Australian radiographers' awareness of cardiac implantable electronic devices (CIEDs) in mammographic imaging

INTRODUCTION

Women presenting for mammography occasionally have pacemakers or other cardiac-implantable electronic devices (CIEDs) in situ. This research investigates Australian radiographers' awareness of CIEDs in the diagnostic and screening settings.

METHODS

A survey of radiographers with mammography experience in Australia was conducted using SurveyMonkey™. Respondents were asked if they could confidently identify images of devices and whether they had imaged them mammographically. A Chi-squared test of independence was used to compare the association between demographics and CIED awareness. A value of p < 0.05 was deemed statistically significant.

RESULTS

There were 220 valid responses. All CIED types had been imaged. Most respondents had imaged a pacemaker (94.5%) and implantable cardioverter-defibrillator (ICD) (85.6%), compared to the three different implantable loop recorders (ILRs) (ILR-1: 63.4%; ILR-2: 14.1%; and IRL-3: 26.9% and the emerging subcutaneous ICDs (S-ICDs) (11.9%). Most respondents felt confident identifying the pacemaker (95%) and the ICD (86.1%). Only 19.4% of respondents could confidently identify the emerging S-ICD.

CONCLUSION

A lack of awareness of new and emerging devices may impact approaches to imaging and present significant risk to patients. The lack of studies comprehensively describing devices and their mammographic appearance to support radiographers' knowledge and awareness highlights an urgent need to progress research in this area.

IMPLICATIONS FOR PRACTICE

As a part of continuing professional development, radiographers performing mammography must ensure they remain up to date with current and emerging technology, including CIEDs. This study has identified a lack of awareness of the different types of CIEDs currently being implanted and imaged, which may translate to unsafe imaging practices. There is an urgent need for further education to bridge this knowledge gap and ensure the safety of practice in imaging women with CIEDs.

FOOTLINE

Mammography: CIED Imaging.

Selected-Lesion Stereotactic Radiosurgery in Treatment of Patients with Multiple Brain Metastases: A Single Institution Retrospective Study

PURPOSE/OBJECTIVE(S)

Stereotactic Radiosurgery (SRS) has been increasingly used as first and subsequent-line treatments for brain metastases. While the appropriate cut-off number of lesions for SRS is still being debated nationally in patients with multiple brain metastases, some institutions use an alternate approach particularly for patients with >10-15 lesions. Selected-lesion SRS (SL-SRS) is where only a subset of lesions are chosen for initial SRS treatment leaving small and clinically inconsequential lesions for treatment using alternate or delayed treatments. This study aims to investigate the patient selection criteria, patient and tumor characteristics and analyze the outcomes in patients receiving SL-SRS for brain metastases at our institution.

MATERIALS/METHODS

Clinical data from patients treated using the SL-SRS approach from 2012-2022 at our institution were retrospectively reviewed. Patients were divided into cohorts based on overall survival from time of SL-SRS treatment and indications for using SL-SRS. We compared the patient characteristics (age, histology, KPS, dsGPA), tumor characteristics (cumulative tumor volumes, tumor dose, number of brain metastases found, number of metastases treated), treatment characteristics (chemotherapy, immunotherapy, previous SRS/ radiation, previous WBRT) and the reason for decision to recommend SL-SRS across these cohort.

RESULTS

A total of 102 patients were treated using the SL-SRS approach. Indications for using SL-SRS were immunotherapy trial (n = 40), CNS penetrating drug options available (n = 18), patient refusing WBRT (n = 6), palliative after prior WBRT/SRS (n = 28), WBRT planned to follow SRS (n = 9). 31 patients were alive at 12 months and 21 patients at 24 months. In patients surviving <12 months - the most common indications for SL-SRS were CNS palliation in the setting of progressive disease after prior WBRT or SRS. Patients in this group had median KPS< = 60 and had predominantly non-small cell carcinoma primary diagnosis. In those patients surviving >12 months - the most common indication for SL-SRS was participation in CNS-penetrant agent clinical trials without WBRT. Patients in this group were more likely to be female, had a median KPS of 90, had predominantly diagnoses of melanoma. Following the SL-SRS treatment, 14 patients required further SRS and 4 patients went on to WBRT in the >12-month survival group. No patients died of CNS progression alone. 10 patients survived 24 months without requiring further CNS radiation.

CONCLUSION

In our institution, SL-SRS has predominantly been used either as palliative treatment at time of disease progression or to facilitate entry onto clinical trial with immunotherapy or potentially CNS-penetrant agents. The latter indication resulted in 47.6% patients surviving >24 month without the need for additional radiation to the CNS and therefore SL-SRS should be considered a feasible, safe and effective alternative to either WBRT or SRS treatment of all radiographically visible brain metastases.

Selected-Lesion SRS as a Novel Strategy in Treatment of Patients with Multiple Brain Metastases

PURPOSE/OBJECTIVE(S)

With the increasing use of intracranial SRS (SRS) for treatment of patients with >10-15 brain metastases treatment; debate remains in the literature about how these patients should be treated. While many advocate for treatment of all lesions with either SRS or whole brain radiation therapy (WBRT), several groups are considering selected-lesion SRS (SL-SRS) where only a subset of intracranial lesions are treated. However, the current practice patterns of SL-SRS are not known.

MATERIALS/METHODS

A survey of 19 questions was created using open-ended and multiple-choice style questions on SL-SRS practices and indications. The survey was distributed to providers in the US and internationally who perform SRS frequently. Ten out of 50 institutions provided responses reflecting the practices of 16 providers. Descriptive statistics was used to compare answers to each question when applicable including percentages and ranges.

RESULTS

SL-SRS was performed at 8/10 institutions, (5 out of 6 US institutions and 3 out of 4 international institutions). Only 2 institutions had established clinical indications for SL-SRS (one in the US and one internationally) and one additional US institution reported clinical trials that require SL-SRS to study efficacy of CNS penetrating targeted therapies. One program reported research protocols for untreated brain metastases that would take priority over SL-SRS (program outside the US). Size of the lesion was cited as the most important factor (90%) when deciding to treat any single lesion. Next, lesion location and focal signs/symptoms were both considered moderately important. 80% ranked distance from prior SRS as the least important factor. Perilesional edema was also less important at most programs (90%). Lesion location and presence of symptoms were also considered important. There were several factors that would encourage providers to consider SL-SRS in a patient. Prior WBRT; progressing systemic disease and CNS-penetrating drug option available; and progressing systemic disease and immunotherapy option available were the most common responses. Most respondents cited "specific request by medical oncology" as well as "cooperative studies in this topic" as factors that might push them towards SL-SRS. Several institutions specified factors beyond the listed options. One institution reported that for patients with >20 lesions, they treated the largest lesions with SRS then follow with WBRT, termed the "pre-WBRT boost." Progression of untreated lesions was the most common reason why providers would bring back patients for additional treatment.

CONCLUSION

The responses to this survey demonstrate that patients with >15-20 intracranial lesions, prior WBRT, and worsening systemic disease with CNS penetrating systemic therapies available are being considered for SL-SRS.

ChatGPT in medical imaging higher education

INTRODUCTION

Academic integrity among radiographers and nuclear medicine technologists/scientists in both higher education and scientific writing has been challenged by advances in artificial intelligence (AI). The recent release of ChatGPT, a chatbot powered by GPT-3.5 capable of producing accurate and human-like responses to questions in real-time, has redefined the boundaries of academic and scientific writing. These boundaries require objective evaluation.

METHOD

ChatGPT was tested against six subjects across the first three years of the medical radiation science undergraduate course for both exams (n = 6) and written assignment tasks (n = 3). ChatGPT submissions were marked against standardised rubrics and results compared to student cohorts. Submissions were also evaluated by Turnitin for similarity and AI scores.

RESULTS

ChatGPT powered by GPT-3.5 performed below the average student performance in all written tasks with an increasing disparity as subjects advanced. ChatGPT performed better than the average student in foundation or general subject examinations where shallow responses meet learning outcomes. For discipline specific subjects, ChatGPT lacked the depth, breadth, and currency of insight to provide pass level answers.

CONCLUSION

ChatGPT simultaneously poses a risk to academic integrity in writing and assessment while affording a tool for enhanced learning environments. These risks and benefits are likely to be restricted to learning outcomes of lower taxonomies. Both risks and benefits are likely to be constrained by higher order taxonomies.

IMPLICATIONS FOR PRACTICE

ChatGPT powered by GPT3.5 has limited capacity to support student cheating, introduces errors and fabricated information, and is readily identified by software as AI generated. Lack of depth of insight and appropriateness for professional communication also limits capacity as a learning enhancement tool.

Cyclooxygenase-2 activates the free radical-mediated apoptosis of polymorphonuclear leukocytes in the maneb- and paraquat-intoxicated rats

Overproduction of free radicals and inflammation could lead to maneb (MB)- and paraquat (PQ)-induced toxicity in the polymorphonuclear leukocytes (PMNs). Cyclooxygenase-2 (COX-2), an inducible COX, is imperative in the pesticides-induced pathological alterations. However, its role in MB- and PQ-induced toxicity in the PMNs is not yet clearly deciphered. The current study explored the contribution of COX-2 in MB- and PQ-induced toxicity in the PMNs and the mechanism involved therein. Combined MB and PQ augmented the production of free radicals, lipid peroxides and activity of superoxide dismutase (SOD) in the rat PMNs. While combined MB and PQ elevated the expression of COX-2 protein, activation of nuclear factor-kappa B (NF-κB) and phosphorylation of c-Jun N-terminal kinase (JNK), release of mitochondrial cytochrome c and levels of procaspase-3/9 were attenuated in the PMNs. Celecoxib (CXB), a COX-2 inhibitor, ameliorated the combined MB and PQ-induced modulations in the PMNs. MB and PQ augmented the free radical generation, COX-2 protein expression, NF-κB activation and JNK phosphorylation and reduced the cell viability of cultured rat PMNs and human leukemic HL60. MB and PQ elevated mitochondrial cytochrome c release and poly (ADP-ribose) polymerase cleavage whilst procaspase-3/9 levels were attenuated in the cultured PMNs. MB and PQ also increased the levels of phosphorylated c-jun and caspase-3 activity in the HL60 cells. CXB; SP600125, a JNK-inhibitor and pyrrolidine dithiocarbamate (PDTC), a NF-κB inhibitor, rescued from MB and PQ-induced changes in the PMNs and HL60 cells. However, CXB offered the maximum protection among the three. The results show that COX-2 activates apoptosis in the PMNs following MB and PQ intoxication, which could be linked to NF-κB and JNK signaling.

Digital Infrastructure Management-Challenges and Opportunities in Post Covid Era

Digital Infrastructure Management-Challenges and Opportunities in Post Covid Era are analyzed in this paper. The 2020 pandemic has been the most serious issue in medical as well as humanity’s history. It has impacted various lives in one way or another. There are multitudes of death cases globally, and the census is pacing at its fastest rate as possible. This lockdown has stressed the medical field and infrastructure and paved its way in the digitalization sector. While observing the lockdown, the world’s economy has faced a steep fall due to sudden and unexpected hampering to the daily work. This opened the door to digitalization. The Digital field has seen a great hike where all the work is shifted from offices to home. It has opened various opportunities but also faces major challenges which expect to furnish after the pandemic crisis. This paper deals with the aspects of digital infrastructure in the post-Covid-19 era.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Mitochondrial Dysfunction Contributes To Zinc-induced Neurodegeneration: a Link with NADPH Oxidase

Mitochondrial dysfunction and nicotinamide adenine dinucleotide phosphate oxidase (NADPH oxidase) are the major sources of augmentation in free radical generation leading to neurodegeneration. Although NADPH oxidase involvement is reported in zinc (Zn)-induced neurodegeneration, contribution of the mitochondrial dysfunction and its association with NADPH oxidase are not known. Therefore, the study was aimed to decipher the role of mitochondrial dysfunction and its link with NADPH oxidase in Zn-induced Parkinsonism. Zn reduced the motor activities, the number of tyrosine hydroxylase (TH)-positive neurons, and level of TH protein. Conversely, Zn increased the mitochondrial reactive oxygen species (ROS) production, lipid peroxidation (LPO), and superoxide dismutase (SOD) activity and reduced the mitochondrial membrane potential and catalytic activities of complex I and III. Zn also attenuated B-cell lymphoma-2 (Bcl-2) and pro-caspase 9/3 levels and augmented the translocation of cytosolic Bcl-2 associated X (Bax) protein to the mitochondria and cytochrome c release into cytosol from the mitochondria. Cyclosporine A, a mitochondrial outer membrane transition pore inhibitor and apocynin, a NADPH oxidase inhibitor, independently, ameliorated the Zn-induced changes. Similarly, Zn reduced cell viability through mitochondrial dysfunction and apoptosis in human neuroblastoma SH-SY5Y cells, which were notably normalized in the presence of cyclosporine or apocynin. The results demonstrate that mitochondrial dysfunction contributes to Zn-induced neurodegeneration, which could be partially aided by the NADPH oxidase.

Autonomous regulation of inducible nitric oxide synthase and cytochrome P450 2E1-mediated oxidative stress in maneb- and paraquat-treated rat polymorphs

Maneb (MB)- and paraquat (PQ)-induced oxidative stress in rat polymorphonuclear leukocytes (PMNs) is regulated in parallel by cytochrome P450 2E1 (CYP2E1) and inducible nitric oxide synthase (iNOS). However, mechanism underlying their regulation is not yet understood. The study investigated the role of nuclear factor- kappa B (NF-κB) and mitogen-activated protein kinase/extracellular signal regulated kinase/protein kinase C (MEK/ERK/PKC) pathway in the regulation of iNOS- and CYP2E1-induced oxidative stress in PMNs. MB + PQ-induced changes in nitrite content, lipid peroxidation (LPO), iNOS expression/activity and inflammatory mediators were alleviated by aminoguanidine (AG), an iNOS inhibitor, without any change in CYP2E1. Alternatively, diallyl sulphide (DAS), a CYP2E1 inhibitor, rescued from MB + PQ-induced changes in CYP2E1 activity/expression, free radical generation, superoxide dismutase (SOD) activity, LPO and pro-inflammatory cytokines without any alterations in nitrite content and iNOS activity/expression. Pyrrolidine dithiocarbamate (PDTC), NF-κB inhibitor, did not alter CYP2E1 but mitigated free radical generation, SOD activity, LPO, nitrite content, iNOS activity/expression and levels of pro-inflammatory cytokines (tumor necrosis factor-α, interleukine-1β and interleukine-4). Ex-vivo treatment with MEK inhibitor (PD98059), ERK1/2 inhibitor (AG126) or PKC inhibitor (rottlerin) ameliorated MB + PQ-induced increase in free radical generation and CYP2E1 activity/expression in PMNs. While PD98059 and AG126 abated MB + PQ-induced increase in ERK1/2, PKC-α/δ and CYP2E1 levels, rottlerin restored PKC-α/δ and CYP2E1 towards normalcy without affecting ERK1/2 level in MB + PQ-treated group. The results suggest that iNOS and CYP2E1 contributing to MB + PQ-induced oxidative stress in rat PMNs exhibit differential regulatory mechanisms. The inflammatory mediators regulate iNOS expression while CYP2E1 expression is triggered via MEK-ERK1/2-PKC pathway.

Whipple's pancreaticoduodenectomy for cancer of the head of the pancreas in a patient with amyotrophic lateral sclerosis: perioperative challenges

The association of amyotrophic lateral sclerosis and pancreatic cancer is rare. Amyotrophic lateral sclerosis is a neurodegenerative disease characterised by pure motor symptoms in the form of progressive muscle weakness and wasting, and can involve the bulbar and respiratory muscles, leading to significant morbidity. Successful surgery for patients with amyotrophic lateral sclerosis for pancreatic cancer has rarely been reported. Surgery in such patients is a dual-edged sword and is decided based on risk-benefit ratio. Patients are at high risk for general anaesthesia because of muscular weakness, increased sensitivity to muscle relaxants and certain anaesthetic drugs. There is a high chance of prolonged postoperative ventilatory support, aspiration pneumonia and pulmonary complications. We report a patient with cancer of the head of the pancreas who underwent successful elective pancreaticoduodenectomy.

POPPIE: protocol for a randomised controlled pilot trial of continuity of midwifery care for women at increased risk of preterm birth

Background

High rates of preterm births remain a UK public health concern. Preterm birth is a major determinant of adverse infant and longer-term outcomes, including survival, quality of life, psychosocial effects on the family and health care costs. We aim to test whether a model of care combining continuity of midwife care with rapid referral to a specialist obstetric clinic throughout pregnancy, intrapartum and the postpartum period is feasible and improves experience and outcomes for women at increased risk of preterm birth.

Methods

This pilot, hybrid, type 2 randomised controlled implementation trial will recruit 350 pregnant women at increased risk of preterm birth to a midwifery continuity of care intervention or standard care. The intervention will be provided from recruitment (antenatal), labour, birth and the postnatal period, in hospital and community settings and in collaboration with specialist obstetric clinic care, when required. Standard care will be the current maternity care provision by NHS midwives and obstetricians at the study site. Participants will be followed up until 6–8 weeks postpartum. The composite primary outcome is the appropriate initiation of any specified interventions related to the prevention and/or management of preterm labour and birth. Secondary outcomes are related to: recruitment and attrition rates; implementation; acceptability to women, health care professionals and stakeholders; health in pregnancy and other complications; intrapartum outcomes; maternal and neonatal postnatal outcomes; psycho-social health; quality of care; women’s experiences and health economic analysis. The trial has 80% power to detect a 15% increase in the rate of appropriate interventions (40 to 55%). The analysis will be by ‘intention to treat’ analysis.

Discussion

Little is known about the underlying reasons why and how models of midwifery continuity of care are associated with fewer preterm births, better maternal and infant outcomes and more positive experiences; nor how these models of care can be implemented successfully in the health services. This will be the first study to provide direct evidence regarding the effectiveness, implementation and evaluation of a midwifery continuity of care model and rapid access to specialist obstetric services for women at increased risk of preterm birth.

Trial registration

ISRCTN37733900. Retrospectively registered on 21 August 2017.

Inhibition of glutathione S-transferase-pi triggers c-jun N-terminal kinase-dependent neuronal death in Zn-induced Parkinsonism

Oxidative stress is recognized as one of the major wrongdoers in Parkinson's disease (PD) while glutathione S-transferase (GST), an endogenous antioxidant, protects from oxidative stress-induced neurodegeneration. Despite GST-pi (GST-π) encounters the toxic manifestations in PD, its role in zinc (Zn)-induced nigrostriatal dopaminergic neurodegeneration remains elusive. The study aimed to explore the role of GST-π in Zn-induced Parkinsonism and its underlying molecular mechanism. Male Wistar rats were treated intraperitoneally with zinc (zinc sulfate), twice a week, for 2-12 weeks. GST-π inducer, benzyl isothiocyanate (BITC) was also administered in a few sets of experiments along with respective vehicle. Catalytic activity and expression of GST-π protein, total GST activity, neurobehavioral indexes, striatal dopamine and its metabolites, nigral tyrosine hydroxylase (TH)-positive neurons and expression of TH and B-cell lymphoma-2 (Bcl-2) proteins were reduced in Zn-treated rats. Conversely, oxidative stress indicators, c-jun N-terminal kinase (JNK) activation, c-jun phosphorylation, cytochrome c release, Bcl-2-associated X protein (Bax) translocation, and procaspase 3/9 to caspase 3/9 conversion were significantly increased in Zn-exposed rats. BITC ameliorated GST-π activity/expression and normalized Zn-induced changes in neurodegenerative indicators, oxidative stress, JNK activation, c-jun phosphorylation and apoptotic indexes. The results demonstrate that Zn inhibits GST-π expression leading to increased oxidative stress and JNK activation, which induce apoptosis thereby degeneration of the nigrostriatal dopaminergic neurons.

Alpha-synuclein aggregation, Ubiquitin proteasome system impairment, and L-Dopa response in zinc-induced Parkinsonism: resemblance to sporadic Parkinson's disease

Alpha-synuclein (α-synuclein) aggregation and impairment of the Ubiquitin proteasome system (UPS) are implicated in Parkinson's disease (PD) pathogenesis. While zinc (Zn) induces dopaminergic neurodegeneration resulting in PD phenotype, its effect on protein aggregation and UPS has not yet been deciphered. The current study investigated the role of α-synuclein aggregation and UPS in Zn-induced Parkinsonism. Additionally, levodopa (L-Dopa) response was assessed in Zn-induced Parkinsonian model to establish its closeness with idiopathic PD. Male Wistar rats were treated with zinc sulfate (Zn; 20 mg/kg; i.p.) twice weekly for 12 weeks along with respective controls. In few subsets, animals were subsequently treated with L-Dopa for 21 consecutive days following Zn exposure. A significant increase in total and free Zn content was observed in the substantia nigra of the brain of exposed groups. Zn treatment caused neurobehavioral anomalies, striatal dopamine decline, and dopaminergic neuronal cell loss accompanied with a marked increase in α-synuclein expression/aggregation and Ubiquitin-conjugated protein levels in the exposed groups. Zn exposure substantially reduced UPS-associated trypsin-like, chymotrypsin-like, and caspase-like activities along with the expression of SUG1 and β-5 subunits of UPS in the nigrostriatal tissues of exposed groups. L-Dopa treatment rescued from Zn-induced neurobehavioral deficits and restored dopamine levels towards normalcy; however, Zn-induced dopaminergic neuronal loss, reduction in tyrosine hydroxylase expression, and increase in oxidative stress were unaffected. The results suggest that Zn caused UPS impairment, resulting in α-synuclein aggregation subsequently leading to dopaminergic neurodegeneration, and that Zn-induced Parkinsonism exhibited positive L-Dopa response similar to sporadic PD.

Implementation and results of an integrated data quality assurance protocol in a randomized controlled trial in Uttar Pradesh, India

BACKGROUND

There are few published standards or methodological guidelines for integrating Data Quality Assurance (DQA) protocols into large-scale health systems research trials, especially in resource-limited settings. The BetterBirth Trial is a matched-pair, cluster-randomized controlled trial (RCT) of the BetterBirth Program, which seeks to improve quality of facility-based deliveries and reduce 7-day maternal and neonatal mortality and maternal morbidity in Uttar Pradesh, India. In the trial, over 6300 deliveries were observed and over 153,000 mother-baby pairs across 120 study sites were followed to assess health outcomes. We designed and implemented a robust and integrated DQA system to sustain high-quality data throughout the trial.

METHODS

We designed the Data Quality Monitoring and Improvement System (DQMIS) to reinforce six dimensions of data quality: accuracy, reliability, timeliness, completeness, precision, and integrity. The DQMIS was comprised of five functional components: 1) a monitoring and evaluation team to support the system; 2) a DQA protocol, including data collection audits and targets, rapid data feedback, and supportive supervision; 3) training; 4) standard operating procedures for data collection; and 5) an electronic data collection and reporting system. Routine audits by supervisors included double data entry, simultaneous delivery observations, and review of recorded calls to patients. Data feedback reports identified errors automatically, facilitating supportive supervision through a continuous quality improvement model.

RESULTS

The five functional components of the DQMIS successfully reinforced data reliability, timeliness, completeness, precision, and integrity. The DQMIS also resulted in 98.33% accuracy across all data collection activities in the trial. All data collection activities demonstrated improvement in accuracy throughout implementation. Data collectors demonstrated a statistically significant (p = 0.0004) increase in accuracy throughout consecutive audits. The DQMIS was successful, despite an increase from 20 to 130 data collectors.

CONCLUSIONS

In the absence of widely disseminated data quality methods and standards for large RCT interventions in limited-resource settings, we developed an integrated DQA system, combining auditing, rapid data feedback, and supportive supervision, which ensured high-quality data and could serve as a model for future health systems research trials. Future efforts should focus on standardization of DQA processes for health systems research.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02148952 . Registered on 13 February 2014.

Serum Levels of Neuroactive Steroids in First-episode Antipsychotic-naïve Schizophrenic Patients and Its Correlation with Aggression: A Case-control Study

BACKGROUND

The evidence of hypothalamic-pituitary-adrenal axis dysfunction in schizophrenia has been reviewed in the context of the stress-diathesis model. Overactivation of this axis leads to altered blood levels of cortisol and dehydroepiandrosterone sulfate (DHEA-S). These neurosteroids in turn act on the hippocampus and interact with gamma-aminobutyric acid and N-methyl-D-aspartate receptors leading to neurotoxicity and may be involved in the neurobiology of aggression. This study aimed to explore the blood level of these neurosteroids and ascertain its correlation with state aggression and psychopathology in first-episode antipsychotic-naïve schizophrenic patients.

METHODS

A total of 30 patients with first-episode schizophrenia along with 20 age- and gender-matched healthy controls participated in the study. Both groups were subjected to serum cortisol and DHEA-S measurement after assessment of psychopathology and aggression on a standardised psychometric scale.

RESULTS

Serum DHEA-S level was significantly higher in the patient group (p = 0.001). No difference was noted between males and females in the patient group (p = 0.93) but female controls had a significantly lower serum DHEA-S level than male controls (p < 0.01). Serum DHEA-S inversely correlated with scores on Modified Overt Aggression Scale (p = 0.01) but not with Positive and Negative Syndrome Scale (p = 0.39) or Clinical Global Impression Scale (p = 0.28).

CONCLUSION

The first-episode antipsychotic-naïve schizophrenic patients showed a significantly higher blood level of DHEA-S compared with healthy controls. Serum DHEA-S level has an inverse relationship with aggression and may serve as a biological adaptive mechanism to antagonise the neuronal damage caused by cortisol.

Development of a high resolution plantar pressure monitoring pad based on fiber Bragg grating (FBG) sensors

BACKGROUND

High importance is given to plantar pressure monitoring in the field of biomedical engineering for the diagnosis of posture related ailments associated with diseases such as diabetes and gonarthrosis.

OBJECTIVE

This paper presents the proof-of-concept development of a new high resolution plantar pressure monitoring pad based on fiber Bragg grating (FBG) sensors.

METHODS

In the proposed configuration, the FBG sensors are embedded within layers of carbon composite material (CCM) in turn conforming to an arc shape. A total of four such arc shaped sensors are instrumented in the pad at the locations of the forefoot and the hind foot. As a test of the pad, static plantar pressure is monitored on normal subjects under various posture conditions. The pad is evaluated both as a standalone platform as well as a pad inserted inside a standard shoe.

RESULTS

An average pressure sensitivity of 1.2 pm/kPa and a resolution of approximately 0.8 kPa is obtained in this special configuration. The pad is found to be suitable in both configurations- stand-alone pad as well as an insert inside a standard shoe.

CONCLUSION

The proposed set up offers a cost-effective high resolution and accurate plantar pressure measurement system suitable for clinical deployment. The novelty of the developed pressure pad lies in its ability to be used both as platform type as well as inserted in-sole type sensor system.

Neuronal Nitric Oxide Synthase Negatively Regulates Zinc-Induced Nigrostriatal Dopaminergic Neurodegeneration

The study aimed to investigate the role of NO and neuronal NO synthase (nNOS) in Zn-induced neurodegeneration. Animals were treated with zinc sulfate (20 mg/kg), twice a week, for 2-12 weeks along with control. In a few sets, animals were also treated with/without a NO donor, sodium nitroprusside (SNP), or S-nitroso-N-acetyl penicillamine (SNAP) for 12 weeks. Moreover, human neuroblastoma (SH-SY-5Y) cells were also employed to investigate the role of nNOS in Zn-induced toxicity in in vitro in the presence/absence of nNOS inhibitor, 7-nitroindazole (7-NI). Zn caused time-dependent reduction in nitrite content and total/nNOS activity/expression. SNP/SNAP discernibly alleviated Zn-induced neurobehavioral impairments, dopaminergic neurodegeneration, tyrosine hydroxylase (TH) expression, and striatal dopamine depletion. NO donors also salvage from Zn-induced increase in lipid peroxidation (LPO), mitochondrial cytochrome c release, and caspase-3 activation. While Zn elevated LPO content, it attenuated nitrite content, nNOS activity, and glutathione level along with the expression of TH and nNOS in SH-SY-5Y cells. 7-NI further augmented Zn-induced changes in the cell viability, oxidative stress, and expression of TH and nNOS. The results obtained thus demonstrate that Zn inhibits nNOS that partially contributes to an increase in oxidative stress, which subsequently leads to the nigrostriatal dopaminergic neurodegeneration.

Combined application of FBG and PZT sensors for plantar pressure monitoring at low and high speed walking

BACKGROUND

Clinical monitoring of planar pressure is vital in several pathological conditions, such as diabetes, where excess pressure might have serious repercussions on health of the patient, even to the extent of amputation.

OBJECTIVE

The main objective of this paper is to experimentally evaluate the combined application of the Fibre Bragg Grating (FBG) and the lead zirconate titanate (PZT) piezoceramic sensors for plantar pressure monitoring during walk at low and high speeds.

METHODS

For fabrication of the pressure sensors, the FBGs are embedded within layers of carbon composite material and stacked in an arc shape. From this embedding technique, average pressure sensitivity of 1.3 pm/kPa and resolution of nearly 0.8 kPa is obtained. These sensors are found to be suitable for measuring the static and the low-speed walk generated foot pressure. Simultaneously, PZT patches of size 10 × 10 × 0.3 mm were used as sensors, utilizing the d<formula>_{33}</formula> (thickness) coupling mode. A sensitivity of 7.06 mV/kPa and a pressure resolution of 0.14 kPa is obtained from these sensors, which are found to be suitable for foot pressure measurement during high speed walking and running. Both types of sensors are attached to the underside of the sole of commercially available shoes. In the experiments, a healthy male subject walks/runs over the treadmill wearing the fabricated shoes at various speeds and the peak pressure is measured using both the sensors. Commercially available low-cost hardware is used for interrogation of the two sensor types.

RESULTS

The test results clearly show the feasibility of the FBG and the PZT sensors for measurement of plantar pressure. The PZT sensors are more accurate for measurement of pressure during walking at high speeds. The FBG sensors, on the other hand, are found to be suitable for static and quasi-dynamic (slow walking) conditions. Typically, the measured pressure varied from 400 to 600 kPa below the forefoot and 100 to 1000 kPa below the heel as the walking speed varied from 1 kilometer per hour (kmph) to 7 kmph.

CONCLUSIONS

When instrumented in combination, the two sensors can enable measurements ranging from static to high speed conditions Both the sensor types are rugged, small sized and can be easily embedded in commercial shoes and enable plantar pressure measurement in a cost-effective manner. This research is expected to have application in the treatment of patients suffering from diabetes and gonarthrosis.

NADPH oxidase mediated maneb- and paraquat-induced oxidative stress in rat polymorphs: Crosstalk with mitochondrial dysfunction

Oxidative stress is a key factor in Parkinson's disease (PD) pathogenesis. Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase and impaired mitochondrion regulate oxidative stress-mediated maneb (MB)- and paraquat (PQ)-induced Parkinsonism. However, their contribution in the MB- and PQ-induced toxicity in polymorphonuclear leukocytes (PMNs) is still elusive. The study investigated the role of NADPH oxidase and mitochondria in MB- and/or PQ-induced oxidative stress in the PMNs and the crossing point between the two. Animals were treated with MB and/or PQ for 1-3 weeks along with respective controls. In a few sets of experiments, rats were treated with/without NADPH oxidase inhibitor, apocynin, an hour prior to MB and/or PQ treatment. PMNs of MB and/or PQ treated animals were also treated with/without carbonyl cyanide 3-chlorophenylhydrazone (CCCP) to assess the role of the mitochondria in superoxide and total free radical productions. MB and/or PQ were found to increase the level of total reactive oxygen species (ROS), superoxide radicals, catalytic activity and expression of NADPH oxidase and superoxide dismutase (SOD1/2) and mitochondrial ROS content in a time dependent manner. Conversely, catalase activity and mitochondrial membrane potential were attenuated. Apocynin alleviated MB- and/or PQ-induced changes in total ROS, superoxide radicals, expression/catalytic activity of NADPH oxidase and SOD1/2 along with the mitochondrial ROS and membrane potential. CCCP also inhibited ROS and superoxide levels in the PMNs of MB and/or PQ-treated animals. The results demonstrate the involvement of NADPH oxidase and mitochondrial dysfunction in MB and PQ-induced oxidative stress in PMNs and a plausible crosstalk between them.

Minocycline Rescues from Zinc-Induced Nigrostriatal Dopaminergic Neurodegeneration: Biochemical and Molecular Interventions

Accumulation of zinc (Zn) in dopaminergic neurons is implicated in Parkinson's disease (PD), and microglial activation plays a critical role in toxin-induced Parkinsonism. Oxidative stress is accused in Zn-induced dopaminergic neurodegeneration; however, its connection with microglial activation is still not known. This study was undertaken to elucidate the role and underlying mechanism of microglial activation in Zn-induced nigrostriatal dopaminergic neurodegeneration. Male Wistar rats were treated intraperitoneally with/without zinc sulphate (20 mg/kg) in the presence/absence of minocycline (30 mg/kg), a microglial activation inhibitor, for 2-12 weeks. While neurobehavioral and biochemical indexes of PD and number of dopaminergic neurons were reduced, the number of microglial cells was increased in the substantia nigra of the Zn-exposed animals. Similarly, Zn elevated lipid peroxidation (LPO) and activities of superoxide dismutase (SOD) and nicotinamide adenine dinucleotide phosphate (NADPH) oxidase; however, catalase activity was reduced. Besides, Zn increased an association of NADPH oxidase subunit p67(phox) with membrane, cytochrome c release from the mitochondria and cleavage of pro-caspase 3. Zn attenuated the expression of tyrosine hydroxylase (TH) and vesicular monoamine transporter-2 (VMAT-2) while augmented the expression of dopamine transporter (DAT) and heme oxygenase-1 (HO-1). Minocycline alleviated Zn-induced behavioural impairments, loss of TH-positive neurons, activated microglial cells and biochemical indexes and modulated the expression of studied genes/proteins towards normalcy. The results demonstrate that minocycline reduces the number of activated microglial cells and oxidative stress, which rescue from Zn-induced changes in the expression of monoamine transporter and nigrostriatal dopaminergic neurodegeneration.

Effective communication enhances the patients' endoscopy experience

BACKGROUND

Undergoing an endoscopy is a stressful experience for patients.

AIMS

To audit the endoscopy pathway to improve patient satisfaction.

METHODS

A prospective survey of endoscopy patients to identify system improvements that were then implemented.

RESULTS

The survey was performed before (N = 71) and after (N = 60) process improvements identified by the initial survey. Information provision and staff communication skills were identified for optimisation. Patient anxiety at home was significantly reduced (median 2 vs. 1, p < 0.01). Education of endoscopy staff significantly improved the quality of information provided before and after the procedure with regard to sedation (median 4 vs. 5, p < 0.01), discomfort (median 4 vs. 5, p < 0.01), complications (28 vs. 82 %, p < 0.01), findings (89 vs. 100 %, p < 0.01) and follow-up (73 vs. 90 %, p = 0.015). Gloucester Comfort Scores during endoscopy improved (median 1 vs. 0, p < 0.01) without increasing sedation levels. Patient feelings of invasion/trauma significantly decreased. Overall 95 % of patients were satisfied.

CONCLUSION

Structured information leaflets and improved staff communication skills reduce anxiety and enhance patients' experiences. They are now standard operating procedures.

Four compartment method: a simplified and cost-effective method of noncultured epidermal cell suspension for the treatment of vitiligo

BACKGROUND

Despite continued progress towards an elucidation of pathogenetic pathways in vitiligo, a definitive cure remains elusive. Noncultured epidermal cell suspension (NCECS) is emerging as the treatment of choice for surgical management of both stable and segmental vitiligo. NCECS is very effective in repigmenting stable vitiligo, but the technique requires an expert and the support of a laboratory facility.

OBJECTIVES

To investigate a simplified and more cost-effective method for NCECS.

METHODS

We simplified the conventional NCECS method and made it more cost-effective and simple enough to be performed in the clinic without laboratory equipment. We named this the four compartment (FC) method. Six patients with vitiligo were treated with this FC method.

RESULTS

The FC method for NCECS is highly cost-effective and simple. Six patients with vitiligo were treated and the results showed marked to complete repigmentation in four patients and > 50% repigmentation in two patients in 3 months.

CONCLUSIONS

The FC method is a cost-effective and simple procedure to prepare epidermal cell suspensions. In this modified method we showed that there is no need for pipette, tips, centrifuge tube and most importantly a centrifuge machine or any other expensive laboratory equipment.

Varied presentation of uterine arteriovenous malformations and their management by uterine artery embolisation

Uterine arteriovenous malformations are rare lesions which have a varied presentation that may range from the patient being asymptomatic to varying degrees of menorrhagia. It can be diagnosed by Doppler sonography but a strong index of suspicion is necessary. Management of this condition depends on presentation and available resources. In asymptomatic patients, we can leave the patients on regular follow-up as many lesions regress spontaneously. In patients with excessive haemorrhage not responding to embolisation or when facilities of embolisation are not available, hysterectomy needs to be done. Uterine artery embolisation should be considered the optimum treatment, as it has a high success rate coupled with few complications and also has fertility-preserving potential. Clinical follow-up usually suffices but sonography may occasionally be required.

The effect of tinted spectacle lenses on contrast sensitivity and colour vision

Aim: Spectacle wearers often prefer tintedlenses to clear or non-tinted lenses for their protection against harmful radiation, improved cos-mesis, enhancement of visual performance and effects on colour vision. Among the available tinted lenses on the market blue, brown and grey tinted spectacle lenses are popular with varying gradesranging from A to D. Due to reduced transmission of light through such lenses, the optical system of the eyes and the environmental vision may be temporarily altered. Colour vision (CV) and con-trast sensitivity (CS) are important aspects of this altered visual world. This study investigated the effect of spectacle lenses of varying grades of tint on CS and CV.Method: The study adopted a pre- and postest research design and a sample of 90 participants were selected from the University of KwaZulu-Natal student population using convenience sam-ling. Each participant was screened for patholgy, dyschromatopsia, severe dry eyes (TBUT<5 seconds), and the presence of any more than low metropia. Thereafter each successful participant was tested for CS and CV with their habitual precription and then tested randomly with a white clear) lens (placebo) and tinted (blue, brown, and grey) spectacle lenses made of CR39 material each having grades A, B and C over their habitual state. Light transmission was 85%, 75%, and 50% for grades A, B, and C respectively. The Functional Acuity Contrast Test (FACT) chart and American Optical Hardy, Rand, and Rittler (AO HRR) were used for the assessment of CS and CV respectively.Results: The data was analysed using the Statistical Package of Social Science (SPSS) version18. Compared to the habitual state, contrast sensitivity was enhanced with all the tinted lensesThe greater enhancement was for low spatial frequencies (LSF) and least for high spatial frequencies (HSF). With all tints Grade C had the least enhancement for very HSF. Many subjects showed no change in CV with any of the lensesused. The grey tint showed greater enhancement of CV as the density increases. Blue and brown tints showed a similar trend with grade B enhancing CV the most while grade C resulted in theleast reduction of CV.Conclusion: Grade A, B, and C of blue, brown and grey tinted spectacle lenses do not alter colour vision significantly but for the selected levels of transmission of the tints used, contrast sensitivity can be improved to some extent.