COVID-19 Vaccine decision-making: trust among the transgender and disability communities in India

BACKGROUND

Historical marginalisation and ongoing trust deficits in health and government systems shape present-day vaccine perceptions among marginalised communities. This paper sought to understand the role of trust in decision-making about COVID-19 vaccine uptake in the transgender and disability communities in India.

METHODS

Using a participatory approach we interviewed 24 community representatives, identifying themselves as transgender individuals or as persons with disability, and 21 key informants such as vaccine programme managers, vaccine providers, and community advocates. We undertook an inductive thematic analysis of the data using a socio-ecological model.

RESULTS

Fear of side effects in relation to specific needs of the two communities and mistrust of systems involved in vaccination shaped four different pathways for vaccine decision-making. Mistrust of systems was influenced by past negative experiences with the health system, creating contexts in which information and misinformation are shared and interpreted. Participants negotiated their doubts about safety and mistrust of systems by interacting with different sources of influence showing patterns of decision-making that are dynamic, context-dependent, and intersectional.

CONCLUSION

These findings will help in determining the content, strategies and approaches to equitable vaccine communication for these two communities. The two communities ought to be included in vaccine trials. Vaccine information must respond to the specific needs of these two communities which could be enabled by collaboration and engagement with community members and influencers. Finally, long-term investment towards the needs of marginalised communities is vital to dismantle cycles of marginalisation and distrust and in turn improve vaccine acceptance and uptake.

SMaRT-PCR: sampling using masks and RT-PCR, a non-invasive diagnostic tool for paediatric pulmonary TB

BACKGROUND

Key challenges in paediatric TB diagnosis are invasive sampling and poor sensitivity of standard methods. This study demonstrates the diagnostic potential of non-invasive sampling of bioaerosols from children using SMaRT-PCR, comprising mask sampling combined with reverse transcriptase-polymerase chain reaction (RT-PCR) for TB.

METHODS

Exhaled bioaerosols were captured on modified N-95 masks in a 10-min talk-cough-breathe process from 51 children (30 with TB confirmed using standard sampling methods and 21 without TB) aged 2-15 years. All mask samples were tested using in-house RT-PCR for 16s and rpoB RNA transcripts. Additional mask samples from children with TB were tested using Xpert® MTB/RIF (n = 3) and Xpert® MTB/RIF Ultra (n = 27).

RESULTS

SMaRT-PCR sensitivity for detecting TB among treatment-naïve children was 96% if 16s or rpoB was present, and 75% if both genes were present, comparable to standard methods (71%) in the same cohort. Specificity was better for both genes, at 95%, than 85% for a single gene detection. Mask sampling with Xpert MTB/RIF or Ultra had a sensitivity of only 13%.

CONCLUSION

This is the first study to provide evidence for testing bioaerosols as a promising alternative for detecting paediatric TB. Sampling is non-invasive and simple, with the potential for point-of-care applications. This pilot study also suggests that RNA transcript-based detection may improve TB diagnostic sensitivity in children; however, further investigation is required to establish its adaptability in clinical settings..

Experiences of transgender persons in accessing routine healthcare services in India: Findings from a participatory qualitative study

Despite having a higher burden of health problems, transgender persons face challenges in accessing healthcare in India. Most studies on healthcare access of transgender persons in India focus only on HIV related care, mental healthcare, gender affirmative services or on the ethno-cultural communities or transgender women. This study fills this gap by focusing on diverse gender identities within the transgender community with a specific focus on experiences in accessing general or routine healthcare services. A qualitative descriptive approach was used in this study. 23 in-depth interviews and 6 focus group discussions were conducted virtually and in-person with a total of 63 transgender persons in different regions of India between May and September 2021. The study used a community-based participatory research approach and was informed by the intersectionality approach. Thematic analysis was conducted to analyze the data. Four key themes emerged: (i) intersectional challenges in accessing healthcare start outside of the health system, continue through cisgender-binary-normative health systems that exclude transgender persons; and at the interface with individuals such as health professionals, support staff and bystanders; (ii) the experiences negatively impact transgender persons at an individual level; (iii) in response, transgender persons navigate these challenges across each of the levels: individual, health system level and from outside of the health system. This is a first of its kind qualitative participatory study focusing on routine healthcare services of transgender persons in India. The findings indicate the need to move conversations on trans-inclusion in healthcare from HIV and gender affirmative services to routine comprehensive healthcare services considering the higher burden of health problems in the community and the impact of poor access on their lives and well-being.

THE STUDY OF VDR FOKI RS2228570 SNP IN AUTOIMMUNE THYROIDITIS

Autoimmune thyroid disease (AITD) is a common organ-specific autoimmune disease. A strong influence of genetic and epigenetic modifications has been demonstrated to take part in the development and progression of autoimmune thyroid diseases. The linkage between the Vitamin D receptor (VDR) polymorphism and several autoimmune disorders, including the AITD. In this article, we aim to investigate the Frequency of VDR Fokl (rs2228570) genotypes (CC, CT, TT) and alleles (C,T) in autoimmune thyroiditis. The investigation of VDR Fokl (rs2228570) was conducted on 150 samples (control (75 healthy women) and diseased women (75 diseased with autoimmune thyroiditis)) patients from the Adjara (Georgia) Population. It also examined some clinical and laboratory characteristics of the study population. Autoimmune thyroiditis's disease was diagnosed by measuring blood antibodies, determining the level of thyroperoxidase, and conducting an ultrasound examination. Anti-TPO and TSH were studied using the ELISA method. The genomic DNA was extracted from the peripheral blood. The polymerase chain reaction was evaluated to examine the VDR Fokl rs2228570 SNP polymorphism. According to VDR Fokl (rs2228570) genotypes (CC; CT, TT) frequency, in the control group, the Frequency of CC-genotype is 48%, CT-heterozygous genotype is 29.33%, and TT-genotype is 22.67%; in the diseased population, the Frequency of CC-genotype is 57.33%, CT-genotype is 34.67%, and TT-genotype is 8%. According to VDR Fokl (rs2228570) alleles (C, T), the Frequency of the C-allele is high, and the Frequency of the T-allele is low in both populations. The Frequency of the CC and CT genotypes of VDR Fokl (rs2228570) is high in the population with autoimmune thyroiditis compared to the control group; the TT genotype is relatively low in the population suffering from autoimmune thyroiditis; According to VDR Fokl (rs2228570) alleles (C, T), the Frequency of C-allele is high both population.

Intersex/Differences of sex development: Human rights at the intersection of cure and care

Intersex people are viewed from the medicalised lens of having a "disorder" of sex development rather than a difference in sex development. This inherent indifference to diversity is also visible in LGBTQIA+ advocacy, as they were initially excluded from the Yogyakarta Principles promoting the human rights of sexual and gender minorities. This paper attempts to explore the issues of discrimination, social exclusion, and unnecessary medical treatments through the lens of the Human Rights in Patient Care framework to advance the human rights of the intersex community and highlight the need for the state to take responsibility. The discussion touches upon intersex people's right to bodily integrity; the right to freedom from torture and cruel, inhuman, and degrading treatment; the right to the highest attainable standard of health; and the right to legal and social recognition. The concept of human rights in patient care moves beyond the traditional philosophical principles of bioethics as it applies legal norms in a patient care context derived from judicial interpretations and international conventions upholding human rights at the intersection of cure and care. As socially accountable health professionals, it is our duty to defend the human rights of intersex people who are marginalised within the marginalised community.

Impact of the COVID-19 pandemic on the mental health of transgender persons in India: Findings from an exploratory qualitative study

Introduction

Transgender persons in India, who are one of the most vulnerable groups, were particularly impacted by the COVID-19 pandemic. Increased risk of COVID-19, challenges with continuing livelihood, uncertainty, and anxiety around the pandemic over pre-existing social discrimination and exclusion pose risk of a mental health impact as well. To investigate this further, this component of a larger study on experiences in healthcare of transgender persons in India during COVID-19 and looks into the question “How did the COVID-19 pandemic impact the mental health of transgender persons in India”.

Methods

22 In-depth interviews (IDI) and 6 focus group discussions (FGD) were conducted virtually and in-person with persons self-identifying as transgender or belonging to ethnocultural transgender communities from different parts of India. Community based participatory research approach was used by ensuring representation from the community in the research team and through a series of consultative workshops. Purposive sampling with snowballing was used. The IDIs and FGDs were recorded, transcribed verbatim and analyzed using an inductive thematic analysis.

Results

Mental health of transgender persons were affected in the following ways. Firstly, COVID-19, its associated fear and suffering combined with pre-existing inaccessibility of healthcare and reduced access to mental health care affected their mental health. Secondly, unique social support needs of transgender persons were disrupted by pandemic linked restrictions. Thirdly, pre-existing vulnerabilities such as precarious employment and underlying stigma were exacerbated. Finally, gender dysphoria was a key mediating factor in the impact of COVID-19 on mental health with a negative and positive impact.

Conclusions

The study reiterates the need to make systemic changes to make mental healthcare and general healthcare services trans-inclusive while also recognizing the essential nature of gender affirmative services and the need to continue them even during emergencies and disaster situations. While this brings out how public health emergencies can exacerbate vulnerabilities, it also shows how the lived mental health experience of transgender person is intricately linked to the way work, travel and housing is structured in our society and therefore points to the structural nature of the linkage between mental health and gender.

Robot assisted radical prostatectomy in fit older patients compared to a standard population: Clinical characteristics, surgical, oncological and functional outcomes

INTRODUCTION

To compare robotic assisted radical prostatectomy (RARP) in well-selected older patients with clinically localized prostate cancer, compared to a younger population. Primary endpoint was perioperative outcomes comparison and secondary endpoint were oncological and functional outcomes comparison to a younger population.

METHODS

Single tertiary center cohort of consecutive patients treated with RARP (2017-2020) with retrospective analysis. Patients were classified by age in two groups: <75: control group (CG) and ≥75: study group (SG). Patients aged ≥75 had a comprehensive geriatric assessment (CGA) and only patients classified Balducci ≤2 were admitted to surgery.

RESULTS

Two hundred and sixty-nine patients were included, 56 in SG and 213 in CG. Median follow-up was 9.8 months. Univariate analysis showed no statistically significant (SS) difference between the groups for patients' characteristics (PSA, digital rectal examination -DRE- and biopsy Gleason Score), perioperative data (operative time, hospitalization length, transfusions rate, immediate complications, Clavien-Dindo complications, 30-days re-interventions and 30-days re-hospitalisation), oncological (TNM, margins, extraprostatic extension, postoperative PSA, BCR, metastases, overall survival -OS- and cancer specific survival -CSS-) and functional outcomes. Median perioperative blood loss was lower in the SG: 200.00 cc IQR [100.00, 300.00] vs 200.00cc IQR [100.00, 400.00] in the CG (P<0.05). A multivariate regression considering age>75, DRE, GS, PSA, cardiovascular history and diabetes showed none of variables associated with early BCR. Limitations are retrospective design, small number of patients and short follow-up.

CONCLUSIONS

RARP shows similar perioperative, oncologic and functional outcomes for older patients selected by a CGA when compared to younger patients. The SG shows a minor perioperative bleeding.

LEVEL OF EVIDENCE

IV.

Assessment of potential risk factors for COVID-19 among health care workers in a health care setting in Delhi, India -a cohort study

INTRODUCTION

Healthcare workers (HCW) are most vulnerable to contracting COVID-19 infection. Understanding the extent of human-to-human transmission of the COVID-19 infection among HCWs is critical in managing this infection and for policy making. We did this study to estimate new infection by seroconversion among HCWs in recent contact with COVID-19 and predict the risk factors for infection.

METHODS

A cohort study was conducted at a tertiary care COVID-19 hospital in New Delhi during the first and second waves of the COVID-19 pandemic. All HCWs working in the hospital during the study period who came in recent contact with the patients were our study population. The data was collected by a detailed face-to-face interview, serological assessment for anti- COVID-19 antibodies at baseline and end line, and daily symptoms. Potential risk factors for seroprevalence and seroconversion were analyzed by logistic regression keeping the significance at p<0.05.

RESULTS

A total of 192 HCWs were recruited in this study, out of which 119 (62.0%) were seropositive. Almost all were wearing Personal protective equipment (PPE) and following Infection prevention and control (IPC) measures during their recent contact with a COVID-19 patient. Seroconversion was observed among 36.7% of HCWs, while 64.0% had a serial rise in the titer of antibodies during the follow-up period. Seropositivity was negatively associated with being a doctor (odds ratio [OR] 0.35, 95% Confidence Interval [CI] 0.18-0.71), having COVID-19 symptoms (OR 0.21, 95% CI 0.05-0.82), having comorbidities (OR 0.14, 95% CI 0.03-0.67), and received IPC training (OR 0.25, 95% CI 0.07-0.86), while positively associated with partial (OR 3.30, 95% CI 1.26-8.69), as well as complete vaccination for COVID-19 (OR 2.43, 95% CI 1.12-5.27). Seroconversion was positively associated with doctor as a profession (OR 13.04, 95% CI 3.39-50.25) and with partially (OR 4.35, 95% CI 1.07-17.65), as well as fully vaccinated for COVID-19 (OR 6.08, 95% CI 1.73-21.4). No significant association was observed between adherence to any IPC measures and PPE adopted by the HCW during the recent contact with COVID-19 patients and seroconversion.

CONCLUSION

Almost all the HCW practiced IPC measures in these settings. High seropositivity and seroconversion are most likely due to concurrent vaccination against COVID-19 rather than recent exposure to COVID-19 patients. Further studies using anti-N antibodies serology may help us find the reason for the seropositivity and seroconversion among HCWs.

Emerging Role and Place of Probiotics in the Management of Pediatric Neurodevelopmental Disorders

The current decade has witnessed significant developments with the latest therapeutic agents for managing various infectious diseases to complex hemato-oncological conditions, leading to a decrease in morbidity and mortality, while improving the quality of life (QoL), and increasing the life span. Non-communicable diseases (NCDs), which are on the rise across all age-groups, are being driven by unhealthy lifestyles and improved mental health issues. The current therapeutic agents were found to offer only symptomatic relief of varying efficacy and significant adverse effects, leading clinicians to evaluate other options for the management of both neurodevelopmental and neurodegenerative disorders. The role of gut microbiota has emerged as a potential target for the treatment of both neurodegenerative diseases and neurodevelopmental disorders like attention-deficit hyperactivity disorder (ADHD)/autism spectrum disorders (ASD) as a result of the decoding of the human genome and advances in our understanding of the human gut microbiome, including its interactions with the human brain. This review has been undertaken to understand on date level of understanding of human microbiota and towards identifying probiotic strains with proven efficacy and safety. According to recent investigations, several lactobacillus strains, including L. Paracasei 37, L. Planetarium 128, L. reuteri DSM 17938, and Bifidobacterium longum, have been effective in treating children's neurodevelopmental disorders such as ASD and ADHD. Future clinical studies are nonetheless required to confirm the long-term safety and effectiveness of probiotic strains in managing the primary and comorbid symptoms, hence improving patient and family quality of life.

How to cite this article

Khanna HN, Roy S, Shaikh A, et al. Emerging Role and Place of Probiotics in the Management of Pediatric Neurodevelopmental Disorders. Euroasian J Hepato-Gastroenterol 2022;12(2):102-108.

Do health care physician need to risk their own lives? Time to change our own attitude towards recommended physical activity

Background

Cardiovascular diseases are the leading cause of death around the world,South Asian population are at higher risk of atherosclerotic coronary artery diseases (CAD) comparatively. There is a recommended physical activity level to prevent atherosclerotic cardiovascular disease (ASCVD). Health care professionals especially doctors are main advisors to prescribe the exercise protocols among general population. Hence we conducted a survey among doctors of Pakistan to identify their physical activity as well as their knowledge and attitude toward recommended physical activity.

Methodology

An online questionnaire was shared with doctors of various specialties working in private and public healthcare system of the Pakistan. It consisted of consent for participation,followed by information regarding demographic profile, preexisting co-morbid conditions, opinion regarding importance of physical activity to prevent ASCVD (5 point scale), perceived physical activity level (4 point scale), knowledge regarding ACC recommended physical activity level for primary prevention of ASCVD, lifestyle, and barriers in following recommended physical activity level. Collected data were entered and analyzed using SPSS version 21.0, participants were categorized into two groups as “cardiologists” and “non-cardiologists” and results were compared between the two groups.

Results

A total of 159 doctors participated in the survey, out of whom 97 (61%) were cardiologist and remaining 62 (39%) were affiliated with other specialties. Male participants (72.3%) were predominant and mean age was 30.44±23.16 years. More than 60% (61.6%) of the participants were free of preexisting co-morbid condition, most common ASCVD risk factor was positive family history (26.4%) followed by smoking (7.5%) and hypertension (6.3%). According to BMI, 21.4% (34) were obese and 40.3% (64) were overweight. A total of 74.8% (119) of the participants claimed to know about ACC recommended physical activity level but 65.5% (78) were actually aware of recommended 150 min of moderate-intensity or 75 min of vigorous-intensity aerobic activity level. According to the lifestyle activities only 26.4% (42) of the participants were found to follow the ACC recommended physical activity level per week, this proportion was same between cardiologists and non-cardiologists, 25.8% vs. 27.4% respectively. Lack of time from daily routine (71.7%) was found to be most commonly stated reason for physical in activeness followed by overburden/over stress at workplace (33.3%) and lack of resources (14.5%).

Conclusion

Knowledge and adherence to the ACC recommended physical actively level was poor among both cardiologists and non-cardiologists even after considering it important for the primary prevention of ASCVD. Majority of doctors were overweight and obese.Lake of time and resources and over stressed work life of doctors are the key barriers in following recommended physical activity level.

Funding Acknowledgement

Type of funding sources: None.

Évaluation médico-economique de l’impact de mesures d’adaptation au virage de la chirurgie robot-assistée en urologie

INTRODUCTION

The development of robot-assisted urological surgery is held back by the lack of robust medico-economic analyses and their heterogeneity. We conducted a medico-economic study to evaluate the implementation of measures to optimize the transition to robotic surgery.

METHOD

We carried out a single-center, controlled study from the point of view of the public healthcare establishment for 4 years. Economic data collection was based on a micro-costing method and revenues from stay-related groups. Clinical data corresponded to mean lengths of stay, operating duration, complications and stays in intensive care. The measures to optimize the transition to robotic, implemented mid-study period, enabled before/after comparison.

RESULTS

Altogether, 668 patients undergoing robotic surgery were included. Robotic activity increased significantly from periods 1 to 2 to 256% (P=<0.001) as did the overall proportion of robotic by 45% to 85% (P=<0.001). The mean lengths of stay fell significantly, 6.8 d vs. 5.1 d (P<0.001). Costs and revenues increased significantly, resulting in a persistent deficit for the activity €226K vs. €382K (P=<0.001). With increased volume of activity, the deficit per operation and the cost per minute of robotic operating room fell significantly, €3,284 vs. €1,474/procedure (P=<0.001) and €27 vs €24/min (P=<0.029), tending towards a break-even point (=zero deficit) at 430 operations per year.

CONCLUSIONS

Robotic-assisted surgery can be significantly optimized by implementing measures for the robotic turn to reach a break-even point at 430 operations per year. A better multidisciplinary case mix could lower the break-even volume of activity in short term.

LEVEL OF EVIDENCE

3.

QT interval in patients receiving HCQ in SARS-CoV-2- A study on risk factors and correlation of baseline QTc with delta QTc in Pakistani population

Funding Acknowledgements

Type of funding sources: None.

Introduction

Hydroxychloroquine(HCQ) use alone or in combination with Azithromycin (AZM) in SARS-CoV-2 infection is associated with QTc prolongation and risk of arrhythmias.

Objectives

To determine changes in QTc interval and factors predictive of extreme QTc prolongation in patients receiving HCQ alone or in azithromycin combination in Pakistani patients.

Methodology

Retrospective review of records of hospitalized patients with SARS-Cov2 RT-PCR positive result who received HCQ or HCQ/Azithromycin in combination from March-May 2020. Baseline ECGs as well as post drug use ECGs data was recorded. Tisdale score was calculated for predicting risk of QTc prolongation,QTc interval was calculated using Bazett formula. Data entry and analysis was done in SPSS version 23. 

Results

A total of 134 patients were included in the study.  82.1%(110) were males and 17.9%(24) were females, mean age was 54.9 ± 13.7 years. 61.2% (82) had severe disease and 38.8 %(52) had non-severe disease. 14.2%(19) had history of cardiac disease, 35.8%(48) had hypertension and 35.1%(47) had diabetes mellitus. 70.1% (94) patients had received HCQ, AZM, or HCQ/AZM in combination. 40(29.9%) patients had not received any drug. Median baseline QTc among controls and non-control group was 383.5 (IQR 342.25-413.75)msec  and 379(IQR 358-402)msec respectively. HCQ alone was administered to 26.9%(36) and HCQ/AZM to 33.6%(45) patients. 55.6% (45/81) developed QTc prolongation(QTc> 480 msec) or delta QTc increase > 60 msec. 6.2%(5/81) had absolute QTc > 500 msec post-drug administration. 55.6%(25/45) and  30.6%(11/36) (p-value 0.024) developed QTc prolongation in combination and HCQ alone groups respectively. Delta QTc increased to >60msec in 42.0% (34/81); 53.3%(24/45) in  combination group and in 27.8%(10/36) of those receiving HCQ alone( p-value 0.021). Median delta change was 63( IQR 25-81) and 48.5(IQR 26.25-66.75) msec; Median Day 2 QTc  was 413.5 msec (IQR 377.5-436) and 413 msec (IQR361-447); and median maximum QTc was 447(IQR391-471) and 429.8(IQR401.5-45.75) msec in those receiving HCQ/AZM combination and HCQ alone respectively. 9%(12/134) had arrhythmias during hospital stay, in  8.9% (4) and 5.6%(2) patients of those receiving HCQ/AZM combination and HCQ alone respectively, no patient developed torsade de pointes, one patient had non-sustained VT. There was no statistically significant association of QTc prolongation  with mortality, acute kidney injury, myocardial injury or severity of disease. Diuretic use was found to be statistically significant association with QTc prolongation(p-value 0.038). There was a weak correlation of baseline QTc with Δ QTc(r = 0.207 and p-value 0.017)

Conclusion

QTc prolongation was observed in a significant population of patients receiving HCQ and HCQ/AZM combination, however, no significant life threating arrhythmias occurred.

A systematic review of immune checkpoint inhibitor-related neurological adverse events and association with anti-neuronal autoantibodies

Introduction: Immune checkpoint inhibitors (ICI) therapy has led to a paradigm shift in cancer drug development and in the clinical evaluation of approaches to combination cancer treatment. Dysregulation of the immune system by ICI therapy may also elicit autoimmune phenomena and consequently manifest clinically as immune-related adverse events (irAEs) including neurological irAEs. Areas Covered: The purpose of this review is to explore the role of autoantibodies in the diagnosis and prediction of neurological irAEs and to evaluate their pathogenicity. We searched Pubmed and Embase for neurological irAEs and associated autoantibodies and found 28 patients with central and peripheral neurological irAEs. Of these patients, up to 40% had encephalitis, 34.4% with myasthenia gravis and 22% of patients with peripheral neuropathy and Guillain-Barre Syndrome had autoantibodies. Expert Opinion: Overall, our survey suggested a causal relationship between neurological irAEs and autoantibodies. Detection of autoantibodies may help to diagnose neurological irAEs and inform their clinical management.

[Outcomes following the triage of patients for urological cancer and non-cancer surgery during Covid-19 pandemic peak]

Introduction

Lors de la première vague épidémique Covid-19, des mesures de triage, sans PCR systématique, étaient mises en place pour sélectionner les patients à opérer. Notre étude a comparé leurs résultats chirurgicaux après triage à ceux d’un groupe contrôle.

Matériel

L’analyse portait sur l’ensemble des patients initialement programmés dans un centre Covid de référence et inclus consécutivement, du 15 mars au 1^er mai 2020 (NCT04352699). Leurs données étaient recueillies prospectivement et ultérieurement comparées à celles des patients opérés 1 an auparavant sur la même période dans ce centre. Le critère d’évaluation principal était l’admission post-opératoire en unité de soins intensifs (USI). La morbidité, la mortalité postopératoire, le report d’interventions, les tests PCR étaient évalués. Des analyses de sous-groupes étaient réalisés pour les patients opérés de cancer.

Résultats

Après triage, 96 des 142 interventions programmées ont dû être reportées. Sur les opérés, 48 (68 %) l’étaient pour cancer. Au total, aucun cas de pneumonie Covid-19 post-opératoire n’a été identifié. Trois patients (4 %) ont été admis en USI, dont un finalement décédé pour sepsis urinaire. Chez ces patients, les RT-PCR étaient négatives. Globalement, comparativement au groupe contrôle, aucune différence d’admission en USI, ni de taux de mortalité post-opératoire n’ont été rapportées.

Conclusions

Le triage de la première vague n’a pas surexposé les patients sélectionnés à un risque de complication ou de décès post-opératoire, particulièrement pas pour ceux opérés pour cancer. En revanche, 67 % des patients ont été reportés, avec un risque associé à des retard de soins pouvant conduire au décès.

Niveau de preuve

3.

Biodegradable dendritic Boltorn™ nanoconstructs: A promising avenue for cancer theranostics

The family of Boltorn™ H40 dendrimers is an imperative subclass of hyperbranched biodegradable polymers (HBPs), which has received mounting attention as a result of its inimitable chemical, physical and biodegradable properties. These properties embrace three-dimensional dendrimeric nanoarchitecture to avert tanglement between polymer branches, adequate spatial cavities for increased encapsulation of guest molecules, good solubility as well as low viscosity to improve processability, and a huge number of surface functional groups for chemical manipulations. Similarly, low toxicity, non-immunogenicity, and natural biodegradation are significant and critical advantages in therapeutic applications as compared to other dendritic polymers. All these characteristics of Boltorn™ H40 are of pronounced importance for planning and developing advanced targeted cargo delivery carriers for cancer therapy. The present review highlights the applications of Boltorn™ H40 HBPs for the transport of chemotherapeutic agents to manage various types of cancers.

P81 Intraoperative MEP recordings from a urethral sphincter electrode for spinal conus tumour surgery and its importance

Objectives

To emphasise the importance of motor evoked potential (MEP) recordings from a simple urethral sphincter electrode along with routine use of bulbocavernosus reflex recordings, anal sphincter and other lower limb muscle free running and stimulated EMG and MEP’s, and SEP techniques for sphincter preservation.

Design

Case report.

Subjects

Patients with conus or other spinal lesions at risk of postoperative sphincter disturbance.

Methods

Transcranial ‘train of 5’ stimulation (5 pulses, interstimulus interval 4msec, 200 µsec pulse width) was applied, with recordings from the urethral sphincter (small electrode taped to Foley catheter to lie just inside the urethra, referred to nearby needle anteriorly in mons pubis) and anal sphincter (paired needle electrodes in both left and right sides of external sphincter).

Results

Intraoperative stimuli of structures during dissection at one point gave a motor response confined to the urethral sphincter suggesting that these fibres may have been considered non-functional and cut had these not been assessed separately. Urethral sphincter MEP’s during the dissection confirmed that these motor fibres remained in continuity throughout.. The patient was intact after tumour removal.

Conclusions

This is an avant-garde technique by which we managed to save the nerve supply to the urethral sphincter and eventually urinary continence which would have been compromised if separate urethral monitoring was not attempted along with usual intraoperative nerve monitoring. We believe its first in the UK.

Improving Metastatic Breast Cancer Care in Kenya Using Information Technology

Background and context: In Africa, up to two thirds of breast cancer patients have been reported to present with an advanced stage of III or IV at diagnosis leading to a disproportionately higher mortality. In Kenya, breast cancer is the most common cancer in females in terms of diagnosis and mortality. Metastatic breast cancer (MBC) patients are an ignored part of the breast cancer community as they are marginalized in many of the breast cancer related initiatives. MBC suffer from clinical depression, anxiety and four out of five of these women do not receive any services, referral or guidance to help them with their emotional distress. Preferred evidence based methods of support desired by women with MBC, include online support. International resources are not always applicable to the local context thus making them unattractive for people from diverse cultures and background, such as those from Africa. Kenya has a high percentage of literate females and highest Internet usage in the area. This provides a unique opportunity in an otherwise limited resource country to reach out to a significant population of MBC patients. The patients voices are a valuable and trustworthy assessment of their actual needs. They have been used frequently in the area of cancer as a first step in designing needs-tailored interventions. We propose to develop a virtual online forum with the aim of providing patients with MBC, and their caregivers an interactive forum for psycho social support, addressing stigmas, seek relevant clinical advice, find links to the nearest healthcare facilities, download helpful information, participate in support group activities and receive links to other important helpful sites that are locally relevant. We also propose that such forum should also reflect the needs of our patients as described by themselves. Aim: Primary aim of this project is developing a virtual online interactive support forum where MBC patients and their caregivers can access information on social, psychological, spiritual, religious and clinical needs. The purpose is to be partly achieved by assessing the patient needs by needs assessment survey and to evaluate the impact of such intervention on patient knowledge and satisfaction with care. Strategy/Tactics: Web site development is the key component of the project. Patients would be asked to fill out the Supportive Care Needs Survey/The Knowledge Assessment Tool. The surveys will take place at four major cancer treatment hospitals in Kenya. Postlaunch promotion and awareness about Web site will be made and, usage data and knowledge tool to be used to assess the impact and acceptability. Web site updated regularly to address issues identified. Program/Policy process: Information gathered would be made part of policy on national cancer strategy, recommendations to factor in identified patient needs in policy. What was learned: Ongoing process.

Prevention of chemotherapy toxicity by agents that neutralize or degrade cell-free chromatin

Background

Toxicity associated with chemotherapy is a major therapeutic challenge and is caused by chemotherapy-induced DNA damage and inflammation. We have recently reported that cell-free chromatin (cfCh) fragments released from dying cells can readily enter into healthy cells of the body to integrate into their genomes and induce DNA double-strand breaks, apoptosis and inflammation in them. We hypothesized that much of the toxicity of chemotherapy might be due to release of large quantities of cfCh from dying cells that could trigger an exaggerated DNA damage, apoptotic and inflammatory response in healthy cells over and above that caused by the drugs themselves.

Methods

We tested this hypothesis by administering cfCh neutralizing/degrading agents namely, anti-histone antibody complexed nanoparticles, DNase I and a novel DNA degrading agent-Resveratrol-Cu concurrently with five different chemotherapeutic agents to examine if chemotherapy-induced toxicity could be minimized.

Results

We observed (i) significant reduction in chemotherapy-induced surge of cfCh in blood; (ii) significant reduction in chemotherapy-induced surge of inflammatory cytokines CRP, IL-6, IFNγ and TNFα in blood; (iii) abolition of chemotherapy-induced tissue DNA damage (γH2AX), apoptosis (active caspase-3) and inflammation (NFκB and IL-6) in multiple organs and peripheral blood mononuclear cells; (iv) prevention of prolonged neutropenia following a single injection of adriamycin and (v) significant reduction in death following a lethal dose of adriamycin.

Conclusion

Our results suggest that toxicity of chemotherapy is caused to a large extent by cfCh released from dying cells and can be prevented by concurrent treatment with cfCh neutralizing/degrading agents.

The Tulip GT® airway versus the facemask and Guedel airway: a randomised, controlled, cross-over study by Basic Life Support-trained airway providers in anaesthetised patients

We performed a randomised, controlled, cross-over study of lung ventilation by Basic Life Support-trained providers using either the Tulip GT® airway or a facemask with a Guedel airway in 60 anaesthetised patients. Successful ventilation was achieved if the provider produced an end-tidal CO2 > 3.5 kPa and a tidal volume > 250 ml in two of the first three breaths, within 60 sec and within two attempts. Fifty-seven (95%) providers achieved successful ventilation using the Tulip GT compared with 35 (58%) using the facemask (p < 0.0001). Comparing the Tulip GT and facemask, the mean (SD) end-tidal CO2 was 5.0 (0.7) kPa vs 2.5 (1.5) kPa, tidal volume was 494 (175) ml vs 286 (186) ml and peak inspiratory pressure was 18.3 (3.4) cmH2 O vs 13.6 (7) cmH2 O respectively (all p < 0.0001). Forty-seven (78%) users favoured the Tulip GT airway. These results are similar to a previous manikin study using the same protocol, suggesting a close correlation between human and manikin studies for this airway device. We conclude that the Tulip GT should be considered as an adjunct to airway management both within and outside hospitals when ventilation is being undertaken by Basic Life Support-trained airway providers.

Molecular and phenotypic characterization of CD133 and SSEA4 enriched very small embryonic-like stem cells in human cord blood

Very small embryonic-like stem cells (VSELs) are immature primitive cells residing in adult and fetal tissues. This study describes enrichment strategy and molecular and phenotypic characterization of human cord blood VSELs. Flow cytometry analysis revealed that a majority of VSELs (LIN(-)/CD45(-)/CD34(+)) were present in the red blood cell (RBC) pellet after Ficoll-Hypaque centrifugation in contrast to the hematopoietic stem cells (LIN(-)/CD45(+)/CD34(+)) in the interphase layer. Thus, after lyses of RBCs, VSELs were enriched using CD133 and SSEA4 antibodies. These enriched cells were small in size (4-6 μm), spherical, exhibited telomerase activity and expressed pluripotent stem cell (OCT4A, OCT4, SSEA4, NANOG, SOX2, REX1), primordial germ cell (STELLA, FRAGILIS) as well as primitive hematopoietic (CD133, CD34) markers at protein and transcript levels. Heterogeneity was noted among VSELs based on subtle differences in expression of various markers studied. DNA analysis and cell cycle studies revealed that a majority of enriched VSELs were diploid, non-apoptotic and in G0/G1 phase, reflecting their quiescent state. VSELs also survived 5-fluorouracil treatment in vitro and treated cells entered into cell cycle. This study provides further support for the existence of pluripotent, diploid and relatively quiescent VSELs in cord blood and suggests further exploration of the subpopulations among them.

Microcirculation in the foot is augmented by neuromuscular stimulation via the common peroneal nerve in different lower limb postures: a potential treatment for leg ulcers

OBJECTIVES

To examine the effects of the geko™ device (a portable electical nerve stimulator) on microcirculatory flow on the dorsum of the foot, and whether this is influenced by lower limb postures and application of a plaster cast.

STUDY DESIGN

Cross-sectional, healthy cohort, open label, physiological response study.

METHODS

In 10 healthy volunteers, aged 19 to 24 years, Laser Doppler Fluxmetry measurements were made on the dorsum of the foot in four postures: standing (weight bearing and non-weight bearing) and supine lying (with the lower limb horizontal and then elevated). Measurements of flux were made both at rest and during stimulation with the geko™ device applied over the common peroneal nerve, at 1Hz for 5 minutes in each posture. Repeat measurement were made after the application of a below knee plaster cast. Measures of flux were compared to basal levels assumed to be in supine with limb horizontal, with no cast and an inactive Geko device.

RESULTS

The geko™ device was effective in increasing microcirculation on the dorsum of the foot in all four postures (Mean difference =141%, 95% CI 70%-212%, p=0.001). This effect was more pronounced than that of using a plaster alone (Mean increase in Flux of 73%, 95% CI 22%-125%, p=0.01) or variances due to the hydrostatic effects of different postures (Mean difference 17-27.6%, p>0.05). There was a 2 to 3 fold increase in flux when stimulation was delivered in combination with the plaster cast.

CONCLUSIONS

Stimulation using the geko™ device augments microcirculation in the foot. The response is greater in lying and non-weight bearing than weight bearing standing but the most striking effect is when stimulation is combined with a plaster cast. The geko™ offers a potential means of promoting conditions favourable for wound healing, where treatment using compression may be contraindicated, such as arterial/mixed aetiology ulcers.

Microcirculation in the foot is augmented by neuromuscular stimulation via the common peroneal nerve in different lower limb postures: a potential treatment for leg ulcers

AIM

Aim of the study was to examine the effects of the geko™ device (a portable electical nerve stimulator) on microcirculatory flow on the dorsum of the foot, and whether this is influenced by lower limb postures and application of a plaster cast.

METHODS

This was a cross-sectional, healthy cohort, open label, physiological response study. In 10 healthy volunteers, aged 19 to 24 years, laser Doppler fluxmetry measurements were made on the dorsum of the foot in four postures: standing (weight bearing and non-weight bearing) and supine lying (with the lower limb horizontal and then elevated). Measurements of flux were made both at rest and during stimulation with the geko™ device applied over the common peroneal nerve, at 1 Hz for 5 minutes in each posture. Repeat measurement were made after the application of a below knee plaster cast. Measures of flux were compared to basal levels assumed to be in supine with limb horizontal, with no cast and an inactive geko™ device.

RESULTS

The geko™ device was effective in increasing microcirculation on the dorsum of the foot in all four postures (mean difference =141%, 95% CI 70%-212%, P=0.001). This effect was more pronounced than that of using a plaster alone (Mean increase in flux of 73%, 95% CI 22%-125%, P=0.01) or variances due to the hydrostatic effects of different postures (mean difference 17-27.6%, P>0.05). There was a 2 to 3 fold increase in flux when stimulation was delivered in combination with the plaster cast.

CONCLUSION

Stimulation using the geko™ device augments microcirculation in the foot. The response is greater in lying and non-weight bearing than weight bearing standing but the most striking effect is when stimulation is combined with a plaster cast. The geko™ offers a potential means of promoting conditions favourable for wound healing, where treatment using compression may be contraindicated, such as arterial/mixed aetiology ulcers.

A pilot study to examine the effect of the Tulip oropharyngeal airway on ventilation immediately after mask ventilation following the induction of anaesthesia

The Tulip airway is an adult, disposable, single-sized oropharyngeal airway, that is connectable to an anaesthetic circuit. After a standardised induction of anaesthesia in 75 patients, the ease of insertion, intracuff pressure and intracuff volume were measured, as were the end-tidal carbon dioxide levels, airway pressures and tidal volumes over three breaths. Successful first-time insertion was achieved in 72 patients (96%, CI 88.8-99.2%) and after two attempts in 74 patients (99%, CI 92.8-100%). There was outright failure only in one patient. In 60 patients (80%, CI 72.2-90.4%), the Tulip airway provided a patent airway without additional manoeuvres, but in 14 patients, jaw thrust or head extension was necessary for airway patency. The main need for these adjuncts appeared to be an initial under-inflation of the cuff. These promising results are consistent with recent manikin studies using this device.

Neuromuscular electrostimulation viathe common peroneal nerve promotes lower limb blood flow in a below-kneecast: A potential for thromboprophylaxis

Objectives

We aimed to examine the characteristics of deep venous flow in the leg in a cast and the effects of a wearable neuromuscular stimulator (geko; FirstKind Ltd) and also to explore the participants’ tolerance of the stimulator.

Methods

This is an open-label physiological study on ten healthy volunteers. Duplex ultrasonography of the superficial femoral vein measured normal flow and cross-sectional area in the standing and supine positions (with the lower limb initially horizontal and then elevated). Flow measurements were repeated during activation of the geko stimulator placed over the peroneal nerve. The process was repeated after the application of a below-knee cast. Participants evaluated discomfort using a questionnaire (verbal rating score) and a scoring index (visual analogue scale).

Results

The geko device was effective in significantly increasing venous blood flow in the lower limb both with a plaster cast (mean difference 11.5 cm/sec^-1; p = 0.001 to 0.13) and without a plaster cast (mean difference 7.7 cm/sec^-1; p = 0.001 to 0.75). Posture also had a significant effect on peak venous blood flow when the cast was on and the geko inactive (p = 0.003 to 0.69), although these differences were less pronounced than the effect of the geko (mean difference 3.1 cm/sec^-1 (-6.5 to 10)). The geko device was well tolerated, with participants generally reporting only mild discomfort using the device.

Conclusion

The geko device increases venous blood flow in the lower limb, offering a potential mechanical thromboprolylaxis for patients in a cast.

Cite this article: Bone Joint Res 2013;2:179–85.

The outcome of patients with nephrogenic systemic fibrosis after successful kidney transplantation

Nephrogenic systemic fibrosis (NSF) is a debilitating disease in patients with severely diminished kidney function. Currently, no standard treatment exists but improvement has been reported after restoration of kidney function. We retrospectively studied 17 NSF patients with and without successful kidney transplantation (KTx) to evaluate the effects of KTx on NSF. Nine of the 11 KTx developed NSF pretransplant whereas two developed NSF immediately after KTx with delayed graft function. Two of the six dialysis patients had previous failed kidney transplants. Age and sex were well matched. All but one patient was dialysis dependent at the time of NSF. Median follow-up was 35 months for KTx patients and 9 months for dialysis patients. Kidney transplants achieved adequate renal function with median serum creatinine of 1.4 (0.9-2.8) mg/dL and a glomerular filtration rate of 42 (19-60) mL/min/1.73 m(2). NSF improved in 54.6% of the transplanted patients and 50% of the nontransplanted patients (p = 0.86). Two KTx patients had complete resolution of their symptoms whereas four had partial improvement. Improvement in the dialysis patients was all partial. Successful KTx did not insure improvement in NSF and in fact appeared to have no significant benefit over dialysis.