Lower prevalence of protective antibodies for 2015/2016 influenza A(H1)pdm circulating strains comparing to seroprevalence for 2009 influenza A(H1)pdm virus

DDI-INSA em colaboração com a Rede Portuguesa de Laboratórios para o Diagnóstico da GripeBackground: Since 2009, influenza A(H1)pdm09 is circulating in the human population infecting in different ways specific age groups. The study aims to assess the seroprotection for A/California /07/2009 vaccine strain and evaluate the seroprotection for the circulating A(H1)pdm09 strains (clade 6B) in the Portuguese population. Seroepidemiological data can determine the vulnerable populations to disease and support intervention and action regarding vaccination programmes and other preventive measures, particularly in high-risk groups. Methods: To study influenza immunity a non-probabilistic sample was used. Samples were collected from people attending to hospital laboratories (n=13) for other reasons aside from influenza infection. We developed a cross-sectional study based on a convenience sample of 734 sera collected during July 2016, from all age groups (0–4; 5–14; 15–44; 45-64 and ≥65 years old), both genders, covering mainland and Atlantic islands. Sera were randomly selected. All samples were anonymized and recorded data: district residence/sample collection, gender and age. Antibody titers to A(H1)pdm09 virus strains [A/California /07/2009 and A/Lisboa/58/2015 (clade 6B)] were assessed by hemagglutination inhibition (HI) assay. HI titer>40 were considered protective. Seroprevalence estimates, overall and by age group, were calculated with 95% confidence intervals (95% CI). The HA1 subunit of the hemagglutinin gene from A(H1)pdm09 viruses used in HI were sequenced. Results: In July 2016, the prevalence of protective antibodies for influenza A/California/07/2009 was 38% (95% CI: 34–41) and for A/Lisboa /58/2015 was 23% (95% CI: 21–27). Highest seroprevalence was observed in 5-14 age group for both strains, 55% (95% CI: 47–63) for A/California/07/2009 and 42% (95% CI: 35–50) for A/Lisboa/58/2015. The lowest seroprevalences were detected in the 65+ age group for A/California/07/2009 (28%; 95% CI: 22–36) and in the 45-64 for the A/Lisboa /58/2015 (9%; 95% CI: 6-15). Was observed a reduced prevalence of protective antibodies for A/Lisboa /58/2015 for all age groups, although a higher decrease was seen in the adults 45-64 years old (24% drop in seroprevalence). The influenza A/Lisboa/58/2015 presented four amino acid substitutions in antigenic sites: S162N e K163Q (Sa), S185T (Sb) and S203T (Ca1), belonging to 6B.1clade. Conclusions: Although 38% of study population have demonstrated to have seroprotection for A(H1)pdm09 vaccine strain this could not represent seroprotection to the currently circulating A(H1)pdm09 strains. Individuals in the age group of 45-64 years old are more susceptible to infection by currently circulating influenza A(H1)pdm09 viruses. The presence of K163Q (Sa), S185T (Sb) substitutions are likely to be involved in antigenic drift, as previously described, allowing the virus to escape from immune response namely the one that could be induced by the vaccine. In future this event should be closely monitored, although WHO recommended a new A(H1)pdm09 strain to be included in the next season flu vaccine.N/

A Case of Cutaneous Infection Caused by Mycobacterium Szulgai with Progression to Acute Respiratory Distress Syndrome

A 59-year-old man presented with a skin eruption and bilateral swelling of the legs. Soon after the initial presentation, he developed acute respiratory distress syndrome (ARDS) with miliary lung nodules. Culture of samples from the skin ulcers, sputum, and bronchoalveolar lavage fluid all revealed Mycobacterium szulgai infection. The patient was successfully treated with antituberculosis drugs. M. szulgai infection is very rarely reported worldwide, and disseminated infection usually occurs in immunocompromised patients. However, the present patient was a non-immunocompromised case, although he was a hepatitis B virus carrier. While the progression to ARDS from M. tuberculosis infection is well known, this is the first case of M. szulgai infection progressing to ARDS

Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit

BACKGROUND: Continual improvements in diagnostic processes are needed to minimise the proportion of patients with cancer who experience diagnostic delays. Clinical audit is a means of achieving this. AIM: To characterise key aspects of the diagnostic process for cancer and to generate baseline measures for future re-audit. DESIGN AND SETTING: Clinical audit of cancer diagnosis in general practices in England. METHOD: Information on patient and tumour characteristics held in the English National Cancer Registry was supplemented by information from GPs in participating practices. Data items included diagnostic timepoints, patient characteristics, and clinical management. RESULTS: Data were collected on 17 042 patients with a new diagnosis of cancer during 2014 from 439 practices. Participating practices were similar to non-participating ones, particularly regarding population age, urban/rural location, and practice-based patient experience measures. The median diagnostic interval for all patients was 40 days (interquartile range [IQR] 15-86 days). Most patients were referred promptly (median primary care interval 5 days [IQR 0-27 days]). Where GPs deemed diagnostic delays to have occurred (22% of cases), patient, clinician, or system factors were responsible in 26%, 28%, and 34% of instances, respectively. Safety netting was recorded for 44% of patients. At least one primary care-led investigation was carried out for 45% of patients. Most patients (76%) had at least one existing comorbid condition; 21% had three or more. CONCLUSION: The findings identify avenues for quality improvement activity and provide a baseline for future audit of the impact of 2015 National Institute for Health and Care Excellence guidance on management and referral of suspected cancer

FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management

Non peer reviewe

Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit.

BACKGROUND: Continual improvements in diagnostic processes are needed to minimise the proportion of patients with cancer who experience diagnostic delays. Clinical audit is a means of achieving this. AIM: To characterise key aspects of the diagnostic process for cancer and to generate baseline measures for future re-audit. DESIGN AND SETTING: Clinical audit of cancer diagnosis in general practices in England. METHOD: Information on patient and tumour characteristics held in the English National Cancer Registry was supplemented by information from GPs in participating practices. Data items included diagnostic timepoints, patient characteristics, and clinical management. RESULTS: Data were collected on 17 042 patients with a new diagnosis of cancer during 2014 from 439 practices. Participating practices were similar to non-participating ones, particularly regarding population age, urban/rural location, and practice-based patient experience measures. The median diagnostic interval for all patients was 40 days (interquartile range [IQR] 15-86 days). Most patients were referred promptly (median primary care interval 5 days [IQR 0-27 days]). Where GPs deemed diagnostic delays to have occurred (22% of cases), patient, clinician, or system factors were responsible in 26%, 28%, and 34% of instances, respectively. Safety netting was recorded for 44% of patients. At least one primary care-led investigation was carried out for 45% of patients. Most patients (76%) had at least one existing comorbid condition; 21% had three or more. CONCLUSION: The findings identify avenues for quality improvement activity and provide a baseline for future audit of the impact of 2015 National Institute for Health and Care Excellence guidance on management and referral of suspected cancer

A1C to Detect Diabetes in Healthy Adults: When should we recheck?

OBJECTIVE: To evaluate the optimal interval for rechecking A1C levels below the diagnostic threshold of 6.5% for healthy adults. RESEARCH DESIGN AND METHODS: This was a retrospective cohort study. Participants were 16,313 apparently healthy Japanese adults not taking glucose-lowering medications at baseline. Annual A1C measures from 2005 to 2008 at the Center for Preventive Medicine, a community teaching hospital in Japan, estimated cumulative incidence of diabetes. RESULTS: Mean age (+/-SD) of participants was 49.7 +/- 12.3 years, and 53% were male. Mean A1C at baseline was 5.4 +/- 0.5%. At 3 years, for those with A1C at baseline of &lt;5.0%, 5.0-5.4%, 5.5-5.9%, and 6.0-6.4%, cumulative incidence (95% CI) was 0.05% (0.001-0.3), 0.05% (0.01-0.11), 1.2% (0.9-1.6), and 20% (18-23), respectively. CONCLUSIONS: In those with an A1C &lt;6.0%, rescreening at intervals shorter than 3 years identifies few individuals (approximately or=6.5%.</or=1%)

Random Capillary Blood Glucose Cut Points for Diabetes and Pre-Diabetes Derived From Community-Based Opportunistic Screening in India

OBJECTIVE: To determine random capillary blood glucose (RCBG) cut points that discriminate diabetic and pre-diabetic subjects from normal individuals. RESEARCH DESIGN AND METHODS: RCBG was performed in 1,333 individuals randomly chosen from 63,305 individuals who had participated in an opportunistic screening program. An oral glucose tolerance test was also performed by venous plasma glucose on an autoanalyzer. RCBG cut points that discriminate diabetes, impaired glucose tolerance (IGT), and impaired fasting glucose (IFG) were determined using receiver operating characteristic curves. RESULTS: Using 2-h plasma glucose >or=200 mg/dl (11.1 mmol/l) criterion, the RCBG cut point of 140 mg/dl (7.7 mmol/l) gave the highest sensitivity and specificity. For 2-h plasma glucose >or=200 mg/dl (11.1 mmol/l) and fasting plasma glucose (FPG) >or=126 mg/dl (7.0 mmol/l) criteria, either 2-h plasma glucose >or=200 mg/dl (11.1 mmol/l) or FPG >or=126 mg/dl (7.0 mmol/l) criterion, and the FPG >or=126 mg/dl (7.0 mmol/l) criterion, RCBG cut point was 143 mg/dl (7.9 mmol/l). RCBG cut points for IGT, IFG according to World Health Organization criterion, and IFG according to American Diabetes Association criterion were 119 mg/dl (6.6 mmol/l), 118 mg/dl (6.6 mmol/l), and 113 mg/dl (6.3 mmol/l), respectively. CONCLUSIONS: Asian Indians with RCBG >110 mg/dl at screening can be recommended to undergo definitive testing