Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Correction: Assessing insecticide susceptibility, diagnostic dose and time for the sand fly Phlebotomus argentipes, the vector of visceral leishmaniasis in India, using the CDC bottle bioassay

[This corrects the article DOI: 10.1371/journal.pntd.0010613.].

Carrollian Origins of Bjorken Flow

Bjorken flow is among the simplest models of fluids moving near the speed of light (c), while Carroll symmetry arises as a contraction of Poincaré group when c→0. We show that Bjorken flow and its phenomenological approximations are completely captured by Carrollian fluids. Carrollian symmetries arise on generic null surfaces, and a fluid moving at c is restricted to such a surface, thereby naturally inheriting the symmetries. Carrollian hydrodynamics is, thus, not exotic, but rather ubiquitous, and provides a concrete framework for fluids moving at or near the speed of light.

Assessing insecticide susceptibility, diagnostic dose and time for the sand fly Phlebotomus argentipes, the vector of visceral leishmaniasis in India, using the CDC bottle bioassay

Visceral leishmaniasis (VL) is a vector-borne protozoan disease, which can be fatal if left untreated. Synthetic chemical insecticides are very effective tools for controlling of insect vectors, including the sand fly Phlebotomus argentipes, the vector of VL in the Indian subcontinent. However, repeated use of the same insecticide with increasing doses potentially can create high selection pressure and lead to tolerance and resistance development. The objective of this study was to determine the lethal concentrations and assess levels of susceptibility, diagnostic doses and times to death of laboratory-reared P. argentipes to five insecticides that are used worldwide to control vectors. Using the Center for Disease Control and Prevention (CDC) bottle bioassay, 20-30 sand flies were exposed in insecticide- coated 500-ml glass bottles. Flies were then observed for 24 hours and mortality was recorded. Dose-response survival curves were generated for each insecticide using QCal software and lethal concentrations causing 50%, 90% and 95% mortality were determined. A bioassay was also conducted to determine diagnostic doses and diagnostic times by exposing 20-30 flies in each bottle containing set concentrations of insecticide. Mortality was recorded at 10-minute intervals for 120 minutes to generate the survival curve. Phlebotomus argentipes are highly susceptible to alpha-cypermethrin, followed by deltamethrin, malathion, chlorpyrifos, and least susceptible to DDT. Also, the lowest diagnostic doses and diagnostic times were established for alpha-cypermethrin (3μg/ml for 40 minutes) to kill 100% of the flies. The susceptibility data, diagnostic doses and diagnostic times presented here will be useful as baseline reference points for future studies to assess insecticide susceptibility and resistance monitoring of field caught sand flies and to assist in surveillance as VL elimination is achieved in the region.

On Fixed-Accuracy Confidence Intervals for the Parameters of Lindley Distribution and Its Extensions

The purpose of the present paper is to deal with sequential estimation of the parameter θ in a Lindley distribution. A fixed-accuracy confidence interval for θ with a preassigned confidence coefficient is developed. It is established that, no fixed sample size procedure can solve the estimation problem and hence a purely sequential methodology is proposed to deal with the situation. The first-order asymptotic efficiency and consistency properties associated with our purely sequential strategy are derived. Similar estimation strategies are also outlined for a few other extensions of the Lindley distribution. Extensive simulation analysis is carried out to validate the theoretical findings. We also provide a real data example, where we estimate the parameter related to the “initial mass function" for a particular cluster of stars.

Unraveling the invisible demon: a study of the oxidative stress markers, antioxidant activities and inflammatory markers in patients admitted with complete heart block

Funding Acknowledgements

Type of funding sources: None.

Introduction

Despite the recent advancements in the management of Complete Heart Block (CHB), the aetiology of CHB is still idiopathic in most of the cases. Our study explores this hitherto untouched aspect of complete heart block.

Purpose

We aimed to assess the aetiological profile of Complete Heart Block patients in our study.

Methods

The study population consisted of 60 patients with complete heart block aged between 30 to 80 years, attending as an inpatient in ER. Oxidative stress was measured by serum MDA, serum GSH, serum Catalase activity and serum SOD activity. Antioxidant activity was obtained by measuring the levels of serum total antioxidant capacity. Inflammatory stress was measured by IL-5 and TNF-alpha levels. These values were compared to 30 healthy controls with no prior history of smoking and diabetes mellitus.

Results

The mean age of the patient was 62.48 ± 7.98 years and the gender distribution was 37 males and 23 females out of 60 patients. The mean value of serum MDA (ng/mL) in cases is 1451.26 ± 206.32, and in controls, the mean value is 1197.98 ± 234.71 (p=&lt;0.001). The mean value of serum GSH (mcg/mL) in cases is 46.982 ± 18.613, and in controls, the mean value is 54.155 ± 10.762 (p=0.027). The mean value of serum Catalase Activity (U/min/mg protein) in cases is 10.763 ± 4.038 and in controls, the mean value is 19.878 ± 7.787 (p=0.003). The mean value of serum SOD Activity (U/g) in cases is 24.950 ± 5.4565, and in controls, the mean value is 46.214 ± 14.6309 (p=0.891). The mean value of serum Total Antioxidant Capacity (U/mL) in cases is 5.546 ± 0.620 and in controls, the mean value is 8.346 ± 2.781 (p=0.025). The mean value of serum IL-5 (pg/mL) in cases is 481.442 ± 28.8995, and in controls, the mean value is 67.347 ± 20.445 (p&lt;0.001). The mean value of serum TNF-ALFA (pg/mL) in cases is 196.741 ± 73.771, and in controls, the mean value is 144.530 ± 42.599 (p= 0.081).

Conclusions

During a complete heart block, SOD (p=0.891), CAT (p=0.003), GSH (p=0.027) and total antioxidant (TAOC) (p=0.025) were significantly decreased in cases, compared to healthy controls, thus suggesting that the elevated levels of oxidative free radicals causes endothelial dysfunctioning. The increase in ROS was observed by a highly significant increase of malondialdehyde (MDA) (p=&lt;0.001) showing high ROS-mediated tissue damage. Besides damage by oxidative stress, our study suggests that there are certain inflammatory markers like TNF-α and IL-5 that actively participate in causing heart block. There was a significant increase in the concentration of IL-5 (p&lt;0.001) in the cases as compared to the controls.

The surprises in optical coherence tomography (OCT) findings in patients presenting with in-stent restenosis: the road less travelled

Funding Acknowledgements

Type of funding sources: None.

Background

Morphological features of neointimal tissue play a pivotal role in the pathophysiology of In-Stent Restenosis (ISR) after percutaneous coronary intervention, hence understanding these features and patterns is crucial.

Purpose

The present study was designed to qualitatively and quantitatively assess neointimal characteristics of lesions using OCT in patients presenting with ISR.

Methods

This was a single-center, prospective, observational study performed between 1st August 2020 and 30th December 2021 at a tertiary-care center in India. Patients diagnosed with stable angina and acute coronary syndrome with post-procedural angiographically documented restenosis (&gt;50%) were included. Qualitative and quantitative assessment of neointimal hyperplasia patterns was performed using OCT.

Results

A total of 34 patients with ISR were studied. Neointimal hyperplasia was classified as (i) homogenous group (n=18) and (ii) non-homogenous group (n=16). As many as 14 (77.8%) diabetics belonged to the homogenous group. Predominant plaque characteristics such as neoatherosclerosis, cholesterol crystals, and calcium were documented in 14 (77.8%), 12 (66.7%), and 11 (61.1%) patients in the homogenous group and in 10 (62.5%), 10 (62.5%), and 9 (56.2%) patients in the non-homogenous group, respectively. Unexpanded stent struts were identified in 11 (61.1%) and 11 (68.8%) patients in the homogenous and non-homogenous groups, respectively. Mean strut thickness was 93.73 ± 31.03 µm and 83.54 ± 18.0 µm, ISR was 72.50 ± 15.93% and 65.37 ± 21.69%, the neointimal thickness was 588.06 ± 167.82 mm and 666.25 ± 218.05 mm, and neointimal hyperplasia was 54.54 ± 11.23% and 59.26 ± 8.86% in the homogenous and non-homogenous groups, respectively.

Conclusion

Neoatherosclerosis and stent underexpansion was predominantly observed in our study, which was in contrast to most of the existing literature [1,2,3], and only diabetes was found to be significantly associated with homogenous neointimal hyperplasia, irrespective of the generation of the stent.

Radiofrequency Ablation for Prevention of Outflow Tract Obstruction in Percutaneous Mitral Valve-in-Valve Replacement

Left ventricular outflow tract obstruction (LVOTO) can complicate percutaneous mitral valve replacement and may preclude patients considered high surgical risk from transcatheter therapies. We report a case of mitral valve-in-valve procedure in a patient at high risk for LVOTO. (Level of Difficulty: Advanced.)

Time Series Simulation and Forecasting of Air Quality Using In-situ and Satellite-Based Observations Over an Urban Region

Air quality is directly associated with the health of society. So, it becomes essential to forecast air pollution, which assumes an imperative part in air pollution warnings and control. A time-series simulation approach was adapted for the forecasting of monthly mean ambient air pollutants (PM2.5, O3, NO2) concentration and Aerosol Optical Depth (AOD) at an urban traffic site (Mathura Road, CSIR-CRRI) in New Delhi, India. Satellite-based aerosol loading (AOD550) retrieved from the Terra MODIS (Collection 6) enhanced Deep Blue (DB) algorithm was used for further analysis. The analysis considered the average monthly mean concentration of air pollutants and AOD between 2012-2017 and, simulates the concentrations of PM2.5, O3, NO2, and AOD for the same period and then forecasts air quality for the years 2020-2023. The forecasted results were validated with 24 months of in-situ and satellite data from 2018-to and 2019. In the year 2020, observed and simulated results are in lower agreement due to the shutdown of anthropogenic activities to combat pandemic situations. Otherwise, modeled and forecasted results are in good harmony with the in-situ and satellite observations. The results also signify that the time series Autoregressive Integrated Moving Average (ARIMA) modeling approach can be an effective and simple tool for air pollution simulation and future forecast. The results are evocative concerning the forecast of near future aerosol loading information and will also be profound to address the problems.

Case-control study of vitamin D status and adult multidrug-resistant pulmonary TB

BACKGROUND: India has the highest prevalence of multidrug-resistant TB (MDR-TB) globally. Vitamin D deficiency is potentially an important risk factor for MDR-TB.METHODS: We conducted a case-control study of 90 newly diagnosed adult MDR-TB cases, 180 household controls and 82 non-household controls in Mumbai, India. Serum 25-hydroxyvitamin D (25(OH)D), anthropometry, clinical status and history, dietary data and sociodemographic data were collected from each participant. Interferon-gamma release assay (IGRA) was also performed in controls to assess latent TB. Multivariable regression was performed to estimate associations between 25(OH)D vs. case status and IGRA positivity.RESULTS: Mean participant age was 33.8 ± 12.0 years; 72.8% had 25(OH)D <20 ng/ml. Mean 25(OH)D was significantly (P < 0.05) lower in cases (12.5 ± 7.9) than both household (17.5 ± 11.2) and non-household controls (16.4 ± 9.1). In multivariable models, 25(OH)D concentration was inversely associated with MDR-TB case status among cases and household controls (OR 0.95 per 1 ng/ml, 95% CI 0.92-0.99; P = 0.015), and among cases and non-household controls (OR 0.94 per 1 ng/ml, 95% CI 0.89-1.00; P = 0.033); 53.6% of controls were IGRA-positive. 25(OH)D status was not associated with IGRA positivity.CONCLUSION: Vitamin D status was independently associated with MDR-TB case status. Research should evaluate the effectiveness of vitamin D supplementation in prevention and adjunctive treatment of MDR-TB.

P-033 A third of men with normospermia attending for initial fertility assessment could have DNA damage

Study question

What is the incidence of sperm DNA damage in men with normal semen analyses attending for initial fertility investigation?

Summary answer

Half of men (54%) attending for infertilty investigation had a normal semen analysis of which a third (32%) of these had abnormal sperm DNA.

What is known already

Conventional semen analysis assesses sperm concentration, motility, and morphology but with a high degree of biological variability. Around 25% of men are given a diagnosis of unexplained infertility by normal semen analysis. The World Health Organisation (WHO) stated in 2021 that ‘clinically there is a growing awareness that chromosomal anomalies and gene mutations underlie a diverse spectrum of male infertility,’ so now recommends that sperm DNA is determined as an extended analysis. Sperm DNA damage occurs more often in infertile men and DNA damage is associated with recurrent pregnancy loss and decreased live birth rates following fertility treatment.

Study design, size, duration

A prospective cohort study of men attending a secondary fertility clinic were offered a standard semen analysis plus sperm DNA fragmentation using SpermComet technology. UK IRAS ethical approval was obtained. Men attending were given a patient information leaflet at their first appointment. The study duration was 6 months. In total, 142 men were recruited out of a possible maximum of 409 attendees.

Participants/materials, setting, methods

Participants included men who had been referred as a couple to a secondary level infertility clinic for an initial assessment. Information leaflets were either posted to them prior to their first appointment or given to them at the initial nurse-led consultation. Those who subsequently contacted our research team re-attended for a sperm analysis and an aliquot was cryopreserved and sent in weekly batches to Examen (Northern Ireland) for SpermComet DNA fragmentation assessment.

Main results and the role of chance

Between May and November 2021, there were 409 attendees of whom 142 consented to the study.

Sperm DNA quality for the participants was assessed and reported as average, low and high DNA damage as a percentage compared with clinical thresholds used by Examen from their sperm bank of 63 fertile sperm donors who had recently achieved clinical pregnancies.

Of the 142 recruited, 77 men (54%) attending for initial investigations had normospermia assessed against the WHO criteria, so were initially classified as unexplained. Of these, 25 (32%) had abnormal sperm DNA values. The average comet score was 39.7% +/-1.3, low comet score was 37.8% +/- 4.4 and high comet score was 17.0% +/-2.0. These values were all significantly outside ( p &lt; 0.001) of the fertile parameters from 63 fertile donors used by Examen (fertile range: average &lt;26%%, low &gt;74% and high &lt;4%).

Our results suggest that up to a third of men reported to have normospermia will have DNA damaged sperm. This is important to consider before labelling a couple as 'unexplained'. Knowing the male's sperm DNA fragmentation assessment would allow for further discussion and exploration of lifestyle and dietary advice.

Limitations, reasons for caution

During the study period, not all attendees agreed to participate as it required an additional hospital visit. In this single site study, men have not yet been followed up for future fertility outcome such as natural conception and need or success of assisted conception.

Wider implications of the findings

Sperm DNA damage was found in a third of men who would previously have been classified as fertile and offered no further investigations or treatment to improve their sperm quality. Thus, this tool could be a useful adjunct to semen analysis to guide these couples’ future treatment pathways.

Trial registration number

not applicable

Clinical Significance of Liver Function Abnormality in Patients with COVID-19: A Single-center Experience from Western India

BACKGROUND AND AIMS

The impact of coronavirus disease-2019 (COVID-19) on liver function remains to be fully elucidated. This study was designed to investigate such and determine the clinical significance in determining mortality risk.

METHODS

A retrospective study was conducted in patients with COVID-19 from March 2020 to July 2020. Clinical details were retrieved from electronic medical records to obtain clinical characteristics, medical history, laboratory tests, therapeutic intervention, and outcome data.

RESULTS

A total of 184 patients with COVID-19 were included (median age: 45.5 years), comprised of 62.5% men. In total, 22 (12.0%) patients had severe infection and 162 (88.0%) had mild to moderate infection. Overall, 95 (51.6%) showed abnormal liver function test (LFT) and 17 (9.2%) showed normal LFT at admission. The median age, hospital stay, and LFT were significantly higher in severe vs. non-severe infection (p<0.001). Out of 12 deaths, the majority were due to severe infection (n=11). Deaths were also due to acute respiratory distress syndrome (n=5), cardiac reasons (n=3), and sepsis with multiorgan failure (n=3). The median age, hospital stay and number of intensive care unit admissions were higher in patients having abnormal LFT compared to normal LFT. Incidence of elevated aspartate aminotransferase (42.8% and 40.4%), alanine transaminase (43.7% and 41.6%), and hypoalbuminemia (71.4% and72.7%) at admission and discharge were more common in severe infection. The mean survival was significantly lower in severe infection compared to those with non-severe disease (17.2 vs. 52.3 days; p<0.001).

CONCLUSIONS

Incidence of abnormal liver function was higher in patients with severe COVID-19 and was associated with prolonged hospital stay; mortality was associated with severity of COVID-19. For ruling out the risk of liver injury, it is crucial to vigilantly monitor the liver function parameters in patients with COVID-19 admitted to hospital.

Role of oral flecainide in assessement of atrio-ventricular conduction in symptomatic bifascicular block

Background

Intravenous flecainide is used to stress Atrio-ventricular (AV) conduction in patients (pts) with a history of syncope & bifascicular (Bi-Fasc) block. Role of oral flecainide is unclear.

Objective

To assess effect of oral Flecainide on infra-Hisian AV conduction in patients with symptomatic Bi-Fasc block.

Methods

Pts presenting with syncope & Bi-Fasc block without advanced AVCD on ECG, 24 hr holter or treadmill exercise test were taken. Those with history suggestive of reflex syncope & positive tilt test were excluded. Remaining underwent electro-physiological (EP) study. Pts with HV interval &gt;100ms or intra/infra-Hisian block at rest or incremental pacing were subjected to PPI. Remaining received oral Flacanide 5 mg/kg (max 300 mg) & EP study was repeated after ½ hr, 1 hr, 2 hrs and 3 hrs. Primary end-point was HV ≥100ms or infra/intra-Hisian type IIB or III block.

Results

Of 41 pts enrolled for study, 28 patients (mean age 60.0 yrs, mean LVEF 60.7%) were eligible for EP Study. Basal PR interval was 185.8±47.4 ms & mean QRS width was 130.6±18.65 ms. On EP study, 4 (14.3%) with resting HV &gt;100 ms & 6 (21.4%) with HV &gt;100 ms on incremental pacing underwent PPI.

Out of remaining 18 pts who were given flecainide, 11 (66.1%) achieved primary endpoint (HV &gt;100 ms in 6, infra-hisian IIB in 2 and 2:1 block in 3 patients). At mean follow up of 6.5 months, 13 (59.1%) out of 22 with PPI had mean 59.1% VP & none of 6 remaining patients had any symptom.

Conclusion

Oral Flecainide significantly increases the diagnostic yield of EP study in patients with symptomatic bi-fasc block.

Funding Acknowledgement

Type of funding sources: None.

Molecular characterization of N-methyl-d-aspartate receptor from Bemisia tabaci

The N-methyl-d-aspartate receptors (NMDARs) are ionotropic ligand gated channels that are highly permeable to calcium ions. In insects, NMDARs are associated with glutamatergic neurotransmission governing diverse physiological and biological processes like vitellogenesis and ovarian development. Therefore, NMDAR may act as attractive target for insect pest control. In present study, we performed structural and functional characterization of NMDARs in Bemisia tabaci, a highly invasive crop pest and potent virus vector. We identified that NMDAR consists of three subunits each encoded by single gene in whiteflies which are highly conserved among different insect orders. Expression analysis suggests that subunit 1 (BtNR1) and subunit 2 (BtNR2) are the main functional units. External supplementation of NMDAR ligand or BtNRs silencing was lethal to insects, which suggested that NMDAR function is highly balanced in whiteflies.

Giant Calculus with More than 100 Small Calculi in Choledochal Cysts

Giant biliary calculus in the common bile duct (CBD) is rare. Giant calculus of choledochal cyst (CC) is even rarer, and no case of giant calculus of CC with more than 100 calculi has been reported in the indexed literature. We present the case of a 8.0 × 4.5 × 4.0 cm sized giant calculus with >100 small calculi in type IVa CCs with heterotopic pancreas in a 45-year-old male, which is a surprisingly rare occurrence. Magnetic resonance cholangiopancreatography showed multifocal irregular dilatation of intrahepatic biliary radicles with multiple filling defects with a giant calculus in CC with cholelithiasis. The case was successfully managed with open cholecystectomy and choledochotomy with retrieval of 1 giant and more than 100 small calculi with excision of CC with Roux-en-Y hepaticojejunostomy. Histopathological examination (HPE) showed inflamed CC identified with focal areas of surface ulceration with increased fibrosis areas in the wall and few pancreatic acini. A bile duct calculus is defined as “giant” when the size is 5 cm or more. Stone formation within is the most frequent complication of CC. Most intracystic calculi have been described as soft, earthy, and pigmented in appearance, supporting bile stasis as a primary etiologic factor. The only treatment for giant calculus of CBD or CC is surgical. Endoscopic treatment is mostly unsuccessful and open surgery is the treatment of choice due to giant size, increased load of calculus, and presence of calculi in the left and right hepatic ducts.

Nanodiagnostics in leishmaniasis: A new frontiers for early elimination

Visceral leishmaniasis (VL) is still a major public health concern in developing countries having the highest outbreak and mortality potential. While the treatment of VL has greatly improved in recent times, the current diagnostic tools are limited for use in the post-elimination setting. Although conventional serological methods of detection are rapid, they can only differentiate between active disease in strict combination with clinical criteria, and thus are not sufficient enough to diagnose relapse patients. Therefore, there is a dire need for a portable, authentic, and reliable assay that does not require large space, specialized instrument facilities, or highly trained laboratory personnel and can be carried out in primary health care settings. Advances in the nanodiagnostic approaches have led to the expansion of new frontiers in the concerned area. The nanosized particles are blessed with an ability to interact one-on-one with the biomolecules because of their unique optical and physicochemical properties and high surface area to volume ratio. Biomolecular detection systems based on nanoparticles (NPs) are cost-effective, rapid, nongel, non-PCR, and nonculture based that provide fast, one-step, and reliable results with acceptable sensitivity and specificity. In this review, we discuss different NPs that are being used for the identification of molecular markers and other biomarkers, such as toxins and antigens associated with leishmaniasis. The most promising diagnostic approaches have been included in the article, and the ability of biomolecular recognition, advantages, and disadvantages have been discussed in detail to showcase the enormous potential of nanodiagnostics in human and veterinary medicine. This article is categorized under: Diagnostic Tools > Diagnostic Nanodevices Therapeutic Approaches and Drug Discovery > Nanomedicine for Infectious Disease Diagnostic Tools > Biosensing.

Gamma-ray flares from relativistic magnetic reconnection in the jet of the quasar 3C 279

Spinning black holes in the centres of galaxies can release powerful magnetised jets. When the jets are observed at angles of less than a few degrees to the line-of-sight, they are called blazars, showing variable non-thermal emission across the electromagnetic spectrum from radio waves to gamma rays. It is commonly believed that shock waves are responsible for this dissipation of jet energy. Here we show that gamma-ray observations of the blazar 3C 279 with the space-borne telescope Fermi-LAT reveal a characteristic peak-in-peak variability pattern on time scales of minutes expected if the particle acceleration is instead due to relativistic magnetic reconnection. The absence of gamma-ray pair attenuation shows that particle acceleration takes place at a distance of ten thousand gravitational radii from the black hole where the fluid dynamical kink instability drives plasma turbulence.

Blazars show variable non-thermal emission across the electromagnetic spectrum from radio waves to gamma rays. Here, the authors show blazar 3C 279 reveals a characteristic peak-in-peak variability pattern on time scales of minutes if particle acceleration is due to relativistic magnetic reconnection.

Cosmic-ray antinuclei as messengers of new physics: status and outlook for the new decade

The precise measurement of cosmic-ray antinuclei serves as an important means for identifying the nature of dark matter and other new astrophysical phenomena, and could be used with other cosmic-ray species to understand cosmic-ray production and propagation in the Galaxy. For instance, low-energy antideuterons would provide a "smoking gun" signature of dark matter annihilation or decay, essentially free of astrophysical background. Studies in recent years have emphasized that models for cosmic-ray antideuterons must be considered together with the abundant cosmic antiprotons and any potential observation of antihelium. Therefore, a second dedicated Antideuteron Workshop was organized at UCLA in March 2019, bringing together a community of theorists and experimentalists to review the status of current observations of cosmic-ray antinuclei, the theoretical work towards understanding these signatures, and the potential of upcoming measurements to illuminate ongoing controversies. This review aims to synthesize this recent work and present implications for the upcoming decade of antinuclei observations and searches. This includes discussion of a possible dark matter signature in the AMS-02 antiproton spectrum, the most recent limits from BESS Polar-II on the cosmic antideuteron flux, and reports of candidate antihelium events by AMS-02; recent collider and cosmic-ray measurements relevant for antinuclei production models; the state of cosmic-ray transport models in light of AMS-02 and Voyager data; and the prospects for upcoming experiments, such as GAPS. This provides a roadmap for progress on cosmic antinuclei signatures of dark matter in the coming years.

Habitual Patellar Dislocation-Management by Two in One Procedure, Short Term Results

AIM

Habitual dislocation of patella is an uncommon pathological condition. Though numerous techniques have been described in the literature for the treatment of patellar dislocations, none of the single procedure is fully effective in the surgical treatment of habitual dislocation of patella. We described our experience with a two in one procedure for habitual dislocation of patella in ten children.

PATIENTS AND METHOD

Ten children having habitual dislocation were reviewed prospectively for twelve months following surgical procedure. The age ranged between 5 and 9 years. We performed graded lateral soft tissue release and patellar tendon transposition as described by Roux Goldthwait. Clinical results were evaluated using Kujala score, ability to do straight leg raise, knee range of motion and visual analogue scale.

RESULT

There has been no recurrence of dislocation. The mean Kujala score before surgery was 48 which improved to 97.8 at 12 months follow-up after the surgical procedure. At 12 months follow-up all patients were able to do straight leg raise and had almost full range of motion.

CONCLUSION

We conclude that extensive proximal lateral release along with Goldthwait Roux procedure helps in treating the habitual dislocation in patella in children. Decision for the extent of lateral release must be taken intra-operatively. Our method of treatment is simple, cost effective and reproducible with excellent functional outcome.

Association Between Serum Testosterone and Serum PSA Among Men With and Without Partial Androgen Deficiency

Serum prostatic specific antigen (PSA) and serum testosterone levels share an undefined relationship with each other, with many conflicting studies showing both positive and negative correlation between them. Our aim was to assess association between serum PSA and serum testosterone in healthy men with normal testosterone levels and men with partial androgen deficiency (PADAM). A cross sectional study was conducted at a teaching hospital setting where serum testosterone and aging male symptom scale (AMS) scores along with PSA were studied in 255 men (> 50 years) with and without PADAM. Mean total testosterone and serum PSA was 9.35 ± 1.33 nmol/L, 1.96 ± 0.76 ng/mL in males with PADAM and 15.30 ± 1.95 nmol/L, 1.85 ± 0.73 ng/mL respectively in males without PADAM. No significant relationship was observed between serum PSA and serum testosterone levels among healthy males irrespective of PADAM in the study population. We suggest, there is no need to adjust PSA values for biopsy decisions according to testosterone levels.

Arthroscopic Repair of a "U" Shaped Rotator Cuff Tear: Modified Margin Convergence with a Single Triple-loaded Suture Anchor

Introduction Repair of a "U" shaped rotator cuff tear tends to create extreme tensile forces at the central part of the rotator cuff margin, causing tensile overload and may result in subsequent failure. We describe our technique of repairing the "U" shaped tear in which margin convergence is done using Ethibond (Ethicon Inc., New Jersey) and a single triple-loaded suture anchor. It results in the reduction of the strain and also allows the repair of seemingly irreparable tears. Patients and method We included 10 patients having a "U" shaped degenerative rotator cuff tear. All patients were assessed preoperatively. The University of California at Los Angeles Shoulder score (UCLA shoulder score) recorded preoperatively and at final follow-up was used to assess functional outcome. Result Out of 10 patients, six were males and four were females. The mean age was 60 years (range 50-70 years). The average follow-up was for 31 months (range 24 - 48 months). The UCLA score increased from an average of 9 preoperatively (range 8 - 12) to an average of 29.6 (range 27 - 31) at the terminal follow-up. The UCLA increased in the postoperative period and was statistically significant (unpaired t-test; p < 0.0001). All patients had good/excellent outcomes (UCLA score > 27). Abduction increased from average 27 degree preoperatively (range 20 degree - 35 degree) to an average 131 degree (range 125 degree - 140 degree) at final follow-up (unpaired t-test; p < 0.0001). Conclusion Our technique of modified margin convergence achieves low tension repair and anatomical footprint reconstruction with good clinical outcomes using a single triple-loaded anchor.

Solution combustion synthesis, characterization, magnetic, and dielectric properties of CoFe2O4 and Co0.5M0.5Fe2O4 (M = Mn, Ni, and Zn)

Co_0.5Zn_0.5Fe₂O₄ (CZF) shows the highest M_s value compared to CoFe₂O₄ (CF), Co_0.5Mn_0.5Fe₂O₄ (CMF), and Co_0.5Ni_0.5Fe₂O₄ (CNF) as Zn²⁺ would prefer to occupy tetrahedral sites with a consequent increase of the Fe³⁺ concentration in octahedral sites.

Hydrogen evolution reaction from bare and surface-functionalized few-layered MoS2 nanosheets in acidic and alkaline electrolytes

Hydrogen is considered as an ideal and sustainable energy carrier because of its high energy density and carbon-free combustion. Electrochemical water splitting is the only solution for uninterrupted, scalable, and sustainable production of hydrogen without carbon emission. However, a large-scale hydrogen production through electrochemical water splitting depends on the availability of earth-abundant electrocatalysts and a suitable electrolyte medium. In this article, we demonstrate that hydrogen evolution reaction (HER) performance of electrocatalytic materials can be controlled by their surface functionalization and selection of a suitable electrolyte solution. Here, we report syntheses of few-layered MoS₂ nanosheets, NiO nanoparticles (NPs), and multiwalled carbon nanotubes (MWCNTs) using scalable production methods from earth-abundant materials. Magnetic measurements of as-produced electrocatalyst materials demonstrate that MoS₂ nanoflakes are diamagnetic, whereas surface-functionalized MoS₂ and its composite with carbon nanotubes have strong ferromagnetism. The HER performance of the few-layered pristine MoS₂ nanoflakes, MoS₂/NiO NPs, and MoS₂/NiO NPs/MWCNT nanocomposite electrocatalysts are studied in acidic and alkaline media. For bare MoS₂, the values of overpotential (η₁₀) in alkaline and acidic media are 0.45 and 0.54 V, respectively. Similarly, the values of current density at 0.5 V overpotential are 27 and 6.2 mA/cm² in alkaline and acidic media, respectively. The surface functionalization acts adversely in the both alkaline and acidic media. MoS₂ nanosheets functionalized with NiO NPs also demonstrated excellent performance for oxygen evolution reaction with anodic current of ~60 mA/cm² and Tafel slope of 78 mVdec^-1 in alkaline medium.

A review of skeletal dysplasia research in India

We aimed to review the contributions by Indian researchers to the subspecialty of skeletal dysplasias (SDs). Literature search using specific keywords in PubMed was performed to retrieve all the published literature on SDs as on July 6, 2017. All published literature on SDs wherein at least one author was from an Indian institute was included. Publications were grouped into different categories based on the major emphasis of the research paper. Five hundred and forty publications in English language were retrieved and categorized into five different groups. The publications were categorized as reports based on: (i) phenotypes (n = 437), (ii) mutations (n = 51), (iii) novel genes (n = 9), (iv) therapeutic interventions (n = 31), and (v) reviews (n = 12). Most of the publications were single-patient case reports describing the clinical and radiological features of the patients affected with SDs (n = 352). We enlisted all the significant Indian contributions. We have also highlighted the reports in which Indians have contributed to discovery of new genes and phenotypes. This review highlights the substantial Indian contributions to SD research, which is poised to reach even greater heights given the size and structure of our population, technological advances, and expanding national and international collaborations.

Patterns of hysterectomy in India: a national and state-level analysis of the Fourth National Family Health Survey (2015-2016)

Objective

The National Family Health Survey‐4 in India provided the first nationally representative estimates of hysterectomy among women aged 15–49. This paper aims to examine the national and state‐level age‐specific prevalence of hysterectomy, individual and household level factors associated with the procedure, and state‐level indicators that may explain variation across states.

Design

Cross‐sectional, nationally representative household survey.

Setting

National Family Health Survey was conducted across all Indian states and union territories between 2015 and 2016.

Population

The survey covered 699 686 women between the ages of 15 and 49 years.

Methods

Descriptive analyses and multivariate logistic regression.

Main outcome measures

Women who reported ever having a hysterectomy and age at hysterectomy.

Results

Age‐specific prevalence of hysterectomy was 0.36% (0.33,0.39) among women aged 15‐29; 3.59% (3.45,3.74) among women aged 30‐39; and 9.20% (8.94,9.46) among women 40‐49 years. There was considerable variation in prevalence by state. Four states reported age‐specific prevalence similar to high‐income settings. Approximately two‐thirds of hysterectomies were conducted in private facilities, with similar patterns across age groups. At the national level, higher age and parity (at least two children); not having had formal schooling; rural residence (adjusted odds ratio [AOR] 1.36; 95% CI 1.27,1.45; P < 0.01) and higher wealth status were associated with higher odds of hysterectomy. Previously sterilised women had lower odds (AOR 0.64; 95% CI 0.61,0,68; P < 0.01) of reporting hysterectomy. Exploratory analyses suggest state‐level factors associated with prevalence of hysterectomy include caesarean section, female illiteracy, and women's employment.

Conclusions

Hysterectomy patterns among women aged 15–49 in India indicate the critical need to ensure treatment options for gynaecological morbidity and to address hysterectomy among young women in particular.

Funding

This study was part of the RASTA initiative of the Population Council's India country office under the Evidence Project supported by USAID.

Tweetable abstract

Hysterectomy patterns in India highlight the need for alternatives to treat gynaecological morbidity among younger women.

Hysterectomy patterns in India highlight the need for alternatives to treat gynaecological morbidity among younger women.

Polyarteritis nodosa presenting as peripheral vascular disease and acute limb ischemia

Acute limb ischemia and peripheral vascular disease (PVD) are unusual presentations of polyarteritis nodosa (PAN). Here, we present a case with PVD of both lower limbs leading to foot claudication. Digital subtraction angiography showed narrowing, irregularity, and occlusion of both lower limb arteries with no involvement of the abdomen visceral arteries. Based on significant weight loss, diastolic blood pressure >90 mmHg, myalgia, testicular pain, and angiographic abnormalities in medium-sized arteries, he was diagnosed as having PAN. He was treated with corticosteroid and bolus intravenous cyclophosphamide following which he had prompt and near-complete recovery of the symptoms without any tissue loss.

Analysis of serum Haptoglobin using glycoproteomics and lectin immunoassay in liver diseases in Hepatitis B virus infection

BACKGROUND

Hepatocellular carcinoma (HCC) due to Hepatitis B viral (HBV) infection is a major cause in Asia-Pacific countries. Its early detection is of paramount importance using a marker having both sensitivity and specificity. The present study promises diagnostic and prognostic markers by the identification of site-specific glycoforms on Haptoglobin (Hp) using LC-MS/MS and lectin ELISA in liver diseased conditions in HBV infection.

METHODS

Three groups of patients: chronic, liver cirrhosis and HCC with HBV infection along with controls were enrolled. Hp was purified using affinity column chromatography and, peptide sequence, N-glycosylation site, glycan composition and glycoforms were identified using mass spectrometry. Quantitative lectin ELISA was used to measure levels of fucosylation on Hp in liver diseases due to HBV.

RESULTS

Hp levels were significantly lower in HCC when compared with Non-HCC cases (p < .05). Fucosylated glycoforms were significantly increased at site Asn184, Asn207 and Asn211 in liver diseased stages versus controls. A significant association was observed between the Fuc-Hp/Hp Elisa index and, advanced liver disease stages and controls using lectin Elisa (p < .001).

CONCLUSION

Quantitation of fucosylation levels on Hp protein using Lectin ELISA may be useful glycobiomarker either alone or in combination (AFP + DCP + FucHp; AUC = 0.94) in HBV HCC diagnosis in clinical practice.

Correlation of axillary lymph nodes involvement and Nottingham prognostic index with various histopathologic prognostic factors in invasive breast carcinoma

Background: Breast cancer is the commonest cancer of urban Indian women and the second commonest in the rural women. The clinical management of this tumor relies on various prognostic factors, most importantly lymph node stage, tumor size and histologic grade. There have been attempts at integration of these factors into meaningful indices. The most widely used of these is the Nottingham prognostic index (NPI), this study was aimed to evaluate the NPI in a group of breast cancer patients and to correlate NPI with other clinical and histo-morphological features.Methods: This was a two-year prospective, observational study was done in the Department of Surgery, Tertiary Care Teaching Hospital of Maharashtra, India. A total of 50 patients who presented with invasive carcinoma of breast from October 2016 to October 2018 were enrolled.Results: Most of the patients belonged to the age group of 41 to 50 years (34%) and the mean age of patients in study was 51.18±11.93 years. Left breast was more affected (62%) than the right breast (38%). Majority of the cases had tumor size of <5 cm (70%) and the mean size of was 4.65±1.89 cms. Majority of the patients (62%) belonged to Bloom Richardson (BR) Grade II and 24% of the patients were ER and PR positive. Lymphovascular invasion was present in 74% of the patients. There was significant positive correlation between tumor size and lymph node involvement. Significant correlation was noted between NPI score and tumor size, positive lymph nodes and BR grade. The mean NPI scores in patients with lymphovascular invasion were noted as 4.92±1.05, compared to 4.83±0.93 among the patients in whom lymphovascular invasion was absent (p=0.779). The mean NPI scores in patients with ER-, PR- were slightly high (4.91±0.94) compared to ER+, PR+ patients (4.76±1.19) (p=0.778).Conclusions: NPI is an essential and valuable prognostic indicator, which should be incorporated in breast cancer reporting by the histopathologists and also primary tumor size, lymph node stage and histological grade which provides further guideline to treating clinicians to choose treatment modalities for the patient and in deciding to follow up plan as well.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The GALAXIES inelastic hard X-ray scattering end-station at Synchrotron SOLEIL

GALAXIES is an in-vacuum undulator hard X-ray micro-focused beamline dedicated to the study of the electronic structure of materials with high energy resolution using both photoelectron spectroscopy and inelastic X-ray scattering and under both non-resonant (NR-IXS) and resonant (RIXS) conditions. Due to the penetrating power of hard X-rays and the `photon-in/photon-out' technique, the sample environment is not a limitation. Materials under extreme conditions, for example in diamond anvil cells or catalysis chambers, thus constitute a major research direction. Here, the design and performance of the inelastic X-ray scattering end-station that operates in the energy range from ∼4 keV up to 12 keV is reported, and its capabilities are highlighted using a selection of data taken from recently performed experiments. The ability to scan `on the fly' the incident and scattered/emitted X-ray energies, and the sample position enables fast data collection and high experimental throughput. A diamond X-ray transmission phase retarder, which can be used to generate circularly polarized light, will also be discussed in the light of the recent RIXS-MCD approach.

Comparative Antiviral Efficacy of Generic Sofosbuvir versus Brand Name Sofosbuvir with Ribavirin for the Treatment of Hepatitis C

BACKGROUND

Chronic hepatitis C infection is a major cause for liver failure and liver cancer and can be treated with highly effective all oral directly acting antiviral (DAA) drugs. Generic versions of these DAAs are available in India.

METHOD

This was an open-label, single-center, prospective, nonrandomized observational study for the comparative safety and efficacy of generic versus brand name sofosbuvir with ribavirin therapy for chronic hepatitis C infection (all genotypes). Between December 2014 and December 2015, 66 patients received either generic sofosbuvir (400mg) or brand name SOLVALDI (400mg) with weight based ribavirin for 24 weeks in a single multispecialty hospital in Mumbai. Monitoring viral loads and safety labs was performed as per national guidelines.

RESULTS

Sustained virologic response was 72.4% versus 75.7% (p=0.78) among patients treated with generics and SOVALDI, respectively. At 4 weeks on-treatment, approximately 90% of patients from both groups had undetectable or below the lower limit of quantification. Change in hemoglobin was comparable in both groups (p=0.26).

CONCLUSION

Generic versions of sofosbuvir reported in this study are safe and efficacious to treat hepatitis C. However, bioequivalency studies of all generic DAAs need to be performed before wider use of such drugs for the treatment of hepatitis C.

Seven additional families with spondylocarpotarsal synostosis syndrome with novel biallelic deleterious variants in FLNB

The location and/or type of variants in FLNB result in a spectrum of osteochondrodysplasias ranging from mild forms, like spondylocarpotarsal synostosis syndrome and Larsen syndrome, to severe perinatal lethal forms, such as atelosteogenesis I and III and Boomerang dysplasia. Spondylocarpotarsal synostosis syndrome is characterized by disproportionate short stature, vertebral anomalies and fusion of carpal and tarsal bones. Biallelic loss-of-function variants in FLNB are known to cause spondylocarpotarsal synostosis syndrome and 9 families and 9 pathogenic variants have been reported so far. We report clinical features of 10 additional patients from 7 families with spondylocarpotarsal synostosis syndrome due to 7 novel deleterious variants in FLNB, thus expanding the clinical and molecular repertoire of spondylocarpotarsal synostosis syndrome. Our report validates key clinical (fused thoracic vertebrae and carpal and tarsal coalition) and molecular (truncating variants in FLNB) characteristics of this condition.

Abstract P1-03-05: Not presented

This abstract was not presented at the symposium.

Investigation of modal-interference-induced fiber optic refractive index sensor: markedly enhanced sensitivity realized by shining an optical vortex beam

A highly sensitive multimode-interference-based refractive index sensor is reported here by shining an optical vortex beam. The sensor probe is formed by splicing a length of no-core fiber in between two air-core vortex fibers. The coupling characteristics of various modes inside the sensor and their effect on sensing properties are numerically analyzed. Simulation results show that the sensing scheme proffers a maximum sensing resolution of 7.59×10^-6 and 4.18×10^-6 RIU for no-core fiber length of 29.40 and 44.60 mm, respectively. Because of its high sensitivity, the study has potential applications in the chemical and biological sensing fields.

Sofosbuvir plus ribavirin in treatment-naïve patients with chronic hepatitis C virus genotype 1 or 3 infection in India

Until 2014, pegylated interferon plus ribavirin was the recommended standard of care for the treatment of chronic hepatitis C virus (HCV) infection in India. This open-label phase 3b study, conducted across 14 sites in India between 31 March 2014 and 30 November 2015, evaluated the efficacy and safety of sofosbuvir plus ribavirin therapy among treatment-naïve patients with chronic genotype 1 or 3 HCV infection. A total of 117 patients with genotype 1 or 3 HCV infection were randomized 1:1 to receive sofosbuvir 400 mg and weight-based ribavirin (1000 or 1200 mg) daily for 16 or 24 weeks. Among those with genotype 1 infection, the primary efficacy endpoint of sustained virologic response at 12 weeks post-treatment (SVR12) was reported in 90% (95% confidence intervals [CI], 73-98) and 96% (95% CI, 82-100) of patients following 16 and 24 weeks of treatment, respectively. For patients with genotype 3 infection, SVR12 rates were 100% (95% CI, 88-100) and 93% (95% CI, 78-99) after 16 and 24 weeks of therapy, respectively. Adverse events, most of which were mild or moderate in severity, occurred in 69% and 57% of patients receiving 16 and 24 weeks of treatment, respectively. The most common treatment-emergent adverse events were asthenia, headache and cough. Only one patient in the 24-week group discontinued treatment with sofosbuvir during this study. Overall, sofosbuvir plus ribavirin therapy achieved SVR12 rates ≥90% and was well tolerated among treatment-naïve patients with chronic genotype 1 or 3 HCV infection in India.

Effect of probiotics on clinical and immune parameters in enthesitis-related arthritis category of juvenile idiopathic arthritis

Gut microflora and dysbiosis as an environmental factor has been linked to the pathogenesis of enthesitis-related arthritis (JIA-ERA); thus, we performed a proof-of-concept study of probiotics to modulate the gut-flora and study the effects on immune and clinical parameters of children having JIA-ERA. Forty-six children with active JIA-ERA were randomized to placebo or probiotic therapy along with non-steroidal anti-inflammatory drugs (NSAIDs) for 12 weeks. Patients were assessed using a six-point composite disease activity index (mJSpADA) based on morning stiffness, joint count, enthesitis count, sacroiliitis/inflammatory back pain, uveitis and erythrocyte sedimentation rate/C-reactive protein (ESR/CRP). Frequencies of T helper type 1 (Th1), Th2, Th17 and regulatory T cells in blood were measured using flow cytometry. Serum cytokines interferon (IFN)-γ, interleukin (IL)-4, IL-17, IL-10, tumour necrosis factor (TNF)-α and IL-6 were measured by cytokine bead array using flow cytometer. The average age of 46 children (44 boys) was 15 ± 2.5 years and duration of disease was 3.5 ± 3 years. There was no significant difference in improvement in mJSpADA between the two groups (P = 0·16). Serum IL-6 levels showed a decrease (P < 0·05) in the probiotic-group. Th2 cell frequency (P < 0·05) and serum IL-10 levels (P < 0·01) showed an increase in the placebo group, but again the probiotic use did not show a significant change in immune parameters when compared to the placebo. Adverse effects among the probiotic and placebo groups were diarrhea (36 versus 45%), abdominal pain (9 versus 20%), minor infections (4·5 versus 20%) and flatulence (23 versus 15%), respectively. Thus, we can conclude that probiotic therapy in JIA-ERA children is well tolerated, but failed to show any significant immune or clinical effects over NSAID therapy.

Second family provides further evidence for causation of Steel syndrome by biallelic mutations in COL27A1

Steel syndrome is a rare disorder of the skeleton characterized by facial dysmorphism, short stature, carpal coalition, dislocated radial heads, bilateral hip dislocation and vertical talus. Homozygous variants in COL27A1 were reported in an extending family from Puerto Rico. Here, we report a 5-year-old girl from a non-consanguineous family with facial dysmorphism, short stature, carpal coalition, dislocation of radial heads, bilateral hip dislocation, scoliosis and vertical talus. Exome sequencing identified 2 novel compound heterozygous variants c.521_528del (p.(Cys174Serfs*34)) and c.2119C>T (p.(Arg707*)) in COL27A1 in this child and the parents were heterozygous carriers. We hence report the second molecularly proven case of Steel syndrome and the first case to be reported among non-Puerto Rican population. Our report further validates the role of COL27A1 mutations in causation of Steel syndrome.

Pt–CeO2 nanoporous spheres – an excellent catalyst for partial oxidation of methane: effect of the bimodal pore structure

Bimodal pore size distribution played the most important role for the catalyst's superior activity during POM.