Bendigo Hospital

ABSTRACT Research on drinking water disinfection continues to find both supporting and non‐supporting evidence that trihalomethanes (THMs) and haloacetic acids (HAAs) are causative agents for adverse human health effects such as bladder cancer and that they are appropriate surrogates for reducing adverse health effects through further regulation. The EPA is revising the microbial/disinfection byproduct (M/DBP) rules to further protect public health; however, the decision to change or add regulations is hindered by uncertainty about the causative agents of DBP‐associated risk and the role of compliance strategies to protect public health. Research conducted since the Stage 2 DBP rule was established helps fill some gaps and outlines lingering uncertainties that should be acknowledged as part of revised rulemaking. This thematic review summarizes regulatory implications of the state of the science in epidemiology, toxicology, occurrence/monitoring, and treatment/compliance, and identifies actions toward meaningful regulatory revisions despite ongoing uncertainty of DBP‐associated human health risk drivers.

Introduction Mycobacterium tuberculosis continues to have a high mortality and morbidity burden globally. IGRA such as Quantiferon Gold Plus aid in diagnosis of latent TB but diagnosis of pleural TB remains challenging. We present a case of active pleural MTB infection with reversion of IGRA from positive to negative, and negative Xpert MTB/RIF Ultra PCR results from pleural biopsy tissues. Case A 52-year-old male presented in 2022 with a two-week history of pleuritic chest pain associated with modest elevation in inflammatory markers. The patient had had a positive QFG-Plus result in 2018, however QFG-Plus during this admission was negative. CTPA and needle thoracocentesis showed an exudative left pleural effusion with predominant lymphocytes. The patient’s symptoms failed to resolve with empiric antimicrobial therapy for community-acquired pneumonia. Broncho-Alveolar Lavage as well as biopsies of pleural tissues via video-assisted thoracoscopic surgery from the left lower lobe yielded negative results on routine microbiological culture as well as Xpert Ultra PCR. Growth of AFB was noted from mycobacterial cultures of pleural tissues which was identified as MTB. Conclusion Despite significant technological advances, microbiological diagnosis of MTB infections remains challenging. We document QFG-Plus reversion during development from latent to active pleural TB. Decline in the ability of CD4+ and CD8+ T cells to produce interferon gamma in response to TB antigens (ESAT-6 and CFP-10) was likely associated with loss of host control of latent MTB. This case serves as a reminder that despite exhaustive testing with state-of-art diagnostic platforms, MTB can still elude discovery.

Retroperitoneal lymph node dissection (RPLND) is an important part of multimodal therapy for node-positive germ cell malignancy [1-4]. However, due to wide heterogeneity in patient status, disease biology and tumour locations, RPLND can be challenging and risky [1]. One such risk is iatrogenic chylous ascites (CA; 8% of cases) [1]. CA is defined as accumulation of chyle, a lipid-rich lymph fluid in the peritoneal cavity [5]. Morbidity from intra-abdominal chyle extravasation includes delayed wound healing, malnutrition, electrolyte disturbances, and immunosuppression [2, 6]. This morbidity impairs postoperative recovery, delays adjuvant oncological therapy, and detrimentally affects quality of life [2, 4]. Limited reliable data exist to describe the management of this complex condition [1]. We outline a difficult case and then review the literature for treatment strategies and propose a contemporary management algorithm for refractory post-RPLND CA. A 32-year-old male presented with a testicular mass. Left orchidectomy revealed a mixed germ cell tumour comprising embryonal carcinoma, seminoma, and yolk sac tumour (pT2). Four cycles of bleomycin, etoposide and platinum (BEP) chemotherapy were administered. Subsequent CT showed residual retroperitoneal lymphadenopathy (2.5 cm). Salvage robotic RPLND was performed and the patient was discharged well on postoperative day 1. Subsequent pathology revealed 10 out of 16 lymph nodes were positive, with the largest viable deposit measuring 19 mm. Lymphovascular invasion was present, but extranodal extension was absent. The postoperative period initially progressed without complications. However, the patient presented again to the emergency department 5 days postoperatively with abdominal pain and ascites. He was admitted for paracentesis (10 L), which led to a diagnosis of chyle leak (Fig. 1). This was complicated and likely compounded by adjuvant paclitaxel, ifosfamide and cisplatin (TIP) chemotherapy [5]. Despite protocol-guided dietary adjustments and a short-chain fatty acid regimen (outlined by a dietician, with structured <20 g fat per day monitored by diet-tracking mobile application), and somatostatin analogue octreotide (200 mcg, s.c., three times daily), limited improvement was observed in managing the chyle leak [7]. Symptomatic re-accumulation required a total of eight ultrasonography-guided paracentesis procedures at approximately weekly intervals. Once the volume drained with these frequent procedures had plateaued for 6 weeks (~10 L), it was deemed to be refractory CA. At this stage, a lymphoscintigram was conducted, demonstrating chyle leak from the left para-aortic region at L1/L2, and from a right groin lymph node (Fig. 2). After further multidisciplinary discussions, glue embolization was performed. Initial embolization via inguinal nodal injection was unsuccessful, however, a subsequent retrograde thoracic duct lymphangiogram proved successful. A tap drain was placed after enabling discharge with functioning drain (Fig. 3). Three months post-lymphangiogram and embolization, the abdominal drain was removed due to pain and reduced output (<50 mL per day for 2 consecutive days), with full diet tolerance. Subsequently, the patient's CA has resolved. Prompt identification and treatment of CA is essential for optimal surgical outcomes. Refractory CA (defined as 4 weeks of plateaued progress on current level of management) is associated with high morbidity and requires multimodal management. High-volume RPLND centres should have a management protocol for this uncommon complication (Fig. 4). Once diagnosed with CA, clinical assessment (examination and imaging) with elevated triglycerides in paracentesis fluid, we recommend commencement of a multimodal management plan with multidisciplinary involvement (senior dietician and provision of a patient information booklet on strict dietary guidelines about fat reduction). This includes a medium-chain fatty acid diet with a somatostatin analogue (e.g., octreotide, which decreases lymphatic flow) as well as consideration of total parenteral nutrition depending on the patient's nutritional state and suspected duration of fasting. If persistent, we would suggest percutaneous drainage for symptomatic relief. If refractory chyle leak is ongoing (>6 weeks) lymphoscintigraphy enables better visualization and characterization of the chyle leak, enabling informed decision making regarding the appropriateness of image-guided embolization. If image-guided embolization fails, peritoneovenous shunt or surgical exploration should be considered for definitive control of the chyle leak. Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians. None declared. Fig. S1. Dynamic insertion of pleurex drain. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

This research is an analysis, in addition to a survey of how theatrical and pedagogical actions developed at the Elon Machado Moita State School, in the municipality of Lagoa Alegre/PI, can contribute to improving the process of emancipation of students and, consequently, produce better academic performance . The main objective of this analysis is to verify whether, using theatrical techniques and methods, it is possible to create emancipated, free students with a sense of equality in intelligence. The research proposal is based on the use of theater as a teaching resource, with the aim of stimulating student autonomy and improving learning. The research question is: is it possible to develop strategies capable of fostering student autonomy with theater? During the writing of the dissertation there is a critical and more detailed look at the teaching practices of the arts teacher, in addition to questioning methodologies and action strategies. In the experiences analyzed, it is possible to approach Paulo Freire's conceptions, in order to create conditions for education to be liberating instead of oppressive. The methodological choice for this study was action research with a descriptive character along the lines of a researcher-participant. Throughout the entire practical research process, various data were generated that served as sources for analysis: photos, videos, logbooks, statements, interviews and protocols (records in text or drawing form). From this, it became clear that theater is a very powerful tool in transforming schools and building free subjects committed to social and political issues. However, the school still fails to use the body as a mechanism for transmitting ideas, which is a problem we encountered, which could open horizons for other studies. The theoretical contribution of the research was delimited after a bibliographical survey of the following authors: Bertolt Brecht, seeing in theater a possibility of sharpening the critical sense of individuals; Jaques Rancière, when presenting politics as a collective process that guarantees the autonomy of speech; Augusto Boal, through his creative actions that aim for political action capable of transforming society.

Complex regional pain syndrome type 1 (CRPS-I) is a devastating complication that can occur after limb extremity injuries. The effectiveness of vitamin C in preventing CRPS-I incidence is debatable. Therefore, we conducted a systematic review and meta-analysis to assess the role of vitamin C in CRPS-I prevention and its effect on pain score, functional outcomes and complications rate after wrist, ankle, and foot fractures.We searched Medline, Embase, the Cochrane Library, Clinicaltrial.gov, and Google Scholar from infinity to May 2021 for relevant studies comparing the incidence of CRPS-I with administration of perioperative vitamin C versus placebo after wrist, ankle, and foot fractures. Continuous data such as functional outcomes and pain scores were pooled as mean differences (MD), whist dichotomous variables such as the incidence of CRPS-I and complications were pooled as odds ratios (OR), with 95% confidence interval (CI). Data analyses was done using R software (meta package, version 4.9-0) for Windows.Eight studies, including two quasi-experimental studies, were included. The timeframe for vitamin C administration ranged from 42 to 50 days post-injury and/or surgical fixation and the dosage was either 500 mg or 1000 mg. The results showed that vitamin C was associated with a lower rate of CRPS-I relative to a placebo (OR 0.33, 95% CI [0.17, 0.63]). No significant difference was found between vitamin C and placebo in terms of complications (OR 1.90, 95% CI [0.99, 3.65]), functional outcomes (MD 6.37, 95% CI [-1.40, 14.15]), and pain scores (MD −0.14, 95% CI [-1.07, 0.79]).The findings demonstrate that when compared to placebo, at least 42 days of vitamin C prophylaxis is associated with prevention of CRPS-I following wrist, ankle, and foot fractures, irrespective of vitamin C dosage or fracture type. No significant differences were found with secondary outcomes.