"TB - Mindedness"-the only way to beat "the great mimicker": A case series with atypical presentation of female genital tuberculosis

BACKGROUND

Incidence of Tuberculosis (TB) cases in India reported in 2019 is 193 per 1 lakh population [National Tuberculosis Elimination Plan (NTEP)]. In India, annual extra pulmonary TB burden is 20-25%, of which 4% of cases are of urogenital origin (Revised National TB Control Programme, 2019; World Health Organization, 2019). The Ministry of Health and Family Welfare has made a target of eliminating tuberculosis by 2025 under the NTEP by the process of identification, notification and treatment of cases. Tuberculosis being a leading cause of infertility in developing countries, employing best clinical practices and being "TB-minded" will also save the patient of enormous anxiety and uncertainity and also decrease the time gap between clinical presentation and diagnosis to optimize fertility outcome.

METHODOLOGY

A prospective cohort study of cases presenting with unusual findings and ultimately being diagnosed as genital tuberculosis was conducted in the gynaecology OPD, AIIMS, New Delhi, from November 2020 to November 2021 (1 year). Patients were investigated judiciously, diagnosis made and followed up for their response to anti tuberculosis therapy (ATT).

RESULTS

This data comprises of conglomerate of ten cases with unconventional exhibition of genital tuberculosis. 70% of the cases presented with pain lower abdomen not specifically related to menstrual cycle and often confused with IBD. Tubo ovarian mass (70%) mimicking as simple ovarian cyst, ovarian carcinoma or endometriosis was the most common clinical finding we came across.

A Survey on Relation of Menopause to Metabolic Syndrome - SAFOMS STUDY (South Asian Federation of Menopause Societies) - Interim Analysis

Background

Metabolic syndrome (MS) is a spectrum of disorders that includes dysglycemia, dyslipidemia, central obesity, and hypertension. South Asian Indians are more prone to harbor MS at a younger age compared to Caucasians. However, there is a lack of large-scale data correlating menopause to MS in South Asian settings.

Aims and Objectives

The study aimed to determine the prevalence of MS and its components in pre- and postmenopausal women. It also assessed the relationship of age, menopausal status, personal and family history, anthropometric parameters, and biochemical markers to MS.

Materials and Methods

It was an interim analysis of a multicountry cross-sectional study in the South Asian Federation of Menopause Society (SAFOMS) countries: India, Pakistan, Bangladesh, Nepal, and Sri Lanka conducted through both online and physical methods. The survey questionnaire consisted of questions about details of personal history, demographics, and family history related to MS. Anthropometric measurements such as height, weight, basal metabolic index (BMI), waist circumference, and blood pressure readings were noted. Relevant history, history of polycystic ovarian syndrome, hypertensive disorders of pregnancy, and vasomotor symptoms were enquired. Biochemical evaluation of markers associated with MS was undertaken.

Results

In this interim analysis, 638 women were recruited. Out of them, 406 (63.6%) women were premenopausal and 232 (36.4%) were postmenopausal. 392 (61.4%) women had MS, while 246 (38.6%) women did not have MS. Increasing age, BMI, and visceral adiposity (waist circumference) were significantly correlated with incidence of MS. Raised fasting blood sugar, hemoglobin A1C, total cholesterol, low-density lipoprotein, serum triglyceride, and reduced high-density lipoprotein levels were significantly associated with the incidence of MS in both pre- and postmenopausal women. Peri- and postmenopausal hot flashes, night sweats, and sleep disturbances were also significantly associated with MS. Personal history of hypertension, diabetes, and dyslipidemia were the strongest factors to be associated with MS with a significantly high odds ratio.

Conclusion

The study has highlighted the role of BMI and waist circumference as the first warning signs, which will encourage to go for regular biochemical screening through lipid profile and fasting blood glucose measurements. Our study is a stepping stone for all future studies for relation of menopause to MS.

Comparison of Intraperitoneal Irrigation With Sodium Bicarbonate Versus Normal Saline in Reducing Pain After Operative Laparoscopy: A Randomized Controlled Trial

Background It has been postulated that sodium bicarbonate can reduce postoperative pain by neutralizing the acidic peritoneal environment created by carbon dioxide. It also prevents phrenic nerve damage and peritoneal irritation. The present study is a randomized controlled trial aimed at studying the effects of sodium bicarbonate in reducing postoperative pain in laparoscopic gynecological surgeries. Materials and methods This was a single-center, prospective, two-arm, double-blinded randomized control trial in which intraperitoneal irrigation with sodium bicarbonate was compared with normal saline in operative laparoscopy. Group I (intervention group) consisted of 40 patients who received intraperitoneal sodium bicarbonate, and Group II (control group) consisted of 40 patients who received normal saline. All procedures were conducted under general anesthesia. Postoperative pain scores were compared between intervention and control groups.  Results The most common indication of laparoscopy was infertility. There was no difference in the duration of surgery between the two arms (p=0.27). The mean value of the visual analog scale (VAS) score at the shoulder tip was found to be significantly reduced in the intervention group at two hours (p=0.02), four hours (p=0.0009), and 12 hours (p=0.0002) after surgery. The mean VAS score at the abdomen and port sites was also found to be significantly reduced in the intervention group in the first 24 hours after surgery (p<0.05). With the increase in the time period from surgery, the mean VAS scores decreased in both intervention and control groups.  Conclusion Intraperitoneal irrigation with sodium bicarbonate is beneficial in reducing postoperative pain in operative laparoscopy. However, multicenter randomized trials with a greater number of participants will be helpful to confirm the findings.

Comparison of Outcomes following Vaginal Natural Orifice Transluminal Endoscopic Surgery and Laparoendoscopic Single-site Surgery in Benign Hysterectomy: A Systematic Review and Meta-analysis

Gradually increasing interest in laparoscopic surgeries has led to the advent of various lesser invasive techniques in the form of vaginal natural orifice transluminal endoscopic surgery (vNOTES) and laparoendoscopic single-site (LESS) surgery. Very few studies have analyzed the advantages and disadvantages of vNOTES over LESS surgeries in hysterectomy. After a comprehensive search, full texts of relevant manuscripts were obtained to assess eligibility for recruitment. A comprehensive meta-analysis was subsequently performed to compare the outcomes of vNOTES and LESS in hysterectomy, and forest plots were constructed. Four articles were rendered for review (three retrospective cohort studies and one randomized controlled trial). Three studies showed lesser postoperative pain in vNOTES compared to LESS. In one study, postoperative vaginal pain was higher in vNOTES due to additional suture between uterine artery and vaginal wall. The meta-analysis concluded that vNOTES could be better alternative to LESS hysterectomies. However, further large multicentric randomized trials are required for the standardization of the surgical method.

Azimuthal Correlations within Exclusive Dijets with Large Momentum Transfer in Photon-Lead Collisions

The structure of nucleons is multidimensional and depends on the transverse momenta, spatial geometry, and polarization of the constituent partons. Such a structure can be studied using high-energy photons produced in ultraperipheral heavy-ion collisions. The first measurement of the azimuthal angular correlations of exclusively produced events with two jets in photon-lead interactions at large momentum transfer is presented, a process that is considered to be sensitive to the underlying nuclear gluon polarization. This study uses a data sample of ultraperipheral lead-lead collisions at sqrt[s_{NN}]=5.02  TeV, corresponding to an integrated luminosity of 0.38  nb^{-1}, collected with the CMS experiment at the LHC. The measured second harmonic of the correlation between the sum and difference of the two jet transverse momentum vectors is found to be positive, and rising, as the dijet transverse momentum increases. A well-tuned model that has been successful at describing a wide range of proton scattering data from the HERA experiments fails to describe the observed correlations, suggesting the presence of gluon polarization effects.

Compassionate Use of Remdesivir in Pregnancy: A Case Series From a COVID-19 Dedicated Center and Review of Literature

Pregnancy is associated with immunological changes that could render an individual vulnerable to the severe coronavirus disease 2019 (COVID-19) disease. Even as we witnessed the third and most widespread pandemic wave, a conclusively advantageous treatment option still remained elusive. Remdesivir was one of the front-running therapeutic options that received emergency use authorization (EUA) and subsequent approval for the management of moderate to severe COVID-19 infections. Here, we report a series of moderate to severe COVID-19-infected pregnancies and the experience of remdesivir use on a compassionate basis. Four cases of pregnancy complicated with moderate to severe COVID-19 infections where remdesivir was administered were recruited into the study, and their outcome was assessed objectively. Of these cases, three women received remdesivir in addition to standard SARS-CoV-2 treatment in the antenatal period. One woman received remdesivir after delivery. One woman received tocilizumab in addition to remdesivir and standard SARS-CoV-2 care. Two women survived and were subsequently discharged to home care. Two succumbed to the disease. One baby who was exposed to remdesivir in utero is doing well at six months post-delivery. Remdesivir had been granted EUA for the treatment of suspected or laboratory-confirmed COVID-19 infection in adults and children who were hospitalized with severe disease or requiring supplemental oxygen and mechanical ventilation or extracorporeal membrane oxygenation (ECMO) in May 2020. This issuance allowed the use of the same dosing regimen in pregnant and parturient women as in the general adult population. Thus, this series of cases tried to assess the outcome of this drug among COVID-19-infected pregnant women. Early initiation of remdesivir in pregnancy in the viremic phase seems to provide some advantages in the survival outcome. Its use may be associated with transient elevation in hepatic transaminases in some cases. No detrimental effects on the ongoing pregnancies, fetuses, or neonates have been observed. Further large-scale studies may provide more conclusive evidence.

Application of a Negative Intrauterine Pressure Suction Device for Prophylactic Management of Atonic Postpartum Hemorrhage: A Quality Improvement Study

BACKGROUND

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. PPH-preventing interventions need to be prioritized and can be integrated with conventional methods of PPH prevention. The introduction of negative intrauterine pressure using a suction cannula can be one of the cheapest modalities to decrease PPH secondary to uterine atonicity. This method has brought a renaissance to practical obstetrics in low-middle income countries (LMIC), where the cost and availability of uterotonics are major health issues.

METHODS

It was a prospective quality improvement (QI) study conducted in the labor and delivery wards of a tertiary care medical institute and teaching center over the duration of one year. We aimed to assess the decrease in the incidence of atonic PPH with a negative intrauterine pressure suction device (NIPSD) integrated with active management of the third stage of labor (AMTSL) in the prevention of atonic PPH following normal vaginal delivery in low-risk antenatal women. In the initial six months, routine AMTSL was instituted for all consenting women (group 1). In the next six months, NIPSD was integrated with AMTSL (group 2). Data pertaining to the amount of blood loss, the incidence of primary PPH, uterine tone, fall in hemoglobin and hematocrit levels post-delivery, need for blood transfusion, and doctor and patient satisfaction were tabulated for all patients.

RESULTS

A total of 1324 consenting women were eligible for enrollment during the study time frame. In the initial six months (baseline period, group 1), 715 participants were subjected to routine AMTSL in the third stage of labor. During the intervention phase (group 2), 609 parturient women were recruited. There was no significant difference in baseline parameters between the two groups. With the introduction of NIPSD to routine AMTSL, there was a significant decrease in the average volume of blood loss during vaginal delivery (group 1 = 389.45+65.42 ml, group 2 = 216.66+34.27 ml; p-value = 0.012). The incidence of atonic PPH was reduced by more than 75% (group 1 = 13 women, group 2 = 3 women; p-value = 0.001) after the introduction of NIPSD complementing routine AMTSL. The introduction of NIPSD has also been instrumental in reducing the cost burden on patient and hospital expenditures. The net benefit of its introduction resulted in a reduction of the overall cost burden of blood transfusions by around 70%.

CONCLUSION

PPH is a public health problem, and measures to reduce PPH must be implemented to decrease this health burden. In countries with low resources, complementing routine AMTSL with NIPSD can be instrumental in decreasing the incidence of PPH. Considering its cost-effectiveness and reusability, LMIC can adopt NIPSD as a routine measure in all vaginal deliveries.

Bayesian approaches to include real-world data in clinical studies

Randomized clinical trials have been the mainstay of clinical research, but are prohibitively expensive and subject to increasingly difficult patient recruitment. Recently, there is a movement to use real-world data (RWD) from electronic health records, patient registries, claims data and other sources in lieu of or supplementing controlled clinical trials. This process of combining information from diverse sources calls for inference under a Bayesian paradigm. We review some of the currently used methods and a novel non-parametric Bayesian (BNP) method. Carrying out the desired adjustment for differences in patient populations is naturally done with BNP priors that facilitate understanding of and adjustment for population heterogeneities across different data sources. We discuss the particular problem of using RWD to create a synthetic control arm to supplement single-arm treatment only studies. At the core of the proposed approach is the model-based adjustment to achieve equivalent patient populations in the current study and the (adjusted) RWD. This is implemented using common atoms mixture models. The structure of such models greatly simplifies inference. The adjustment for differences in the populations can be reduced to ratios of weights in such mixtures. This article is part of the theme issue 'Bayesian inference: challenges, perspectives, and prospects'.

Assessment of Fertility Outcomes Following Combined Clomiphene and Letrozole Versus Letrozole Therapy for the Treatment of Polycystic Ovarian Syndrome Subfertility

BACKGROUND

Poly Cystic Ovarian Syndrome (PCOS) affects 8-13% of women in their reproductive age and is one of the foremost causes of female subfertility. Traditionally, clomiphene citrate has been the first-line treatment for ovulation induction in PCOS. However, the European Society of Human Reproduction and Embryology (ESHRE) international evidence-based guidelines in 2018 recommended the use of letrozole as first-line therapy for ovulation induction in anovulatory PCOS women, due to better pregnancy and live birth rates. Here we aimed to evaluate the effect of combined - clomiphene and letrozole versus letrozole for the treatment of PCOS subfertility.

METHODS

It was a retrospective cohort study conducted on reproductive-age women fulfilling Rotterdam Criteria for PCOS with a history of subfertility. All participants receiving at least one cycle of letrozole and clomiphene combination were recruited as cases. However, women receiving letrozole only for ovulation induction were taken as controls. Hospital records were abstracted for data on baseline characteristics such as age, duration of infertility, PCOS phenotype, body mass index (BMI), past medical and fertility history, treatment with ovulation induction agents, and metformin use. The mean size of the largest follicle, number of dominant follicles of size greater than 15 mm and endometrial thickness on Days 12-14 or on the day of the luteinizing hormone (LH) surge were recorded. A cycle was termed ovulatory if serum progesterone levels were > 5.0 ng/ml on the seventh day after the LH surge or day 22 in the absence of the LH surge. Data pertaining to therapy-associated side effects were also abstracted from the clinical records.

RESULTS

Amongst the ovulatory cycles in both groups, there was no significant difference in the day of the LH surge. Serum progesterone levels on the seventh day post-ovulation were higher with combination therapy (19.35 v/s 26.71, p=0.004). The number of ovulatory cycles was also greater with combination therapy, but the difference was just short of significant (25 vs 18, p=0.08). The mean diameter of the largest follicle, incidence of multi-follicular ovulation, and thin endometrium were similar in both groups. The adverse effect profile was similar in both groups.

CONCLUSION

Combination treatment of clomiphene citrate with letrozole may potentially improve fertility outcomes in PCOS subfertility in terms of the likelihood of ovulation and higher post-ovulatory progesterone levels, however, larger studies are required.

Status of Contraceptive Use for Birth Spacing After a Teenage Pregnancy: Where Do We Stand?

BACKGROUND

Adolescence is the most complex stage of reproductive health. The knowledge and awareness of adolescent-related reproductive issues are limited, particularly in lower-middle-income countries. Adolescent pregnancies are associated with major maternal and neonatal complications. Effective contraception use can prevent teenage pregnancy and subsequent complications.

METHODS

It was a cross-sectional study conducted in a tertiary care hospital and teaching institute over a period of one year. Through this study, we aimed to assess the prevalence of postpartum use of approved standard methods of contraception for birth spacing among teenage mothers and to assess the reasons for their non-acceptance. A total of 133 consecutive consenting postpartum teenage mothers were recruited in the study. Participants were asked about their age at the time of marriage and delivery, marital status, parity, education and economic status, the number of antenatal visits, mode of delivery, and antenatal complications. Compliance with postpartum contraception was noted, and reasons for its non-acceptance were asked in detail.

RESULTS

Among the 133 participants, contraceptive users were categorized into Group A and non-users into Group B. The mean age at the time of marriage was 17.6±0.4 and 17.5±0.6 years in Group A and Group B, respectively. Mothers in Group A were more educated than their counterparts in Group B (82.2% of mothers were educated up to 12th standard in Group A compared to 46.6% in Group B). Among the contraception users, 70% had four or more antenatal visits compared to 7.9% of the non-users. Reasons for non-acceptance of postpartum contraception were elicited in Group B: 42.0% had fear of becoming infertile, 38.6% feared that contraceptives interfere with breastfeeding and quality of breastmilk, 13.6% had opposition from family members, and 5.8% did not mention any reason.

CONCLUSION

Teenage pregnancy is associated with increased feto-maternal complications. It also accounts for an increased incidence of unsafe abortions and maternal mortality. So it is crucial to make the adolescent group aware of effective methods of postpartum contraceptives to prevent adolescent pregnancies. Collaborative larger multicentric studies from different countries will help to reach a better, generalized conclusion regarding the same.

Static in vitro digestion model adapted to the general older adult population: an INFOGEST international consensus

Understanding the mechanisms of food digestion is of paramount importance to determine the effect foods have on human health. Significant knowledge on the fate of food during digestion has been generated in healthy adults due to the development of physiologically-relevant in vitro digestion models. However, it appears that the performance of the oro-gastrointestinal tract is affected by ageing and that a model simulating the digestive conditions found in a younger adult (<65 years) is not relevant for an older adult (>65 years). The objectives of the present paper were: (1) to conduct an exhaustive literature search to find data on the physiological parameters of the older adult oro-gastrointestinal tract, (2) to define the parameters of an in vitro digestion model adapted to the older adult. International experts have discussed all the parameters during a dedicated workshop organized within the INFOGEST network. Data on food bolus properties collected in the older adult were gathered, including food particle size found in older adult boluses. In the stomach and small intestine, data suggest that significant physiological changes are observed between younger and older adults. In the latter, the rate of gastric emptying is slowed down, the pH of the stomach content is higher, the amount of secretions and thus the hydrolytic activities of gastric and intestinal digestive enzymes are reduced and the concentration of bile salts lower. The consensus in vitro digestion model of the older adult proposed here will allow significant progress to be made in understanding the fate of food in this specific population, facilitating the development of foods adapted to their nutritional needs. Nevertheless, better foundational data when available and further refinement of the parameters will be needed to implement the proposed model in the future.

Addressing the high prevalence of uterine fundal pressure in low-middle income country during vaginal delivery through a quality improvement initiative: Road to respectful maternity care

BACKGROUND

Intrapartum care is of paramount importance in overall respectful maternity care (RMC). Uterine fundal pressure maneuver (UFPM) is the most controversial obstetric maneuver considered obsolete in many countries. UFPM is associated with adverse life threatening maternal and fetal effects. The baseline prevalence of UFPM in our tertiary care teaching hospital with a heavy patient load was 78.4% which was quite high. Our aim was to reduce the prevalence of UFPM by 75% from baseline over a period of 10 months.

METHODS

After root cause analysis, we formulated the departmental Standard Operating Procedures on safe vaginal delivery and birth practices and initiated the Labour Room Quality Improvement Initiative. We sensitized and created awareness among the resident doctors and nursing staff regarding the high prevalence of UFPM through dedicated lectures, intercommunication via WhatsApp groups and strict vigilance in the labor wards. The point of care quality improvement (QI) methodology was used. The primary outcome was decrease in the prevalence of UFPM.

RESULTS

The prevalence of UFPM reduced from the baseline value of 78.4%-4% over the period of 7 months. Post intervention it gradually increased and sustained at 21.2% over a follow-up period of 3 months.

CONCLUSION

QI methods can effectively and rapidly improve the acceptance and adherence to newer initiatives in a busy tertiary care health facility to reduce the prevalence of UFPM and eventually improve the overall RMC.

Pharmacotherapeutic treatment options for recurrent epithelial ovarian cancer

INTRODUCTION

Almost 80% of epithelial ovarian cancer present in advanced stage at diagnosis and despite excellent response to surgery and chemotherapy, more than 70% cancers recur. Subsequent therapies become decreasingly effective in controlling the disease, with each successful therapy being effective for a shorter duration. As a result, there is a need for novel therapeutic strategies to effectively treat recurrence.

AREAS COVERED

In this extensive literature review of high-quality articles, we have focused on surveillance strategy to detect recurrence early, classification of recurrence based on timeline, role of surgery, chemotherapy, and targeted agents such as anti-angiogenetic drugs, PARP inhibitors, and immune checkpoint inhibitors in platinum-sensitive and platinum-resistant disease, respectively.

EXPERT OPINION

Recurrent ovarian cancers (ROC) are represented by a heterogenous group of patient population in terms of platinum-free interval (PFI), histology, molecular characteristics and immune recognition. In today's era of precision medicine, chemotherapy should be combined with appropriate targeted agent in a multipronged approach to prolong survival and provide better quality of life outcomes by minimizing side effects.

Measurements of the associated production of a W boson and a charm quark in proton-proton collisions at s = 8 TeV

Measurements of the associated production of a W boson and a charm ( c ) quark in proton-proton collisions at a centre-of-mass energy of 8 TeV are reported. The analysis uses a data sample corresponding to a total integrated luminosity of 19.7 fb - 1 collected by the CMS detector at the LHC. The W bosons are identified through their leptonic decays to an electron or a muon, and a neutrino. Charm quark jets are selected using distinctive signatures of charm hadron decays. The product of the cross section and branching fraction σ ( pp → W + c + X ) B ( W → ℓ ν ) , where ℓ = e or μ , and the cross section ratio σ ( pp → W + + c ¯ + X ) / σ ( pp → W - + c + X ) are measured in a fiducial volume and differentially as functions of the pseudorapidity and of the transverse momentum of the lepton from the W boson decay. The results are compared with theoretical predictions. The impact of these measurements on the determination of the strange quark distribution is assessed.

Assessing the Barriers to Postpartum Tubal Ligation Among Multiparous Women

Background: Unmet demands for postpartum tubal ligation are estimated to be greater than the actual number of tubal ligations done, especially in low-resource settings. Through this study, we therefore assessed the barriers to postpartum tubal ligation in the developing world.

Materials and Methods: It is a prospective cohort study including 3671 multiparous women from northern India. Recruited patients were given survey questionnaires during their antenatal and postpartum period which evaluated the patient-related, healthcare facility-related and social factors which were the determining factors for the unfulfillment of their desire for permanent sterilization.

Results: Out of the recruited population, 1576 women wished to undergo tubal ligation. Following attrition, a total of 1024 were followed up prospectively. Of them, sterilization was successfully done only in 309 (30.18%) participants. A large proportion of mothers had their demand unmet (715 mothers; 69.82%). Out of them, 505 (70.63%) women stated that tubal ligation was not done because they did not deliver by Caesarean section. Insufficient counselling regarding tubal ligation was quoted by 325 (45.45%) mothers. Majority of the participants denied tubal ligation as they were not given enough information about the procedure (589 participants; 82.38%). While 568 (79.44%) mothers had changed their mind after delivery, 257 (35.94%) thought that their health was not fit to undergo the procedure and 213 (29.79%) mothers wanted more children in the future. We found that there was strong opposition from their male partners (56.78%).

Conclusion: Postpartum tubal ligation is of paramount importance in women with completed families, especially in developing countries. This prospective study addressed the barriers to tubal ligation, which would help combat future unintended pregnancies.

Search for Resonances Decaying to Three W Bosons in Proton-Proton Collisions at sqrt[s]=13 TeV

A search for resonances decaying into a W boson and a radion, where the radion decays into two W bosons, is presented. The data analyzed correspond to an integrated luminosity of 138  fb^{-1} recorded in proton-proton collisions with the CMS detector at sqrt[s]=13  TeV. One isolated charged lepton is required, together with missing transverse momentum and one or two massive large-radius jets, containing the decay products of either two or one W bosons, respectively. No excess over the background estimation is observed. The results are combined with those from a complementary channel with an all-hadronic final state, described in an accompanying paper. Limits are set on parameters of an extended warped extra-dimensional model. These searches are the first of their kind at the LHC.

Probing Charm Quark Dynamics via Multiparticle Correlations in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

Multiparticle azimuthal correlations of prompt D^{0} mesons are measured in Pb-Pb collisions at a nucleon-nucleon center-of-mass energy of sqrt[s_{NN}]=5.02  TeV. For the first time, a four-particle cumulant method is used to extract the second Fourier coefficient of the azimuthal distribution (v_{2}) of D^{0} mesons as a function of event centrality and the D^{0} transverse momentum. The ratios of the four-particle v_{2} values to previously measured two-particle cumulant results provide direct experimental access to event-by-event fluctuations of charm quark azimuthal anisotropies. These ratios are also found to be comparable to those of inclusive charged particles in the event. However, hints of deviations are seen in the most central and peripheral collisions. To investigate the origin of flow fluctuations in the charm sector, these measurements are compared to a model implementing fluctuations of charm quark energy loss via collisional or radiative processes in the quark-gluon plasma. These models cannot quantitatively describe the data over the full transverse momentum and centrality ranges, although the calculations with collisional energy loss provide a better description of the data.

First Search for Exclusive Diphoton Production at High Mass with Tagged Protons in Proton-Proton Collisions at sqrt[s]=13 TeV

A search for exclusive two-photon production via photon exchange in proton-proton collisions, pp→pγγp with intact protons, is presented. The data correspond to an integrated luminosity of 9.4  fb^{-1} collected in 2016 using the CMS and TOTEM detectors at a center-of-mass energy of 13 TeV at the LHC. Events are selected with a diphoton invariant mass above 350 GeV and with both protons intact in the final state, to reduce backgrounds from strong interactions. The events of interest are those where the invariant mass and rapidity calculated from the momentum losses of the forward-moving protons match the mass and rapidity of the central, two-photon system. No events are found that satisfy this condition. Interpreting this result in an effective dimension-8 extension of the standard model, the first limits are set on the two anomalous four-photon coupling parameters. If the other parameter is constrained to its standard model value, the limits at 95% confidence level are |ζ_{1}|<2.9×10^{-13}  GeV^{-4} and |ζ_{2}|<6.0×10^{-13}  GeV^{-4}.

Pyometrocolpos in an 18-Month-Old Child: A Rare Cause of Acute Abdomen

Acute abdomen secondary to pyometrocolpos as a result of microperforate hymen in an 18-month-old child is extremely rare to witness. Such a child was admitted with a history of poor appetite, lethargy, high-grade febrile episodes, frequent urination, and multiple episodes of vomiting in seven days. There was no relief of symptoms on oral antibiotics. On careful examination, the abdomen was distended. A suprapubic bulge with mild tenderness was palpable. Genital examination revealed the absence of vaginal introitus with a bulging membrane. Ultrasound showed the presence of echogenic contents within the dilated uterine and vaginal cavities. An emergency hymenotomy drained 150 cc of malodorous purulent material. Symptoms were relieved post-surgery. This, to our knowledge, being the youngest case of microperforate hymen presenting with acute abdomen makes it worth reporting.

CURRENT THERAPEUTIC STRATEGIES AND CHALLENGES IN NSCLC TREATMENT: A COMPREHENSIVE REVIEW

Non-small cell lung cancer (NSCLC) is one of the most lethal malignancies accountings for nearly 80% of all lung cancer cases diagnosed and causing over one million deaths annually worldwide. The discovery of molecular alterations including driver mutations and gene fusions has led to innovation of numerous targeted therapies, which certainly provided an edge over the classical chemotherapeutic treatment regimens and improved survival of the patients. Despite all the breakthrough innovations, the five-year survival statistics has not improved the way it was expected, pointing the challenges and limitations of currently approved diagnostic methods and therapies. This review summarizes various innovative therapies, treatment regimens developed over the last two decades for NSCLC treatment and the current challenges and limitations in the NSCLC treatment landscape.

Search for low-mass dilepton resonances in Higgs boson decays to four-lepton final states in proton-proton collisions at s = 13 TeV

A search for low-mass dilepton resonances in Higgs boson decays is conducted in the four-lepton final state. The decay is assumed to proceed via a pair of beyond the standard model particles, or one such particle and a Z boson. The search uses proton-proton collision data collected with the CMS detector at the CERN LHC, corresponding to an integrated luminosity of 137 fb - 1 , at a center-of-mass energy s = 13 TeV . No significant deviation from the standard model expectation is observed. Upper limits at 95% confidence level are set on model-independent Higgs boson decay branching fractions. Additionally, limits on dark photon and axion-like particle production, based on two specific models, are reported.

Using Z Boson Events to Study Parton-Medium Interactions in Pb-Pb Collisions

The spectra measurements of charged hadrons produced in the shower of a parton originating in the same hard scattering with a leptonically decaying Z boson are reported in lead-lead nuclei (Pb-Pb) and proton-proton (pp) collisions at a nucleon-nucleon center-of-mass energy of 5.02 TeV. Both Pb-Pb and pp data sets are recorded by the CMS experiment at the LHC and correspond to an integrated luminosity of 1.7  nb^{-1} and 320  pb^{-1}, respectively. Hadronic collision data with one reconstructed Z boson candidate with the transverse momentum p_{T}>30  GeV/c are analyzed. The Z boson constrains the initial energy and direction of the associated parton. In heavy ion events, azimuthal angular distributions of charged hadrons with respect to the direction of a Z boson are sensitive to modifications of the in-medium parton shower and medium response. compared to reference data from pp interactions, the results for central Pb-Pb collisions indicate a modification of the angular correlations. The measurements of the fragmentation functions and p_{T} spectra of charged particles in Z boson events, which are sensitive to medium modifications of the parton shower longitudinal structure, are also reported. Significant modifications in central Pb-Pb events compared to the pp reference data are also found for these observables.

Search for strongly interacting massive particles generating trackless jets in proton-proton collisions at s = 13 TeV

A search for dark matter in the form of strongly interacting massive particles (SIMPs) using the CMS detector at the LHC is presented. The SIMPs would be produced in pairs that manifest themselves as pairs of jets without tracks. The energy fraction of jets carried by charged particles is used as a key discriminator to suppress efficiently the large multijet background, and the remaining background is estimated directly from data. The search is performed using proton-proton collision data corresponding to an integrated luminosity of 16.1 fb - 1 , collected with the CMS detector in 2016. No significant excess of events is observed above the expected background. For the simplified dark matter model under consideration, SIMPs with masses up to 100 GeV are excluded and further sensitivity is explored towards higher masses.