Cylindrospermopsin impairs zebrafish (Danio rerio) embryo development

Cyanotoxins are among common contaminants that can impair human, animal, and environmental health. Cylindrospermopsin (CYN) is an abundant form of cyanotoxins elevated following algal bloom in the water worldwide. Previous studies have described CYN effects on several organs in mammals. However, little is known about its toxicity mechanisms in other vertebrates. This study aims to characterize the developmental effects of CYN using zebrafish larvae as an aquatic model organism. A wide range of CYN concentrations (0-2000 μg/L) was tested using a morphometric approach for survival, hatching, various growth and developmental abnormalities. We also investigated the expression of genes related to oxidative stress, osmoregulation, and thyroid function. Exposure to CYN resulted in decreased growth, increased developmental abnormalities such as pericardial and yolk sac edema as well as swim bladder absence. In addition, CYN increased tr1a, and decreased dio1 and dio3 transcript levels which are involved in thyroid-mediated function. It also increased transcript levels related to oxidative stress, including hsp70, ahr1a, cyp1a, gpx and cat. Lastly, CYN exposure increased aqp3a and decreased dab2, which are involved in osmoregulation with a threshold of 10 μg/L. The present study demonstrates multiple effects of exposure to environmentally relevant CYN concentrations in zebrafish embryos.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Forest yield prediction under different climate change scenarios using data intelligent models in Pakistan

This study aimed to develop and evaluate data driven models for prediction of forest yield under different climate change scenarios in the Gallies forest division of district Abbottabad, Pakistan. The Random Forest (RF) and Kernel Ridge Regression (KRR) models were developed and evaluated using yield data of two species (Blue pine and Silver fir) as an objective variable and climate data (temperature, humidity, rainfall and wind speed) as predictive variables. Prediction accuracy of both the models were assessed by means of root mean squared error (RMSE), mean absolute error (MAE), correlation coefficient (r), relative root mean squared error (RRMSE), Legates-McCabe's (LM), Willmott's index (WI) and Nash-Sutcliffe (NSE) metrics. Overall, the RF model outperformed the KRR model due to its higher accuracy in forecasting of forest yield. The study strongly recommends that RF model should be applied in other regions of the country for prediction of forest growth and yield, which may help in the management and future planning of forest productivity in Pakistan.

Diffuse Idiopathic Neuroendocrine Cell Hyperplasia (DIPNECH) on Electromagnetic Navigation Bronchoscopy (EMN) Guided Fine Needle Aspiration (FNA): A Case Report

Introduction/Objective

DIPNECH is a clinicopathological diagnosis characterized by abnormal proliferation of single or clusters of neuroendocrine cells in the bronchial mucosa. The World health organization includes DIPNECH as a preinvasive lesion to carcinoid tumors of the lung. Diagnosis is often delayed or missed due to insidious presentation and rarity of the disease. High degree of suspicion in the appropriate clinical and radiological context is important for early diagnosis. We describe a unique case of DIPNECH diagnosed by EMN guided aspiration cytology in the setting of multiple incidental lung nodules and confirmed on surgical resection.

Methods/Case Report

A 69-year-old female with history of insidious cough was referred to pulmonology clinic for multiple incidental bilateral lung nodules detected by CT scan, largest involving the right middle lobe. Although the main diagnostic consideration was pulmonary metastasis, several radiological features, including diffuse mosaic attenuation pattern, prompted the possibility of a diffuse neuroendocrine process. Electromagnetic navigation bronchoscopy (ENB) guided fine needle aspiration cytology was performed. Air-dried and Papanicolaou stained smears were scant but showed dispersed and clusters of small cells with fine chromatin with minimal cytoplasm. No necrosis or mitosis were seen. A cell block was prepared that showed rare clusters of tumor cells positive for immunostains synaptophysin, chromogranin, CD56, with a Ki-67 of 1%. In the appropriate clinical and radiological context findings were consistent with a well differentiated neuroendocrine process such as DIPNECH. Right middle lobe resection confirmed extensive DIPNECH with multiple typical carcinoid tumors and tumorlets.

Results (if a Case Study enter NA)

NA

Conclusion

It is essential to be familiar with the clinical and radiological findings of DIPNECH and include it in the differential diagnosis of its mimickers. Although the diagnosis is challenging on limited specimens, this report indicates that EMN guided aspiration cytology can be used as a valuable early tool for accurate diagnosis and timely management of DIPNECH.

1600 Assessing Necessity and Cost-Effectiveness of Routine Pre-Thyroidectomy Group and Save Tests

Aim

To determine the necessity and cost effectiveness of routine blood group and save tests (G&S) before thyroidectomy

Background

Sub-total or total thyroidectomy is the mainstay of treatment for several thyroid disorders. The incidence of post-thyroidectomy haemorrhage has been reported between 0.36% and 4.3% in the literature. Many patients undergo routine G&S testing in anticipation of a peri-operative haemorrhage requiring blood transfusion.

Method

Retrospective review identified 276 patients undergoing an elective total or sub-total thyroidectomy at a London University Teaching Hospital between February 2018 and August 2020. Electronic medical and transfusion department records were audited to identify patients who had pre-operative G&S tests, pre-operatively reserved blood products and peri-operative transfusions.

Results

261 (94.6%) patients had a valid pre-operative group and save test. 17 (6.16%) patients had a total of 61 units of blood products ordered pre-operatively. Only 2 patients required transfusion.

Conclusions

The blood transfusion rate for elective thyroidectomies at this centre was 0.72%. Routine G&S tests cost the trust thousands of pounds and create unnecessary burden on healthcare providers’ time and hospital resources. We propose that routine pre-operative G&S tests are unnecessary for elective thyroidectomies.

111 The Systemic Effects of Intra-Articular Steroid Injections- Should COVID-19 Change Our Practice?

Aim

The COVID-19 pandemic prompted us to review and often suspend services, while patients continue to suffer with painful musculoskeletal conditions. The diagnostic and therapeutic value of intra-articular corticosteroid injections (IACSI) cannot be denied. Current BOA guidelines advise giving the lowest effective dose for inflammatory arthritis and limit use in osteoarthritis to patients with high levels of pain and disability. We aimed to evaluate the literature pertaining to the use of IACSI and the potential systemic immunosuppressive effects.

Method

We searched Medline, using the terms “systemic effects of intra-articular steroid” and “clinical course of Coronavirus infection in patients with steroid use”, between 1997 and 2020.

Results

No studies specifically looked at the systemic effects of intra-articular steroids in the presence of COVID-19 infection; however, four studies were identified which concluded that intra-articular steroid injections resulted in sufficient systemic absorption to cause suppression of the hypothalamic-pituitary-adrenal axis and endogenous cortisol production. These effects are dose dependent and are more common in patients with inflammatory joint diseases. A further four RCT’s, including one systematic review, showed that suppressed cortisol concentration was associated with a significant increase in mortality.

Conclusions

There is a lack of evidence in relation to the use of intra-articular steroids in COVID-19. However, evidence suggests that intra-articular steroids can result in systemic absorption and suppression of endogenous cortisol production thus increasing the potential risk of complications of COVID-19. We therefore support cautious use of low dose steroid injections in patients with inflammatory arthritis, where no alternative treatment is available.

The Siberian pine growth dynamics in Altai Mountains, China

Climatic factors play an essential role in the growth of tree ring width. In this study, we aimed to evaluate the correlation between climatic variables and tree-ring growth characteristics of Pinus sibirica in Altai mountains, northwestern China. This study being is first of its kind on climate growth analysis of Pinus sibirica in northwestern China. The study showed great potential to understand the species growing under the specific climatic conditions. Total of 70 tree cores collected from three sites in the sampling area, out of which 63 tree cores considered for this study. The effect of climatic variables which was studied include precipitation, temperature and PDSI. Our results showed that Tree Ring Width chronology has a significantly positive correlation with the late winter (March) temperature and significant negative correlation with the July temperatures. A significant correlation was observed with the late summer precipitation whereas no significant relation found with the Palmer Drought Severity Index. These significant correlations with temperature and precipitation suggested that this tree species had the potential for the reconstruction of the past climate in the area.

Mucosal Bacteria Modulate Candida albicans Virulence in Oropharyngeal Candidiasis

Oropharyngeal candidiasis (OPC) is the most prevalent oral infection in immunocompromised patients, primarily associated with Candida albicans. Increasing evidence points to a significant role of mucosal bacteria on the transition of C. albicans from commensal to pathogenic. In this work, we hypothesized that changes in the abundance or composition of the mucosal bacterial microbiota induced by dietary sucrose during the development of OPC can modulate C. albicans virulence. C. albicans burdens and mucosal lesions were evaluated in a mouse cortisone immunosuppression model amended with sucrose. We also analyzed the mucosal bacterial composition using 16S rRNA gene sequencing and culture methods. In immunocompetent mice, sucrose significantly increased total bacterial burdens and reduced alpha diversity, by increasing the relative abundance of mitis group streptococci. In immunocompromised mice, C. albicans infection was associated with a significantly reduced bacterial alpha diversity due to an increase in the relative abundance of enterococci. When exposed to dietary sucrose, these mice had reduced C. albicans burdens and reduced bacterial alpha diversity, associated with an increase in the relative abundance of Lactobacillus. SparCC correlation networks showed a significant negative correlation between Lactobacillus and Enterococcus in all Candida-infected mice. Depletion of lactobacilli with antibiotic treatment partially restored C. albicans burdens in mice receiving sucrose. In coculture in vitro experiments, mouse oral Lactobacillus johnsonii isolates inhibited growth of Enterococcus faecalis isolates and C. albicans. These results support the hypothesis that the sucrose-induced attenuation of C. albicans virulence was a result of changes in the mucosal bacterial microbiome characterized by a reduction in enterococci and an increase in lactobacilli. IMPORTANCE By comparing Candida albicans virulence and the mucosal bacterial composition in a mouse oral infection model, we were able to dissect the effects of the host environment (immunosuppression), infection with C. albicans, and local modulating factors (availability of sucrose as a carbon source) on the mucosal bacterial microbiome and its role on fungal virulence. We showed that changes in endogenous microbial communities in response to sucrose can lead to attenuation of fungal disease. We also showed that Lactobacillus johnsonii may curtail Candida virulence both by inhibiting its growth and by inhibiting the growth of potentially synergistic bacteria such as enterococci. Our results support the concept that Candida pathogenesis should be viewed in the contexts of both a susceptible host and a mucosal bacterial microbiota conducive to virulence.

Payment for ecosystem services (PES): a holistic tool for sustainable forest management-a case study from Pakistan

Economic valuation of ecosystem services is a new concept in forest management. Economic valuation provides basis for payment for ecosystem services (PES). Therefore, objective of this study was to evaluate eco-tourism and carbon stock services of the Maindam valley, District Swat, Pakistan. For the carbon stock calculation, a sample size of 155 plots of 0.1 hectare (Ha) was taken using preliminary survey at 95% confidence interval and 10% allowable error. The data for tourism services was collected from owners of all the hotels, 100 tourists and key informants of the area at 10% sampling intensity on pretested questionnaire for twenty years period (1997-2017). Results showed that Miandam valley has carbon stock worth US$ 16,306,000 while the value of eco-tourism was US$ 1,578,458 on annual basis. The results also showed that trend of tourism has drastically declined after the 9/11 incident for foreigners and locals and the situation was further deteriorated during the era of Talibanization or militancy from 2008-2011. This study recommends implementation of PES strategy at the rate of 5%, thus a total of US$ 78,922 can be earned from eco-tourism and carbon crediting in the study area annually, which could play important role in sustainable forest management.

Quality of life with first-line pembrolizumab for PD-L1-positive advanced gastric/gastroesophageal junction adenocarcinoma: results from the randomised phase III KEYNOTE-062 study

BACKGROUND

In the randomised phase III KEYNOTE-062 study, pembrolizumab was non-inferior to chemotherapy for overall survival in patients with programmed death-ligand 1 (PD-L1)-positive [combined positive score (CPS) ≥1] advanced gastric/gastroesophageal junction (GEJ) cancer. We present findings of prespecified health-related quality-of-life (HRQOL) analyses for pembrolizumab versus chemotherapy in this population.

MATERIALS AND METHODS

HRQOL, a secondary endpoint, was measured in patients who received ≥1 dose of study treatment and completed ≥1 HRQOL questionnaire [European Organisation for the Research and Treatment of Cancer (EORTC) 30-question quality-of-life (QLQ-C30), EORTC 22-question quality-of-life gastric-cancer-specific module (QLQ-STO22)]. Least squares mean (LSM) change (baseline to week 18) in global health status/quality of life (GHS/QOL; EORTC QLQ-C30) and time to deterioration (TTD) in GHS/QOL, nausea/vomiting and appetite loss scores (EORTC QLQ-C30) and abdominal pain/discomfort scores (EORTC QLQ-STO22) were evaluated.

RESULTS

The HRQOL population comprised 495 patients with CPS ≥1 (pembrolizumab, 252; chemotherapy, 243). Compliance rates at week 18 were similar for pembrolizumab and chemotherapy (EORTC QLQ-C30, 87.9% and 81.9%; EORTC QLQ-STO22, 87.9% and 81.3%, respectively). There was no between-arm difference in LSM score change in GHS/QOL [-0.16; 95% confidence interval (CI) -5.01 to 4.69; P = 0.948]. The LSM score change for most subscales showed comparable worsening in both arms. TTD for GHS/QOL [hazard ratio (HR), 0.96; 95% CI, 0.67-1.38; P = 0.826], appetite loss (HR, 0.83; 95% CI, 0.58-1.20; P = 0.314) and pain (HR, 1.22; 95% CI, 0.78-1.91; P = 0.381) were similar between arms. Longer TTD was observed for pembrolizumab versus chemotherapy for nausea/vomiting (HR, 0.61; 95% CI, 0.44-0.85; P = 0.003).

CONCLUSIONS

HRQOL was maintained with first-line treatment with pembrolizumab in patients with PD-L1-positive advanced gastric/GEJ cancer and was similar between pembrolizumab and chemotherapy in this population.

Sudden sensorineural hearing loss in COVID-19: A case series from the Wrightington, Wigan and Leigh Teaching Hospitals, United Kingdom

Sudden sensory neural hearing Loss (SSNHL) needs to be identified and managed correctly in a secondary or tertiary centre. Whilst 45% of presentations are said to be idiopathic in nature, several viruses have been linked to its aetiology. It was noted, anecdotally, that more patients were presenting with SSNHL during the COVID-19 pandemic to our ENT service at Wrightington Wigan and Leigh teaching hospitals, UK (WWL). We identified 4 COVID-19 positive patients who presented to our ENT service with SSNHL. Despite normal findings on external ear examination, three of the patients showed bilateral hearing loss, whilst one had a predominantly unilateral loss. Given our findings we would like to present these four cases, as well as providing hypotheses on possible aetiology of this association. This may aid in research, diagnosis and treatment of future COVID positive patients with SSNHL.

Trocar site closure with a novel anchor-based (neoClose®) system versus standard suture closure: A prospective randomized controlled trial

Objective

Patients with obesity have a higher risk of trocar site hernia. The objective of the present study was to compare a standard suture passer versus the neoClose® device for port site fascial closure in patients with obesity undergoing laparoscopic bariatric surgery.

Methods

This is a randomized, controlled trial with two parallel arms. Thirty five patients with BMI ≥ 35 kg/m2 and undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass were randomized to each group. Port site fascial closure for trocars ≥ 10 mm was performed with the neoClose® device in the study group and the standard suture passer in the control group. Primary outcomes were time required to complete closure and intensity of postoperative pain at the fascial closure sites. Secondary outcomes were intraabdominal needle depth and incidence of trocar site hernia.

Results

The use of the neoClose® device resulted in shorter closure times (20.2 vs 30.0 s, p = 0.0002), less pain (0.3 vs 0.9, p = 0.002) at port closure sites, and decreased needle depth (3.3 cm vs 5.2 cm, p < 0.0001) compared to the standard suture passer. There was no trocar site hernia at the one-year follow-up in either group.

Conclusion

Use of the neoClose® device resulted in faster fascial closure times, decreased intraoperative needle depth, and decreased postoperative abdominal pain at 1 week as compared to the standard suture passer. These data need to be confirmed on larger cohorts of patients with longer follow-up, especially in terms of long-term hernia recurrence rates.

An ethno-botanical study of indigenous medicinal plants and their usage in rural valleys of Swabi and Hazara region of Pakistan

An ethnobotanical study was conducted to document indigenous medicinal plants and their usage from knowledgeable and elderly persons in Razzar and Gadoon valley of Swabi and Allai and Tanawal valley of Hazara region of Pakistan during 2016-2019. Several systematic field visits and questionnaire surveys were carried out in selected sites of the study area to gather relevant information from the local community. Rapid assessment method was adopted for data collection by interviewing the local people having enough knowledge of medicinal plants use for treatment of different ailments. UV (UV) formula was applied to calculate the relative importance of medicinal plant species in each site of the study area. In the present study, 221 medicinal plants belonging to 105 families have been reported through 580 respondents (385 males, 138 females and 57 local health healer) from the Swabi and Hazara region. The main sources of herbal medicines were leaves (21%) followed by fruits (21%), seeds (17%), whole plants (14%), roots (9%), bark (9%), flowers (7%) and gum (2%). Mentha spicata L. and Berberis lycium Royle were reported with highest UV (UV) i.e. 0.92 and 0.68 in Razzar tehsil and Gadoon valley of Swabi, whereas Mentha longifolia L and Geranium wallichianum D were reported with highest UV i.e. (0.65) and (0.88) in Allai and Tanawal valley of Hazara region, respectively. It was concluded that Swabi and Hazara region is rich in medicinal plants species and associated traditional knowledge. Moreover, ethno-medicines have played significant role in the indigenous healthcare system of the study area. However, uprooting the entire plant for ethno-medicine is a big threat to conservation of medicinal plants diversity in the study area.