THE ROLE OF DISTAL LOCKING IN INTRAMEDULLARY NAILS FOR HIP FRACTURE FIXATION: A REVIEW OF CURRENT LITERATURE

Traditionally, it was believed that both proximal and distal locking are essential for achieving stability during intra-medullary fixation for extra-capsular hip fractures. However, recent literature has presented varying perspectives on the necessity of distal locking. Distal locking plays a significant role in managing hip fractures with uncertainties regarding longitudinal and rotational stability. This includes cases of comminuted intertrochanteric fractures with subtrochanteric extension, reverse oblique and high oblique fractures, broad medullary canals, comminution of the lateral wall, diaphyseal fractures, and large posteromedial fragments extending below the level of the lesser trochanter. In stable pertrochanteric fractures, with the lag screw passing through the lateral cortex of the distal fragment, may not require a distal locking screw. Distal locking has been associated with potential complications, including irritation of the fascia lata, prolonged operation time, increased radiation exposure, greater blood loss, implant loosening, secondary femoral stress fractures, and damage to the femoral artery. Thus, although distal locking is of doubtful significance in stable pertrochanteric fractures it is essential in unstable fracture patterns.

CURRENT CONCEPTS IN THE MANAGEMENT OF BOXER'S FRACTURE

Fractures of the metacarpal particularly the 5th metacarpal is quite common among all hand fractures and has a high incidence in male adult population. Proper management of these fractures plays a key role in rehabilitation and early return to work thus reducing the economic burden. Treatment of these injuries depends on the type of injury: whether it is a closed/open fracture, degree of angulation at the fracture site and also mal-rotation and shortening of the finger. Non-operative management is suitable for fractures which are closed, non-displaced and without angulation or rotation. Open fractures, fractures with angulation and/or mal-rotation and fractures with neuro-vascular injury are more suitable for operative management. The acceptable angulation for conservative management for most studies is 70 degrees. Buddy strapping with a Futura splint provides good functional results. In fractures requiring operative intervention, K-wire fixation is a minimally invasive method of fixation, which in most cases has good functional results. Plate and screw fixation, however, is preferred for cases with significant comminution or multiple metacarpal fractures.

Ethnomedicinal uses of plants for various diseases in the remote areas of Changa Manga Forest, Pakistan

Abstract This study aims at reporting the indigenous knowledge of the medicinal flora from the inhabitants of surroundings of the World’s largest artificial planted forest “Changa Manga”, Pakistan. Data were collected by direct interviews and group meetings from 81 inhabitants including 32 local healers having information regarding the use of indigenous medicinal plants over a period of one year. Different statistical tools were applied to analyze the data including Frequency citation (FC), Relative frequency citation (RFC), Use Value, Factor of informants consensus and fidelity level. This study reported 73 plant species belonging to 37 plant families and 46 genera. The majority of plant species belong to compositae family. The most commonly used medicinal plants were P. hysterophorus L., P. dactylifera L., S. indicum L, P. harmala L., P. emblica L., and A. indica A.Juss. The greatest number of species was used to cure gastrointestinal disorders. The highest fidelity level (68.18%) was of E. helioscopia to cure gastrointestinal disorders. Maximum fresh uses (17) were reported by C. dactylon (L.) Pars. While the highest number of species reporting fresh uses in similar number was 13. In this study, five novel plants are being reported for the first time in Pakistan for their ethnomedicinal worth. Our data reflect unique usage of the medicinal plants in the study area. The statistical tools used in the study proved useful in pointing the most important and disease category specific plants. High use value plant and the new reported medicinal plants might prove an important source of the isolation of pharmacologically active compounds.

Unlocking integrated waste biorefinery approach by predicting calorific value of waste biomass

The current study analyzed the high heating values (HHVs) of various waste biomass materials intending to the effective management and more sustainable consumption of waste as clean energy source. Various biomass waste samples including date leaves, date branches, coconut leaves, grass, cooked macaroni, salad, fruit and vegetable peels, vegetable scraps, cooked food waste, paper waste, tea waste, and cardboard were characterized for proximate analysis. The results revealed that all the waste biomass were rich in organic matter (OM). The total OM for all waste biomass ranged from 79.39% to 98.17%. Likewise, the results showed that all the waste biomass resulted in lower ash content and high fixed carbon content associated with high fuel quality. Based on proximate analysis, various empirical equations (HHV=28.296-0.2887(A)-656.2/VM, HHV=18.297-0.4128(A)+35.8/FC and HHV=22.3418-0.1136(FC)-0.3983(A)) have been tested to predict HHVs. It was observed that the heterogeneous nature of various biomass waste considerably affects the HHVs and hence has different fuel characteristics. Similarly, the HHVs of waste biomass were also determined experimentally using the bomb calorimeter, and it was observed that among all the selected waste biomass, the highest HHVs (21.19 MJ kg-1) resulted in cooked food waste followed by cooked macaroni (20.25 MJ kg-1). The comparison revealed that experimental HHVs for the selected waste biomass were slightly deviated from the predicted HHVs. Based on HHVs, various thermochemical and biochemical technologies were critically overviewed to assess the suitability of waste biomass to energy products. It has been emphasized that valorizing waste-to-energy technologies provides the dual benefits of sustainable management and production of cleaner energy to reduce fossil fuels dependency. However, the key bottleneck in commercializing waste-to-energy systems requires proper waste collection, sorting, and continuous feedstock supply. Moreover, related stakeholders should be involved in designing and executing the decision-making process to facilitate the global recognition of waste biorefinery concept.

Hippocampus shapes cortical sensory output and novelty coding through a direct feedback circuit

To extract behaviorally relevant information from our surroundings, our brains constantly integrate and compare incoming sensory information with those stored as memories. Cortico-hippocampal interactions could mediate such interplay between sensory processing and memory recall1-4 but this remains to be demonstrated. Recent work parsing entorhinal cortex-to-hippocampus circuitry show its role in episodic memory formation5-7 and spatial navigation8. However, the organization and function of the hippocampus-to-cortex back-projection circuit remains uncharted. We combined circuit mapping, physiology and behavior with optogenetic manipulations, and computational modeling to reveal how hippocampal feedback modulates cortical sensory activity and behavioral output. Here we show a new direct hippocampal projection to entorhinal cortex layer 2/3, the very layer that projects multisensory input to the hippocampus. Our finding challenges the canonical cortico-hippocampal circuit model where hippocampal feedback only reaches entorhinal cortex layer 2/3 indirectly via layer 5. This direct hippocampal input integrates with cortical sensory inputs in layer 2/3 neurons to drive their plasticity and spike output, and provides an important novelty signal during behavior for coding objects and their locations. Through the sensory-memory feedback loop, hippocampus can update real-time cortical sensory processing, efficiently and iteratively, thereby imparting the salient context for adaptive learned behaviors with new experiences.

Malignant Dural Solitary Fibrous Tumor; An Exceedingly Rare Entity

Introduction/Objective

A solitary fibrous tumor (SFT) is an extremely rare mesenchymal neoplasm, accounting for <1% of all primary CNS tumors. Most SFT is dural-based and occurs predominantly in the fourth to sixth decade of life. Here, we present a case of a dural solitary fibrous tumor.

Methods/Case Report

A 28-year-old male presented with intermittent throbbing headache, nausea, and vomiting. Imaging revealed a large, well-circumscribed left parafalcine, dural-based multilobulated, solid, and cystic mass. The patient underwent craniotomy with mass resection. Preliminary intraoperative findings were of a spindle cell neoplasm. Histopathologic examination showed hypercellular neoplasm composed of the spindle to ovoid cells with a high nuclear to cytoplasmic ratio and limited intervening stroma arranged in a haphazard pattern with prominent branching staghorn vasculature. Focal areas of necrosis and mitotic counts of 8/10 high power field were also seen. The lesional cells showed focal cytoplasmic CD34 expression and strong STAT6 nuclear expression. Finally, a diagnosis of SFT, haemangiopericytoma phenotype classified as grade 3, was made.

Results (if a Case Study enter NA)

NA

Conclusion

Most SFTs are considered clinically benign (grade 1 tumors) with favorable outcomes after complete resection. However, haemangiopericytoma phenotype with hypercellularity, necrosis, and elevated mitotic count (> 4/10 HPF) is known to have an increased risk of local recurrence and rare metastasis, requiring patients to receive adjuvant radiotherapy after resection for longer progression-free survival. Therefore, it is vital to be aware of this entity for optimal management and more active systemic surveillance in patients with high-grade SFT tumors. Our patient is currently doing well post-adjuvant radiotherapy and is under active annual surveillance.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Isolation and In Silico Characterization of Defensin Genes from Some Indigenous Plant Species of Pakistan

Aims: Damage of crop plants due to pathogenic attacks, postharvest crops spoilage and lethal effects of chemical pesticides has enforced scientists to find some potential natural alternative. Plants produce different types of antimicrobial peptides including defensins in response to biotic and abiotic stresses. Defensins are small cysteine rich, cationic peptide with 40-45 amino acid residues with a variety of biological activities. Hence defensins have pharmaceutical and agricultural significance especially wide range of antifungal activities. Methodology: Nine plant species viz Brassica napus, Brassica nigra, Conyza bonariensis, Alhagi marorum, Sonchus arvensis, Brassica compestris, Eruca sativa, Cirsium arvensis and Brassica juncea were selected for the study. Four set of primers were applied on extracted genomic DNAs and four amplified genes were isolated from different plants species by PCR. The amplified genes were cloned via pTZ57R/T in E.coli. The cloned fragments were sequenced and characterized by different bioinformatics tool such as coding length and peptide sequence, site of cell aggregation, peptide physico-chemical properties, antimicrobial properties and gene expression pattern. Result: The amplified products from B. napus, B. nigra, B. compestris, E. sativa and B. juncea were about 330 bp in length and showed upto 85% nucleotide homology to the reported defensins. Deduced amino acid sequence from Bn-Def, Es-Def Bj-Def and Bc- Def showed the conserved defensin domain. These sequences were also characterized for different characteristic like charged amino acids, pI value, shelflife and stability.  Sonchus arvensis didn’t give any specific product by prescribed set of primers. However the products from Alhagi marorum was about 770 bp and B. napus was of 270 bp but both give homology below 30%. Conclusion: This study showed that in silico characterization of deduced antimicrobial peptides from different plant species has depicted these as an effective alternative to communal therapeutics. However, further work is needed to verify defensins specific activity at protein level.

Placental Mesenchymal Dysplasia, An Exceedingly Rare Entity and Challenging Diagnosis

Introduction/Objective

Placental mesenchymal dysplasia (PMD) is an extremely rare entity with an incidence of only 0.02/1000 deliveries.

Methods/Case Report

We present a case of a 26 year-old female Gravida 3, Para 1 with intrauterine pregnancy at 37 weeks of gestation. Fetal ultrasound showed mildly cystic upper portion of the placenta. The noninvasive prenatal testing was negative for triploidy. A viable healthy female infant was delivered with no maternal complications.

On gross examination, placenta was heavy with approximately 25% incomplete cotyledons. Placental maternal surface showed, spongiform cut surfaces admixed with multiple cystic structures ranging in size from 0.5 to 1.5 cm and markedly dilated blood vessels.

Histopathologic examination revealed markedly enlarged villi, mesenchymal hyperplasia, and hyper vascularity of small vessels. No trophoblast proliferation was identified. Subsequently, the diagnosis of PMD was made.

Results (if a Case Study enter NA)

NA

Conclusion

PMD is a rare anomaly which is characterized by placentomegaly and grape like vesicles resembling molar pregnancy. Etiologies include imbalance of paternal and maternal alleles, androgenetic and bi-parental mosaicism, and Beckwith Weidman Syndrome (BWS). Differential diagnosis includes partial molar pregnancy, complete mole with co-existing normal fetus, hemangioma, subchorionic hematoma, confined placental mosaicism and hydropic complications. Histologic features, ancillary studies including immunohistochemistry and genetic testing are helpful in differentiating PMD. PMD is an underdiagnosed entity with increased risk of premature delivery and intrauterine fetal death. It is pertinent for the clinicians to be aware of this entity for optimal patient management.

Duodenal Duplication Cyst in adult male; An Extremely Rare Entity and a Diagnostic Pitfall leading to Whipple procedure

Introduction/Objective

Whipple procedure is a complex, invasive operation and has high morbidity and mortality. It is the most commonly indicated treatment for treating malignant tumors, however, it can be also used for benign entities as well including biliary stricture, chronic pancreatitis, choledochal cyst, inflammatory pseudotumour, and duodenal angiodysplasia.

Methods/Case Report

We report a case of a 50-year-old man who presented with symptoms of gastric outlet obstruction. Esophagogastroduodenoscopy and CT scan showed an obstruction at the level of the second part of the duodenum with proximal dilation. Subsequently, a Whipple procedure was performed based on high clinical suspicion of duodenal cancer. Gross examination revealed a unilocular thick walled cyst (4.2 cm) in the duodenum. Histopathologic examination showed a cyst lined by duodenal mucosa with thick smooth muscle wall and focal ectopic gastric tissue. This was finally diagnosed as a duodenal cyst consistent with duplication cyst.

Results (if a Case Study enter NA)

NA

Conclusion

Duplication cysts are rare congenital abnormality predominantly diagnosed in infancy and childhood. They are most commonly located in the distal ileum, followed by the esophagus and ileocecal region, and are extremely rare in duodenum. Differential diagnosis includes choledochocele, pancreatic pseudocyst, and cystic tumors of the pancreas, mesenteric cysts, and duodenal diverticulums. Treatment options include total excision, cystojejunostomy, and endoscopic marsupialization but occasionally may lead to more invasive measures such as the Whipple procedure. Although duodenal duplication cysts can have variable clinical presentation and radiological findings, making preoperative diagnosis very challenging, it is still pertinent to be aware of this entity for the optimal patient care.

Rhabdomyosarcoma in Ovary- Pathologist’s Diagnostic Dilemma

Introduction/Objective

Rhabdomyosarcoma is the most common pediatric soft tissue sarcoma. However, rhabdomyosarcoma in the ovary is exceptionally unusual and presents a diagnostic challenge. We report one such case and its clinical and pathological perspective.

Methods/Case Report

16-year-old female presented with an enlarging pelvic mass, abdominal distension, and pain. Imaging revealed a heterogeneous left ovarian mass, right axillary lymphadenopathy, and right-hand soft tissue mass. CA-125 was 1833.0 U/ml. Patient underwent left salphingo-oophorectomy, omentectomy, peritoneal and mesenteric biopsy for ovarian staging, incidental appendectomy, and right axillary lymph node excision with suspicion of ovarian epithelial tumor. Pathological evaluation revealed a 16-cm intact ovary with multiple solid and cystic nodules with areas of hemorrhage and necrosis. Microscopic examination of ovarian tumor showed a high-grade malignant tumor consisting of sheets of small round blue cells with severe cytologic atypia, increased mitoses, and features suggestive of rhabdoid morphology. The other specimens were positive for metastases. The tumor cells were immunopositive for Myogenin and MyoD1 while immunonegative for Cytokeratin AE1/AE3, SF-1, PLAP, SALL4, MelanA, and S-100. INI-1 and BRG-1 demonstrated intact nuclear expression. FISH testing identified rearrangement of the FOX01 gene at 13q14. Based on these findings, diagnosis of alveolar rhabdomyosarcoma was rendered. Currently, the patient is receiving rhabdomyosarcoma chemotherapy treatment and has responded well.

Results (if a Case Study enter NA)

NA

Conclusion

In cases with complex and urgent clinical presentation, where the existence of a primary tumor is unknown and where symptoms attributable to primary ovarian tumor dominate the clinical picture, rhabdomyosarcoma is rarely proposed in the differential diagnoses of small round blue cell tumors of the ovary. At present, the right-hand mass is under evaluation; thus, the true nature of the ovarian mass, primary or metastatic is unknown. Our case illustrates the importance of exact diagnoses, as treatment of rhabdomyosarcoma, is different from other ovarian tumors.

Closing the Osteoporotic-Fracture Care Gap for Frail Older Persons

Aim To implement standardised fracture risk assessment in the frail older person. Methods Frail older patients underwent opportunistic screening for fracture risk. Roadblocks to standardised assessment were identified. An Integrated Care Team for older persons (ICT) trained in fracture risk assessment using FRAX. Clinical assessment was via a locally agreed algorithm. Data was entered onto Excel. The SQUIRE guidelines for quality improvement programmes were used to report the results. Results Of 96 patients opportunistically screened, the average age was 84 years. FRAX was completed for 19% (n=18). 89% (n=16) met the pharmacotherapy threshold. Nine were recommended pharmacotherapy. Of sixteen patients recommended for DXA, just 31% (n=5) were booked. Following implementation of a quality improvement project, 100 patients were assessed, and average age was 80 years. FRAX was completed for 62% (n=63) and 95% (n=60) required pharmacotherapy. 24% (n=14) had untreated prior fracture. All had pharmacotherapy prescribed. 59% (n=59) required DXA scanning. 70% (n=41) had DXA ordered. Conclusion ICT ownership increased FRAX assessment 3-fold and point of contact prescribing to 100%.

Traditional knowledge about medicinal plant in the remote areas of Wari Tehsil, Dir Upper, Pakistan

Traditional medicine is cheaper and easily available to local people, to care for most frequent diseases in the Northern parts of Pakistan. Our study aimed at inventorying medicine from local plants, documenting their uses, and assessing their market value in 2015-2018 during spring, summer, and winter seasons. A total of 15 trips were made, 5 in each season. Semi-structured interviews with 165 inhabitant's age range between 20-80 years were conducted, analyzed the data is analyzed using Relative frequency of citation(RFC), Use Value(UV), Fidelity Level(FL), Informants consensus factor(ICF), and Jaccard index(JI) to find the most frequent and well-known used species in the area. A total of 86 species belonging to 39 vascular plant families, 33 genera were documented as medicinally important. Family Asteraceae was observed as the dominant family among all the families with 10 species, the leaf was the most used parts and decoction 36% was the most preferred preparation type. Herb was the predominant life form (67%). The maximum UV (0.92) was demonstrated by J. adhatoda L. species, while A. sativum L. shows maximum RFC (0.58), the highest ICF value represented by diarrhea and dermatitis 0.92, and high FL value is recorded 100%. According to our collections, wild species were 45%, invasive species were 38% and cultivated 17% recorded, dicots species were recorded more 81%. Seven 7 medicinal species is being economically important and export to the local and international market of the world, whereas P. integrima L. species were the most exported species according to the local dealers. The investigated area is rural and the local people depend on the area's plants for their health needs, and other uses like a vegetable, fuelwood, fodder, etc. The current result of RFC, UV, ICF, FL, and JI shows that medicinal flora needs to be pharmacologically and phytochemically investigated to prove their efficacy. The documentation of medicinal knowledge is important to preserve this precious old knowledge before it is lost forever, due to technological and environmental changes in the world.

Primary Conjunctival Kaposi Sarcoma; A Rare And Unheard Entity

Introduction/Objective

Kaposi’s sarcoma (KS) is the most common malignant vascular tumor in human immunodeficiency virus (HIV) patients caused by human herpesvirus 8. It can affect the vascular endothelium of any part of the body however ocular KS as an initial manifestation has been reported only in 3 cases so far. It affects the vascular endothelium of the lacrimal gland, eyelids, orbit, palpebral and bulbar conjunctiva. It presents as a violaceous fleshy nodular mass.

Methods

A 23-year-old male with a past medical history of HIV presented with bilateral eye erythema and significant upper and lower lid edema. The patient was initially admitted for facial swelling which led to a conjunctival biopsy and a diagnosis of KS was made and doxorubicin along with chemotherapy was started. Four months later after the initiation of chemotherapy, the patient experienced worsening of facial swelling, and an area on the left side of his face got very firm. His physical examination was positive for a fever, drooling, facial swelling with trouble swallowing, and change of voice along with shortness of breath.

Results

CT of the orbit revealed symmetric enhancement swelling of the preseptal periorbital soft tissues which was thought to be nonspecific and a differential diagnosis included lymphedema, acute sinusitis, and orbital cellulitis was considered. A chest x-ray revealed bilateral pleural effusions and CT head revealed diffuse scalp and facial cutaneous and subcutaneous edema. Lab findings were significant for a low CD4: CD8 ratio. Cytological examination of the pleural fluid revealed predominantly blood, reactive mesothelial cells, macrophages, neutrophils, and lymphocytes, and appropriately controlled immunostain was positive for ERG and HHV8 with a possibility that Kaposi’s sarcoma cannot be completely excluded. Unfortunately, the patient passed away during the same time of pleural fluid analysis.

Autopsy findings revealed multiple metastatic foci in the mediastinal soft tissue, within the right land left lung, scalp soft tissue, retroperitoneal soft tissue, and hilar lymph node which were positive for CD34, CD31, and HHV8 and consistent with metastatic KS.

Conclusion

Thus, it is important to keep in mind that isolated conjunctival KP with later on systemic metastasis is rare with conjunctiva being an unusual site for the initial presentation, and a possibility of primary conjunctival KS should be considered in HIV positive patients.

A predictive model for Covid-19 spread - with application to eight US states and how to end the pandemic

A compartmental model is proposed to predict the coronavirus 2019 (Covid-19) spread. It considers: detected and undetected infected populations, social sequestration, release from sequestration, plus reinfection. This model, consisting of seven coupled equations, has eight coefficients which are evaluated by fitting data for eight US states that make up 43% of the US population. The evolution of Covid-19 is fairly similar among the states: variations in contact and undetected recovery rates remain below 5%; however, variations are larger in recovery rate, death rate, reinfection rate, sequestration adherence and release rate from sequestration. Projections based on the current situation indicate that Covid-19 will become endemic. If lockdowns had been kept in place, the number of deaths would most likely have been significantly lower in states that opened up. Additionally, we predict that decreasing contact rate by 10%, or increasing testing by approximately 15%, or doubling lockdown compliance (from the current ~15% to ~30%) will eradicate infections in Texas within a year. Extending our fits for all of the US states, we predict about 11 million total infections (including undetected), and 8 million cumulative confirmed cases by 1 November 2020.

SAT0189 SAMPLE SIZES AND RECRUITMENT RATES ARE DECREASING WHILE PLACEBO RESPONSE RATES ARE INCREASING IN CLINICAL TRIALS FOR SYSTEMIC LUPUS ERYTHEMATOSUS - A MANDATE FOR NEW STRATEGIES

Background:

Randomized controlled trials in Systemic Lupus (SLE) have shown disappointing results for decades. Key challenges may include the heterogenous population coupled with high placebo response rates.

Objectives:

To evaluate trends in SLE study metrics over time and explore associations between primary endpoint failure and response in placebo/standard of care arms.

Methods:

Data from Phase II or III trials which enrolled ≥ 100 patients with SLE and reported SRI-4 and/or BICLA responses after a minimum of 24 weeks were included in the analysis. Sample size, recruitment rates, regional patient distributions, and results in placebo arms (at 24-36 weeks or 48-52 weeks) were examined according to the start date of each study in order to determine trends over time. Placebo group SRI-4 response rates in studies that met their primary endpoint were compared with those that did not.

Results:

Twenty-seven (14 phase II and 13 phase III) studies met the search criteria. Eleven of them met their primary endpoints. The study start dates ranged from Dec 2006 to Jan 2017. Mean/median total subject numbers were 461/349. Mean/median placebo subjects’ age at baseline were 39.9/39.2 and SLEDAI: 10.6/10.6. Mean/median placebo SRI-4 responses at Week 24-36 were 47.2%/45.8% and 42.8%/43% at Week 48-52. For BICLA, the rates were 40.3%/37.2% at Week 24-36 and 33.2%/33.5% at Week 48-52.

As expected, lower placebo response was found in trials that met primary endpoints vs studies that did not (p=0.005). Total subject numbers and recruitment rates decreased over time while placebo SRI-4 response rates increased overall (Figure). However, there has been a greater range of placebo responses in more recent trials. Similar trends were observed in BICLA responses at Week 24-36 and 48-52, and in a corticosteroid reduction endpoint (percent of patients with reduction in steroid dose by ≥25% and to ≤7.5 mg/day prednisone/equivalent) at Week 48-52. Enrollment of patients from North America decreased while proportions of Eastern Europeans increased over time (Figure).

Conclusion:

High placebo response rates pose a continuing challenge in SLE studies and are associated with primary endpoint failures.

Clinical trial metrics have been changing over time, with declining size and recruitment rates, possibly due to competition from increasing numbers of studies.

These trends should be considered while designing and conducting future trials. Attention to site training and data quality may be particularly important to control high placebo rates, especially as trial sizes decrease.

Figure.

Disclosure of Interests:

Ewa Olech Grant/research support from: BMS, Consultant of: Abbvie, Amgen, Remegen, Employee of: IQVIA, Speakers bureau: Abbvie, Amgen, Merck, Pfizer, UCB, Eduard van Rijen Employee of: IQVIA, Faizi Hussain Employee of: IQVIA, Gregory Dennis Employee of: IQVIA, Ali Ashrafzadeh Employee of: IQVIA, Joan T Merrill Grant/research support from: Xencor, Bristol Myers Squibb, Glaxo Smith Kline, Consultant of: Xencor, Abbvie, UCB, Glaxo Smith Kline, EMD Serono, Astellas, Remegen, Celgene/Bristol Myers Squibb, Exagen, Astra Zeneca, Amgen, Jannsen, Servier, ILTOO, Daitchi Sankyo, Lilly, Paid instructor for: Abbvie, Bristol Myers Squibb

Developing antimicrobial calcium alginate fibres from neem and papaya leaves extract

OBJECTIVE

The aim of this study was to evaluate an alternative approach to developing antimicrobial alginate fibres using plant extracts, such as those from neem and papaya leaves.

METHOD

Aqueous leaves extract from neem, papaya and their hybrid combinations were used as solvent to develop sodium alginate fibres. Sodium alginate polymer containing these extracts was extruded in a calcium chloride (CaCl₂) bath to develop neem (NE), papaya (PE) and their hybrid combinations-based calcium alginate fibres (H-1 to H-5). The surface morphology, spectra, liquid absorption, tensile strength and antimicrobial activity of these developed fibres were measured.

RESULTS

NE fibre showed greater tensile strength than PE. The liquid absorption property of all developed fibres decreased, but showed antibacterial properties against Staphylococcus aureus and reduced bacterial growth up to 85% when compared with pure calcium alginate fibre.

CONCLUSION

Neem, papaya and hybrid extract-based calcium alginate fibres have the potential to be used as wound dressings.

Study of selected therapeutic potentials of Momordica charantia fruit

M. charantia extract partitioned in different solvents was assessed for antioxidant (2, 2-diphenyl l-picrylhydrazyl), total phenolic contents (TPC), total flavonoid contents (TFC), antiglycation, alpha amylase and acetylcholinesterase inhibitory activities along with cytotoxic, thrombolytic and antibiofilm potentials. Most effective antioxidant fraction was n-hexane with TPC and TFC, highest in n-butanol and ethanol fractions, respectively. Ethyl acetate fraction showed maximum glycation and alpha amylase inhibitions and optimum acetylcholinesterase inhibition was by ethanol fraction. Fractions exhibited significant hemolytic and thrombolytic efficacies and bacterial growth restraint. The present research reveals some medicinal potency of M. charantia.

Irritable Bowel Syndrome: Is it Rare in Children?

Irritable bowel syndrome (IBS) is one of the most common and best studied disorders among the group of functional gastrointestinal disorders. It is a functional bowel disorder in which abdominal pain or discomfort is associated with defecation or a change in bowel habit. Visceral hypersensitivity and increased GIT motility are the main patho-physiological mechanism for developing IBS. IBS present with diarrhea and constipation or both. Investigation is least needed for diagnosis of IBS rather done to exclude differential diagnosis. Diagnosis is done on the basis of Rome-III criteria. Proper counseling, dietary management, anti-spasmotic and antidepressant are the mainstay of treatment.

Survival of Direct Posterior Composites With and Without a Bulk Fill Base

OBJECTIVES

Direct composite restorations are increasingly popular and a flowable bulk-fill base material (SDR, Dentsply) claims to minimise stress through a more flexible polymerisation process. This retrospective audit of restorations placed in general practice compares SDR based restorations with conventional composite restorations.

METHODS

Restorations were all placed by one operator using a similar clinical technique and were audited as Group G, placed with a conventional layering composite (G-aenial, GC) and Group S which had a bulk-fill base of SDR (Dentsply) and then were covered with G-aenial (GC). Data regarding survival, post-operative sensitivity and mode of failure were recorded and analysed.

RESULTS

In total 54 Group S restorations and 71 Group G restorations were followed for a minimum of 24 months. Group S had a 92.6% survival and Group G 93%. Group S was more prone to failure by tooth fracture (p=0.033). In both groups failure was more likely in larger cavities, in both those with an increased number of surfaces (p⟨0.001) and cuspal coverage (p=0.004).

CONCLUSIONS

There appears to be similar survival of the two techniques in the short-term although there were significantly more tooth fractures in teeth restored with SDR.

Is the shortened dental arch still a satisfactory option?

Aims Dental practitioners may hold the view that missing posterior teeth should be replaced to ensure a healthy masticatory system and satisfactory oral function. However, the shortened dental arch (SDA) concept is still in use, but after 35 years is it acceptable? This review searches the literature for the evidence and opinions regarding the suitability of the SDA as a current treatment modality.Methods Medline and PubMed databases were searched for relevant terms, all the abstracts were assessed and articles selected according to the pre-set exclusion and inclusion criteria.Results The search yielded 1,895 articles and after the assessment of the abstracts and application of the exclusion and inclusion criteria, 44 articles were selected for this review. These included 11 cohort studies, two longitudinal studies, two animal studies, three cross sectional studies, eight clinical studies and 18 case control studies. There appears to be a trend over the past three decades for more papers to be opposed to the SDA concept.Conclusion Evidence that the SDA causes pathology is lacking. Clinicians, healthcare authorities and patients have shown favourable attitudes towards the SDA and this continues, although there is an increase in studies opposing the concept and some are dissatisfied with this option. The concept remains viable particularly for the medically compromised patient or where restorations are considered unsuitable but further more specific studies are warranted.

First report of pediatric hematopoietic stem cell transplantation activities in the eastern mediterranean region from 1984 to 2011: on behalf of the pediatric cancer working committee of the eastern mediterranean blood and marrow transplantation group

To describe the hematopoietic stem cell transplantation (HSCT) activities for children in the Eastern Mediterranean (EM) region, data on transplants performed for children less than 18 years of age between 1984 and 2011 in eight EM countries (Egypt, Iran, Jordan, Lebanon, Oman, Pakistan, Saudi Arabia and Tunisia) were collected. A total of 5187 transplants were performed, of which 4513 (87%) were allogeneic and 674 (13%) were autologous. Overall, the indications for transplantation were malignant diseases in 1736 (38.5%) and non-malignant in 2777 (61.5%) patients. A myeloablative conditioning regimen was used in 88% of the allografts. Bone marrow (BM) was the most frequent source of stem cells (56.2%), although an increasing use of PBSC was observed in the last decade. The stem cell source of autologous HSCT has shifted over time from BM to PBSC, and 80.9% of autologous HSCTs were from PBSCs. The donors for allogeneic transplants were matched-related in 94.5% of the cases, and unrelated transplants, mainly cord blood (99%) in 239 (5.5%) cases. This is the first report to describe the pediatric HSCT activities in EM countries. Non-malignant disorders are the main indication for allogeneic transplantation. Frequency of alternate donor transplantation is low.

Improved Endurance and Resistive Switching Stability in Ceria Thin Films Due to Charge Transfer Ability of Al Dopant

An improvement in resistive switching (RS) characteristics of CeO2-based devices has been reported by charge transfer through Al metal as a dopant. Moreover, density functional theory (DFT) calculations have been performed to investigate the role of Al-layer sandwiched between CeO2 layers by the Vienna ab initio simulation package (VASP). Total density of states (TDOS) and partial electron density of states (PDOS) have been calculated and analyzed with respect to resistive switching. It is established that the oxygen vacancy based conductive filaments are formed and ruptured in the upper region of CeO2 layer, because of the fact that maximum transport of charge takes place in this region by Al and Ti (top electrode), while the lower region revealed less capability to generate conductive filaments because minimum charge transfer takes place in this region by Al and/or Pt (bottom electrode). The effect of Al and Al2O3 on both the electronic charge transfer from valence to conduction bands and the formation stability of oxygen vacancies in conductive filament have been discussed in detail. Experimental results demonstrated that the Ti/CeO2:Al/Pt sandwich structure exhibits significantly better switching characteristics including lower forming voltage, improved and stable SET/RESET voltages, enhanced endurance of more than 10(4) repetitive switching cycles and large memory window (ROFF/RON > 10(2)) as compared to undoped Ti/CeOx/Pt device. This improvement in memory switching behavior has been attributed to a significant decrease in the formation energy of oxygen vacancies and to the enhanced oxygen vacancies generation within the CeO2 layers owing to charge transferring and oxygen gettering ability of Al-dopant.

Sodium calcium exchanger operates in the reverse mode in metastatic human melanoma cells

Cytosolic Ca2+ ([Ca2+]cyt) is important in the regulation of several cellular functions involved in metastasis. We hypothesize that distinct [Ca2+]cyt regulation explains the acquisition of a more metastatic phenotype. To test this hypothesis, we used highly and lowly metastatic human melanoma cells and [Ca2+]cyt was monitored using Fura—2AM and fluorescence spectroscopy. Stimulation with ATP elicited a sustained increase in [Ca2+]cyt in highly metastatic cells, but a transient increase in lowly metastatic cells. Na+ substitution revealed Na+/Ca2+ exchanger (NCX) activity in reverse mode in highly, but not in lowly metastatic cells. In highly metastatic cells, addition of Na+ in the plateau phase of [Ca2+]cyt increase elicited with ATP, in the absence of Na+, resulted in a rapid return to basal, indicating that NCX can operate in both reverse and forward modes. Inhibition and knockdown of NCX, using KB—R7943 and siRNA NCX—1 respectively, supported the significance of NCX in [Ca2+]cyt regulation in highly metastatic cells. Stimulation with UTP triggered a rapid increase in highly metastatic cells [Ca2+]cyt, but not in lowly metastatic cells suggesting that highly and lowly metastatic cells exhibit distinct purinergic receptors. These data indicate that following agonist—stimulation, NCX operates preferentially in the reverse mode to enable a sustained [Ca2+]cyt increase in highly metastatic cells. The forward mode of NCX operation to extrude Ca2+ is preferred in lowly metastatic cells. The acquisition of a more metastatic phenotype involves a switch in NCX activity from forward to reverse mode that is favorable to maintain elevated [Ca2+]cyt in response to agonist stimulation.

V-ATPase regulates communication between microvascular endothelial cells and metastatic cells

To metastasize distant organs, tumor cells and endothelial cells lining the blood vessels must crosstalk. The nature of this communication that allows metastatic cells to intravasate and travel through the circulation and to extravasate to colonize different organs is poorly understood. In this study, we evaluated one of the first steps in this process—the proximity and physical interaction of endothelial and metastatic cells. To do this, we developed a cell separator chamber that allows endothelial and metastatic cells to grow side by side. We have shown in our previous studies that V-ATPases at the cell surface (pmV-ATPase) are involved in angiogenesis and metastasis. Therefore, we hypothesized that the physical proximity/interaction between endothelial and metastatic cells expressing pmV-ATPase will increase its activity in both cell types, and such activity in turn will increase pmV-ATPase expression on the membranes of both cell types. To determine pmV-ATPase activity we measured the proton fluxes (JH+) across the cell membrane. Our data indicated that interaction between endothelial and metastatic cells elicited a significant increase of JH+ via pmV-ATPase in both cell types. Bafilomycin, a V-ATPase inhibitor, significantly decrease JH+. In contrast, JH+ of the non-metastatic cells were not affected by the endothelial cells and vice-versa. Altogether, our data reveal that one of the early consequences of endothelial and metastatic cell interaction is an increase in pmV-ATPase that helps to acidify the extracellular medium and favors protease activity. These data emphasize the significance of the acidic tumor microenvironment enhancing a metastatic and invasive phenotype.

Anaplastic Thyroid Cancer: a Retrospective analysis of 120 cases

INTRODUCTION

Anaplastic Thyroid Cancer (ATC) is one of the most lethal malignancies with very short survival and extremely poor treatment outcome. ATC accounts for 2-5% of all thyroid cancers worldwide with an annual incidence of about 2 million.

OBJECTIVE

To review the natural history and treatment outcome of ATC patients treated at King Faisal Specialist Hospital and Research Centre (KFSH and RC) located at Riyadh, Saudi Arabia.

MATERIAL AND METHODS

Retrospective review of 120 Saudi cancer patients collected from registry data at KFSH & RC from 1976-2008. Search key words included: thyroid cancer, anaplastic, undifferentiated and not otherwise specified. Search was not restricted to particular age, gender, treatment or tumor size. Demographic information, baseline patient characteristics including date of diagnosis, type of treatment and date of death were obtained from KFSH & RC registry data and Saudi death registry.

RESULTS

A total of 120 cases were identified at our cancer centre from 1976 to 2008. Of these total, 73 were females (60.8%) and 47 were males (39.2%). The average age at diagnosis was 63.34 +/- 12.8 years. Thirty-four patients underwent surgery (28.3%), 52 had a palliative radiation treatment (43.3%) and only 5 had chemotherapy (4.2%). The median survival was 53 days (0-457).

CONCLUSION

Our review proves that ATC is rapidly fatal cancer and is unresponsive to currently available therapeutic options. More research is needed to understand the tumor biology and novel treatment options.

KEYWORDS

thyroid cancer, anaplastic, undifferentiated, radiation treatment, chemotherapy, median survival, Riyadh and Saudi Arabia.