MR Imaging Differences in the Circle of Willis between Healthy Children and Adults

BACKGROUND AND PURPOSE

Asymmetries in the circle of Willis have been associated with several conditions, including migraines and stroke, but they may also be age-dependent. This study examined the impact of age and age-dependent changes in cerebral perfusion on circle of Willis anatomy in healthy children and adults.

MATERIALS AND METHODS

We performed an observational, cross-sectional study of bright and black-blood imaging of the proximal cerebral vasculature using TOF-MRA and T2 sampling perfection with application-optimized contrasts by using different flip angle evolution (T2-SPACE) imaging at the level of the circle of Willis in 23 healthy children and 43 healthy adults (4-74 years of age). We compared arterial diameters measured manually and cerebral perfusion via pseudocontinuous arterial spin-labeling between children and adults.

RESULTS

We found that the summed cross-sectional area of the circle of Willis is larger in children than in adults, though the effect size was smaller with T2-SPACE-based measurements than with TOF-MRA. The circle of Willis is also more symmetric in children, and nonvisualized segments occur more frequently in adults than in children. Moreover, the size and symmetry of the circle of Willis correlate with cerebral perfusion.

CONCLUSIONS

Our results demonstrate that the circle of Willis is different in size and symmetry in healthy children compared with adults, likely associated with developmental changes in cerebral perfusion. Further work is needed to understand why asymmetric vasculature develops in some but not all adults.

Cost-effectiveness of Tamoxifen, Aromatase Inhibitor, and Switch Therapy (Adjuvant Endocrine Therapy) for Breast Cancer in Hormone Receptor Positive Postmenopausal Women in India

Background

Breast cancer is the leading cause of cancer among women in India. Treatment with hormone therapy reduces recurrence. We undertook this cost-effectiveness study to ascertain the treatment option offering the best value for money.

Methods

The lifetime costs and health outcomes of using tamoxifen, AI and switch therapy were measured in a cohort of 50-year-old women with HR-positive early stage breast cancer. A Markov model of disease was developed using a societal perspective with a lifetime study horizon. Local, contralateral, and distant recurrence were modelled along with treatment related adverse effects. Primary data collected to obtain estimates of out-of-pocket expenditure (OOPE) and utility weights. Both health system cost and OOPE were included. The future costs and consequences were discounted at 3%. A probabilistic sensitivity analysis was used.

Results

The lifetime cost of hormone therapy with tamoxifen, AI and switch therapy was to be ₹1,472,037 (I$ 68,947), ₹1,306,794 (I$ 61,208) and ₹1,281,811 (I$ 60,038). The QALYs lived per patient receiving tamoxifen, AI and switch were 13.12, 13.42 and 13.32. tamoxifen was found to be more expensive and less effective. As compared to switch therapy, AI for five years incurred an incremental cost of ₹259,792 (I$12,168) per QALY gained. At the willingness to pay equals to per capita GDP of India, there is 55% probability of AI therapy to be cost-effective compared to switch therapy.

Conclusion

In postmenopausal women with HR-positive early-stage breast cancer, switch therapy is recommended for use on the basis of cost-effectiveness.

Systematic review of health workforce surge capacity during COVID-19 and other viral pandemics

Background

Healthcare decision-makers need comprehensive evidence to mitigate surges in the demand for human resources for health (HRH) during infectious disease outbreaks, in terms of both short- and longer-term impacts. This study aimed to assess the state of the evidence to address HRH surge capacity during COVID-19 and other outbreaks of global significance in the 21st century.

Methods

We systematically searched eight bibliographic databases to extract primary research articles published between 01/2000-06/2020, capturing temporal changes in HRH requirements and responses surrounding viral respiratory infection pandemics. A systems approach was used, considering providers in hospitals, out-of-hospital systems, emergency medical services, and public health. We narratively synthesized the evidence following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) standard.

Results

Of the 1,155 retrieved records, 16 studies met our inclusion criteria; of these, 5 focused on COVID-19, 3 on H1N1, and 8 on a hypothetical pandemic. Different training, mobilization, and redeployment options to address pandemic-time health system capacity were assessed. Few governance scenarios drew on observational HRH data allowing for comparability across contexts. Notable evidence gaps included occupational and psychosocial factors affecting healthcare workers' absenteeism and risk of burnout, gendered considerations of HRH capacity, evaluations in low- and lower-middle income countries, and policy-actionable assessments to inform post-pandemic recovery and sustainability of services for noncommunicable disease management.

Conclusions

This research emphasized the critical need for timely, internationally comparable, and equity-informative HRH data and research to enhance preparedness, response, and recovery policies for this and future pandemics. Full paper is available at: https://doi.org/10.1002/hpm.3137

Key messages

The COVID-19 pandemic has highlighted the critical need for enhanced health workforce data and research, including better tracking of demographics, exposures, infections and deaths of health workers. Although women comprise 70% of the health workforce in many countries, gender-blindness persists in the global literature on health workforce research and governance in public health emergencies./bodyt

Subdural empyema in adult with recent SARS-CoV-2 positivity case report

Intracranial abscess, including subdural empyema, is a rare central nervous system infectious disease and diagnosis is often delayed due to patient presentation with non-specific neurologic findings. Here we report a 65-year-old male with a recent past medical history of SARS-CoV-2 infection who presented with three weeks of escalating headache in whom MRI imaging revealed a subdural empyema. He subsequently underwent two craniectomies, which resulted in eradication of the abscess and clinical improvement. This report highlights a potential link between SARS-CoV-2 infection and this patient's development of subdural empyema, which has not been documented elsewhere in the literature.

A Case of Severe COVID-19 Infection in a Patient with Acute Myeloid Leukaemia: Critical Care Management and a Review of the Literature

Acute myeloid leukaemia (AML) is a highly heterogeneous disorder and is characterised by the proliferation of poorly differentiated myeloid cells due to underlying mutation, eventually causing bone marrow failure. Accounting for approximately 25% of cases, AML is the most frequent form of leukaemia in the world yet has the lowest survival rate among all leukaemias. Patients with haematological malignancy are more susceptible to severe acute respiratory syndrome coronavirus-2 infection and further development of severe infection, including pneumonia with poor blood oxygenation. The management of such patients is more challenging than expected. Successful management of one such case is discussed in this report. COVID-19 infection can cause great harm to a patient with underlying leukaemia and increase the mortality risk. It has a major impact on the physical and psychological health of the patient. Therefore, these patients need special care and attention. The authors emphasise the importance of supportive management (oxygen with bilevel positive airway pressure, prone positioning, and physiotherapy) to prevent complications.

639 Emergency Surgical Approach to A Bleeding Pseudoaneurysm Of the Posterior Inferior Pancreaticoduodenal Artery After Failed Embolisation

Background

Pseudoaneurysms of visceral arteries are uncommon, with a prevalence of 0.01% to 0.2%1. Initial treatment is radiological embolisation (RE)2. If this fails, surgical access to the pseudoaneurysm is extremely difficult. They are associated with major complications such as rupture, ischaemia and shock2, with a 20-70% mortality rate3. We report the case of a patient admitted with a life-threatening bleed from an aberrant inferior pancreaticoduodenal artery (IPDA) with failed RE.

Case Summary

A 44-year-old patient presented with right upper quadrant pain, shock and low haemoglobin. His computerised tomography (CT) scan showed a large retroperitoneal haematoma with active bleeding from a 5x6mm IPDA pseudoaneurysm. After resuscitation, access to the IPDA during RE via the coeliac axis and superior mesenteric artery was unsuccessful and he deteriorated. He underwent an emergency laparotomy, which showed the retro-peritoneal haematoma had ruptured into the peritoneal cavity through the transverse mesocolon. Four-quadrant abdominal packing and supra-coeliac manual compression of the aorta was utilised. The right colon was mobilised with full kocherisation of the duodenum. The gastrocolic omentum was divided to enter the lesser sac. The haematoma was evacuated and bleeding branches from the IPDA were suture ligated. He required 26 units of blood throughout admission and underwent 24-hour damage control laparostomy on intensive care. CT mesenteric angiogram post-surgery and re-look laparotomy showed no further active bleeds. He had an uneventful recovery and discharged safely.

Conclusions

RE of visceral artery pseudoaneurysms is challenging. Surgery remains the last resort and should be performed by appropriately trained specialist surgeons.

Effect of coronavirus-19 infection on maternal and perinatal outcome: A case control study

Introduction: Coronavirus 2019 virus infections has an impact on the obstetric population. Methods: We performed a single centre, prospective case-control study in a tertiary care centre during the first wave of the pandemic, over a period of six months. All Labouring women who were tested positive for SARS-CoV2 on the date of admission were included in the study (cases). As a control, SARS-CoV2 negative women who delivered before and after the corona virus-positive delivery were included. Results: The control group were significantly younger than the cases ( p = 0.001). The odds of spontaneous labour were observed to be significantly higher among the cases as compared to the control group ( p  =  0.002). The likelihood of NICU admission was significantly higher among the cases as compared to the control group on applying Fischer exact test ( p < 0.001) Conclusion: SARS-CoV2 positive mothers are more likely to deliver neonates with feeding difficulties and requiring NICU admission, compared to SARS-CoV2 negative mothers.

Noncontrast MRI Protocol for Selected Pediatric Pituitary Endocrinopathies: A Procedure with High Diagnostic Yield and Potential to Reduce Anesthesia and Gadolinium-Based Contrast Exposure

BACKGROUND AND PURPOSE

Although many pediatric neuroradiology practices empirically use noncontrast brain and pituitary MR imaging for evaluation of growth hormone deficiency, central precocious puberty, and short stature, there are currently insufficient published data to support this practice in an evidence-based fashion. Therefore, the use of contrast-enhanced MR imaging for all pediatric pituitary endocrinopathies remains widespread. We evaluated whether noncontrast MR imaging has adequate diagnostic yield for the evaluation of pediatric growth hormone deficiency, central precocious puberty, and short stature.

MATERIALS AND METHODS

Pituitary MR imaging studies obtained for growth hormone deficiency, central precocious puberty, or short stature in patients 0-18 years of age from 2010 to 2019 were analyzed. Separate blinded review of noncontrast images in cases with abnormalities on the original radiology report was performed by 2 subspecialty-trained pediatric neuroradiologists, with discrepancies resolved by consensus.

RESULTS

Of the 134/442 MR imaging studies obtained for growth hormone deficiency, central precocious puberty, or short stature with hypothalamic-pituitary region abnormalities, there was 70% concordance with the original reports on blinded review of noncontrast images. Twenty-two of 40 discrepancies were deemed unrelated to the indication, and 9 cases originally interpreted as possible microadenoma were read as having normal findings on blinded review. Only 9 of 40 discrepancies required contrast for further characterization.

CONCLUSIONS

In our study, most relevant radiologic findings in patients with growth hormone deficiency, central precocious puberty, and short stature were detectable without contrast, providing evidence that contrast can be avoided in routine MR imaging evaluation of these indications. We propose a "rapid noncontrast pituitary" MR imaging protocol for pediatric patients presenting with growth hormone deficiency, central precocious puberty, or short stature, which may increase efficiency and decrease contrast and anesthesia exposure.

Women Representation as First and Corresponding Authors in Neuroanesthesiology and Neurocritical Care Journals: A Retrospective Analysis

INTRODUCTION

There is limited literature on the representation of women in leading roles in neuroanesthesiology and neurocritical care academia. We aimed to determine the representation of women as first and corresponding authors in articles published in 3 dedicated journals of neuroanesthesiology and neurocritical care during last 5 years.

METHODS

Articles published in the Journal of Neurosurgical Anesthesiology, Neurocritical Care, and Journal of Neuroanaesthesiology and Critical Care between July 1, 2015 and June 30, 2020 were included in this study. The primary outcome was the proportion of women first authors, and secondary outcomes were the percentage of women corresponding authors, and representation of women as first and corresponding author by article type and country of affiliation.

RESULTS

Of the 1164 articles included in the study, 403 (34.6%) had a woman first author. Women first authorship was highest for Special Articles (5/11; 45.5%), Clinical Reports (44/113; 38.9%) and Narrative Review Articles (58/151; 38.4%) and lowest for Original Research Articles (198/597; 33.2%). Women accounted for 29.6% (344/1164) of corresponding authors across all article types. Overall, the United States and India had the highest representation of women first authors (159/403; 39.0% and 107/344; 31.0%, respectively), and India also had highest proportion of women corresponding authors (107/272; 39.3%).

CONCLUSIONS

Women were underrepresented compared with men as first author of articles published in 3 dedicated neuroanesthesiology and neurocritical care journals over the last 5 years. Women had the lowest representation as authors of Original Research Articles.

Chondrosarcoma of the Nasal Septum—A Rare Subsite: Case Report with Review of Literature

Chondrosarcomas are the second most common primary malignant bone tumors. Head and neck chondrosarcomas constitute less than 10% of these tumors, rarely arising from the nasal septum. These are locally aggressive malignant tumors arising from the cartilaginous framework of the nasal septum. Rarity of the tumor coupled with nonspecific symptoms makes it a diagnostic dilemma. Diagnosis requires endoscopy, radiology, and final histopathology for confirmation. Treatment is mainly surgical, requiring complete surgical excision with clear margins. Radiation has a role in unresectable tumors or for tumors with positive margins after surgery. Survival depends on the grade of tumor that predicts the metastatic potential of the tumor. We present a rare case of chondrosarcoma arising from the nasal septum in a 29-year-old young female presenting with complaints of nasal obstruction. Computed tomography was suggestive of a calcified cartilaginous tumor arising from the nasal septum. Endoscopic excision was done and postoperative histopathology showed grade II chondrosarcoma with clear margins. No adjuvant treatment was given to our patient and 2 years post-excision patient is disease free.

To conclude, chondrosarcoma of the nasal septum is a rare tumor, with nonspecific symptoms. Surgery with clear margins remains the treatment of choice. Prognosis depends on the extent of tumor at presentation, resection margins, and grade of tumor.

Exploring the Antibacterial and Antibiofilm Efficacy of Silver Nanoparticles Biosynthesized Using Punica granatum Leaves

The current research work illustrates an economical and rapid approach towards the biogenic synthesis of silver nanoparticles using aqueous Punica granatum leaves extract (PGL-AgNPs). The optimization of major parameters involved in the biosynthesis process was done using Box-Behnken Design (BBD). The effects of different independent variables (parameters), namely concentration of AgNO3, temperature and ratio of extract to AgNO3, on response viz. particle size and polydispersity index were analyzed. As a result of experiment designing, 17 reactions were generated, which were further validated experimentally. The statistical and mathematical approaches were employed on these reactions in order to interpret the relationship between the factors and responses. The biosynthesized nanoparticles were initially characterized by UV-vis spectrophotometry followed by physicochemical analysis for determination of particle size, polydispersity index and zeta potential via dynamic light scattering (DLS), SEM and EDX studies. Moreover, the determination of the functional group present in the leaves extract and PGL-AgNPs was done by FTIR. Antibacterial and antibiofilm efficacies of PGL-AgNPs against Gram-positive and Gram-negative bacteria were further determined. The physicochemical studies suggested that PGL-AgNPs were round in shape and of ~37.5 nm in size with uniform distribution. Our studies suggested that PGL-AgNPs exhibit potent antibacterial and antibiofilm properties.

Assessment of Relationship of ABO Blood Groups in Oral Cancer Patients - A Retrospective Study

Introduction:

India is a high-risk region for oropharyngeal cancer (OC) due to high prevalence of tobacco, betel nut, and alcohol and accounts for 30% of all new cases of oral cancer annually.

Materials and Methods:

Records of all 73 diagnosed cases of different types of OC and oropharynx patients were analyzed who reported in “Tobacco cessation center”’ of the Institute between January 2017 and December 2019. The patients’ demographic details, blood groups, oral habits, and clinicohistological records were obtained from the medical records available in the hospital.

Results:

OC incidence was 3.75 cases/year with male-to-female ratio 3.29:1. Mean age was 51.25 ± 13.6 years. The most common site of tumour presentation was mandibular alveolar ridge. Combined use of tobacco/betal nut/alcohol constituted the major cause for the development of oral squamous cell carcinoma (OSCC). Majority patients were presented in Stage II (43.8%). Histopathological reports were suggestive of maximally well-differentiated (52.1%) OSCC. People with blood group A+ve had 3.22 times higher risk of developing OSCC compared to people of other blood groups.

Discussion:

Male: female ratio was reported higher than in most of other studies. Mandibular alveolus was the most frequent site because most of the patients tend to keep the tobacco quid in the buccal vestibule with close proximity to alveolus. The relative downregulation of glycosyl transferase that is involved in the biosynthesis of A and B antigens as seen in association with tumour development could be the reason for increased OC reported in blood group A subjects.

Kinetic Monte Carlo simulations of self-organization of Ge islands on Si(001)

The self-organization of germanium islands on a silicon(001) substrate is studied using lattice-based kinetic Monte Carlo simulations. These islands form spontaneously via the Stranski-Krastanov mode during growth. The interplay of deposition flux and competing surface diffusion leads to a size and shape distribution of islands that varies with temperature and coverage. For the simulation parameters chosen, a kinetic regime of irreversible growth is observed at 500 K, and this changes to quasi-equilibrium growth at 600 K. At 550 K, we see that the surface roughness increases abruptly from a low value and crosses the roughness curve at 600 K. This behavior is explained on the basis of a change in the island formation mechanism. At 500 K, the island formation involves a nucleation barrier; whereas at 600 K this barrier is almost nonexistent. At an intermediate temperature, the stochastic effects due to the incoming flux initially slow down island growth, but the subsequent island nucleation rapidly increases the roughness. These results illustrate how island self-assembly is affected by mechanistic in addition to kinetic and energetic effects. Our results are discussed in the context of experiments on a Si-Ge system and show how the kMC models can be used to understand the processes in heteroepitaxial growth.

Post-transcriptional and translational control of the morphology and virulence in human fungal pathogens

Host-pathogen interactions at the molecular level are the key to fungal pathogenesis. Fungal pathogens utilize several mechanisms such as adhesion, invasion, phenotype switching and metabolic adaptations, to survive in the host environment and respond. Post-transcriptional and translational regulations have emerged as key regulatory mechanisms ensuring the virulence and survival of fungal pathogens. Through these regulations, fungal pathogens effectively alter their protein pool, respond to various stress, and undergo morphogenesis, leading to efficient and comprehensive changes in fungal physiology. The regulation of virulence through post-transcriptional and translational regulatory mechanisms is mediated through mRNA elements (cis factors) or effector molecules (trans factors). The untranslated regions upstream and downstream of the mRNA, as well as various RNA-binding proteins involved in translation initiation or circularization of the mRNA, play pivotal roles in the regulation of morphology and virulence by influencing protein synthesis, protein isoforms, and mRNA stability. Therefore, post-transcriptional and translational mechanisms regulating the morphology, virulence and drug-resistance processes in fungal pathogens can be the target for new therapeutics. With improved "omics" technologies, these regulatory mechanisms are increasingly coming to the forefront of basic biology and drug discovery. This review aims to discuss various modes of post-transcriptional and translation regulations, and how these mechanisms exert influence in the virulence and morphogenesis of fungal pathogens.

Medical publishing: a flawed model in dire need of reform

Recently, in the midst of the Covid-19 pandemic, high-profile retractions of some papers published in prestigious medical journals have highlighted the necessity for structural reform to the current model of medical publishing. We discuss what ails the current system and what can be done to remedy it.

Remission in Cushing's disease is predicted by cortisol burden and its withdrawal following pituitary surgery

AIM

To ascertain the predictors of remission and relapse in patients of Cushing's disease (CD) undergoing pituitary transsphenoidal surgery (TSS).

METHODS

Patients with CD subjected to TSS over 35 years at a tertiary care center were included. Patients were grouped into remission and persistent disease at 1 year after surgery, and were further followed up for relapse. Demographic, clinical, biochemical, histological, radiological and post-operative follow-up parameters were analyzed.

RESULTS

Of the 152 patients of CD, 145 underwent TSS. Remission was achieved in 95 (65.5%) patients at 1 year. Patients in remission had shorter duration of symptoms prior to presentation (p = 0.009), more frequent presence of proximal myopathy (p = 0.038) and a tumor size of < 2.05 cm (p = 0.016) in comparison to those with persistent disease. Post-TSS, immediate post-operative 0800-h cortisol (< 159.85 nmol/L; p = 0.001), histological confirmation of tumor (p = 0.045), duration of glucocorticoid replacement (median 90 days; p = 0.001), non-visualization of tumor on MRI (p = 0.003), new-onset hypogonadism (p = 0.001), 3-month 0800-h cortisol (< 384.9 nmol/L; p = 0.001), resolution of diabetes (p = 0.001) and hypertension (p = 0.001), and recovery of hypothalamic-pituitary-adrenal axis (p = 0.018) favored remission. In logistic regression model, requirement of glucocorticoid replacement (p = 0.033), and resolution of hypertension post-TSS (p = 0.003) predicted remission. None of the parameters could predict relapse.

CONCLUSION

The study could ascertain the predictors of remission in CD. Apart from the tumor characteristics, surgical aspects and low post-operative 0800-h cortisol, the results suggest that baseline clinical parameters, longer glucocorticoid replacement, and resolution of metabolic complications post-TSS predict remission in CD. Long-term follow-up is essential to look for relapse.

Molecular Characterization of NDL1-AGB1 Mediated Salt Stress Signaling: Further Exploration of the Role of NDL1 Interacting Partners

Salt stress is considered to be the most severe abiotic stress. High soil salinity leads to osmotic and ionic toxicity, resulting in reduced plant growth and crop production. The role of G-proteins during salt stresses is well established. AGB1, a G-protein subunit, not only plays an important role during regulation of Na⁺ fluxes in roots, but is also involved in the translocation of Na⁺ from roots to shoots. N-Myc Downregulated like 1 (NDL1) is an interacting partner of G protein βγ subunits and C-4 domain of RGS1 in Arabidopsis. Our recent in-planta expression analysis of NDL1 reported changes in patterns during salt stress. Based on these expression profiles, we have carried out functional characterization of the AGB1-NDL1 module during salinity stress. Using various available mutant and overexpression lines of NDL1 and AGB1, we found that NDL1 acts as a negative regulator during salt stress response at the seedling stage, an opposite response to that of AGB1. On the other hand, during the germination phase of the plant, this role is reversed, indicating developmental and tissue specific regulation. To elucidate the mechanism of the AGB1-NDL1 module, we investigated the possible role of the three NDL1 stress specific interactors, namely ANNAT1, SLT1, and IDH-V, using yeast as a model. The present study revealed that NDL1 acts as a modulator of salt stress response, wherein it can have both positive as well as negative functions during salinity stress. Our findings suggest that the NDL1 mediated stress response depends on its developmental stage-specific expression patterns as well as the differential presence and interaction of the stress-specific interactors.

Serotype and genotype diversity of dengue viruses circulating in India: a multi-centre retrospective study involving the Virus Research Diagnostic Laboratory Network in 2018

OBJECTIVES

A retrospective study was undertaken to investigate the circulating dengue virus (DENV) serotypes and genotypes in India in 2018.

METHODS

In total, 4963 samples referred to virus research diagnostic laboratories (n=21), the Indian Council of Medical Research-National Institute of Virology (ICMR-NIV) and ICMR-NIV field units (n=2) for diagnosis of dengue in 2018 were tested using a real-time reverse transcription polymerase chain reaction assay for the presence of DENV serotypes. Representative samples were sequenced for the envelope (E) gene.

RESULTS

Regional diversity was observed with regard to the dominant circulating serotypes. DENV-2 was found to be the most common serotype in many states. Thrombocytopenia, petechiae and malaise were associated with DENV-2 infection. Phylogenetic analyses of DENV E gene sequences revealed the circulation of genotypes I and V of DENV-1, two lineages of DENV-2 genotype IV, DENV-3 genotype III and DENV-4 genotype I.

CONCLUSIONS

This study found regional differences in the prevalence of circulating DENV serotypes in India, and provides baseline data for continuous molecular surveillance. Molecular surveillance may have implications for predicting large-scale outbreaks of dengue if regional shifts in the predominantly circulating serotypes and genotypes are detected during the early phase of the dengue season.

A Review on Recent Developments in the Anticancer Potential of Oleanolic acid and its analogs (2017-2020)

Oleanolic acid (OA) is a pentacyclic triterpenoid class of natural product known to possess a broad range of biological activities, specifically, anticancer. Considering the anticancer potential of OA, a large number of analogs have been prepared by several researchers through modifications at C-3, C-12 and C-28 -COOH to develop the potent anticancer agents with improved cytotoxicity and pharmaceutical properties. Some of the synthesized derivatives have been assessed in clinical trials also. This review summarizes the most recent synthetic and biological efforts in the development of oleanolic acid and its analogs during the period 2017-2020. Reports published during this period revealed that both OA and its analogs possess a remarkable potential for the development of effective anticancer agents along with several others such as anti-inflammatory, anti-viral, anti-microbial and anti-diabetic agents.

Cost-Effectiveness of Temozolamide for Treatment of Glioblastoma Multiforme in India

PURPOSE

Glioblastoma multiforme (GBM) has poor outcomes following surgery and radiation. Adjuvant temozolamide along with radiation therapy has been shown to improve survival. In this paper, we evaluate the cost-effectiveness of concomitant temozolamide with radiation and maintenance temozolamide for 6 months of treatment for GBM in India.

MATERIALS AND METHODS

We used a Markov model to evaluate the lifetime costs and consequences of treating GBM with radiation alone versus radiation with adjuvant temozolamide. The model was calibrated using the published evidence from European Organisation for Research and Treatment of Cancer-NCIC trial on progression-free survival and overall survival to estimate the life years (LYs) and quality-adjusted LYs (QALYs). Cost of treatment and management of complications were estimated using the data from the National Health System Cost Database and Indian studies. Future cost and consequences were discounted at 3%. Incremental cost per QALY gained with temozolamide was estimated to assess cost effectiveness.

RESULTS

Temozolamide resulted in an increase of 0.59 (0.53-0.66) LY and 0.33 (0.29-0.40) QALY per person at an incremental cost of ₹75,120 in Indian national rupee (INR) (59,337-93,960). Overall, the use of temozolamide incurs an incremental cost of ₹212,020 INR (138,127-401,466) per QALY gained, which has a 4.7% probability to be cost-effective at 1-time per capita Gross Domestic Product (GDP) threshold. In case the current price of temozolamide could be decreased by 90%, the probability of its use for GBM being cost-effective increases to 80%.

CONCLUSION

Temozolamide is not cost-effective for treatment of patients with GBM in India. This evidence should be used while framing guidelines for treatment and price regulation.

Anesthetic Management in an Infant with Dandy–Walker Syndrome Presenting with Acyanotic Heart Disease and Hydrocephalous Post-COVID-19 Recovery: A Rare Experience

We report a case of hydrocephalus with Dandy–Walker malformation in a 2-month-old girl child recently recovered from COVID-19. The child was detected to have acyanotic heart disease with left-to-right shunt and severe pulmonary arterial hypertension during the preoperative evaluation process for ventriculoperitoneal (VP) shunt placement. We share our experience of the perioperative management for pulmonary artery banding (PAB) and patent ductus arteriosus ligation as a part of staged cardiac corrective surgery, followed by VP shunt to relieve hydrocephalus in the single setting. Our management was focused on the preservation of the normal cerebral and cardiac physiology to prevent rise in intracranial pressure and pulmonary artery pressure. A multidisciplinary team, consisting of cardiac- and neuroanesthesiologists and cardiac and neurosurgeons, was involved in management of the case. Diligent maintenance of airway, stable hemodynamics, meticulous ventilation, along with postoperative ICU management helped in the successful outcome of this unique case.

Systematic review confirmed the benefits of early skin-to-skin contact but highlighted lack of studies on very and extremely preterm infants

AIM

We systematically reviewed the literature to identify the benefits of early skin-to-skin contact (SSC) for all gestational ages.

METHODS

The MEDLINE, Embase and CINAHL databases were searched for papers published in English from 1 January 1975 to 31 March 2020. Early SSC was defined as when the infant was placed directly onto the mother's chest within 180 min of birth. Two authors independently searched the databases, appraised study quality and extracted the study design and outcome data. The primary outcomes were the infants' physiological stability after birth: thermoregulation and stabilisation. The secondary outcomes were exclusive breastfeeding and mother-infant interaction.

RESULTS

We reviewed 30 studies that assessed the benefits of early SSC: 22 comprised term-born healthy infants and eight focused on preterm or ill infants. These included various gestational ages, birth methods and cultural backgrounds. The studies demonstrated that early SSC stabilised neonatal physiological parameters, promoted exclusive breastfeeding and supported bonding. Most of the data were from term and late preterm births.

CONCLUSION

This systematic review showed that early SSC could be beneficial. Further studies that focus on providing very and extremely preterm infants with SSC, and parental experiences, are needed to enable SSC to be adopted as routine practice.

Development of National Cancer Database for Cost and Quality of Life (CaDCQoL) in India: a protocol

INTRODUCTION

The rising economic burden of cancer on healthcare system and patients in India has led to the increased demand for evidence in order to inform policy decisions such as drug price regulation, setting reimbursement package rates under publicly financed health insurance schemes and prioritising available resources to maximise value of investments in health. Economic evaluations are an integral component of this important evidence. Lack of existing evidence on healthcare costs and health-related quality of life (HRQOL) makes conducting economic evaluations a very challenging task. Therefore, it is imperative to develop a national database for health expenditure and HRQOL for cancer.

METHODS AND ANALYSIS

The present study proposes to develop a National Cancer Database for Cost and Quality of Life (CaDCQoL) in India. The healthcare costs will be estimated using a patient perspective. A cross-sectional study will be conducted to assess the direct out-of-pocket expenditure (OOPE), indirect cost and HRQOL among cancer patients who will be recruited at seven leading cancer centres from six states in India. Mean OOPE and HRQOL scores will be estimated by cancer site, stage of disease and type of treatment. Economic impact of cancer care on household financial risk protection will be assessed by estimating prevalence of catastrophic health expenditures and impoverishment. The national database would serve as a unique open access data repository to derive estimates of cancer-related OOPE and HRQOL. These estimates would be useful in conducting future cost-effectiveness analyses of management strategies for value-based cancer care.

ETHICS AND DISSEMINATION

Approval was granted by Institutional Ethics Committee vide letter no. PGI/IEC-03/2020-1565 of Post Graduate Institute of Medical Education and Research, Chandigarh, India. The study results will be published in peer-reviewed journals and presented to the policymakers at national level.

Cost Effectiveness of Trastuzumab for Management of Breast Cancer in India

PURPOSE

We undertook this study to evaluate the incremental cost per quality-adjusted life-year (QALY) gained with use of adjuvant trastuzumab as compared with chemotherapy alone among patients with nonmetastatic breast cancer in India.

METHODS

We used a Markov model to estimate the incremental cost of using trastuzumab (for 1 year, 6 months, or 9 weeks) as compared with chemotherapy alone using a societal perspective, excluding indirect productivity losses. Although the outcomes (QALYs) in the standard chemotherapy arm were estimated after calibrating the model as per survival data from 2 Indian cancer registries, effectiveness estimates from the HERA trial and a joint analysis of the NSABP B-31 and NCCTG N9831 trials were used to estimate the consequences of 1-year trastuzumab use. The cost of treatment was estimated using national standard treatment guidelines and real-world use estimates for different treatment modalities as per data from Indian cancer registries. Probabilistic sensitivity analysis was undertaken to evaluate parameter uncertainty.

RESULTS

For 1 year of trastuzumab use, the incremental benefit per patient, incremental cost per QALY gained, and probability of being cost effective using HERA trial estimates were 1.29 QALYs, 178,877 Indian national rupees (INRs; US$2,558), and 4%, respectively, whereas the corresponding figures using joint analysis estimates were 1.69 QALYs, INR 134,413 (US$1,922), and 57.3%, respectively.

CONCLUSION

Use of trastuzumab for 1 year is not cost effective in India at the current price. However, trastuzumab use for 9 weeks is cost effective and should be included in clinical guidelines and reimbursement policies. A price reduction of 15% to 35% increases the probability of 1-year trastuzumab use being cost effective, to 90%.

Structures of the ApoL1 and ApoL2 N-terminal domains reveal a non-classical four-helix bundle motif

Apolipoprotein L1 (ApoL1) is a circulating innate immunity protein protecting against trypanosome infection. However, two ApoL1 coding variants are associated with a highly increased risk of chronic kidney disease. Here we present X-ray and NMR structures of the N-terminal domain (NTD) of ApoL1 and of its closest relative ApoL2. In both proteins, four of the five NTD helices form a four-helix core structure which is different from the classical four-helix bundle and from the pore-forming domain of colicin A. The reactivity with a conformation-specific antibody and structural models predict that this four-helix motif is also present in the NTDs of ApoL3 and ApoL4, suggesting related functions within the small ApoL family. The long helix 5 of ApoL1 is conformationally flexible and contains the BH3-like region. This BH3-like α-helix resembles true BH3 domains only in sequence and structure but not in function, since it does not bind to the pro-survival members of the Bcl-2 family, suggesting a Bcl-2-independent role in cytotoxicity. These findings should expedite a more comprehensive structural and functional understanding of the ApoL immune protein family.

Day-to-day pattern of work and leisure time physical behaviours: are low socioeconomic status adults couch potatoes or work warriors?

Background

Most studies on day-to-day patterns of physical behaviours (i.e. physical activities and sedentary behaviour) are based on adults with high socioeconomic status (SES) and without differentiating between work and leisure time. Thus, we aimed to characterise the day-to-day leisure time physical behaviours patterns among low SES adults and investigate the influence of work physical behaviours.

Methods

This cross-sectional study included 963 adults from low SES occupations (e.g. manufacturing, cleaning and transportation). The participants wore accelerometers for 1–7 days to measure physical behaviours during work and leisure time, expressed as time-use compositions consisting of time spent sedentary, standing or being active (walking, running, stair climbing, or cycling). Compositional multivariate multilevel models were used to regress daily leisure time-use composition against work time-use compositions. Interaction between weekday and (1) type of day, (i.e., work/non-work) and (2) the work time-use composition were tested. Compositional isotemporal substitution was used to interpret the estimates from the models.

Results

Each weekday, workers consistently spent most leisure time being sedentary and most work time standing. Leisure time physical behaviours were associated with type of day (p < 0.005, more sedentary on workdays vs. non-workdays), weekday (p < 0.005, more sedentary on Friday, Saturday and Sunday), standing work (p < 0.005, more sedentary and less standing and active leisure time on Sunday), and active work (p < 0.005, less sedentary and more standing and active leisure time on Sunday). Sedentary leisure time increased by 18 min, while standing and active leisure time decreased by 11 and 7 min, respectively, when 30 min were reallocated to standing at work on Sunday. Conversely, sedentary leisure time decreased by 25 min, and standing and active leisure time increased by 15 and 10 min, respectively, when 30 min were reallocated to active time at work on Sunday.

Conclusions

While low SES adults’ leisure time was mostly sedentary, their work time was predominantly standing. Work physical behaviours differently influenced day-to-day leisure time behaviours. Thus, public health initiatives aiming to change leisure time behaviours among low SES adults should consider the influence of work physical behaviours.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11409-0.

A Prospective Study to Determine if Management of Cases of Gestational Diabetes Mellitus (GDM) can be Modified

Background

To study maternal-fetal outcomes in patients of GDM diagnosed by International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria but subsequently using a twenty-four-hour seven-value sugar profile to evaluate patients before instituting management.

Methods

This prospective observational study was conducted at a tertiary hospital in New Delhi, India, over a period of one year. During this period, women diagnosed as GDM between 24 and 28 weeks of gestation using IADPSG criteria underwent seven-value sugar profile in twenty-four hours before initiating any therapy. Those with normal profile were kept on observation only, whereas others were managed by Medical Nutrition Therapy (MNT) with or without pharmacotherapy as required to maintain euglycemia. Maternal and fetal outcomes were documented and analysed to detect differences between the groups.

Results

Out of 2279 pregnant women, 201 (8.8%) were diagnosed as GDM. The twenty-four-hour seven-value sugar profile was normal in 78 (38.8%) patients, who were managed only by close observation. Treatment was given to other patients; 93 (46.2%) patients were managed with MNT only, whereas pharmacotherapy by way of metformin was added to 22 (10.9%) patients and 8 (3.9%) patients required insulin. Differences in maternal-fetal outcomes between the treated and untreated groups were not found to be statistically significant.

Conclusions

The policy of evaluating patients with twenty-four-hour seven-value sugar profile after an abnormal Oral Glucose Tolerance Test eliminated over one-third women from receiving treatment and interventions for GDM without compromising maternal-fetal outcomes.

Physiologic Specialization and Genetic Differentiation of Puccinia triticina Causing Leaf Rust of Wheat on the Indian Subcontinent During 2016 to 2019

Wheat is the second most cultivated cereal crop in the world and is an important crop in India. Leaf (brown) rust, caused by Puccinia triticina, was the most prevalent among the three rusts found in all the wheat-growing areas of India, Bhutan, and Nepal during 2016 to 2019. Leaf rust samples from wheat crops in these countries were pathotyped using the wheat differential genotypes and binomial Indian system of nomenclature. To facilitate international communication, each pathotype identified was also tested using the North American differentials. A total of 33 pathotypes were identified from 1,086 samples, including three new pathotypes: 61R47 (162-5 = KHTPM) and 93R49 (49 = NHKTN) from India and 93R57 (20-1 = NHKTN) from Nepal. Two pathotypes, 121R60-1 (77-9/52 = MHTKL) and 121R63-1 (77-5 = THTTM), accounted for 79.46% of the population. Virulence on Lr19 was identified in 0.27% of the samples from Nepal only. The proportion of pathotype 121R60-1 (77-9 = MHTKL) increased to 57.55% during these years. Virulence was not observed on Lr9, Lr24, Lr25, Lr28, Lr32, Lr39, Lr45, and Lr47 in the population of the Indian subcontinent. Eighteen polymorphic simple sequence repeat (SSR) primer pairs tested on the isolates amplified 48 alleles with an average of 2.66 alleles per primer pair. Based on SSR genotyping, these pathotypes could be grouped into two clades with another two subclades each. Many of the Lr genes present in Indian wheat germplasm (Lr1, Lr3a, Lr10, Lr11, Lr14a, Lr15, Lr16, Lr17, Lr20, Lr23, and Lr26) were ineffective for a majority of pathotypes. Most of these varieties possessed a high degree of leaf rust resistance. The field resistance of wheat varieties could be attributed to the interaction of genes, unknown resistance, or adult plant resistance.

Impact of COVID-19 on Outcomes for Patients With Cervical Cancer in India

PURPOSE

The COVID-19 pandemic has placed unprecedented demands on the health system. This led to delays in the initiation and completion of cancer treatment. We assessed the long-term health consequences because of the delay in diagnosis and treatment for cervical cancer due to COVID-19 in India.

METHODS

We used a Markov-model–based analysis assessing the lifetime health outcomes of the cohort of women population at risk from cervical cancer in India. The decrease in survival for those with the treatment interruption was calculated based on the number of days the treatment was extended beyond the standard duration. Furthermore, to model the impact of late diagnosis and delayed treatment initiation, the patients were assumed to have upstaged during the delay period, as per natural progression of disease.

RESULTS

We estimate 2.52% (n = 795) to 3.80% (n = 2,160) lifetime increase in the deaths caused by cervical cancer with treatment restrictions ranging from 9 weeks to 6 months, respectively, as compared to no delay. On the contrary, 88-238 deaths because of COVID-19 disease are estimated to be saved during this restriction period among the patients with cervical cancer. Overall, the excess mortality because of cervical cancer led to 18,159-53,626 life-years being lost and an increase of 16,808-50,035 disability-adjusted life-years.

CONCLUSION

Delays in diagnosis and treatment are likely to lead to more cervical cancer deaths as compared to COVID-19 mortality averted among the patients with cervical cancer. Health systems must reorganize in terms of priority setting for provision of care, starting with prioritizing the treatment of patients with early-stage cervical cancer, increasing use of teleconsultation, and strengthening the role of primary care physicians in provision of cancer care.

Primary hyperparathyroidism in pregnancy: observations from the Indian PHPT registry

PURPOSE

To present the data on primary hyperparathyroidism (PHPT) in pregnancy from India obtained from a large database maintained over 15 years.

METHODS

We retrieved data of all women with gestational PHPT from the Indian PHPT registry between July 2005 and January 2020, and compared their clinical, biochemical, and other characteristics with age-matched non-pregnant women with PHPT.

RESULTS

Out of 386 women, eight had gestational PHPT (2.1%). The common presenting manifestations were acute pancreatitis (50%) and renal stone disease (50%); two were asymptomatic. Five women (62.5%) had a history of prior miscarriages. Seven patients (88%) had preeclampsia during the present gestation. Serum calcium and intact parathyroid hormone (iPTH) were not statistically different from the age-matched non-pregnant PHPT group. Six patients with mild-to-moderate hypercalcemia were medically managed with hydration with/without cinacalcet while one patient underwent percutaneous ethanol ablation of the parathyroid adenoma; none underwent surgery during pregnancy. Mean serum calcium maintained from treatment initiation till delivery was 10.5 ± 0.4 mg/dl. One patient had spontaneous preterm delivery at 36 weeks; the remaining patients had normal vaginal delivery at term. None had severe preeclampsia/eclampsia. Fetal outcomes included low birth weight in three newborns (37.5%); two of them had hypocalcemic seizures.

CONCLUSION

The prevalence of gestational PHPT was 2.1% in this largest Indian PHPT cohort, which is higher than that reported from the West (< 1%). Gestational PHPT can lead to preeclampsia and miscarriage. Pregnant PHPT patients with mild-to-moderate hypercalcemia can be managed with hydration/cinacalcet; however, long-term safety data and large-scale randomized controlled trials are required.

Asymptomatic malaria infection prevailing risks for human health and malaria elimination

There has been a consistent rise in malaria cases in the last few years. The existing malaria control measures are challenged by insecticide resistance in the mosquito vector, drug résistance in parasite populations, and asymptomatic malaria (ASM) in healthy individuals. The absence of apparent malaria symptoms and the presence of low parasitemia makes ASM a hidden reservoir for malaria transmission and an impediment in malaria elimination efforts. This review focuses on ASM in malaria-endemic countries and the past and present research trends from those geographical locations. The harmful impacts of asymptomatic malaria on human health and its contribution to disease transmission are highlighted. We discuss certain crucial genetic changes in the parasite and host immune response necessary for maintaining low parasitemia leading to long-term parasite survival in the host. Since the chronic health effects and the potential roles for disease transmission of ASM remain mostly unknown to significant populations, we offer proposals for developing general awareness. We also suggest advanced technology-based diagnostic methods, and treatment strategies to eliminate ASM.

Number of steps and systolic blood pressure: Do work and leisure matter?

The number of steps per day influences blood pressure and health. However, the association between steps at work and leisure and blood pressure is unknown. Thus, we aimed to investigate the association between the domain‐specific number of steps and systolic blood pressure. A thigh‐worn accelerometer was used to measure the steps of 694 workers over 1–5 consecutive days, separated into work and leisure domains using a self‐reported diary. We linearly regressed steps at work, leisure and total day against systolic blood pressure, adjusting for age, sex, body mass index, smoking, and antihypertensive medication. Additionally, we stratified the analyses on job type (blue‐collar or white‐collar). The results of this cross‐sectional analysis indicated a beneficial association between the number of steps (per 2000‐step interval) and systolic blood pressure for the total day (−0.5 mmHg; −1.0 to −0.8, 95% CI, p < 0.05) and work (−0.9 mmHg; −1.5 to −0.4, 95% CI, p < 0.05), but not for leisure (+0.1 mmHg; −0.7 to 0.9, 95% CI, p = 0.75). Blue‐collar workers took almost twice as many steps at work (9143 ± SD3837) as white‐collar workers (5863 ± SD3565) and, after stratification on job type, we observed a beneficial association between the number of steps at work and systolic blood pressure among blue‐collar workers (−1.1 mmHg; −1.7 to −0.4, 95% CI, p < 0.05), but not for white‐collar workers (−0.3 mmHg; −1.7 to 1.1, 95% CI, p = 0.7). These findings indicate that the number of steps at work, particularly among blue‐collar workers, is beneficially associated with systolic blood pressure. Such findings support the potential of work (re)design to promote walking to improve blood pressure.

PRELIMINARY EXPERIMENTATIONS ON THE IN VITRO REARING OF HEMATOPHAGOUS PIGEON LOUSE HOHORSTIELLA LATA (AMBLYCERA: PHTHIRAPTERA: INSECTA)

Rearing hematophagous amblyceran lice in vitro is a challenging task. The hematophagous nature and active habits of amblycerans are distinct hurdles to in vitro rearing. The literature indicates only limited success in rearing the hematophagous amblyceran avian louse. Herein we report on the results of in vitro experimentation on an amblyceran pigeon louse, Hohorstiella lata. The incubation period of eggs was 5.47 ± 0.52 days. The durations of first, second, and third nymphal instars were 5.14 ± 0.55, 5.65 ± 0.83, and 6.35 ± 0.82 days, respectively. The average lifespan of adult females (7.45 ± 5.88 days) was higher than adult males (4.61 ± 3.57 days). Adult females laid a lifetime average of 3.73 eggs at a rate of 0.45 eggs/female/day under in vitro conditions (35 ± 1 C, 75-82% relative humidity, feather diet).

Glucose- regulated protein 78 (GRP78) in renal cell carcinoma: A novel biomarker for predicting tumor behavior

Objective

To study the mRNA and protein expression of GRP78 in tumor and serum of the RCC patients and compare with the controls and to correlate the expression with the grade and stage of RCC.

Materials and methods

A prospective cohort study involving 60 patients planned for radical/partial nephrectomy for primary RCC between July 2017 to June 2019. The RCC and adjacent non-tumorous renal tissues (Control) along with serum samples of patients were collected. Control for the serum samples is from the patients undergoing simple nephrectomy for non-functioning kidney due to benign etiology. The GRP78 expression was studied using RT-PCR for mRNA expression, Western blot analysis and immunohistochemistry (IHC) for protein expression and using ELISA in serum for both the subjects and controls.

Results

Mean age of patients was 50.3 years. The mRNA and protein expression of GRP78 in tissue samples were significantly higher in RCC patients as compared to controls (p < 0.001). IHC also demonstrated significantly higher expression in tumour samples as compared to controls (p < 0.001). Circulatory levels of GRP78 in serum samples were also significantly increased (p < 0.0001) in RCC patients in comparison to control subjects. The expression of GRP78 in circulation significantly correlated with the pathological tumor stage (p = 0.03), grade of disease (p < 0.001).

Conclusion

The GRP78 in RCC is significantly upregulated both at molecular and protein level expression. The overexpression of GRP78 correlates with the stage and grade of disease, thereby, highlighting its prognostic ability.

From Plant Survival Under Severe Stress to Anti-Viral Human Defense - A Perspective That Calls for Common Efforts

Reprogramming of primary virus-infected cells is the critical step that turns viral attacks harmful to humans by initiating super-spreading at cell, organism and population levels. To develop early anti-viral therapies and proactive administration, it is important to understand the very first steps of this process. Plant somatic embryogenesis (SE) is the earliest and most studied model for de novo programming upon severe stress that, in contrast to virus attacks, promotes individual cell and organism survival. We argued that transcript level profiles of target genes established from in vitro SE induction as reference compared to virus-induced profiles can identify differential virus traits that link to harmful reprogramming. To validate this hypothesis, we selected a standard set of genes named 'ReprogVirus'. This approach was recently applied and published. It resulted in identifying 'CoV-MAC-TED', a complex trait that is promising to support combating SARS-CoV-2-induced cell reprogramming in primary infected nose and mouth cells. In this perspective, we aim to explain the rationale of our scientific approach. We are highlighting relevant background knowledge on SE, emphasize the role of alternative oxidase in plant reprogramming and resilience as a learning tool for designing human virus-defense strategies and, present the list of selected genes. As an outlook, we announce wider data collection in a 'ReprogVirus Platform' to support anti-viral strategy design through common efforts.

Three Patient Kindred with a Novel Phenotype of Osteogenesis Imperfecta due to a COL1A1 Variant

Osteogenesis imperfecta (OI) is characterized by fractures and progressive bone deformities. Fracture rates peak during the toddler and adolescent years and decline during adulthood but do not stop entirely. We describe a kindred, the affected members of which were the mother and two sons, who presented with an apparently unique phenotype of OI. Our patients demonstrated a pattern of prenatal bone deformities followed by multiple, nontraumatic long bone fractures within the first two years of life and then an absence of nontraumatic fractures thereafter. No extra-skeletal manifestations have been noted to date. The mother did not receive bisphosphonate therapy but had no nontraumatic fractures after the age of five months. Intravenous bisphosphonate therapy was started for both sons within two months of birth, with the most recent infusions at age 18 months and 28 months in Patients 2 and 3, respectively. Two patients harbored a variant of uncertain significance in the COL1A1 gene. This heterozygous variant, c.3548C>T; p.(Pro1183Leu), is listed in the OI Variant Database as affecting only one other individual with osteopenia. We describe three family members with a unique presenting phenotype of OI, characterized by cessation of nontraumatic fractures after the first two years of life.

Chemical system biology approach to identify multi-targeting FDA inhibitors for treating COVID-19 and associated health complications

In view of many European countries and the USA leading to the second wave of COVID-19 pandemic, winter season, the evolution of new mutations in the spike protein, and no registered drugs and vaccines for COVID-19 treatment, the discovery of effective and novel therapeutic agents is urgently required. The degrees and frequencies of COVID-19 clinical complications are related to uncontrolled immune responses, secondary bacterial infections, diabetes, cardiovascular disease, hypertension, and chronic pulmonary diseases. It is essential to recognize that the drug repurposing strategy so far remains the only means to manage the disease burden of COVID-19. Despite some success of using single-target drugs in treating the disease, it is beyond suspicion that the virus will acquire drug resistance by acquiring mutations in the drug target. The possible synergistic inhibition of drug efficacy due to drug-drug interaction cannot be avoided while treating COVID-19 and allied clinical complications. Hence, to avoid the unintended development drug resistance and loss of efficacy due to drug-drug interaction, multi-target drugs can be promising tools for the most challenging disease. In the present work, we have carried out molecular docking studies of compounds from the FDA approved drug library, and the FDA approved and passed phase -1 drug libraries with ten therapeutic targets of COVID-19. Results showed that known drugs, including nine anti-inflammatory compounds, four antibiotics, six antidiabetic compounds, and one cardioprotective compound, could effectively inhibit multiple therapeutic targets of COVID-19. Further in-vitro, in vivo, and clinical studies will guide these drugs' proper allocation to treat COVID-19.Communicated by Ramaswamy H. Sarma.

Adapting health technology assessment for drugs, medical devices, and health programs: Methodological considerations from the Indian experience

INTRODUCTION

Heterogeneity in methods of economic evaluation makes the use of health technology assessment (HTA) evidence difficult. Thereby, several countries including India have developed their own standard guidelines for conducting HTAs. However, diverse HTA studies involving drugs, medical devices, health programs, and platforms require an adaptation of the standard methods.

AREAS COVERED

This review presents the specific characteristics of HTAs involving medical devices and health programs requiring adaptation of the standard guidelines. We use recent HTA studies in India to illustrate specific issues. These considerations involve the nature of decision-making problems, multiple scenarios in case of health programs, and specific attention to costing and the valuation of consequences. In case of medical devices, we discuss the issue of costing application of devices, multiple usage, learning curve for achieving effects, long causal path for health outcomes, and the issue of valuing false positives.

EXPERT OPINION

While standard guidelines are essential, specific features of health programs and medical devices need to be considered while undertaking HTAs. Additionally, the context in which the HTA is being undertaken, characteristics of the health system, methods of financing healthcare, and demand-side characteristics of healthcare utilization should be reflected in the HTA for health programs and medical devices.

Neurological Soft Signs in Schizophrenia: A Cross-sectional Study

Context:

Soft neurological signs are present more frequently in schizophrenics than other patients suffering from other psychiatric illnesses and normal individuals.

Objectives:

The objective of this study is to find out the causal relationship of neurological soft signs (NSSs) to schizophrenia.

Materials and Methods:

The study was initiated after taking approval of the institute ethics committee. A total of thirty schizophrenic patients and thirty controls were included in the study. Their diagnosis was confirmed by consultant and then were administered Neurological Evaluation Scale developed by Robert Buchanan. The accumulated data were then analyzed statistically.

Results:

This study shows a higher prevalence of NSSs in schizophrenia as compared to controls.

Conclusion:

To ascertain their role in aetiogenesis and pathogenesis of schizophrenia, further research is needed.

The association of Candida and antifungal therapy with pro-inflammatory cytokines in oral leukoplakia

OBJECTIVES

To study the association of Candida and antifungal therapy with pro-inflammatory cytokines (PIC) in oral leukoplakia (OL).

MATERIALS AND METHODS

A prospective observational study where immunocompetent adult subjects with OL (30 homogenous (HL), 30 non-homogenous (NHL)) and 30 age and sex-matched healthy controls (C) with no predisposing factors for oral Candida infection were recruited. Sterile cotton swabs and ophthalmic sponges were used to sample the lesion surface in OL and buccal mucosa in C, for direct microscopy and culture for Candida and to determine levels of PIC (IL-6, IL-8. IL-17, TNF-α) by ELISA, respectively. Sampling for PIC was repeated at same sites in OL, 2 weeks after antifungal therapy.

RESULTS

Candida was associated with 55.3% of NHL, 23.3% of HL and 13.3% of C. The oral secretary levels of PIC were raised in NHL as compared to HL and C. The levels of IL-6, IL-8, TNF-α (p<0.001) and IL-17 (p<0.01) were significantly raised in Candida positive NHL while IL-6 (p<0.05) and TNF-α (p<0.01) were significantly raised in Candida positive HL before antifungal treatment. After antifungal treatment, there was significant reduction in PIC in Candida positive NHL and HL.

CONCLUSIONS

Candida infection contributes to the inflammatory milieu in Candida associated OL which increases the risk of carcinogenesis. Antifungal therapy reduces the PIC in Candida associated OL.

CLINICAL RELEVANCE

Identification and elimination of predisposing factors for Candida infection, like cessation of harmful habits, maintenance of oral/denture hygiene, surveillance for Candida and antifungal therapy at intervals, are recommended in OL.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04712929.

A Preliminary Study on the Evaluation of In-vitro Inhibition Potential of Antimicrobial Efficacy of Raw and Commercial Honey on Escherichia coli: An Emerging Periodontal Pathogen

Periodontitis, a multiple pathogen disease has the latest addition to the family i.e. Escherichia coli as a potential and emerging periodontal pathogen owing to its lipopolysaccharide more potent than Porphyromonas gingivalis, which makes it an emerging threat in periodontal disease. The role of antimicrobial agents in the management of periodontal diseases is of utmost importance. However, in the present scenario, antibiotic resistance is a public health concern now and there are very few options left for treatment. So, honey, a pioneer in traditional medicine was tried in the treatment against Escherichia coli to evaluate and compare the "in-vitro" antibacterial activity and efficacy of raw and commercial honey at different concentrations in comparison to tetracycline as a control on patient-isolated Escherichia coli and the American Type Culture Collection (ATCC) Escherichia coli 25922 strain from 5th Aug 2018 to 15th Feb 2019 at the Department of Microbiology, Rama Medical College, Kanpur (UP), India. In the in-vitro study different concentrations (100%, 75%, 50% and 25% v/v) of raw and commercial honey were studied and sensitivity tests were used to evaluate their antibacterial effect on patient-isolated Escherichia coli and the ATCC Escherichia coli 25922 strain. Minimum inhibitory concentration (MIC) and Minimum bactericidal concentration (MBC) were also determined for raw honey, and commercial honey in comparison to tetracycline. In case of raw honey, zone of inhibition was seen at 100%, 75% and 50% concentration, with maximum inhibition being 27±1.154mm and 23±0.666mm for patient-isolated Escherichia coli and ATCC Escherichia coli 25922 strain respectively at 100% concentration, whereas, the commercial honey was effective only at 100% and 75% concentration, with maximum inhibition zone of 13±1.054mm and 17±0.942mm at 100% concentration on patient-isolated Escherichia coli and ATCC Escherichia coli 25922 strain respectively. However, no effect was observed at 25% concentration for both raw and commercial honey. The MIC and MBC of raw and commercial honey were determined by the broth dilution method, where raw honey exhibited both MIC and MBC at 512 mg/ml whereas, and commercial honey exhibited MIC at 512mg/ml and MBC at 1024 mg/ml respectively. While comparing the zone of inhibition of raw and commercial honey, it was observed that the raw honey showed almost equivalent potency and efficacy as compared to a positive control tetracycline (2.5%). There was statistically significant difference (p≤0.01) in zone of inhibition of raw and commercial honey at 100% concentration on patient-isolated Escherichia coli and ATCC Escherichia coli 25922 strain. Antimicrobial activity of raw honey at 100% concentration was equivalent to that of tetracycline and was significantly better than commercial honey.

Therapeutic implications of candida phenotypes, virulence factors and antifungal sensitivity in Oral leukoplakia

Objectives

To determine the association of Candida phenotypes, virulence factors, antifungal sensitivity and clinical response to Fluconazole in Oral leukoplakia (OL).

Methods

Sterile swabs were obtained from oral lesions in immunocompetent subjects [30 Homogenous (HOL), 31 Non- Homogenous (NHOL] and normal buccal mucosa in 30 age and sex-matched healthy controls (C). Candida phenotypes, virulence factors (Secreted Aspartyl Proteinase (SAP), Phospholipase (PL), Biofilm formation (BF) and antifungal sensitivity were determined. Clinical features (Size, Erythema, thickness, oral burning sensation (VAS scores) before and after Fluconazole therapy in OL were recorded by two calibrated observers.

Results

Candida was associated with OL (p ​< ​0.01). Candida albicans was the most common phenotype sensitive to Fluconazole. SAP, PL and BF activity was significantly high in NHOL. Strong positive correlation was seen between SAP, and PL activity and pre-treatment VAS scores in NHOL. There was significant reduction in VAS scores, size of lesion [HOL (p ​< ​0.001) NHOL (p ​< ​0.05)], erythematous areas (67.8%) in NHOL and thickness of lesions (42.6%) in both types OL after Fluconazole therapy with substantial inter-observer agreement. Non albicans candida (NAC) species had similar virulence profiles but resistant to Fluconazole and showed minimal clinical improvement.

Conclusions

Virulence activity of Candida in OL increases severity of lesions. Fluconazole is effective against virulent Candida albicans, causes clinical improvement and down-staging from high -risk NHOL to low-risk HOL which can reduce risk of malignant transformation. Detection of highly virulent NAC infection and antifungal sensitivity is recommended in OL recalcitrant to Fluconazole therapy.

Micro-electromechanical-system-tuned resonant filters spanning the 8-12 µm band

The spectral band covering ∼8-12µm is atmospherically transparent and therefore important for terrestrial imaging, day/night situational awareness systems, and spectroscopic applications. There is a dearth of tunable filters spanning the band. Here, we propose and demonstrate a new, to the best of our knowledge, tunable-filter method engaging the fundamental physics of the guided-mode resonance (GMR) effect realized with a non-periodic lattice. The polarization-dependent filter is fashioned with a one-dimensional Ge grating on a ZnSe substrate and interrogated with a ∼1.5mm Gaussian beam to show clear transmittance nulls. To expand the tuning range, the device parameters are optimized for sequential operation in TM and TE polarization states. The theoretical model exhibits a tunable range exceeding 4 µm, thus covering the band fully. In the experiment, a prototype device exhibits a spectral range of 8.6-10.0 µm in TM and 9.9-11.7 µm in TE polarization or >3µm total. With additional efforts in fabrication, we expect to achieve the full range.