Gurdeep S. Mannu

The non-cardiac use and significance of cardiac troponins.

Cardiac Troponins are blood markers of myocardial damage and are widely utilised across all acute medical departments. However, with a massive rise in requests for this test, the interpretation of raised serum levels in the absence of cardiac sounding clinical features can become a clinical conundrum. This is especially true if the numerous causes of positive test results are not fully appreciated. A thorough understanding of the strengths and weaknesses of this blood test in light of a patient population living longer, increasing in comorbidities and possible causes of false test results can provide invaluable support in establishing an accurate diagnosis and instigating effective management. This article will describe the history of cardiac markers along with a discussion of the various causes of elevated cardiac troponins outside acute coronary syndrome. It will elaborate on the applications and significance of this blood test and the potential uses of positive results with elevated serum Troponin levels.

Prognosis of multi-lobar pneumonia in community-acquired pneumonia: A systematic review and meta-analysis

BACKGROUND Pneumonia is the leading cause of infection related mortality. Multilobar pneumonia (MLP) may have poorer outcomes and is a constituent of some prognostic indices. Our aim was to systematically-review and meta-analyse the impact of multi-lobar involvement in pneumonia. METHODS We searched PubMed in June 2012 for studies reporting on the association between MLP and clinical outcomes. Potentially relevant studies were cross checked by two independent reviewers before final inclusion. Odds-ratios (OR) for the association between MLP and mortality, unfavourable outcomes, and poor treatment response were pooled using random effects meta-analysis. RESULTS Twenty-two studies were included in this report. There were a total of 11,456 pneumonia patients including 2897 (25.3%) patients with MLP. As there was substantial clinical and statistical heterogeneity in the overall dataset, we limited the main meta-analysis to patients with community-acquired pneumonia (CAP). This showed that MLP was associated with increased mortality, OR 2.57 (95% CI: 1.83-3.61), with no statistical heterogeneity (I(2)=0%). Evidence from other settings suggests that MLP may also be associated with higher likelihood of other poor outcomes such as worsening clinical/radiological status, delayed resolution, and need for mechanical ventilation. CONCLUSION MLP appears to be an independent risk factor for mortality in CAP. It may be possible to improve commonly used prognostic indices in CAP by addition of MLP as a criterion.

Management of Pruritus in Chronic Liver Disease

Background. There continues to be uncertainty on the ideal treatment of pruritus in chronic liver disease. The aim of this study was to gather the latest information on the evidence-based management of pruritus in chronic liver disease. Methodology. A literature search for pruritus in chronic liver disease was conducted using Pubmed and Embase database systems using the MeSH terms “pruritus,” “chronic liver disease,” “cholestatic liver disease,” and “treatment.” Results. The current understanding of the pathophysiology of pruritus is described in addition to detailing research into contemporary treatment options of the condition. These medical treatments range from bile salts, rifampicin, and opioid receptor antagonists to antihistamines. Conclusion. The burden of pruritus in liver disease patients persists and, although it is a common symptom, it can be difficult to manage. In recent years there has been greater study into the etiology and treatment of the condition. Nonetheless, pruritus remains poorly understood and many patients continue to suffer, reiterating the need for further research to improve our understanding of the etiology and treatment for the condition.

Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction does not significantly delay surgery in early breast cancer.

Sentinel lymph node biopsy (SLNB) before mastectomy and immediate breast reconstruction (IBR) may help to avoid the negative cosmetic effects of radiotherapy on reconstructed breasts in lymph node‐positive patients. Concerns have been raised regarding possible delays whilst awaiting the SLNB result prior to definitive surgery, which needs to be performed within 31 days of cancer diagnosis. The aim was to investigate whether initial SLNB delays mastectomy and IBR.

An interesting rash following bowel and abdominal wall transplantation

A 41-year-old man developed an ischaemic bowelfrom a paroxysmal embolic event via patentforamen ovale (PFO). As a result he had emergencylaparotomy and had a near total enterectomy(leaving just 18 cm colon remaining) with duode-nostomy and loss of abdominal domain. His PFOwas closed and he was established on total parentalnutrition for irreversible intestinal failure.He underwent a successful isolated bowel andabdominal wall composite allograft transplant froma donor (human leucocyte antigen match: 2–2-1),one year after the ischaemic event. Postoperatively,his immunosuppression was maintained with tacro-limus therapy. Several weeks following his trans-plant he attended the outpatient clinic with a 4-dayhistory of a non-pruritic rash (shown in the image)over his transplanted abdominal graft (figure 1).The faint non-pruritic erythematous papular fol-licular eruption spread over the entire abdominalgraft. The rest of the patient ’s skin was normal. A1 mm punch biopsy was obtained which showed peri-follicularchronicinflammatory cellinfiltrate and over-lying spongiosis suggesting Banff grade II acuterejection. However, there were no signs of rejectionon endoscopic examination of the transplantedbowel, which had healthy pink mucosa throughout.He received three doses of methylprednisolone andtherashsubsequentlyresolvedwith thistreatment.

Incidentally raised cardiac Troponin I has a worse prognosis in older patients compared to those with normal cardiac Troponin I and patients with Acute Coronary Syndrome:A Cohort Study

Background: Incidentally elevated cardiac troponin I (cTnI) levels are common in acutely unwell older patients. However, little is known about how this impacts on the prognosis of these patients. Objective: We aimed to investigate whether incidentally elevated cTnI levels (group 1) are associated with poorer outcome when compared to age- and sex-matched patients without an elevated cTnI level (group 2), and to patients diagnosed with acute coronary syndrome (group 3). Patients and Methods: This prospective, matched cohort study placed patients ≥75 years old who were admitted to a University teaching hospital into groups 1-3, based on the cTnI levels and underlying diagnosis. Outcomes were compared between the groups using mixed-effects regression models and adjusted for renal function and C-reactive protein. All-cause mortality at discharge, at 1 month and 3 months, alongside the length of hospital stay (LOS), were recorded. Results: In total, 315 patients were included, with 105 patients in each of the 3 groups. The mean age was 84.8 ± 5.5 years, with 41.9% males. All patients were followed up for 3 months. The percent all-cause mortality at discharge and the LOS for groups 1, 2 and 3 were 12.4, 3.8 and 8.6% and 11.2, 8.5 and 7.7 days, respectively. Group 1 had significantly increased mortality at 3 months [odds ratio (OR) 2.80, 95% confidence interval (CI) 1.12-6.96; p = 0.040] and LOS (OR 1.39, 95% CI 1.08-1.79; p = 0.008) compared to group 2 and did not differ significantly when compared to 3-month mortality (OR 2.39, 95% CI 0.91-6.29; p = 0.079) or LOS (OR 1.26, 95% CI 0.96-1.66; p = 0.097) in group 3. Conclusion: There is a significant association between an incidental rise in cTnI level with mortality and LOS in older patients. Further research is required to evaluate whether a more systematic management of these patients would improve the prognosis.

The ideal timing of ureteric stent removal in transplantation patients

Dear Sirs, With great interest, we read the paper by Alberts et al. [1], in which the authors report the results of their systematic review of urological complications following various ureterovesical anastomotic techniques. The authors included a subanalysis of the effect of stenting on outcomes from various ureterovesical anastomotic techniques. The authors compared the impact of stenting and nonstenting to assess the amount of bias, and this may have contributed to the rates of urological complications between different ureterovesical anastomotic techniques. These analyses did not show significant differences between the outcomes for both stented and nonstented groups. However, we feel that it is an oversimplification to cohort all studies using ureteric stents together as the duration of ureteric stent in situ is a significant factor in longer-term morbidity and it may obscure differences in outcomes between shorterand longer-term stent durations. The authors note that there were different durations of ureteric stenting within the stented study group and that there is a risk of urinary tract infection (UTI) with stents in situ for longer periods. However, they did not conduct a subanalysis based on ureteric stent duration in situ. The ideal timing of stent removal post-transplantation is a contentious issue. The authors have explained that there were not enough data in the included studies to assess the effect of ureteric stenting on UTIs and so we have collated our centres’ longer-term data on this topic to contribute our experience of ureteric stenting. The guideline at our institution is for ureteric stent removal at 6 weeks post-operatively. We investigated how the rates of UTI varied on the duration of ureteric stent in situ. We conducted a retrospective observational study on all patients who had ureteric stents inserted postrenal transplantation between January 2009 and March 2013 at our centre. A total of 404 patients were included. The average age of the cohort was 47.8 years (SD 12.7) of which 51 patients (14%) had UTIs. A large proportion of patients (26%) had their stent removed 7–8 weeks post-operatively. The reasons for late removal were pragmatic; however, there was no increase in UTI rate in this cohort compared with patients who had their stent removed before 7 weeks (Table 1). The average age of patients who had complications was 50.2 years (SD 12.5). Several studies have concluded that early stent removal at 1 week [2,3], 2 weeks [4,5], 4 weeks [6] and 4–6 weeks [7] is beneficial. However, these studies have not assessed UTI risk in stents as long as 6–8 weeks in situ [2,8], and our cohort is the largest study on longer-duration stents and shows that this risk appears to tail off over time (Table 1) and is not linearly related to the duration of stent in situ as previously perceived [3]. It is clear that the duration of stents is important for UTIs, and so, it may be equally important when considering urological complications from different anastomotic techniques. It may be possible that the outcomes from the stented group described by Alberts et al. [1] may be confounded if outcomes from studies with longer-duration stents are obscured by results from studies with

Graft versus host disease following small bowel and abdominal wall transplantation.

A 24-year-old man with short gut syndrome due to severe fistulating Crohns disease, underwent a simultaneous isolated small bowel and abdominal wall transplantation. He had Campath-1H induction and tacrolimus as maintenance immunosuppression. On day18 postoperatively, he presented with increasing shortness of breath and a diffuse macular, blanching, erythematous eruption rash on his trunk and back (host), however sparing the transplanted abdominal wall skin (graft). A chest radiograph is shown in online supplementary …

Making progress in early breast cancer: Taking time or accepting risk?

Outcomes for patients diagnosed with early breast cancer in developed countries have improved substantially over recent decades. Adjuvant therapies have contributed to this improvement and their benefits have been confirmed in large randomised controlled trials (RCTs) and meta-analyses. Lower event rates, whilst welcome, have created problems for RCTs, that need to be larger and often take longer to provide a reliable result. In an effort to maintain the rate of progress and to obviate the complexity, cost and time required to conduct large RCTs, there has been an increased tendency to rely on observational data to determine a treatment effect and also to accelerate progress by the use of a surrogate marker (pathological complete remission after neoadjuvant chemotherapy). We highlight the pitfalls in these approaches and suggest some simplifications in the conduct of RCTs.

Age but not ABCD(2) score predicts any level of carotid stenosis in either symptomatic or asymptomatic side in transient ischaemic attack.

The ABCD2 score is routinely used in assessment of transient ischaemic attack (TIA) to assess the risk of developing stroke. There remains uncertainty regarding whether the ABCD2 score could be used to help predict extent of carotid artery stenosis (CAS).