Mechanistic correlation of molecular pathways in obesity-mediated stroke pathogenesis

Obesity, a prominent risk factor for the development of heart attacks and several cardiovascular ailments. Obesity ranks as the second most significant avoidable contributor to mortality, whereas stroke stands as the second leading cause of death on a global scale. While changes in lifestyle have been demonstrated to have significant impacts on weight management, the long-term weight loss remains challenging, and the global prevalence of obesity continues to rise. The pathophysiology of obesity has been extensively studied during the last few decades, and an increasing number of signal transduction pathways have been linked to obesity preclinically. This review is focused on signaling pathways, and their respective functions in regulating the consumption of fatty food as well as accumulation of adipose tissue, and the resulting morphological and cognitive changes in the brain of individuals with obesity. We have also emphasized the recent progress in the mechanisms behind the emergence of obesity, as elucidated by both experimental and clinical investigations. The mounting understanding of signaling transduction may shed light on the future course of obesity research as we move into a new era of precision medicine.

Understanding mechanistic aspect of the therapeutic role of herbal agents on neuroplasticity in cerebral ischemic-reperfusion injury

ETHNOPHARMACOLOGICAL RELEVANCE

Stroke is one of the leading causes of death and disability. The only FDA-approved therapy for treating stroke is tissue plasminogen activator (tPA), exhibiting a short therapeutic window. Due to this reason, only a small number of patients can be benefitted in this critical period. In addition, the use of endovascular interventions may reverse vessel occlusion more effectively and thus help further improve outcomes in experimental stroke. During recovery of blood flow after ischemia, patients experience cognitive, behavioral, affective, emotional, and electrophysiological changes. Therefore, it became the need for an hour to discover a novel strategy for managing stroke. The drug discovery process has focused on developing herbal medicines with neuroprotective effects via modulating neuroplasticity.

AIM OF THE STUDY

We gather and highlight the most essential traditional understanding of therapeutic plants and their efficacy in cerebral ischemia-reperfusion injury. In addition, we provide a concise summary and explanation of herbal drugs and their role in improving neuroplasticity. We review the pharmacological activity of polyherbal formulations produced from some of the most frequently referenced botanicals for the treatment of cerebral ischemia damage.

MATERIALS AND METHODS

A systematic literature review of bentham, scopus, pubmed, medline, and embase (elsevier) databases was carried out with the help of the keywords like neuroplasticity, herbal drugs, neural progenitor cells, neuroprotection, stem cells. The review was conducted using the above keywords to understand the therapeutic and mechanistic role of herbal neuroprotective agents on neuroplasticity in cerebral ischemic-reperfusion injury.

RESULTS

Neuroplasticity emerged as an alternative to improve recovery and management after cerebral ischemic reperfusion injury. Neuroplasticity is a physiological process throughout one's life in response to any stimuli and environment. Traditional herbal medicines have been established as an adjuvant to stroke therapy since they were used from ancient times and provided promising effects as an adjuvant to experimental stroke. The plants and phytochemicals such as Curcuma longa L., Moringa oliefera Lam, Panax ginseng C.A. Mey., and Rehmannia glutinosa (Gaertn.) DC., etc., have shown promising effects in improving neuroplasticity after experimental stroke. Such effects occur by modulation of various molecular signalling pathways, including PI3K/Akt, BDNF/CREB, JAK/STAT, HIF-1α/VEGF, etc. CONCLUSIONS: Here, we gave a perspective on plant species that have shown neuroprotective effects and can show promising results in promoting neuroplasticity with specific targets after cerebral ischemic reperfusion injury. In this review, we provide the complete detail of studies conducted on the role of herbal drugs in improving neuroplasticity and the signaling pathway involved in the recovery and management of experimental stroke.

Glycosylation: A new signaling paradigm for the neurovascular diseases

A wide range of life-threatening conditions with complicated pathogenesis involves neurovascular disorders encompassing Neurovascular unit (NVU) damage. The pathophysiology of NVU is characterized by several features including tissue hypoxia, stimulation of inflammatory and angiogenic processes, and the initiation of intricate molecular interactions, collectively leading to an elevation in blood-brain barrier permeability, atherosclerosis and ultimately, neurovascular diseases. The presence of compelling data about the significant involvement of the glycosylation in the development of diseases has sparked a discussion on whether the abnormal glycosylation may serve as a causal factor for neurovascular disorders, rather than being just recruited as a secondary player in regulating the critical events during the development processes like embryo growth and angiogenesis. An essential tool for both developing new anti-ischemic therapies and understanding the processes of ischemic brain damage is undertaking pre-clinical studies of neurovascular disorders. Together with the post-translational modification of proteins, the modulation of glycosylation and its enzymes implicates itself in several abnormal activities which are known to accelerate neuronal vasculopathy. Despite the failure of the majority of glycosylation-based preclinical and clinical studies over the past years, there is a significant probability to provide neuroprotection utilizing modern and advanced approaches to target abnormal glycosylation activity at embryonic stages as well. This article focuses on a variety of experimental evidence to postulate the interconnection between glycosylation and vascular disorders along with possible treatment options.

GCMS characterization and biological potential of the seeds and aerial part of Galium tricorne Stokes

Abstract Natural products have long been proven very effective against various challenging diseases including cancer and bacterial infections. Galium tricorne is one of the important source of natural products, which has not been explored till date in spite of its profound ethnomedicinal prominence. The current study has been designed to explore the biological potential of G. tricorne and to extract and isolate chemical constituents from its aerial part and seeds respectively along with identification of their chemical constituents. Phytochemical screening was performed to figure out the presence of secondary metabolite in G. tricorne. Crude Methanolic extract (Gt.Crd), which was obtained from the aerial part while the fatty acids were extracted from the seeds, which were later on analyzed by GCMS. Similarly, Well Diffusion and MTT method were used for antibacterial activity and cancer cell line assay respectively. To evaluate the cytotoxic potential, brine shrimps were used. Likewise, in Gas Chromatography-Mass Spectroscopy (GC-MS) analysis a total number of 23 compounds were identified in Gt.Crd extract out of which 7 compounds were sorted out to have some sort of toxicity profile. In the same fashion, 5 fatty acids were identified in the seeds of G. tricorne. Moreover, among the fractions, chloroform fraction (Gt.Chf) exhibited greater zone of inhibition (ZOI) 20.37 mm followed by Gt.Crd 18.40 mm against S. aureus and S. pyogenes respectively. In cytotoxicity Gt.Chf was more active followed by ethyl acetate fraction (Gt.Eta) by exhibiting 88.32±0.62% (LC50=60 µg/mL) and 73.95±2.25% (LC50=80 µg/mL) respectively at 1000 µg/mL concentration of the tested sample. Gt.Chf exhibited greater cell line inhibitory activity (IC50=61 µg/mL) against HeLa cell line. Similarly, Gt.Crd displayed IC50 values of 167.84 µg/mL and 175.46 µg/mL against HeLa and NIH/3T3 cell line respectively. Based on the literature review and screenings, it may be concluded that the aerial part and seeds of G. tricorne are the rich sources of bioactive compounds. The results of the current study also authenticate the scientific background for the ethnomedicinal uses of G. tricorne.

Therapeutic targeting of angiopoietins in tumor angiogenesis and cancer development

The formation and progression of tumors in humans are linked to the abnormal development of new blood vessels known as neo-angiogenesis. Angiogenesis is a broad word that encompasses endothelial cell migration, proliferation, tube formation, and intussusception, as well as peri-EC recruitment and extracellular matrix formation. Tumor angiogenesis is regulated by angiogenic factors, out of which some of the most potent angiogenic factors such as vascular endothelial growth factor and Angiopoietins (ANGs) in the body are produced by macrophages and other immune cells within the tumor microenvironment. ANGs have a distinct function in tumor angiogenesis and behavior. ANG1, ANG 2, ANG 3, and ANG 4 are the family members of ANG out of which ANG2 has been extensively investigated owing to its unique role in modifying angiogenesis and its tight association with tumor progression, growth, and invasion/metastasis, which makes it an excellent candidate for therapeutic intervention in human malignancies. ANG modulators have demonstrated encouraging outcomes in the treatment of tumor development, either alone or in conjunction with VEGF inhibitors. Future development of more ANG modulators targeting other ANGs is needed. The implication of ANG1, ANG3, and ANG4 as probable therapeutic targets for anti-angiogenesis treatment in tumor development should be also evaluated. The article has described the role of ANG in tumor angiogenesis as well as tumor growth and the treatment strategies modulating ANGs in tumor angiogenesis as demonstrated in clinical studies. The pharmacological modulation of ANGs and ANG-regulated pathways that are responsible for tumor angiogenesis and cancer development should be evaluated for the development of future molecular therapies.

Mechanistic Implications of GSK and CREB Crosstalk in Ischemia Injury

Ischemia-reperfusion (IR) injury is a damage to an organ when the blood supply is less than the demand required for normal functioning, leading to exacerbation of cellular dysfunction and death. IR injury occurs in different organs like the kidney, liver, heart, brain, etc., and may not only involve the ischemic organ but also cause systemic damage to distant organs. Oxygen-glucose deprivation in cells causes oxidative stress, calcium overloading, inflammation, and apoptosis. CREB is an essential integrator of the body's various physiological systems, and it is widely accepted that dysfunction of CREB signaling is involved in many diseases, including ischemia-reperfusion injury. The activation of CREB can provide life to a cell and increase the cell's survival after ischemia. Hence, GSK/CREB signaling pathway can provide significant protection to cells of different organs after ischemia and emerges as a futuristic strategy for managing ischemia-reperfusion injury. Different signaling pathways such as MAPK/ERK, TLR4/MyD88, RISK, Nrf2, and NF-κB, get altered during IR injury by the modulation of GSK-3 and CREB (cyclic AMP response element (CRE)-binding protein). GSK-3 (protein kinase B) and CREB are the downstream targets for fulfilling the roles of various signaling pathways. Calcium overloading during ischemia increases the expression of calcium-calmodulin-dependent protein kinase (CaMK), which subsequently activates CREB-mediated transcription, thus promoting the survival of cells. Furthermore, this review highlights the crosstalk between GSK-3 and CREB, promoting survival and rendering the cells resistant to subsequent severe ischemia.

Pharmacological modulation of HIF-1 in the treatment of neuropsychiatric disorders

Hypoxia-inducible factor 1 has been identified as an important therapeutic target in psychiatric illnesses. Hypoxia is a condition in which tissues do not receive enough oxygen, resulting in less oxidative energy production. HIF-1, the master regulator of molecular response to hypoxia, is destabilized when oxygen levels fall. HIF-1, when activated, increases the gene transcription factors that promote adaptive response and longevity in hypoxia. HIF-regulated genes encode proteins involved in cell survival, energy metabolism, angiogenesis, erythropoiesis, and vasomotor control. Multiple genetic and environmental variables contribute to the pathophysiology of psychiatric disease. This review focuses on the most recent findings indicating the role of oxygen deprivation in CNS damage, with strong attention on HIF-mediated pathways. Several pieces of evidence suggested that, in the case of hypoxia, induction and maintenance of HIF-1 target genes may help reduce nerve damage. Major new insights into the molecular mechanisms that control HIF's sensitivity to oxygen are used to make drugs that can change the way HIF works as a therapeutic target for some CNS diseases.

Nuclear orphan receptors: A novel therapeutic agent in neuroinflammation

Orphan receptors constitute a historically varied subsection of a superfamily of nuclear receptors. Nuclear receptors regulate gene expression in response to ligand signals and are particularly alluring therapeutic targets for chronic illnesses. Neuroinflammation and neurodegenerative diseases have been linked to these orphan nuclear receptors. Preclinical and clinical evidence suggests that orphan receptors could serve as future targets in neuroinflammation, such as Parkinson's disease (PD), Alzheimer's Disease (AD), Huntington's Disease (HD), Multiple Sclerosis (MS), and Cerebral Ischemia. Given the therapeutic relevance of certain orphan receptors in a variety of disorders, their potential in neuroinflammation remains unproven. There is substantial evidence that ligand-activated transcription factors have great promise for preventing neurodegenerative and neurological disorders, with certain orphan nuclear receptors i.e., PPARγ, NR4As, and orphan GPCRs holding particularly high potential. Based on previous findings, we attempted to determine the contribution of PPAR, NR4As, and orphan GPCRs-regulated neuroinflammation to the pathogenesis of these disorders and their potential to become novel therapeutic targets.

Therapeutic implications of phosphorylation- and dephosphorylation-dependent factors of cAMP-response element-binding protein (CREB) in neurodegeneration

Neurodegeneration is a condition of the central nervous system (CNS) characterized by loss of neural structures and function. The most common neurodegenerative disorders (NDDs) include Alzheimer's disease (AD), Huntington's disease (HD), amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD), multiple sclerosis (MS), motor neuron disorders, psychological disorders, dementia with vascular dementia (VaD), Lewy body dementia (DLB), epilepsy, cerebral ischemia, mental illness, and behavioral disorders. CREB (cAMP-response element-binding protein) represent a nuclear protein that regulates gene transcriptional activity. The primary focus of the review pertains to the exploration of CREB expression and activation within the context of neurodegenerative diseases, specifically in relation to the phosphorylation and dephosphorylation events that occur within the CREB signaling pathway under normal physiological conditions. The findings mentioned have contributed to the elucidation of the regulatory mechanisms governing CREB activity. Additionally, they have provided valuable insights into the potential mediation of diverse biological processes, such as memory consolidation and neuroprotective effects, by various related studies. The promotion of synaptic plasticity and neurodevelopment in the central nervous system through the targeting of CREB proteins has the potential to contribute to the prevention or delay of the onset of neurodegenerative disorders. Multiple drugs have been found to initiate downstream signaling pathways, leading to neuroprotective advantages in both animal model studies and clinical trials. The clinical importance of the cAMP-response element-binding protein (CREB) is examined in this article, encompassing its utility as both a predictive/prognostic marker and a target for therapeutic interventions.

Correlation of Transient Elastography with Liver Iron Concentration and Serum Ferritin Levels in Patients with Transfusion-Dependent Thalassemia Major from Oman

Aims

In a longitudinal study, we aimed to assess the correlation between ultrasound transient elastography (TE), serum ferritin (SF), liver iron content (LIC) by magnetic resonance imaging (MRI) T2* along with the fibrosis-4 (FIB-4) score as a screening tool to detect significant liver fibrosis among chronically transfusion-dependent beta-thalassemia (TDT) patients.

Methods

The study was conducted at a tertiary health center treating TDT patients. Transient elastography was performed within 3 months of Liver MRI T2* examinations at the radiology department over a median of one-year duration. T-test for independent data or Mann-Whitney U test was used to analyze group differences. Spearman correlation with linear regression analysis was used to evaluate the correlation between TE liver stiffness measurements, Liver MRI T2* values, and SF levels.

Results

In this study on 91 patients, the median age (IQR) of the subjects was 33 (9) years, and the median (IQR) body mass index was 23.8 (6.1) kg/m2. Median (IQR) TE by fibroscan, MRI T2*(3T), Liver iron concentration (LIC) by MRI Liver T2*, and SF levels were 6.38 (2.6) kPa, 32.4 (18) milliseconds, 7(9) g/dry wt., and 1881 (2969) ng/mL, respectively. TE measurements correlated with LIC g/dry wt. (rS =0.39, p=0.0001) and with SF level (rS =0.43, P=0.001) but not with MRI T2* values (rS =-0.24; P=0.98).

Conclusion

In TDT patients, liver stiffness measured as TE decreased significantly with improved iron overload measured as LIC by MRI and SF levels. However, there was no correlation of TE with the fibrosis-4 (FIB-4) score.

Post-COVID-19 vaccine uveitis: A case series

OBJECTIVE

With the recent emergence and worldwide distribution of COVID-19 vaccines, many side effects may be underreported and possibly unknown. Cases of vaccine-associated uveitis have been linked to almost all vaccines administered in the past; however, there is scarcity of literature providing insight into post-COVID-19 vaccine-associated uveitis. This case series documents patients presenting with uveitis after administration of the Pfizer and Moderna mRNA vaccines, in hope of advancing our current understanding of potential ocular complications of COVID-19 vaccines.

METHODS

Patients with ocular symptoms consistent with uveitis within 14 days after administration of the Pfizer or Moderna COVID-19 vaccines were included in this case series.

RESULTS

Eight patients with a mean age of 44.4 years (range, 19-83) were included. Six patients received a Pfizer, and 2 received a Moderna vaccine. Four patients presented after their first dose, 3 after their second dose, and 1 after both doses. The mean onset of ocular symptoms after the vaccine was 5.19 days (range, 1-14), and the mean BCVA was 0.678. Patients were diagnosed with bilateral anterior granulomatous uveitis (case 1), unilateral non-granulomatous anterior uveitis (case 2, 5-8), and bilateral non-granulomatous anterior uveitis (case 3-4).

CONCLUSIONS

The pathogenesis of vaccine-induced uveitis is not properly understood; however, the outcomes of this case series will aid in establishing a temporal association between the Pfizer and Moderna COVID-19 vaccines and the onset of uveitis. As the rate of COVID-19 vaccinations increases globally, it is imperative for physicians to be aware of the possible association and presentation of these ocular findings and diagnoses in order to treat patients effectively.

Therapeutic potential of NOX inhibitors in neuropsychiatric disorders

RATIONALE

Neuropsychiatric disorders encompass a broad category of medical conditions that include both neurology as well as psychiatry such as major depressive disorder, autism spectrum disorder, bipolar disorder, schizophrenia as well as psychosis.

OBJECTIVE

NADPH-oxidase (NOX), which is the free radical generator, plays a substantial part in oxidative stress in neuropsychiatric disorders. It is thought that elevated oxidative stress as well as neuroinflammation plays a part in the emergence of neuropsychiatric disorders. Including two linked with membranes and four with subunits of cytosol, NOX is a complex of multiple subunits. NOX has been linked to a significant source of reactive oxygen species in the brain. NOX has been shown to control memory processing and neural signaling. However, excessive NOX production has been linked to cardiovascular disorders, CNS degeneration, and neurotoxicity. The increase in NOX leads to the progression of neuropsychiatric disorders.

RESULT

Our review mainly emphasized the characteristics of NOX and its various mechanisms, the modulation of NOX in various neuropsychiatric disorders, and various studies supporting the fact that NOX might be the potential therapeutic target for neuropsychiatric disorders.

CONCLUSION

Here, we summarizes various pharmacological studies involving NOX inhibitors in neuropsychiatric disorders.

Evolutionary unmasking Resuscitative therapeutics potential of centhaquin citrate in hypovolemic shock

Hypovolemic shock (HS), a clinical condition of insufficient blood perfusion and oxygenation in body tissues, is associated with immense morbidity and mortality. Treatment approaches include fluid replacement and surgical repair of reversible causes of hemorrhage; however, they cause irreversible blood perfusion loss, systemic inflammation, multiple organ failure, and death. Centhaquin citrate (CC) is an innovative centrally acting cardiovascular active agent that is initially intended as an antihypertensive drug. However, due to its positive ionotropic effect, Centhaquin citrate is being tested clinically as a resuscitative agent for the management of hypovolemic shock It acts at the α2B-adrenergic receptor to produce venous constriction followed by an increase in venous return to the heart. These actions are assumed to be capable of resuscitative activity observed by centhaquin citrate, through an increase in cardiac output and tissue perfusion. Pharmacokinetics investigations in animals and humans have shown that centhaquin citrate is well tolerated and has insignificant side effects. Therefore, centhaquin citrate seems to be a promising entity and gaining the interest of researchers to develop it as a resuscitative agent in HS. The review gives insight into the development of centhaquin citrate as a resuscitative agent and provides insight into the associated mechanism of action and molecular signalling to foster future research on CC for its clinical use in HS.

Mechanistic insights on impact of Adenosine monophosphate-activated protein kinase (AMPK) mediated signalling pathways on cerebral ischemic injury

Cerebral ischemia is the primary cause of morbidity and mortality worldwide due to the perturbations in the blood supply to the brain. The brain triggers a cascade of complex metabolic and cellular defects in response to ischemic stress. However, due to the disease heterogeneity and complexity, ischemic injury's metabolic and cellular pathologies remain elusive, and the link between various pathological mechanisms is difficult to determine. Efforts to develop effective treatments for these disorders have yielded limited efficacy, with no proper cure available to date. Recent clinical and experimental research indicates that several neuronal diseases commonly coexist with metabolic dysfunction, which may aggravate neurological symptoms. As a result, it stands to a reason that metabolic hormones could be a potential therapeutic target for major NDDs. Moreover, fasting signals also influence the circadian clock, as AMPK phosphorylates and promotes the degradation of the photo-sensing receptor (cryptochrome). Here, the interplay of AMPK signaling between metabolic regulation and neuronal death and its role for pathogenesis and therapeutics has been studied. We have also highlighted a significant signaling pathway, i.e., the adenosine monophosphate-activated protein kinase (AMPK) involved in the relationship between the metabolism and ischemia, which could be used as a target for future studies therapeutics, and review some of the clinical progress in this area.

Evidence of Antineutrinos from Distant Reactors Using Pure Water at SNO

The SNO+ Collaboration reports the first evidence of reactor antineutrinos in a Cherenkov detector. The nearest nuclear reactors are located 240 km away in Ontario, Canada. This analysis uses events with energies lower than in any previous analysis with a large water Cherenkov detector. Two analytical methods are used to distinguish reactor antineutrinos from background events in 190 days of data and yield consistent evidence for antineutrinos with a combined significance of 3.5σ.

Paediatric tibial shaft fractures: an instructional review for the FRCS exam

This instructional review presents the literature and guidelines relevant to the classification, management and prognosis of paediatric tibial shaft fractures at a level appropriate for the FRCS exit examination in Trauma and Orthopaedic surgery.

Emerging Targets for Modulation of Immune Response and Inflammation in Stroke

The inflammatory and immunological responses play a significant role after stroke. The innate immune activation stimulated by microglia during stroke results in the migration of macrophages and lymphocytes into the brain and are responsible for tissue damage. The immune response and inflammation following stroke have no defined targets, and the intricacies of the immunological and inflammatory processes are only partially understood. Innate immune cells enter the brain and meninges during the acute phase, which can cause ischemia damage. Activation of systemic immunity is caused by danger signals sent into the bloodstream by injured brain cells, which is followed by a significant immunodepression that encourages life-threatening infections. Neuropsychiatric sequelae, a major source of post-stroke morbidity, may be induced by an adaptive immune response that is initiated by antigen presentation during the chronic period and is directed against the brain. Thus, the current review discusses the role of immune response and inflammation in stroke pathogenesis, their role in the progression of injury during the stroke, and the emerging targets for the modulation of the mechanism of immune response and inflammation that may have possible therapeutic benefits against stroke.

“Achieving Optimal Clinical Outcomes in Autologous Fat Grafting: A Systematic Review of Processing Techniques”

BACKGROUND

Autologous fat grafting (AFG) is a versatile technique in reconstructive and cosmetic surgery. Graft processing is a key source of variability resulting in unreliable clinical outcomes, with no consensus on the optimal methodology. This systematic review identifies the evidence base supporting different processing paradigms.

METHODS

A systematic literature search was conducted using the PubMed, Scopus and The Cochrane Foundation databases. Studies comparing AFG processing methods and reporting long-term patient outcomes were identified.

RESULTS

Twenty-four studies (2413 patients) were identified. Processing techniques evaluated included centrifugation, decantation, washing, filtration, gauze rolling, as well as commercial devices and adipose-derived stem/stromal cell (ASC) enrichment methods. Objective volumetric and subjective patient-reported outcomes were discussed. There was a variable reporting of complications and volume retention rates. Complications were infrequent; palpable cysts (0-20%), surgical-site infections (0-8%) and fat necrosis (0-58.4%) were the most reported. No significant differences in long-term volume retention between techniques were found in AFG in the breast. In head and neck patients, greater volume retention was documented in ASC enrichment (64.8-95%) and commercial devices (41.2%) compared to centrifugation (31.8-76%).

CONCLUSIONS

Graft processing through washing and filtration, including when incorporated into commercial devices, results in superior long-term outcomes compared to centrifugation and decantation methods. ASC enrichment methods and commercial devices seem to have superior long-term volume retention in facial fat grafting.

Therapeutic and mechanistic intervention of vitamin D in neuropsychiatric disorders

Vitamin D deficiency is believed to affect between 35 and 55% of the world's population, making it a hidden pandemic. In addition to its role in bone and calcium homeostasis, vitamin D has also been linked in preclinical and clinical research to brain function. These outcomes have also been used for a variety of neuropsychiatric and neurodevelopmental problems. Nevertheless, these individuals are more prone to develop signs of cognitive decline. This review will emphasize the association between vitamin D and neuropsychiatric illnesses such as autism, schizophrenia, depression, and Attention Deficit Hyperactivity Disorder (ADHD). While numerous research show vitamin D's essential role in cognitive function in neuropsychiatric illnesses, it is too early to propose its effect on cognitive symptoms with certainty. It is necessary to conduct additional research into the associations between vitamin D deficiency and cognitive abnormalities, particularly those found in autism, schizophrenia, depression, and ADHD, to develop initiatives that address the pressing need for novel and effective preventative therapeutic strategies.

Paediatric distal radius fractures: an instructional review for the FRCS examination

An instructional review of the literature and guidelines relevant for the classification, management and prognosis of paediatric distal radius fractures. Aimed at the knowledge level required for the trauma and orthopaedic FRCS examination.

Energetic and myocellular pathways in cardiac and skeletal muscle following anthracycline chemotherapy

Background

Anthracycline-related cardiac dysfunction is a recognised consequence of cancer therapies. Here we assess resting cardiac and skeletal muscle energic status as an early mechanistic pathway of myocyte derangement and explore molecular targets of skeletal myocyte metabolism, protein synthesis/degradation and mitochondrial biogenesis signalling.

Methods

We conducted a prospective, mechanistic, observational, longitudinal study of chemotherapy-naive breast cancer patients undergoing anthracycline-based chemotherapy, compared to a healthy control group. 31P-Magnetic Resonance spectroscopy in cardiac and skeletal muscle (phosphocreatine/gamma adenosine triphosphate (PCr/yATP) and inorganic phosphate/phosphocreatine (Pi/PCr) ratios respectively), cardiac magnetic resonance (CMR) imaging inclusive of T1 and T2 mapping, echocardiography-derived global longitudinal strain function, serum NT-pro-BNP and skeletal muscle biopsies from the right vastus lateralis were assessed before and after 3 cycles of Flurouracil, Epirubicin and Cyclophosphamide followed by 3 cycles of Docetaxel. Statistical significance was set at p<0.05.

Results

Twenty-five female breast cancer patients (median age 53 years, range 32–74 years) receiving a mean epirubicin dose 307 mg/m2) and twenty-eight controls (median age 44 years, range 23–65) were recruited. All study assessments in breast cancer patients at pre-chemotherapy stage were comparable to the matched healthy controls. However, following chemotherapy, breast cancer patients demonstrated a small but significant reduction in cardiac function (global longitudinal strain −22.9±3.9 vs −19.1±3.3%, p=0.01 and CMR-derived ejection fraction 65±5 vs 62±4%, p=0.047), a mild increase in CMR-derived indexed left ventricular volumes (end diastolic 65±10 vs 74±11 ml/m2, p=0.014 and end systolic 23±5 vs 28±5 ml/m2, p=0.01) as well as an increase in left ventricular T1 and T2-mapping (1289±29 vs 1321±31 ms, p=0.004 and 50±4 vs 55±7 ms, p=0.027, respectively) and serum NT-Pro-BNP (49±25 vs 108±84 pg/m, p=0.008). After epirubicin, there was significant reduction in cardiac PCr/yATP ratio (2.0±0.7 vs 1.2±0.6, p=0.007) and a significant increase in skeletal muscle Pi/PCr ratio (0.13±0.04 vs 0.22±0.2, p=0.008) – Figure 1.

Following chemotherapy, there was significant upregulation of skeletal myocyte protein synthesis (mammalian target of rapamycin, 0.44±0.4 vs 0.53±0.2, p<0.001) and degradation (Calcium/calmodulin dependent protein kinase II, 1.4±0.7 vs 2.7±1.1, p<0.001), metabolism (peroxisome proliferator-activated receptor gamma, 0.35±0.2 vs 0.60±0.1, p<0.001) and muscle mass regulator myostatin-2 (0.16±0.1 vs 0.24±0.1, p<0.001).

Conclusion

Contemporary doses of epirubicin for breast cancer result in significant reduction of cardiac and skeletal muscle high energy 31P-metabolism alongside skeletal myocellular alterations of protein synthesis and metabolic regulation pathways.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Tenovus ScotlandNHS Grampian Endowment fund

Renin-angiotensin and endothelin systems in patients post takotsubo syndrome

Background

We investigate if renin-angiotensin and endothelin-1 response pathways follow the same pattern of recovery as left ventricular ejection fraction in patients with takotsubo syndrome.

Purpose

To provide better insight into the pathophysiology underlying this condition.

Methods

Ninety takotsubo syndrome patients [n=30 in each of “acute”, “convalescent” (3–5 months) and “recovered” (>1 year) groups] who were on minimal or no medication and were free of any significant cardiac/metabolic co-morbidities, and 30 healthy controls were studied. Serum concentrations of renin, angiotensin converting enzyme, angiotensin II, big endothelin-1, endothelin-1 were measured using commercially available ELISA, and BNP was measured using an immunoassay.

Results

Left ventricular ejection fraction was 38±1.6% in acute, 63±2.0% in convalescent and 64±2.6% in recovered takotsubo syndrome patients. As shown in Figure 1, serum renin concentrations are persistently elevated after a takotsubo episode (p=0.03 vs controls). Angiotensin converting enzyme levels are significantly depressed during the acute phase compared to convalescent (p=0.004), recovered takotsubo (p=0.02) or controls (p=0.03). Angiotensin II is increased in takotsubo patients (p<0.001 vs controls) remaining persistently elevated long-term in the recovered group (p=0.03 vs controls). B-type natriuretic peptide concentrations remain elevated after a Takotsubo episode compared to controls (p=0.003). Big endothelin-1 levels are unchanged, but endothelin-1 is significantly lower after takotsubo syndrome compared to controls (p=0.03).

Conclusions

Despite “normalisation” of the left ventricular ejection fraction, there is long-term maladaptive activation of renin-angiotensin system in takotsubo syndrome patients. This suggests therapy aimed at modulating this pathway may be beneficial in the long-term.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart Foundation

OUES from submaximal cardiopulmonary exercise

Introduction

Cardiopulmonary exercise testing (CPEX) provides valuable diagnostic and prognostic cardiopulmonary function data. However, in clinical setting a maximal test is not always achievable. The Oxygen Efficiency Uptake Slope (OUES) has been proposed as a possible submaximal measure of cardiopulmonary function as it remains relatively stable during the final quartile of the exercise test. This study explored the validity of OUES as a surrogate marker for cardiopulmonary function in the event of a submaximal test.

Methods

Four groups of subjects [128 healthy controls (73 M), 44 asymptomatic hypertensive (HT) patients (26 M), 67 adult cardiac congenital heart disease (ACHD) patients (44 M) and 35 Heart Failure with preserved Ejection Fraction (HFpEF) (10M) patients] were recruited after informed consent. All subjects underwent clinical assessment, resting ECG, blood pressure and spirometry prior to a treadmill CPEX to volitional exhaustion and a respiratory exchange ratio (RER) of at least 1.1 using the same testing protocol. Peak VO2 (ml/min) was recorded from the last 5s of the maximal test (RER=1.1) and OUES was calculated from complete (RER=1.1) and truncated (RER=0.9) gas exchange data. The linear relationships between absolute peak VO2 and OUES from complete and truncated gas exchange data were assessed using Pearson's correlation coefficient. Subsequently, the two correlations obtained in each patient group were compared. Statistical significance was set at p<0.01.

Results

Mean and 95% confidence intervals of the peak VO2 for males and females in each decile of life examined in the 4 subject groups are shown in the Figure. Peak VO2 values achieved in each of the patient groups were significantly lower when matched for age and sex compared to healthy participants (HT p=0.006, ACHD patients p<0.001 and HFpEF patients p<0.001).

In all 4 groups there was a good correlation between absolute peak VO2 and the OUES at RER 1.1 (healthy volunteers r=0.910, p<0.001, HT r=0.899, p<0.001, ACHD r=0.816, p<0.001 and HFpEF r=0.846, p<0.001). Correlations were inferior for absolute peak VO2 and OUES at RER 0.9 (healthy volunteers r=0.74, p<0.001, HT r=0.780, p<0.001, ACHD r=0.651, p<0.001 and HFpEF r=0.817, p<0.001). Correlations between absolute peak VO2 vs OUES at RER of 1.1 and 0.9 were significantly different only for healthy controls (p=0.001, Z-score = −4.649), but not for HT (p=0.05, Z-score = −1.909), ACHD (p=0.04, Z-score = −2.080) or HFpEF (p=0.7, Z-score = −0.377) patients.

Conclusion

Our data support the use of submaximal OUES at an RER of 0.9 as a surrogate marker for absolute peak VO2 obtained at an RER of 1.1, especially in patients, in whom it can often be difficult to achieve maximal exercise.

Funding Acknowledgement

Type of funding sources: None.

Assessment of skeletal relationships in cleft palate with or without cleft lip: A cone-beam computed tomography study in a pakistani population

BACKGROUND

Understanding the different skeletal relationships in orofacial clefts by using cone-beam computed tomography (CBCT) may eventually lead to developing better diagnosis and treatment protocols for facial deformities.

AIMS

The objective of this study was to investigate the different skeletal relationships in the cleft palate with or without cleft lip (CP ± L), using CBCT scans. This is a retrospective study conducted at the Orthodontics and Oral Radiology department, CMH-Lahore medical college and Institute of dentistry. In the current study, 4,152 CBCT scans (dcm format) were collected from a radiology center in Lahore, Pakistan between February 2015 and February 2018. All CBCT scans were imported to the Romexis Viewer, version 4.4.0 (Planmeca, Finland). Data sorting was performed to identify age, sex, cleft phenotype, unilateral cleft quadrant, sagittal skeletal relationship, and facial soft tissue involvement.

MATERIALS AND METHODS

Statistics were generated, using the Chi-square test. A P value <0.05 was considered statistically significant.

RESULTS

We identified 73 cases of CP ± L in the sample. The male-to-female ratio was 1.21:1. Bilateral cleft lip and palate (BCLP) mostly affected males (60%), whereas unilateral cleft lip and palate (UCLP) mainly affected females (57.6%), with a left-side female predominance. The different cleft phenotypes do not show any statistically significant difference regarding skeletal relationships and sex (P > 0.05).

CONCLUSIONS

Skeletal class III relationships were found to be predominant in both sexes, followed by class II, and class I skeletal relationships. Henceforth, such CP ± L patients should be pre-emptively screened in early life to avoid such skeletal complications.

Adenosine as a Key Mediator of Neuronal Survival in Cerebral Ischemic Injury

Several experimental studies have linked adenosine's neuroprotective role in cerebral ischemia. During ischemia, adenosine is formed due to intracellular ATP breakdown into ADP, further when phosphate is released from ADP, the adenosine monophosphate is formed. It acts via A1, A2, and A3 receptors found on neurons, blood vessels, glial cells, platelets, and leukocytes. It is related to various effector systems such as adenyl cyclase and membrane ion channels via G-proteins. Pharmacological manipulation of adenosine receptors by agonists (CCPA, ADAC, IB-MECA) increases ischemic brain damage in various in vivo and in vitro models of cerebral ischemia whereas, agonist can also be neuroprotective. Mainly, receptor antagonists (CGS15943, MRS1706) indicated neuroprotection. Later, various studies also revealed that the downregulation or upregulation of specific adenosine receptors is necessary during the recovery of cerebral ischemia by activating several downstream signaling pathways. In the current review, we elaborate on the dual roles of adenosine and its receptor subtypes A1, A2, and A3 and their involvement in the pathobiology of cerebral ischemic injury. Adenosine-based therapies have the potential to improve the outcomes of cerebral injury patients, thereby providing them with a more optimistic future.

No significant increase in Guillain-Barré syndrome after COVID-19 vaccination in adults: A vaccine adverse event reporting system study

Objective

To investigate the association between Guillain-Barré syndrome (GBS) and COVID-19 vaccination.

Background

On July 13, 2021, the US Food and Drug Administration (FDA) released a new warning that Johnson & Johnson COVID-19 vaccine could increase the risk of developing GBS.

Methods

The reporting rate of adult GBS after COVID-19 vaccination, ascertained with Brighton criteria, was compared with the reporting rate after other vaccinations during the same time period, and also compared with the reporting rate during control periods. Statistical methods such as proportion tests, and Pearson’s chi-squared test were utilized to identify significant relationships. Self-controlled and case centered analyses were conducted. A machine learning model was utilized to identify the factors associated with a worse outcome defined as emergency room (ER) or doctor visits, hospitalizations, and deaths.

Results

The reporting rate of GBS after COVID-19 vaccination was significantly higher than after influenza and other vaccinations (49.7, 0.19, 0.16 per 10 million, p < 0.0001). However, the reporting rate was within the incidence range of GBS in the general population. Using self-controlled and case centered analyses, there was a significant difference in the reporting rate of GBS after COVID-19 vaccination between the risk period and control period (p < 0.0001). There was an estimated 0.7–1.7 per million excess reports of GBS within 6 weeks of COVID-19 vaccination. Machine learning model demonstrated that female gender and age between 18 and 44 are associated with worse outcome. No association was found between the onset interval of GBS and its prognosis.

Conclusions

Although the reporting rate of GBS after COVID-19 vaccination was not statistically different than that of the general population, the increased reporting of GBS within the first 6 weeks after COVID-19 vaccination, more so than with other vaccinations, suggests that some cases of GBS are temporally associated with COVID-19 vaccination. However, there is a reduction in the reporting rate of GBS after other vaccines, compared to reporting rates pre-COVID-19, highlighting limitations inherent in any passive surveillance system. These findings warrant continuous analysis of GBS after COVID-19 vaccination. Further improvement of the machine learning model is needed for clinical use.

9 Complications of Bone-Anchored Hearing Aids (BAHA) in Patients

Aim

BAHA implants utilise bone conduction to treat hearing loss. The aim of the study was to understand the complication rate of patients receiving the implant compared to other studies and to identify any causative factor. Recommendations would therefore be made to reduce these complications.

Methodology

A retrospective cohort study was undertaken on 134 patients who received a BAHA implant performed by a single surgeon at Salford Royal NHS Foundation Trust between 01/01/2016 to 31/12/2018. Data collected identified complications of the surgery, whether or not the abutment was still in situ and whether the patient had any comorbidities or history of smoking

Results

33.6% of the patients had no complications after surgery with the remaining 66.4% having at least one complication. BAHA connect devices had a 67.2% complication rate, attract devices had a 33% complication rate. 13.6% of BAHAs were extruded. There was no positive correlation between either smoking or diabetes and poorer complication rate.

Conclusion

Implant extrusion can be prevented with irrigation cooling of the drill site. Immobilisation of the implant, proper wound care with brushing and using an Allevyn Acticoat 7 wound dressing improves outcomes. Attract systems have fewer complications rates so must be maximised where appropriate.

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.

POS0198 COVID-19 OUTCOMES IN PATIENTS WITH DERMATOMYOSITIS: A REGISTRY-BASED COHORT ANALYSIS

Background

Dermatomyositis (DM) patients have fewer risks of COVID-19 infection compared to the general population, however, certain subgroups with DM have worse outcomes. Men. African Americans, those with interstitial lung disease, exhibited higher risks of severe COVID-19. DMARD and glucocorticoid use was associated with frequent hospitalisations and severe sepsis.

Objectives

Rheumatic diseases (RDs) like DM, are previously known to be vulnerable towards various types of infections due to its aggressive activity mandating high dose immunosuppressive therapy. The severity of COVID-19 in RDs is limited in literature due to the heterogeneous nature of the condition. Therefore, specific details on mortality is essential to navigate any precautions required in the treatment.

Methods

Retrospective data of individuals with DM and COVID-19 and the general population with COVID-19 between January 2020 to August 2020 was retrieved from the TriNetX database. A one-to-one matched COVID-19 positive control was selected using propensity score (PS) matching. We assessed COVID-19 outcomes such as mortality, hospitalisation, ICU admission, severe COVID-19, mechanical ventilation (MV), acute kidney injury (AKI), venous thromboembolism (VTE), ischemic stroke, acute respiratory distress syndrome (ARDS), renal replacement therapy (RRT) and sepsis. Subgroup analyses included gender, race, ILD, cancer patients, disease-modifying rheumatic drugs (DMARDs) use, and glucocorticoids (GC) use (Figure 1).

Figure 1.

Overview of study

Results

We identified 5,574 DM patients with COVID-19, and 5,574 general population with COVID-19 (controls). DM with COVID-19 had a lower risk of mortality in comparison to controls [RR 0.76], hospitalisation [RR 0.8], severe COVID-19 [RR 0.76], AKI [RR 0.83], and sepsis [RR 0.73]. Males and African Americans were more likely to develop AKI [RR 1.35, 1.65], while African Americans had higher odds for severe COVID-19 [RR 1.62] and VTE [RR 1.54]. DM with ILD group also experienced higher odds for severe COVID-19 infection [RR 1.64], and VTE [RR 2.06] (Figure 1).

DM patients receiving DMARDs and glucocorticoids had higher odds for hospitalisation [RR 1.46, 2.12], and sepsis [RR 3.25] Subgroup analysis of neoplasms amongst DM patients with COVID-19 was inadequate for meaningful comparison (Figure 1).

Conclusion

DM patients are protected for certain aspects of COVID-19 disease, including severe COVID-19, hospitalization, and mortality. The African American race, male gender, ILD, DMARDS and glucocorticoid users, are associated with poor outcomes.

Disclosure of Interests

Latika Gupta: None declared, Haig Pakhchanian: None declared, Hiba Khan: None declared, Rahul Raiker: None declared, Maryam Abbasi: None declared, Charles DeYoung: None declared, Sinan Kardes Grant/research support from: SK has received congress travel, accommodation, and participation fee support (12th Anatolian Rheumatology Days) from Abbvie, Sakir Ahmed Speakers bureau: SA has received honorarium as speaker for Pfizer, Chengappa Kavadichanda: None declared, Parikshit Sen: None declared, Rohit Aggarwal Consultant of: RA has/had a consultancy relationship with and/or has received research funding from the following companies-Bristol Myers-Squibb, Pfizer, Genentech, Octapharma, CSL Behring, Mallinckrodt, AstraZeneca, Corbus, Kezar, and Abbvie, Janssen, Alexion, Argenx, Q32, EMD-Serono, Boehringer Ingelheim, Roivant., Grant/research support from: RA has/had a consultancy relationship with and/or has received research funding from the following companies-Bristol Myers-Squibb, Pfizer, Genentech, Octapharma, CSL Behring, Mallinckrodt, AstraZeneca, Corbus, Kezar, and Abbvie, Janssen, Alexion, Argenx, Q32, EMD-Serono, Boehringer Ingelheim, Roivant.

POS1421 AROMATASE INHIBITORS AND SKELETAL HEALTH – NATURAL HISTORY AND INTERVENTIONAL EPIDEMIOLOGY

Background

Breast cancer remains the most common cancer diagnosed in women worldwide. Aromatase inhibitors (AI) are employed for hormone sensitive disease in mainly postmenopausal women. AI related bone loss (AIBL) is a known complication; although data regarding the natural history in the real-world, long-term outcomes and the role of bone active therapy in fracture prevention is sparse.

Objectives

Our aim was to determine the real-world impact of AIBL and whether bone sparing therapy utilising standard risk stratification model is sufficient for fracture prevention.

Methods

We undertook a longitudinal study of patients prescribed AI for breast cancer over a seven-year period at our university teaching hospital. All the data was recorded electronically with full access to demographics, disease parameters, investigations and drug management. DEXA scans performed prior to initiation of AI were compared with subsequent imaging over a mean follow up of 3 years. Outcome data for cancer and all fractures was collected. Statistical analysis was done to investigate significant relationships amongst the variables of interest.

Results

1001 women were identified during the study period. The mean age of the cohort was 64 years (range 29-93). 929 (93%) were Caucasian, 57 (6%) were Asian and 15 (1%) were Afro-Caribbean. 723 women (72%) were diagnosed with invasive ductal carcinoma and 863 women (86%) were postmenopausal. At diagnosis, 428 women (43%) had node positive disease and 35 women (4%) had metastases. 91 women (9%) had sustained fractures prior to their breast cancer diagnosis.

All women had a baseline DEXA: 496 (49.6%) had osteopenia, 151 (15%) had osteoporosis and 354 (35.4%) had a normal result. 478 (48%) of women had a repeat scan available. Overall, there was a decline (from a mean of 0.888 g/cm2 to 0.858 g/cm2, p<0.0001) in left neck of femur (LNOF) bone mineral density (BMD) over time (mean of 3 years, with a range of 1-6).

334 (33%) were prescribed bone active therapy with 276 women (83%) given oral bisphosphonates. This group had an improvement in BMD by 0.4% (LNOF mean BMD of 0.785 g/cm2 at baseline compared to LNOF mean BMD of 0.788 at repeat DEXA, p=0.82).

Women who were not offered any treatment (n=667, 66%), showed a significant decline in bone density with the decline being -5%. (LNOF mean BMD of 0.939 g/cm2 at baseline compared to LNOF mean BMD of 0.888 g/cm2 at repeat DEXA, p< 0.0001).

The rate of fractures remained the same between the treatment (19 fractures, 5.67%) and non-treatment group (38 fractures, 5.70%)

Conclusion

Our study provides long term data for AIBL and confirms a significant decline in BMD over seven years. It confirms that bone sparing therapy is effective in reducing the pace of decline in BMD. However standard risk stratification model such as FRAX based intervention thresholds in mainly those with WHO defined osteoporosis (T ≤-2.5) is ineffective in fracture prevention in keeping with prior literature. Since our study period overlaps with publication of newer guidelines recommending different T score-based risk model, further studies are required to confirm their utility.

References

[1]https://www.wcrf.org/dietandcancer/worldwide-cancer-data/. Date accessed: 26.01.2022

[2]R. Coleman, J.J. Body, M. Aapro, et al., Bone health in cancer patients: ESMO clinical practice guidelines, Ann. Oncol. 25 (Suppl 3) (2014) iii124–iii137.

[3]E. Amir, B. Seruga, S. Niraula, et al., Toxicity of adjuvant endocrine therapy in postmenopausal breast cancer patients: a systematic review and meta-analysis, J. Natl. Cancer Inst. 103 (2011) 1299–1309.

Disclosure of Interests

None declared

OP0244 AROMATASE INHIBITORS AND FRACTURE PREVENTION – DO NEW GUIDELINES WORK IN REAL WORLD?

Background

2,261,419 women were diagnosed with breast cancer worldwide in 2020. For postmenopausal women with hormone sensitive disease, aromatase inhibitors (AI) are recommended for their mortality benefit. However, AI bone loss (AIBL) is a recognised adverse event with resultant increase in fracture risk. In 2017, a consensus statement of 7 international bone and cancer societies was published proposing an algorithm based on clinical risk factors and different bone mineral density (BMD) threshold for bone active therapeutic intervention.

Objectives

To determine the real-world impact of the 2017 consensus guidelines on AIBL and whether bone sparing therapy utilising proposed risk stratification model is effective in fracture prevention.

Methods

Over a 7-year study period, 1001 women were prescribed AI at our university teaching hospital. The new guidelines were adopted in July 2017. We split the participants in two groups: 361 (36%) women had commenced their AI prior to the adoption of guidelines and 640 (64%) were in the post implementation group.

First group were offered bone active treatment based on NOS 2009 guidelines whereas the second group followed the 2017 consensus guidelines. Women with osteoporosis were all offered treatment, however the difference in guideline is pertinent to osteopenia and we compared the results of that group.

Results

1001 women were included. Mean age was 64 years (range 29-93). 929 (93%) were Caucasian, 57 (6%) were Asian and 15 (1%) were Afro-Caribbean. 723 women (72%) had invasive ductal carcinoma and 863 women (86%) were postmenopausal. At diagnosis, 428 women (43%) had node positive disease and 35 women (4%) had metastases. 91 women (9%) had sustained fractures prior to their cancer diagnosis.

276 women (28%) were offered oral bisphosphonates based on DEXA result, with 58 (6%) offered parenteral therapy.

First group: 361 women had a baseline DEXA with a mean left neck of femur (LNOF) BMD of 0.888 g/cm2 (range 0.552-1.222). 143 (40%) women had a normal DEXA, 174 (48%) had osteopenia and 44 (12%) had osteoporosis.

Of the women with osteopenia, 44 (25%) women were offered treatment and 33 women had a repeat DEXA after a mean of 4 years. In the treatment group, LNOF mean BMD remained relatively unchanged from 0.814 g/cm2 to 0.812 g/cm2 at the repeat DEXA (p= 0.94).

Of the 174 women with osteopenia, 22 (13%) women had a fracture.

Second group: 640 women had a baseline DEXA with a mean LNOF BMD of 0.888 g/cm2 (range 0.512-1.390). 216 (33%) women were normal, 322(50%) had osteopenia and 107 (17%) had osteoporosis.

Of the women with osteopenia, 127 (39%) women were offered treatment and 56 women had a repeat DEXA after a mean of 3 years. In the treatment group, LNOF mean BMD remained relatively unchanged from 0.822 g/cm2 to 0.829 g/cm2 at the repeat DEXA (p= 0.6169).

Of the 322 women with osteopenia, 8 (2.5%) women had a fracture.

Conclusion

Our study provides real world evidence of the success of 2017 consensus statement in lowering fracture risk. Though there has been data for positive impact on BMD decline with this approach, evidence for fracture prevention has been limited. This study showcases the success of lowering bone active therapy threshold employing alternative risk modelling strategy for women with breast cancer commenced on AI. A significant reduction in fractures pre (13%) and post guidelines change (2.5%) was demonstrated (absolute risk reduction of 10.5%) which has implications for healthcare systems worldwide as we have demonstrated this approach can reduce morbidity.

References

[1]https://www.wcrf.org/dietandcancer/worldwide-cancer-data/. Accessed: 26.01.2022.

[2]Reid DM, Doughty J, Eastell R, et al. Guidance for the management of breast cancer treatment-induced bone loss: a consensus position statement from a UK Expert Group. Cancer Treat Rev. 2008;34 Suppl 1:S3-S18.

[3]Hadji P, Aapro MS, Body JJ, et al. Management of Aromatase Inhibitor-Associated Bone Loss (AIBL) in postmenopausal women with hormone sensitive breast cancer: Joint position statement of the IOF, CABS, ECTS, IEG, ESCEO IMS, and SIOG. J Bone Oncol. 2017;7:1-12.

Disclosure of Interests

None declared

Mathematical calculation of COVID-19 disease in Pakistan by emergency response modeling based on complex Pythagorean fuzzy information

The new emerged infectious disease that is known the coronavirus disease (COVID-19), which is a high contagious viral infection that started in December 2019 in China city Wuhan and spread very fast to the rest of the world. This infection caused millions of infected cases globally and still poses an alarming situation for human lives. Pakistan in Asian countries is considered the third country with higher number of cases of coronavirus with more than 649824. Recently, some mathematical models have been constructed for better understanding the coronavirus infection. Mostly, these models are based on classical integer-order derivative using real numbers which cannot capture the fading memory. So at the current position it is a challenge for the world to understand and control the spreading of COVID-19. Therefore, the aim of our paper is to develop some novel techniques, namely complex Pythagorean fuzzy weighted averaging (abbreviated as CPFWA) operator, complex Pythagorean fuzzy ordered weighted averaging (abbreviated as CPFOWA) operator, complex Pythagorean fuzzy hybrid averaging (abbreviated as CPFHA) operator, induced complex Pythagorean fuzzy ordered weighted averaging (abbreviated as I-CPFOWA) operator and induced complex Pythagorean fuzzy hybrid averaging (abbreviated as I-CPFHA) operator to analysis the spreading of COVID-19. At the end of the paper, an illustrative the emergency situation of COVID-19 is given for demonstrating the effectiveness of the suggested approach along with a sensitivity analysis, showing the feasibility and reliability of its results.

α-Lipoic Acid, an Organosulfur Biomolecule a Novel Therapeutic Agent for Neurodegenerative Disorders: An Mechanistic Perspective

Lipoic acid (α-LA) (1,2-dithiolane3-pentanoic acid (C₈H₁₄O₂S₂) is also called thioctic acid with an oxidized (disulfide, LA) and a reduced (di-thiol: dihydro-lipoic acid, DHLA) form of LA. α-LA is a potent anti-oxidative agent that has a significant potential to treat neurodegenerative disorders. α-LA is both hydrophilic and hydrophobic in nature. It is widely distributed in plants and animals in cellular membranes and in the cytosol, which is responsible for LA's action in both the cytosol and plasma membrane. A systematic literature review of Bentham, Scopus, PubMed, Medline, and EMBASE (Elsevier) databases was carried out to understand the Nature and mechanistic interventions of the α-Lipoic acid for central nervous system diseases. Moreover, α-LA readily crosses the blood-brain barrier, which is a significant factor for CNS activities. The mechanisms of α-LA reduction are highly tissue-specific. α-LA produces its neuroprotective effect by inhibiting reactive oxygen species formation and neuronal damage, modulating protein levels, and promoting neurotransmitters and anti-oxidant levels. Hence, the execution of α-LA as a therapeutic ingredient in the therapy of neurodegenerative disorders is promising. Finally, based on evidence, it can be concluded that α-LA can prevent diseases related to the nervous system.

Vitamin D as therapeutic modulator in cerebrovascular diseases: a mechanistic perspectives

Vitamin D deficiency has been linked to several major chronic diseases, such as cardiovascular and neurodegenerative diseases, diabetes, and cancer, linked to oxidative stress, inflammation, and aging. Vitamin D deficiency appears to be particularly harmful to the cardiovascular system, as it can cause endothelial dysfunctioning and vascular abnormalities through the modulation of various downstream mechanisms. As a result, new research indicates that therapeutic approaches targeting vitamin D inadequacies or its significant downstream effects, such as impaired autophagy, abnormal pro-inflammatory and pro-oxidant reactions, may delay the onset and severity of major cerebrovascular disorders such as stroke and neurologic malformations. Vitamin D modulates the various molecular pathways, i.e., Nitric Oxide, PI3K-Akt Pathway, cAMP pathway, NF-kB Pathway, Sirtuin 1, Nrf2, FOXO, in cerebrovascular disorder. The current review shows evidence for vitamin D's mitigating or slowing the progression of these cerebrovascular disorders, which are significant causes of disability and death worldwide.

Therapeutic implications of cyclooxygenase (COX) inhibitors in ischemic injury

INTRODUCTION

Ischemia-reperfusion injury (IRI) is the inexplicable aggravation of cellular dysfunction that results in blood flow restoration to previously ischemic tissues. COX mediates the oxidative conversion of AA to various prostaglandins and thromboxanes, which are involved in various physiological and pathological processes. In the pathophysiology of I/R injuries, COX has been found to play an important role. I/R injuries affect most vital organs and are characterized by inflammation, oxidative stress, cell death, and apoptosis, leading to morbidity and mortality.

MATERIALS AND METHODS

A systematic literature review of Bentham, Scopus, PubMed, Medline, and EMBASE (Elsevier) databases was carried out to understand the Nature and mechanistic interventions of the Cyclooxygenase modulations in ischemic injury. Here, we have discussed the COX Physiology and downstream signalling pathways modulated by COX, e.g., Camp Pathway, Peroxisome Proliferator-Activated Receptor Activity, NF-kB Signalling, PI3K/Akt Signalling in ischemic injury.

CONCLUSION

This review will discuss the various COX types, specifically COX-1 and COX-2, which are involved in developing I/R injury in organs such as the brain, spinal cord, heart, kidney, liver, and intestine.

Mechanistic Insight on Autophagy Modulated Molecular Pathways in Cerebral Ischemic Injury: From Preclinical to Clinical Perspective

Cerebral ischemia is one of the most devastating brain injuries and a primary cause of acquired and persistent disability worldwide. Despite ongoing therapeutic interventions at both the experimental and clinical levels, options for stroke-related brain injury are still limited. Several evidence suggests that autophagy is triggered in response to cerebral ischemia, therefore targeting autophagy-related signaling pathways can provide a new direction for the therapeutic implications in the ischemic injury. Autophagy is a highly conserved lysosomal-dependent pathway that degrades and recycles damaged or non-essential cellular components to maintain neuronal homeostasis. But, whether autophagy activation promotes cell survival against ischemic injury or, on the contrary, causes neuronal death is still under debate. We performed an extensive literature search from PubMed, Bentham and Elsevier for various aspects related to molecular mechanisms and pathobiology involved in autophagy and several pre-clinical studies justifiable further in the clinical trials. Autophagy modulates various downstream molecular cascades, i.e., mTOR, NF-κB, HIF-1, PPAR-γ, MAPK, UPR, and ROS pathways in cerebral ischemic injury. In this review, the various approaches and their implementation in the translational research in ischemic injury into practices has been covered. It will assist researchers in finding a way to cross the unbridgeable chasm between the pre-clinical and clinical studies.

Intriguing interfacial characteristics of the CS contact with MX2 (M = Mo, W; X = S, Se, Te) and MXY ((X ≠ Y) = S, Se, Te) monolayers

Using (hybrid) first principles calculations, the electronic band structure, type of Schottky contact and Schottky barrier height established at the interface of the most stable stacking patterns of the CS–MX₂ (M = Mo, W; X = S, Se, Te) and CS–MXY ((X ≠ Y) = S, Se, Te) MS vdWH are investigated. The electronic band structures of CS–MX₂ and CS–MXY MS vdWH seem to be simple sum of CS, MX₂ and MXY monolayers. The projected electronic properties of the CS, MX₂ and MXY layers are well preserved in CS–MX₂ and CS–MXY MS vdWH. Their smaller effective mass (higher carrier mobility) render promising prospects of CS–WS₂ and CS–MoSeTe as compared to other MS vdWH in nanoelectronic and optoelectronic devices, such as a high efficiency solar cell. In addition, we found that the effective mass of holes is higher than that of electrons, suggesting that these heterostructures can be utilized for hole/electron separation. Interestingly, the MS contact led to the formation of a Schottky contact or ohmic contact, therefore we have used the Schottky Mott rule to calculate the Schottky barrier height (SBH) of CS–MX₂ (M = Mo, W; X = S, Se, Te) and CS–MXY ((X ≠ Y) = S, Se, Te) MS vdWH. It was found that CS–MX₂ (M = Mo, W; X = S, Se, Te) and CS–MXY ((X ≠ Y) = S, Se, Te) (in both model-I and -II) MS vdWH form p-type Schottky contacts. These p-type Schottky contacts can be considered a promising building block for high-performance photoresponsive optoelectronic devices, p-type electronics, CS-based contacts, and for high-performance electronic devices.

Electronic band structure, type of Schottky contact and Schottky barrier height established at the interface of the CS–MX₂ (M = Mo, W; X = S, Se, Te) and CS–MXY ((X ≠ Y) = S, Se, Te) MS vdWH.

Neuropeptides: Potential neuroprotective agents in ischemic injury

AIM

Ischemic damage to the brain is linked to an increased rate of morbidity and mortality worldwide. In certain parts of the world, it remains a leading cause of mortality and the primary cause of long-term impairment. Ischemic injury is exacerbated when particular neuropeptides are removed, or their function in the brain is blocked, whereas supplying such neuropeptides lowers ischemic harm. Here, we have discussed the role of neuropeptides in ischemic injury.

MATERIALS & METHODS

Numerous neuropeptides had their overexpression following cerebral ischemia. Neuropeptides such as NPY, CGRP, CART, SP, BK, PACAP, oxytocin, nociception, neurotensin and opioid peptides act as transmitters, documented in several "in vivo" and "in vitro" studies. Neuropeptides provide neuroprotection by activating the survival pathways or inhibiting the death pathways, i.e., MAPK, BDNF, Nitric Oxide, PI3k/Akt and NF-κB.

KEY FINDINGS

Neuropeptides have numerous beneficial effects in ischemic models, including antiapoptotic, anti-inflammatory, and antioxidant actions that provide a powerful protective impact in neurons when combined. These innovative therapeutic substances have the potential to treat ischemia injury due to their pleiotropic modes of action.

SIGNIFICANCE

This review emphasizes the neuroprotective role of neuropeptides in ischemic injury via modulation of various signalling pathways i.e., MAPK, BDNF, Nitric Oxide, PI3k/Akt and NF-κB.

Duodenal volvulus: a rare cause of small bowel obstruction

Small bowel volvulus is a rare but life-threatening emergency. Volvulus of the duodenum is even rarer without the presence of predisposing factors. The clinical presentation is vague, including abdominal pain, nausea and vomiting, prompt diagnosis of volvulus therefore relies heavily on radiographs. The treatment options lie between conservative or surgical management, where the decision is influenced by the patient and their presentation. This case is of a 100-year-old female with an extensive surgical and medical background presenting with signs of small bowel obstruction. With the help of imaging, a rare case of duodenal volvulus was diagnosed but managed conservatively due to the patient's background, age and personal wishes.

Pharmacological Modulation of Ubiquitin-Proteasome Pathways in Oncogenic Signaling

The ubiquitin-proteasome pathway (UPP) is involved in regulating several biological functions, including cell cycle control, apoptosis, DNA damage response, and apoptosis. It is widely known for its role in degrading abnormal protein substrates and maintaining physiological body functions via ubiquitinating enzymes (E1, E2, E3) and the proteasome. Therefore, aberrant expression in these enzymes results in an altered biological process, including transduction signaling for cell death and survival, resulting in cancer. In this review, an overview of profuse enzymes involved as a pro-oncogenic or progressive growth factor in tumors with their downstream signaling pathways has been discussed. A systematic literature review of PubMed, Medline, Bentham, Scopus, and EMBASE (Elsevier) databases was carried out to understand the nature of the extensive work done on modulation of ubiquitin-proteasome pathways in oncogenic signaling. Various in vitro, in vivo studies demonstrating the involvement of ubiquitin-proteasome systems in varied types of cancers and the downstream signaling pathways involved are also discussed in the current review. Several inhibitors of E1, E2, E3, deubiquitinase enzymes and proteasome have been applied for treating cancer. Some of these drugs have exhibited successful outcomes in in vivo studies on different cancer types, so clinical trials are going on for these inhibitors. This review mainly focuses on certain ubiquitin-proteasome enzymes involved in developing cancers and certain enzymes that can be targeted to treat cancer.

Synthesis, characterization and urease inhibitory activities of Zn(II) complexes bearing C1-symmetric ligands derived from (R)-phenylethanamine

ABSTRACT. A series of Zn(II) complexes, supported with N-substituted phenylethanamine derivatives, [LnZnCl2] (where Ln = LA ((R)-1-phenyl-N-(thiophene-2-ylmethyl)ethanamine; LB (R)-N-(5-meyhylthiophene-2-yl)methyl-1-phenylethanamine; LC ((R)-N-(furan-2-ylmeththyl)-1-phenylethanamine and LD (R)-N-((5-methylfuran-2-yl)methyl)-1-phenylethanamine) were synthesized and characterized. The urease inhibitory activities of these complexes were determined against selected urease inhibitors where [LBZnCl2] was found to be the most prominent inhibitor of Jack bean urease (J. B. urease) (IC50 = 10.39±0.78 μM), whereas the activity of Bacillus pasteurii urease (B. P. urease) was predominantly inhibited by [LAZnCl2] (IC50 = 8.68±0.7 μM). Additionally, MOE-Dock program was used to affirm the probable binding modes of these complexes into the crystal structure of J. B. urease which certainly verified the inhibitory mechanism of these novel complexes.                     KEY WORDS: Zn(II) complexes, (R)-Phenylethanamine, Urease inhibition, Molecular docking   Bull. Chem. Soc. Ethiop. 2021, 35(2), 301-314. DOI: https://dx.doi.org/10.4314/bcse.v35i2.7

Synthesis, characterization, POM analyses and biological evaluation of n-[(2-methoxy-5- nitrophenyl)]-4-oxo-4-[oxy] butenamide based zinc(II) carboxylate complexes

ABSTRACT. The aim of medicinal chemistry is to links many scientific disciplines and allows the scientists in researching and developing new drugs with enhance and targeted properties. In this article we are exploring the preparation of four new zinc(II) carboxylate complexes based on N-[(2-methoxy-5-nitrophenyl)]-4-oxo-4-[oxy]butenamide which were characterized through FT-IR and EDX studies. The DNA binding ability and binding type of complexes were assessed by spectroscopic (UV-Visible) and viscosity measurements, exhibiting an intercalative pattern of interaction. The synthesized compounds were also assessed to know theoretically about their nature by molecular docking studies resulting also in intercalation mode. Analysis of the complexes for biological applications such as anti-microbial, anti-leishmanial, cytotoxicity and DNA damage activities showed that these complexes carries good anti-microbial, anti-leishmanial activity with no toxicity to human blood thyrocytes and DNA. The bioavailability prediction and drug likeness score has also been evaluated through Insilco studies.                     KEY WORDS: Zn(II) carboxylate complex, DNA binding, Anti-leishmanial activity, Cytotoxicity, Docking study   Bull. Chem. Soc. Ethiop. 2021, 35(2), 365-380. DOI: https://dx.doi.org/10.4314/bcse.v35i2.11

57 A Closed Loop Audit of Post-Operative Driving Advice Documentation

Aim

The Driving and Vehicle Licensing Agency state post-operatively it is between the patient and doctor to establish when would be safe to resume driving, providing recovery does not exceed three months. This audit aimed to assess and improve the documentation rate of driving advice in the discharge summaries given to patients post abdominal surgery.

Method

Retrospective data collection from electronic records over the months of August and September 2020. 132 discharge summaries were screened to assess the baseline rate of verbal/documented driving advice given on discharge. Following the 1st cycle, posters encouraging the inclusion of driving advice and demonstrating how to access driving advice to discharge summaries were developed and distributed across the surgical wards. A 2nd cycle re-audit was conducted in October 2020 to measure the effect of change, and a further 3rd cycle audit was conducted in November 2020.

Results

1st cycle included 132 patients. 62% had documented advice on their discharge summaries, while 38% had no proof of driving advice. After intervention, 2nd cycle included 30 patients. Results showed a significant increase in advice documentation (80%). A 3rd cycle was carried out with 47 patients. This showed a reduction in advice documentation (66%).

Conclusions

Driving advice on discharge in post-operative patients is crucial part of patient safety. Implementation of intervention has increased the documentation of driving advice showing enhancing patient safety. However, 3rd cycle after registrar’s changeover showed a decrease in the rate of documentation. A teaching session is planned for new doctors followed by 4th cycle.