Determining the validity of the mycobacterium polymerase chain reaction assay in histological samples showing granulomatous inflammation with a negative ziehl-neelsen stain

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment for the Degree of Master of Medicine In the branch of Anatomical Pathology Johannesburg 2015Background: Mycobacterium tuberculosis (Mtb) poses a major global health problem. According to the World Health Organization, South Africa is a country with one of the highest reported incidence rates of this disease. Key to overcoming this preventable and treatable disease lies in establishing a reliable and rapid diagnostic approach. Aims and Objectives: This study aims to investigate the validity of the mycobacterium polymerase chain reaction (PCR) assay applied to formalin-fixed, paraffin-embedded tissue in which the histology showed granulomatous inflammation with no demonstrable acid-fast bacilli. Methods: A retrospective, cross sectional and non-interventional study was conducted on 121 histopathology cases showing granulomatous inflammation with a negative Ziehl-Neelsen (ZN) stain. The mycobacterium PCR results obtained in these cases were compared against the results of mycobacterium culture obtained from a specimen derived from the same or related site as the biopsy. Results: The mean age of the study population was 35.3 years and the study cohort included 63 males and 58 females. The sensitivity of nested mycobacterium PCR (detecting the 133 base pair product of the heat shock protein 65 kilo Dalton gene), was 64.1% and the specificity was 68.2%. The positive and negative predictive values were 49% and 80% respectively. Twenty six of the 121 cases studied had a false positive result (21.5%). CONCLUSION: There are many factors that may influence the result of a PCR assay and the interpretation thereof. Some of these factors include the inability of the test to distinguish between live and dead bacilli, the high risk of carry over contamination, and the paucibacillary nature of certain samples with an unequal distribution of the few bacilli that may be present. Although the sensitivity and specificity of mycobacterium PCR on paucibacillary, formalin-fixed, paraffin embedded tissue is suboptimal, the interpretation of these results must be performed in conjunction with the overall clinical presentation of the patient.MT201

Enhanced minimum variance optimisation: a pragmatic approach

Since the establishment of Markowitz's theory, numerous studies have been carried out over the past six decades or so that cover the benefits, limitations, modifications and enhancements of Mean Variance (MV) optimisation. This study endeavours to extend on this, by means of adding factors to the minimum variance framework, which would increase the likelihood of outperforming both the market and the minimum variance portfolio (MVP). An analysis of the impact of these factor tilts on the MVP is carried out in the South African environment, represented by the FTSE-JSE Shareholder weighted Index as the benchmark portfolio. The main objective is to examine if the systematic and robust methods employed, which involve the incorporation of factor tilts into the multicriteria problem, together with covariance shrinkage – improve the performance of the MVP. The factor tilts examined include Active Distance, Concentration and Volume. Additionally, the constant correlation model is employed in the estimation of the shrinkage intensity, structured covariance target and shrinkage estimator. The results of this study showed that with specific levels of factor tilting, one can generally improve both absolute and risk-adjusted performance and lower concentration levels in comparison to both the MVP and benchmark. Additionally, lower turnover levels were observed across all tilted portfolios, relative to the MVP. Furthermore, covariance shrinkage enhanced all portfolio statistics examined, but significant improvement was noted on drawdown levels, capture ratios and risk. This is in contrast to the results obtained when the standard sample covariance matrix was employed

A day in the life of a paediatric surgeon: a PAPSA research study

Objectives This study aimed to create a snapshot picture of the global workload of paediatric surgeons and identify differences between countries.Methods Surgeons from 13 paediatric surgical units in different countries across the world were asked to record the number and type of admissions to the paediatric surgery service over a 24-h period from 8 a.m. on 23 May 2012.Results Data were recorded for 13 units from 13 countries: 11 low and middle  income countries (LMICs) and two high-income countries (HICs). Dar es Salaam, Tanzania, had the greatest number of admissions. Two units in HICs had the lowest number of admissions, other than the Nigerian unit, which only had three admissions due to a hospital strike on the day surveyed. The percentage of emergency  admissions ranged from 38 to 83%. Those units with the highest number of total admissions tended to also have the highest proportion of emergencies. Trauma was  the most frequently reported admission reason, accounting for 18% of admissions. However, there were no cases of trauma in HIC units.Conclusion The spectrum of paediatric surgery differs between countries, in  particular between LMICs and HICs. Units in LMICs tend to have a greater number  of admissions, including a wider variety of conditions and a higher proportion of emergency work. Paediatric surgery in LMICs faces many challenges. This  highlights the importance of training specialist paediatric surgeons in these countries. Further data are still needed to fully outline the burden of disease in paediatric surgery, especially in LMICs.Keywords: epidemiology, global surgery, paediatric surger

A pitfall in the interpretation of plain abdnominal radiographs in neonatal intestinal perforation: a case report

<p>Abstract</p> <p>Introduction</p> <p>The recognition of neonatal intestinal perforation relies on identification of free gas in the peritoneum on plain abdominal radiographs and the associated clinical signs. The neonatal bowel takes several hours to fill with gas, potentially obscuring one of the radiological signs of bowel perforation in the neonate.</p> <p>Case presentation</p> <p>We describe the case of a male, Caucasian neonate, born prematurely at 35⁺²weeks of gestation, who was suspected before birth to be at risk of intestinal perforation, based on antenatal ultrasound signs of bowel obstruction. However, the diagnosis of intestinal perforation after birth was initially delayed because the first abdominal radiograph, requested by the neonatal team, was taken too early in the clinical progression of the neonate's condition. As a consequence, this delayed referral to the paediatric surgical team and definitive management.</p> <p>Conclusion</p> <p>This case illustrates how consideration of the timing of abdominal radiographs in suspected intestinal perforation in the neonate may avoid misinterpretation of radiographic signs, thereby avoiding delays in referral and treatment in the crucial first few hours of life.</p

Management of undescended testes: a comparative study in England and Africa

Objective The aim of our study was to determine the timing of referrals and the outcome of undescended testes (UDT) over a 4-year period in a tertiary centre in England, and to compare this with a similar centre in Nigeria. Background data Cryptorchidism is a recognized cause of infertility and a key risk factor for testicular malignancy. Current recommendations are that orchidopexy be performed between 12 and 18 months of age; however, there is no consensus on this.Materials and methods Data were obtained for orchidopexies performed between 2003 and 2007 from a tertiary referral centre in England. A standardized proforma was used to collect data into an Excel database, which was analysed and compared with data from a similar centre in Nigeria.Results Eighty-eight patients from a tertiary referral centre in England underwent surgery for UDT. Fifty-six (63.6%) patients were referred and 38 (43.2%) patients were operated on within 2 years of age. Doctors and health visitors accounted for 69 (78.5%) referrals to the tertiary centre. Data from Nigeria demonstrated that of the 61 cases, 13 (21%) patients presented and 11 (18%) patients were operated on by 24 months. Referral beyond 60 months of age in the English series was due to ascending testis, whereas in the Nigerian study, the delayed presentation was due to delayed referral from lack of knowledge of the condition.Conclusion In England and Nigeria, there is a lack of definitive guidelines relating to the appropriate age of referral of patients with UDT. A structured care pathway is needed to enable early detection and definitive management

Building back better children's surgical services toward universal health coverage: Perspectives from Bangladesh and Zimbabwe

IntroductionThis article is part of the Research Topic ‘Health Systems Recovery in the Context of COVID-19 and Protracted Conflict’. Children's surgical services are crucial, yet underappreciated, for children's health and must be sufficiently addressed to make and sustain progress toward universal health coverage (UHC). Despite their considerable burden and socioeconomic cost, surgical diseases have been relatively neglected in favor of communicable diseases living up to their inauspicious moniker: ‘the neglected stepchild of global health'. This article aims to raise awareness around children's surgical diseases and offers perspectives from two prototypical LMICs on strengthening surgical services in the context of health systems recovery following the COVID-19 experience to make and sustain progress toward UHC.ApproachWe used a focused literature review supplemented by the perspectives of local experts and the 6-components framework for surgical systems planning to present two case studies of Bangladesh and Zimbabwe. The lived experiences of the authors are used to describe the impact of COVID-19 on respective surgical systems and offer perspectives on building back the health system and recovering essential health services for sustainability and resilience.FindingsWe found that limited high-level policy and planning instruments, an overburdened and under-resourced health and allied workforce, underdeveloped surgical infrastructure (from key utilities to essential medical products), lack of locally generated research, and the specter of prohibitively high out-of-pocket costs for children's surgery are common challenges in both countries that have been exacerbated by the COVID-19 pandemic.DiscussionContinued chronic underinvestment and inattention to children's surgical diseases coupled with the devastating effect of the COVID-19 pandemic threaten progress toward key global health objectives. Urgent attention and investment in the context of health systems recovery is needed from policy to practice levels to improve infrastructure; attract, retain and train the surgical and allied health workforce; and improve service delivery access with equity considerations to meet the 2030 Lancet Commission goals, and make and sustain progress toward UHC and the SDGs

Exploratory laparotomy in the management of confirmed necrotizing enterocolitis

Introduction: Necrotizing enterocolitis (NEC) is a serious gastrointestinal emergency in newborn infants. Surgical management includes primary peritoneal drainage and/or exploratory laparotomy with bowel resection. This study describes obstetric complications, postnatal comorbidities, surgical care and intermediate postoperative outcomes in all infants with surgically and/or histologically proven NEC, who underwent exploratory laparotomy at our tertiary referral centre.Materials and methods: We conducted a retrospective review between January 2005 and December 2010. Results are reported as median (range). Fisher’s exact test (two tailed) was used for statistical analysis. A P-value of 0.05 or less was considered statistically significant.Results: A total of 71 infants had suspected (Bell’s stageZ1) NEC. Of them, 32 infants underwent laparotomy for stage 2–3 NEC. We excluded 11 infants with surgically and/or histologically proven spontaneous intestinal perforation. In the remaining 21 infants with confirmed NEC, median gestational age was 27 weeks (23–39 weeks) and median birth weight was 720 g (440–3510 g). NEC was suspected after a median 14 days of life (1–49 days of life). Fifteen patients (71%) were initially managed medically for a median total of 8 days (1–25 days). Laparotomy was performed after a median of 7 days (&lt;1–35 days) from the suspicion of NEC. Eleven infants (52%) underwent bowel resection and enterostomy, four infants (19%) underwent  bowel resection with primary anastomosis and one infant (5%) underwent proximal diverting jejunostomy. Bowel perforation was seen in seven patients (33%). Necrosis totalis was evident in five patients (24%). There were 12 postoperative deaths (57% mortality), and seven deaths (58%) occurred during the first 30 days. Infants who died were more likely to have had absent/reversed enddiastolic flow (n=5, P= 0.64), intrauterine growth retardation (n=5, P = 0.18) or a gestational birth weight between 501 and 750 g (n=9, P = 0.08). In the surviving children (n= 9), the median length of hospital stay was 134 days (87–190 days) and postoperative sequelae were frequently seen.Conclusion: The morbidity and mortality for infants with confirmed NEC who undergo laparotomy remain high in infants despite optimal medical and surgical care. Keywords: exploratory laparotomy, necrotizing enterocolitis, surger

British Association of Paediatric Surgeons International Affairs Committee: A report of international fellowships

Objective This paper describes the fellowship programme of the International Affairs Committee of the British Association of Paediatric Surgeons.Patients and methods The selection of low-income and middle-income country (LMIC) fellows from 2005 to 2016, their funding, experience, and current roles are described. Qualitative and quantitative analysis was performed. Results Thirty-eight trainees from 21 LMIC were awarded fellowships over the 11-year period. Thirty-two have completed the fellowship at time of writing, all are now in consultant positions. Obtaining a visa was the single most cited barrier to starting the fellowship. Twenty completed the questionnaire. Hundred percent felt the  fellowship had contributed to personal development and 71% had altered clinical practice subsequent to their experience. Thirty-three percent have gained research opportunities.Conclusion This evaluation supports LMIC-high-income country partnerships and highlights the benefits of fellowships to both the individual surgeon, their department and patient population.  Keywords: BAPS, fellowship, low- and middle-income country, partnershi

Lessons Learnt from Operationalising an International Collaborative Multi-Centre Study

Many medical students are both skilled and experienced in healthcare research, statistical analysis and evidence synthesis; assets that can be deployed to great effect in order to conduct research and contribute to the body of evidence - particularly in outbreak situations where senior doctors may be redeployed to clinical duties, thus ensuring that the next generation of academic clinicians’ interest and knowledge does not go in vain.&nbsp;Here, we document the process by which a group of medical students across the world, with senior support, harnessed their enthusiasm and the power of technology to play leading roles in an international multi-centre study run by the Global Health Research Group on Children’s Non-Communicable Diseases (Global Children’s NCDs). Many lessons have been learnt from the successful operationalisation of this study, which we hope to impart in this article. Our operations team consisted of: a social media team who manage our various accounts; a graphic design team who produce visuals to illustrate milestones achieved or highlight countries from which we did not yet have representatives; a network team who constructed a database to manage our extensive collaborator network; a communications team who managed emails and maintained regular contact with collaborators as well as producing a guide of common issues; a researcher support team who worked to ensure that any issues faced were dealt with promptly by hosting drop-in sessions; and finally a research capacity building team. We found that medical students bring fresh perspectives and an open-minded approach which is useful in reframing challenges and generating innovative solutions; thus it is vital to give them the opportunity to collaborate with, and learn from senior academics and policy-makers.&nbsp