of breast cancers. HER2 overexpression and/or gene amplification is associated with a worse clinical outcome and an important predictive marker for sensitivity to anthracycline-based chemotherapy and HER2- targeted therapy. In Korea, the HER2 status has usually been assessed by immunohistochemistry (IHC) in the laboratories. To verify the preanalytic, analytic, and postanalytic factors of IHC in multi-institutions, we assessed the interlaboratory variability of HER2 IHC by comparing the local IHC with the central IHC and SISH results, as a first step toward building a nationwide quality assurance program. Methods: The Breast Pathology Study Group of Korean Society of Pathologists collected 1,198 breast carcinoma samples from 7 university-based hospitals and constructed 56 tissue microarray (TMA) blocks with triplicate of 1 mm cores. Local IHC results for HER2 were obtained from 1,130 patients. We performed IHC (PATHWAY anti-HER2/neu (4B5) rabbit monoclonal antibody, Ventana Medical Systems) and SISH (INFORM HER2 DNA Probe Kit, Ventana Medical Systems) for HER2 on the TMA sections using the automated Benchmark platform (Ventana Medical Systems). We interpreted the results according to the American Society of Clinical Oncology/College of American Pathologists guidelines. Results from local IHC were compared with central IHC and SISH. The concordant rates between central IHC and SISH results were also calculated. Results: The total percentage of cases in each category of local IHC score was: 0/1+, 70.4%; 2+, 8.8% (range among hospitals, 0-36%); and 3+, 20.8% (10.8-28.8%). The percentage of central IHC results (1,110 patients) in each category was: 0/1+, 79.7%; 2+, 3.6% (1.1-8.3%); and 3+, 16.7% (13.1-18.8%). SISH results were obtained from 1,033 patients: negative, 79.5%; equivocal, 0.2% (0-1.6%); and positive, 20.3% (19.2-22.6%). SISH amplifications in each local IHC category were observed as follows: 0/1+, 4.3% (0.6-10%); 2+, 18.8% (5.6-66.7%); and 3+, 71.2% (50-97.3%). When considering the central SISH as gold standard, 3% of cases (30/995) were false negative and 6.3% (63/995) were false positive in local IHC. In central lab, the concordance rates between IHC 3+ and SISH-positive, and IHC 0/1+ and SISH-negative were 95.5% and 98%, respectively. Conclusions: The results of central IHC and SISH markedly decreased the interlaboratory variability of HER2 status. The measurement of HER2 gene amplification by SISH was less affected by the preanalytic factors than the measurement of overexpression of HER2 protein by IHC. Because the rate of false positivity is higher than that of false negativity in the local IHC, the quality assurance program needs to be focused on decreasing not only the false negativity, but also the false positivity of HER2 IHC in local laboratories Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-08-05.

M1203 Gastrointestinal Assessment in a Large Cohort of Patients Suffering from Systemic Sclerosis

G A A b st ra ct s opiate analgesics, non-steroidal anti-inflammatory drugs(NSAIDS), corticosteroids, aspirin and calcium antagonists. Results: A total of 899 patients with an incident diagnosis of perforated diverticular disease were identified. Compared with the population that did not smoke the OR of ever smoking was 1.49 (95% confidence interval [95% CI] 1.27-1.76), compared to those with a body mass index (BMI) 30 was 1.31 (95% CI, 1.03-1.66), and compared to those with no comorbidity those with a Charlson index >2 had an OR 2.39 (95% CI, 2.01-2.84) all data were mutually for each other. Current opiate analgesics and steroid use was associated with an increase in perforation (Table1) although the total percentage of cases exposed was small. Current use of a calcium antagonists, NSAIDs and aspirin were not associated with an increased risk of perforation. Data were adjusted for smoking, comorbidity, abdominal pain and BMI. Conclusion: Perforated diverticular disease is a serious surgical emergency and opiate analgesics and oral steroids increase the risk of diverticular perforation however obesity and smoking represent the principal modifiable risk factors at a population level. Table 1. Odds ratio for current use of NSAIDS, Opiate analgesics and steroids adjusted for BMI, smoking and comorbidity.

Pathology specimens over three decades

Objective To determine the range and frequency of diagnoses in specimens submitted for histopathological examination by general dental practitioners (GDPs). Methods A retrospective analysis was carried out of all cases submitted by GDPs for the period 1974–2003, using a Foxpro™ Windows database. The data were collated into 10 diagnostic categories each comprising number of diagnoses, percentage of each diagnosis within a diagnostic category and each diagnosis as a percentage of total cases. Results GDPs submitted 6,666 cases out of a total of 53,474 for this period. While the total number of specimens increased four-fold over the 30-year period, specimens from GDPs increased from 7% to 17%. The range of diagnoses increased from 18 to 45. Of the 617 GDPs who submitted material, 279 (45%) submitted less than two specimens each in 30 years. Nine malignant neoplasms were diagnosed. Other significant pathology included 320 benign neoplasms as well as diagnoses ranging from mucosal lesions such as lichen planus to odontogenic cysts. Conclusions It is clear that GDPs have provided an increased number of biopsy specimens over the last three decades. This reflects an increasing demand by GDPs for a diagnostic oral histopathology service and their use of this service should be encouraged.

Live Nativity and Brucellosis, Sicily

To the Editor: Worldwide, brucellosis remains a major zoonosis and an important cause of travel-associated illness (1). Brucellosis is transmitted to humans through the consumption of infected, unpasteurized, animal-milk products; direct contact with infected animal parts; or inhalation of infected aerosolized particles. We report an outbreak of brucellosis in a small village of the Ionic coast of Messina province (eastern Sicily). In 2003, health authorities in the Messina province were notified of 29 cases of brucellosis; 18 of the patients were members of 9 different families. All patients had observed a Nativity pantomime that used live animals and was organized by the local population. Nativities in Sicily last ≈1 month, during which the sheep are milked, cheese and are produced, and these products are sold or offered fresh to tourists. All 29 patients had consumed dairy products: tuma cheese by 29 (100%) and tuma and by 16 (55%). No other risk factors for brucellosis were reported. Symptoms appeared after a median of 45 days (range 30–70). Eight patients were children (3 male), and 21 were adults (10 male). The median age of the children was 10.5 years (range 6–13) and of the adults, 42 years (range 16–67). Hospitalization was required for 5 patients. For 2 adults, brucellosis was complicated by spondylitis. The real extent of the outbreak was likely large because in Sicily ≈60% of cases may go unreported. Furthermore, we report only the cases that occurred in the villages of Messina province and that were reported to health authorities; but tourists from many other areas in Italy and some from outside Italy generally attend such events. Southern Italy has commonly been implicated as a venue for travel-associated brucellosis (2). In Italy, the overall incidence of brucellosis has gradually declined in the past 30 years, especially in northern Italy, where the disease is now reported only sporadically. This trend, however, has led to an increase in the percentage of total cases in Italians reported from the southern provinces of Calabria, Campagna, Puglia, and Sicily; of the 520 cases reported in 2003, 488 (93.8%) were reported from 4 southern regions, compared with 63.7% in 1994. Sicily alone reported 57.6% of the 2003 cases and for the past decade has had an average annual incidence of >100 cases per million (1,3). The disease is almost always caused by Brucella melitensis (4). The southern localization of the disease in Italy is obviously related to the relative high prevalence of infections in sheep and goats (5). Ovine and caprine population density is higher in the southern regions of Italy than in the rest of the country (6). The Italian brucellosis eradication plan consists of a test-and-slaughter practice. However, in Sicily a vaccination campaign with B. melitensis Rev.1 strain has been started. In 2003, ≈99% of the stock farms were tested, and ≈18% of them were infected (3). The major problems reside with small flocks that undergo frequent transhumance (seasonal movement of herds between regions with different climates) in isolated regions where testing by veterinarians is difficult or avoided by the owners (a typical drawback of test-and-slaughter practices). Technically, is not a cheese, but rather is a cheese by-product. The name ricotta means cooked again, referencing the production method. Ricotta is made from whey drained from tuma, provolone, and other cheeses. Heat is then used to separate, by precipitation, the remaining albumin from the whey left after making lactic acid/rennet–precipitated cheeses. It is eaten as is or used for food seasoning (e.g., classic Italian lasagna and ravioli). A cream made of sieved and sugar is used to prepare many desserts, like cannoli and cassata cake. Being cooked 2 times, should not contain viable Brucella organisms; however, shepherds sprinkle fresh milk on wicker baskets to refresh the they contain, thereby contaminating the product. Tuma is a typical Sicilian fresh cheese made from sheep's milk. It has a cylindrical appearance and is sold fresh, no more than 2 days old. It has no crust, and the dough is white or ivory-white without holes. The texture is very soft, tender, and wet. It is generally served with ham, wines, and fruits as a table cheese. Tuma cheese should be considered as the major vehicle of B. melitensis infection in Sicily. Although most similar dairy products produced in Sicily are derived from organized dairy companies and have been pasteurized, traditional delicacies from small villages may still cause brucellosis outbreaks.

Lower-Class Mobilization and Policy Linkage in the U.S. States: A Correction

Hill, Leighley, and Hinton-Andersson (1995) report a series of empirical analyses intended to test four hypotheses about the association between lower-class mobilization and public policies in the American states. Those hypotheses are: (1) the higher the turnout of the lower class, the more liberal is state welfare policy; (2) the higher economic and fiscal stress, the lower the association between lower-class turnout and welfare policy; (3) liberal party control of state government is the linkage mechanism that relates lower-class mobilization to policy; and (4) party competition is the linkage mechanism that relates lower-class mobilization to policy. In this note we explain how the incorrect handling of missing data in those original analyses led to an erroneous conclusion about the third hypothesis test, an incorrect sign reported for one control variable in the first two hypothesis tests, and small changes in the significance of a few other control variables. We explain the cause of the errors, report corrected analyses, and close with brief observations about the theoretical and practical implications of the correct empirical results. The error in the original analyses arose because missing data codes for three variables in a cross-sectional data set originally created in SPSSX were interpreted as valid values when the data set was expanded into a pooled, cross-sectional time-series design and analyzed with the MICROCRUNCH software package. Those three variables were for state party competition, mass political liberalism, and state party elite liberalism, and the missing data affect four states. Thus the missing data values biased the coefficients reported for these variables in the original analyses. The optimal procedures for handling such missing data problems are unsettled (Bartels and Brady 1991, 136-7). For the purposes of this note we report analyses that are conservative by some, but not all, criteriaanalysis of only those cases with complete data on the variables under study. This procedure appears especially appropriate in light of the absence of a consensus on an alternative one and the small percentage of total cases eliminated from consideration by the procedure in the present instance.