Clinicopathological Profile and Survival Outcomes in Patients with Localised Extremity Synovial Sarcomas

AIMS

Synovial sarcoma is a rare but aggressive variant of soft-tissue sarcoma. Literature is sparse and reported mostly from the West. We analysed the clinical profiles and prognostic factors of extremity synovial sarcoma patients in order to study their clinical journey.

MATERIALS AND METHODS

This was a retrospective analysis. All patients with extremity synovial sarcoma treated between 1992 and 2020 were included. Patients with metastases at presentation were excluded. A descriptive analysis of demographic and clinicopathological features of patients undergoing limb salvage surgery (LSS) or amputation was carried out. Overall survival and disease-free survival were calculated for the entire cohort as well as for the LSS and amputation groups. Factors prognostic for survival were identified.

RESULTS

In total, 157 patients had localised extremity synovial sarcoma. Predominantly, young adults (median 31 years) and males (61%) were affected. Over 70% of patients presented after recurrence or unplanned surgeries. Sixty-seven per cent of tumours were >5 cm, 69% were deep and 23% involved bone. The limb salvage rate was 64%. In the LSS group, adjuvant radiotherapy and chemotherapy were given to 72% and 68% of patients, respectively. In the amputation group, 72% of patients received adjuvant chemotherapy. In a median follow-up of 59 months, 39.4% of patients had recurrences, the majority (61.2%) were systemic. Five-year overall survival and disease-free survival were 53.4% and 49.8%, respectively. Overall survival was 63.9% and 29.7% in the LSS and amputation groups, respectively. On multivariate analysis, tumour size, depth, omission of radiotherapy and bone invasion were found to be the adverse prognostic factors.

CONCLUSION

This is one of the largest studies on extremity synovial sarcoma. Mostly males and young adults were affected. The limb salvage rate was 64%, despite most being referred after unplanned surgery. Almost 70% of patients received radiotherapy and chemotherapy. Overall survival was inferior in the amputation group. Tumour size >5 cm, depth and bone invasion were negative, whereas adjuvant radiotherapy was a positive prognostic factor for survival. Chemotherapy had no impact on survival.

Bilateral Adrenal Hemorrhage Heralds Bronchogenic Carcinoma

This case study delves into the unusual presentation of non-small cell lung carcinoma (NSCLC), where bilateral hemorrhagic adrenal metastasis served as the primary indication of an underlying malignancy. Our patient, a 58-year-old male, sought medical attention due to acute abdominal pain and lower back discomfort, leading to an in-depth diagnostic exploration. Radiological examinations revealed bilateral adrenal masses exhibiting hemorrhagic characteristics, a distinctive feature not commonly associated with NSCLC. The subsequent biopsy and histopathological analysis definitively identified metastatic NSCLC as the culprit. The uniqueness of this case lies in the bilateral nature of the metastasis and the presence of hemorrhagic elements, challenging traditional diagnostic expectations. This report emphasizes the necessity for a nuanced approach to diagnostic investigations when confronted with atypical presentations, especially considering the rarity of bilateral involvement and hemorrhagic features in adrenal metastases from NSCLC. It highlights the importance of interdisciplinary collaboration between radiologists, pathologists, and oncologists to ensure accurate and timely diagnosis. The overarching significance of this case extends beyond its rarity; it underscores the imperative for healthcare practitioners to broaden their diagnostic considerations in the absence of conventional symptoms. By presenting this distinctive case, we contribute to the evolving understanding of the diverse clinical manifestations of NSCLC, advocating for heightened vigilance and comprehensive diagnostic approaches in the pursuit of early intervention and optimal patient care.

Operationalising targeted next-generation sequencing for routine diagnosis of drug-resistant TB

BACKGROUND

Phenotypic drug susceptibility testing (pDST) for Mycobacterium tuberculosis can take up to 8 weeks, while conventional molecular tests identify a limited set of resistance mutations. Targeted next-generation sequencing (tNGS) offers rapid results for predicting comprehensive drug resistance, and this study sought to explore its operational feasibility within a public health laboratory in Mumbai, India.

METHODS

Pulmonary samples from consenting patients testing Xpert MTB-positive were tested for drug resistance by conventional methods and using tNGS. Laboratory operational and logistical implementation experiences from study team members are shared below.

RESULTS

Of the total number of patients tested, 70% (113/161) had no history of previous TB or treatment; however, 88.2% (n = 142) had rifampicin-resistant/multidrug-resistant TB (RR/MDR-TB). There was a high concordance between resistance predictions of tNGS and pDST for most drugs, with tNGS more accurately identifying resistance overall. tNGS was integrated and adapted into the laboratory workflow; however, batching samples caused significantly longer result turnaround time, fastest at 24 days. Manual DNA extraction caused inefficiencies; thus protocol optimisations were performed. Technical expertise was required for analysis of uncharacterised mutations and interpretation of report templates. tNGS cost per sample was US$230, while for pDST this was US$119.

CONCLUSIONS

Implementation of tNGS is feasible in reference laboratories. It can rapidly identify drug resistance and should be considered as a potential alternative to pDST.

Micro-/bio-/nano-/syn-encapsulations and co-treatments of bioactive microbial feed supplementation in augmenting finfish health and aquaculture nutrition: a review

Finfish and fish products are globally the most acknowledged health-promoting foods. The rising incidence of pathogenic and disease outbreaks have had a sizeable impact on aquaculture. Microbial supplementation of food in the form of probiotics, prebiotics, and their controlled release combinations (=co-encapsulations) as 'synbiotics' is noted for its significant biotherapeutic and health benefits. Supplementation of probiotic microbial feed additives in the fish diet claims to improve fish health by modulation of resident intestinal microbiota and by introducing healthy microbiota procured from an exogenous source, capable of combating pathogens, improving nutrient uptake, assimilation, growth as well as survival. Prebiotics are selectively digestible substrates beneficially used by host gut microbes to enhance probiotic effects. Formulating a fish diet with augmented probiotics and prebiotic microbial bio-supplements can ensure a sustainable alternative for establishing fish health in a naturally susceptible aquaculture scenario. Micro-encapsulation, co-encapsulation, and nano-encapsulation are novel strategies of biotechnical interventions in functional feeds for finfish. These aim to improve probiotic persistence, survivability, and efficacy in commercial formulations during probiotic transit through the host-gut environment. This review discusses the importance of co-treatment and encapsulation strategies for improving probiotic and prebiotic potential in aquafeed formulations, reliably improving finfish health and nutritional returns from aquaculture, and, consequently, for consumers.

Clinical and ultrasonographic assessment of airway indices among non-pregnant, normotensive pregnant and pre-eclamptic patients: a prospective observational study

BACKGROUND

Prediction of a difficult airway is of paramount importance for an anaesthesiologist. Various anatomical and physiological factors contribute to a difficult airway in pregnant females, especially those with pre-eclampsia. The aim of the study was to assess airway indices using both routinely used clinical methods and ultrasound.

METHODS

Fifty-five non-pregnant females, 55 normotensive pregnant females and 55 females with pre-eclampsia were included in this prospective study. Clinical airway assessment was the modified Mallampati score, thyromental distance, hyomental distance, hyomental distance ratio, chest circumference, neck circumference and chest-to-neck circumference ratio. Sonographic assessment included tongue width, tongue volume, anterior neck soft tissue thickness at the level of hyoid, epiglottis and vocal cords, subglottic diameter, ratio of pre-epiglottic space to anterior, posterior and midpoint of anterior and posterior vocal folds.

RESULTS

Several significant differences were observed between pregnant and non-pregnant females, with additional changes in pre-eclamptic females. These included clinical parameters such as the modified Mallampati score and sonographic measurements of tongue width, tongue volume, subglottic diameter, anterior neck soft tissue thickness at the level of hyoid, epiglottis and vocal cords, and the ratio of pre-epiglottic space to anterior, posterior and midpoint of anterior and posterior vocal folds.

CONCLUSION

Routinely used clinical methods of airway assessment lack sensitivity and specificity. Ultrasound can visualise anatomical structures in the supraglottic and subglottic views and is encouraging as an airway assessment tool.

Characterization of Polycyclic Aromatic Hydrocarbons (PAHs) associated with fine aerosols in ambient atmosphere of high-altitude urban environment in Sikkim Himalaya

Polycyclic Aromatic Hydrocarbons (PAHs) compounds are ubiquitous in ambient air due to their persistence, carcinogenicity, and mutagenicity. Gangtok being one of the cleanest cities in India located in Eastern Himalayan region, witnesses high developmental activities with enhanced urbanization affecting the ambient air quality. The present study aims to measure PM_2.5 and PAHs in the ambient atmosphere of the Sikkim Himalaya to understand the influence of natural and anthropogenic activities on aerosol loading and their chemical characteristics. The PM_2.5 samples were collected and analysed for the duration from Jan 2020 to Feb 2021.The seasonal mean concentrations of PM_2.5 and PAHs were observed to be high during autumn and low during summer season. Overall, the annual mean concentration of PM_2.5 was found higher than the prescribed limit of World Health Organization and National Ambient Air Quality Standards. The concentration of the 16 individual PAHs were found to be highest during autumn season (55.26 ± 37.15 ng/m³). Among the different PAHs, the annual mean concentration of fluorene (3.29 ± 4.07 ng/m³) and naphthalene (1.15 ± 3.76 ng/m³) were found to be the highest and lowest, respectively. The Molecular Diagnostic Ratio (MDR) test reveals higher contribution from heavy traffic activities throughout the winter and autumn seasons. The other possible sources identified over the region are fossil fuel combustion, and biomass burning. The multivariate statistical analysis (Multifactor Principal Component Analysis) also indicates a strong association between PM_2.5 /PAHs and meteorological variables across the region in different seasons. The precipitation and wind pattern during the study period suggests that major contribution of the PM_2.5 and PAHs were from local sources, with minimal contribution from long-range transport. The findings are important for comprehending the trends of PAH accumulation over a high-altitude urban area, and for developing sustainable air quality control methods in the Himalayan region.

Machine learning-driven clinical decision support system for concept-based searching: a field trial in a Norwegian hospital

BACKGROUND

Natural language processing (NLP) based clinical decision support systems (CDSSs) have demonstrated the ability to extract vital information from patient electronic health records (EHRs) to facilitate important decision support tasks. While obtaining accurate, medical domain interpretable results is crucial, it is demanding because real-world EHRs contain many inconsistencies and inaccuracies. Further, testing of such machine learning-based systems in clinical practice has received limited attention and are yet to be accepted by clinicians for regular use.

METHODS

We present our results from the evaluation of an NLP-driven CDSS developed and implemented in a Norwegian Hospital. The system incorporates unsupervised and supervised machine learning combined with rule-based algorithms for clinical concept-based searching to identify and classify allergies of concern for anesthesia and intensive care. The system also implements a semi-supervised machine learning approach to automatically annotate medical concepts in the narrative.

RESULTS

Evaluation of system adoption was performed by a mixed methods approach applying The Unified Theory of Acceptance and Use of Technology (UTAUT) as a theoretical lens. Most of the respondents demonstrated a high degree of system acceptance and expressed a positive attitude towards the system in general and intention to use the system in the future. Increased detection of patient allergies, and thus improved quality of practice and patient safety during surgery or ICU stays, was perceived as the most important advantage of the system.

CONCLUSIONS

Our combined machine learning and rule-based approach benefits system performance, efficiency, and interpretability. The results demonstrate that the proposed CDSS increases detection of patient allergies, and that the system received high-level acceptance by the clinicians using it. Useful recommendations for further system improvements and implementation initiatives are reducing the quantity of alarms, expansion of the system to include more clinical concepts, closer EHR system integration, and more workstations available at point of care.

Clinical utility of target-based next-generation sequencing for drug-resistant TB

BACKGROUND: In high TB burden countries, access to drug susceptibility testing is a major bottleneck. Targeted next-generation sequencing (tNGS) is a promising technology for rapid resistance detection. This study assessed the role of tNGS for the diagnosis of drug-resistant TB (DR-TB).METHODS: A total of 161 samples from bacteriologically confirmed TB cases were subjected to tNGS using the Deeplex^® Myc-TB kit and sequenced using the MiSeq platform. These samples were also processed for conventional phenotypic DST (pDST) using 13 drugs on Mycobacteria Growth Indicator Tube and line-probe assays (MTBDRplus and MTBDRsl).RESULTS: There were 146 DR-TB and 15 drug-susceptible TB (DS-TB) samples. About 70% of patients with DR-TB had no previous TB treatment history. Overall, 88.2% had rifampicin-resistant/multidrug-resistant TB (RR/MDR-TB), 58.5% pre-extensively drug-resistant TB (pre-XDR-TB) and 9.2% had XDR-TB as defined by the WHO (2020). Around 8% (n = 13) of samples were non-culturable; however, identified 8 were resistant to first and second-line drugs using tNGS. Resistance frequency was similar across methods, with discordance in drugs less reliable using pDST or with limited mutational representation within databases. Sensitivities were aligned with literature reports for most drugs. We observed 10% heteroresistance, while 75% of strains were of Lineages 2 and 3.CONCLUSIONS: Programme data supported tNGS in the diagnosis of DR-TB for early treatment using individualised regimens.

Retrospective national cohort study of pregnancy outcomes for women with type 1 and type 2 diabetes mellitus in Republic of Ireland

AIM

Report the outcomes of pregnant women with type 1 and type 2 diabetes and to identify modifiable and non-modifiable factors associated with poor outcomes.

METHODS

Retrospective analysis of pregnancy preparedness, pregnancy care and outcomes in the Republic of Ireland from 2015 to 2020 and subsequent multivariate analysis.

RESULTS

In total 1104 pregnancies were included. Less than one third attended pre-pregnancy care (PPC), mean first trimester haemoglobin A1c was 7.2 ± 3.6% (55.5 ± 15.7 mmol/mol) and 52% received pre-conceptual folic acid. Poor preparation translated into poorer pregnancy outcomes. Livebirth rates (80%) were comparable to the background population however stillbirth rates were 8.7/1000 (four times the national rate). Congenital anomalies occurred in 42.5/1000 births (1.5 times the background rate). More than half of infants were large for gestational age and 47% were admitted to critical care. Multivariate analyses showed strong associations between non-attendance at PPC, poor glycaemic control and critical care admission (adjusted odds ratio of 1.68 (1.48-1.96) and 1.61 (1.43-1.86), p < 0.05 respectively) for women with type 1 diabetes. Smoking and teratogenic medications were also associated with critical care admission and hypertensive disorders of pregnancy.

CONCLUSION

Pregnancy outcomes in women with diabetes are suboptimal. Significant effort is needed to optimize the modifiable factors identified in this study.

A systematic review and meta-analysis of efficacy and safety of Romosozumab in postmenopausal osteoporosis

The study was conducted to illustrate the effect of Romosozumab in postmenopausal osteoporosis patients. Romosozumab decreased the incidence of vertebral, nonvertebral, and clinical fractures significantly. In addition, decreased incidence of falls and increased bone mineral density at lumbar spine, total hip, and femoral neck was observed. Romosozumab is a monoclonal antibody that acts against the sclerostin pathway leading to enhanced bone formation and reduced bone resorption in patients with osteoporosis. Electronic search was performed on Medline (via PubMed), The Cochrane Central Register of Controlled Trials, and clinicaltrials.gov, till May 2020, for RCTs evaluating the effectiveness of Romosozumab in postmenopausal osteoporosis. RCTs evaluating the effect of Romosozumab on fractures and bone mineral density in postmenopausal osteoporosis patients. Meta-analysis was performed by Cochrane review manager 5 (RevMan) version 5.3. Cochrane risk of bias 2.0 tool and GRADE pro-GDT were applied for methodological quality and overall evidence quality, respectively. One hundred seventy-nine studies were screened, and 10 eligible studies were included in the analysis, with a total of 6137 patients in romosozumab group and 5732 patients in control group. Romosozumab significantly reduced the incidence of vertebral fractures [OR = 0.43 (95%CI = 0.35-0.52), High-quality evidence], nonvertebral fractures [OR = 0.78 (95%CI = 0.66-0.92), High quality], and clinical fractures [OR = 0.70 (95%CI = 0.60-0.82), High quality] at 24 months. Significant reduction in incidence risk of falls [OR = 0.87 (95%CI = 0.78-0.96), High quality] was observed with romosozumab. Bone mineral density was significantly increased in the romosozumab treated groups at lumbar spine [MD = 12.66 (95%CI = 12.66-12.67), High quality], total hip [MD = 5.69 (95%CI = 5.68 - 5.69), Moderate quality], and femoral neck [MD = 5.18 (95%CI = 5.18-5.19), Moderate quality] at 12 months. The total adverse events [RR = 0.98(95%CI = 0.96-1.01), Moderate quality] and serious adverse events [RR = 0.98(95%CI = 0.88-1.08), Moderate quality] with romosozumab were comparable to the control group. The current analysis with evidence on efficacy and safety of Romosozumab, authors opine to recommend the use of Romosozumab treatment for post-menopausal osteoporosis.Systematic review registration: PROSPERO registration number: CRD42019112196.

Patient tracking during treatment of children with cancer in India - An exploratory study

BACKGROUND

Abandonment of treatment, a major cause of treatment failure in low- and middle-income countries like India, is particularly high during the diagnostic and initial phase of treatment. Tracking of patients during this risk period may reduce treatment abandonment rates and increase quality of care.

AIM

The primary aim was to pilot the use and check the acceptability of a tool for tracking children with cancer in New Delhi during the initial part of their treatment. Secondary aim was to estimate abandonment rates among these patients.

METHODS

This prospective study was carried out in two centers of North India in New Delhi and enrolled children less than 18 years diagnosed with cancer at these centers and who had registered with Cankids for social support. Parent support group (PSG) workers maintained contact with the child's family at least once a week for the first 12 weeks. Details of each contact and subsequent action were recorded in a customized book (called "You are not alone" or YANA Book). Descriptive analysis of these contacts was done in Microsoft Excel and presented in frequencies and percentages. The five-point Likert scale was used to check the acceptability of the tool among the PSG workers.

RESULTS

Seven PSG workers enrolled and tracked 81 patients (73% male with a median age of 6 years). During the 12-week study period, 986 contacts were attempted and three (3.7%) patients had abandoned their treatment. All PSG workers strongly agreed that the YANA book was simple to understand and use, decreased their workload, and helped provide better assistance to patients.

CONCLUSION

The tool for patient tracking was well accepted by the PSG workers and considered easy to use. We now plan to implement our model as a routine service at all the partnering hospitals in India.

P6293Assessment of testosterone/estradiol ratio, DHEA-S level and correlation with coronary inflammatory markers IL-1 & 6, TNF-1 and hsCRP predict 5 years risk of cardiovascular disease in men

Background

Previous data showed the adrenal sex hormone dehydroepiandrosterone (DHEA) which is present in serum mainly as the sulfate DHEA-S is the most abundant steroid hormone and another hormones like testosterone, estradiol are related to cardiovascular risk in men. Literatures revealed vascular and metabolic actions of DHEA/-S, evidence for an association between DHEA/-S levels and cardiovascular events is controversy.

Objectives

Our aim is to review and clear the contradictory point regarding cardiovascular risk and correlation of testeosterone/ estradiol ratio, DHEA-S level with coronary inflammatory markers in men.

Methods

Large population based cohort study done at multi centre of cardiology from 2013- 2018 in India. We enrolled total 23631 normal healthy male population age between 40 to 60 years and divided into two groups based on testosterone/estradiol ratio (Group A (n=2450) lower value of T/E ratio and Group B (n=21181) normal or higher T/E ratio. We did cohort analysis for 5 years and evaluated DHEA-S level and correlated it with coronary inflammatory markers and cardiovascular risk.

Results

In group A (low T/E ratio) we found low level of DHEA-S (98% of individual) and higher value of interleukins IL-1 (68%),IL-6 (74%) and tumor necrosis factor TNF-1 (71%) and high sensitive C-reactive protein (hsCRP) (73% of individual). Data revealed two fold increase of high blood pressure and LDL cholesterol level as compared to group B (normal or high T/E ratio and normal or high value of DHEA-S). 2.5 fold higher rate of coronary heart disease (CHD) found in group A versus in group B. We did not found as much significant difference in stroke, carotid and peripheral artery disease. T/E ratio and DHEA-S levels were inversely associated with the age-adjusted risk of a CHD event; the hazard ratios and 95% confidence intervals per standard deviation (SD) increase were 0.76 (0.66 to 0.91) and 0.82 (0.72 to 0.93), respectively.

Conclusions

Decrease ratio of testosterone/estradiol levels correlate decreased levels of DHEA-S which may increase the risk of CHD in men. For future aspect, correction of T/E ratio, DHEA-S and increase its awareness should be at mass level for prevention of CHD.

Fungal Planet description sheets: 868-950

Novel species of fungi described in this study include those from various countries as follows: Australia, Chaetomella pseudocircinoseta and Coniella pseudodiospyri on Eucalyptus microcorys leaves, Cladophialophora eucalypti, Teratosphaeria dunnii and Vermiculariopsiella dunnii on Eucalyptus dunnii leaves, Cylindrium grande and Hypsotheca eucalyptorum on Eucalyptus grandis leaves, Elsinoe salignae on Eucalyptus saligna leaves, Marasmius lebeliae on litter of regenerating subtropical rainforest, Phialoseptomonium eucalypti (incl. Phialoseptomonium gen. nov.) on Eucalyptus grandis × camaldulensis leaves, Phlogicylindrium pawpawense on Eucalyptus tereticornis leaves, Phyllosticta longicauda as an endophyte from healthy Eustrephus latifolius leaves, Pseudosydowia eucalyptorum on Eucalyptus sp. leaves, Saitozyma wallum on Banksia aemula leaves, Teratosphaeria henryi on Corymbia henryi leaves. Brazil, Aspergillus bezerrae, Backusella azygospora, Mariannaea terricola and Talaromyces pernambucoensis from soil, Calonectria matogrossensis on Eucalyptus urophylla leaves, Calvatia brasiliensis on soil, Carcinomyces nordestinensis on Bromelia antiacantha leaves, Dendryphiella stromaticola on small branches of an unidentified plant, Nigrospora brasiliensis on Nopalea cochenillifera leaves, Penicillium alagoense as a leaf endophyte on a Miconia sp., Podosordaria nigrobrunnea on dung, Spegazzinia bromeliacearum as a leaf endophyte on Tilandsia catimbauensis, Xylobolus brasiliensis on decaying wood. Bulgaria, Kazachstania molopis from the gut of the beetle Molops piceus. Croatia, Mollisia endocrystallina from a fallen decorticated Picea abies tree trunk. Ecuador, Hygrocybe rodomaculata on soil. Hungary, Alfoldia vorosii (incl. Alfoldia gen. nov.) from Juniperus communis roots, Kiskunsagia ubrizsyi (incl. Kiskunsagia gen. nov.) from Fumana procumbens roots. India, Aureobasidium tremulum as laboratory contaminant, Leucosporidium himalayensis and Naganishia indica from windblown dust on glaciers. Italy, Neodevriesia cycadicola on Cycas sp. leaves, Pseudocercospora pseudomyrticola on Myrtus communis leaves, Ramularia pistaciae on Pistacia lentiscus leaves, Neognomoniopsis quercina (incl. Neognomoniopsis gen. nov.) on Quercus ilex leaves. Japan, Diaporthe fructicola on Passiflora edulis × P. edulis f. flavicarpa fruit, Entoloma nipponicum on leaf litter in a mixed Cryptomeria japonica and Acer spp. forest. Macedonia, Astraeus macedonicus on soil. Malaysia, Fusicladium eucalyptigenum on Eucalyptus sp. twigs, Neoacrodontiella eucalypti (incl. Neoacrodontiella gen. nov.) on Eucalyptus urophylla leaves. Mozambique, Meliola gorongosensis on dead Philenoptera violacea leaflets. Nepal, Coniochaeta dendrobiicola from Dendriobium lognicornu roots. New Zealand, Neodevriesia sexualis and Thozetella neonivea on Archontophoenix cunninghamiana leaves. Norway, Calophoma sandfjordenica from a piece of board on a rocky shoreline, Clavaria parvispora on soil, Didymella finnmarkica from a piece of Pinus sylvestris driftwood. Poland, Sugiyamaella trypani from soil. Portugal, Colletotrichum feijoicola from Acca sellowiana. Russia, Crepidotus tobolensis on Populus tremula debris, Entoloma ekaterinae, Entoloma erhardii and Suillus gastroflavus on soil, Nakazawaea ambrosiae from the galleries of Ips typographus under the bark of Picea abies. Slovenia, Pluteus ludwigii on twigs of broadleaved trees. South Africa, Anungitiomyces stellenboschiensis (incl. Anungitiomyces gen. nov.) and Niesslia stellenboschiana on Eucalyptus sp. leaves, Beltraniella pseudoportoricensis on Podocarpus falcatus leaf litter, Corynespora encephalarti on Encephalartos sp. leaves, Cytospora pavettae on Pavetta revoluta leaves, Helminthosporium erythrinicola on Erythrina humeana leaves, Helminthosporium syzygii on a Syzygium sp. bark canker, Libertasomyces aloeticus on Aloe sp. leaves, Penicillium lunae from Musa sp. fruit, Phyllosticta lauridiae on Lauridia tetragona leaves, Pseudotruncatella bolusanthi (incl. Pseudotruncatellaceae fam. nov.) and Dactylella bolusanthi on Bolusanthus speciosus leaves. Spain, Apenidiella foetida on submerged plant debris, Inocybe grammatoides on Quercus ilex subsp. ilex forest humus, Ossicaulis salomii on soil, Phialemonium guarroi from soil. Thailand, Pantospora chromolaenae on Chromolaena odorata leaves. Ukraine, Cadophora helianthi from Helianthus annuus stems. USA, Boletus pseudopinophilus on soil under slash pine, Botryotrichum foricae, Penicillium americanum and Penicillium minnesotense from air. Vietnam, Lycoperdon vietnamense on soil. Morphological and culture characteristics are supported by DNA barcodes.

Nanomaterials for the control of bacterial blight disease in pomegranate: quo vadis?

Bacterial blight, caused by Xanthomonas axonopodis pv. punicae, Xap is a serious threat to commercially successful pomegranate (Punica granatum L) crop. Owing to the non-availability of disease-resistant varieties of pomegranate, integrated disease management involving change of season, adequate nutrition, and preventive sprays of bactericides is used to control Xap. We undertook a systematic study to assess the efficacy of metal-based nanomaterials (Cu, CuO, ZnO, CaO, MgO) for the control of Xap. The antimicrobial effectiveness was in the order Cu > ZnO > MgO > CuO with MIC (minimum inhibitory concentration) 2.5, 20, 190, 200, and 1600 μg/ml. A time-to-kill curve indicated that Cu nanoparticles (CuNPs) killed Xap cells within 30 min at 2.5 μg/ml. Under controlled conditions (polyhouse), foliar application of CuNPs (400 μg/ml) resulted in ~ 90 and ~ 15% disease reduction in 6-month-old infected plants at early (disease severity 10%) and established (disease severity 40%) stages of infection, respectively. In a subsequent field study on severely infected 7-year-old plants, applications of nanoparticles reduced the disease incidence by ~ 20% as compared to untreated control. Microscopic observations revealed that CuNPs reduced the bacterial colonization of the leaf surface. Anti-Xap activity of foliar applied CuNPs was on par with conventionally used copper oxychloride (3000 μg/ml) albeit at 8-fold reduced copper concentration. Thus, early disease detection and application of effective dosage of copper nanoparticles can indeed help the farmer in achieving rapid infection control. Further studies on use of combinations of nanoparticles for management of bacterial blight are warranted.

Feasibility of Hyperfunctioning Parathyroid Gland Localization Using [18F]fluciclovine PET/CT

PURPOSE

To evaluate the ability of anti-1-amino-3-anti-1-amino-3-[¹⁸F]fluorocyclobutane-1-carboxylic acid ([¹⁸F]fluciclovine) positron emission tomography/X-ray computed tomography (PET/CT) in comparison to Technetium-99m 2-methoxy isobutyl isonitrile ([^99mTc]sestamibi) single-photon emission computed tomography/CT (SPECT/CT) for the localization of hyperfunctioning parathyroid glands in patients with hyperparathyroidism.

PROCEDURES

Four patients with hyperparathyroidism underwent 60-minutes sequential neck and thorax PET/CT after [¹⁸F]fluciclovine (352 ± 28 MBq) injection. Lesion uptake and target-to-background ratios (TBR) were compared with [^99mTc]sestamibi (798 ± 27 MBq) SPECT/CT in the same patient.

RESULTS

Both techniques detected 4/5 hyperfunctioning parathyroid glands identified at surgery. The highest [¹⁸F]fluciclovine uptake and TBRs were at 5-9 min with rapid washout. [^99mTc]sestamibi had significantly higher TBRs compared with [¹⁸F]fluciclovine (5-9 min) for blood pool (10.9 ± 4.7 vs 1.3 ± 0.6; p < 0.01) and reference muscle backgrounds (5.8 ± 3.0 vs 1.7 ± 0.6; p < 0.01), with non-significant trend for thyroid tissue background (1.3 ± 0.5 vs 1.1 ± 0.5; p = 0.73).

CONCLUSION

Hyperfunctioning parathyroid glands can be detected on [¹⁸F]fluciclovine PET/CT at early imaging, but conspicuity (TBR) is better with [^99mTc]sestamibi. [¹⁸F]fluciclovine PET/CT does not seem promising in the detection of hyperfunctioning parathyroid glands.

Systematic review of interventions for the prevention and treatment of postoperative urinary retention

Background

Postoperative urinary retention (PO‐UR) is an acute and painful inability to void after surgery that can lead to complications and delayed hospital discharge. Standard treatment with a urinary catheter is associated with a risk of infection and can be distressing, undignified and uncomfortable. This systematic review aimed to identify effective interventions for the prevention and treatment of PO‐UR that might be alternatives to urinary catheterization.

Methods

Electronic databases were searched from inception to September 2017. Randomized trials of interventions for the prevention or treatment of PO‐UR were eligible for inclusion. Studies were assessed for risk of bias using the Cochrane (2.0) tool. Two reviewers were involved at all review stages. Where possible, data were pooled using random‐effects meta‐analysis. The overall quality of the body of evidence was rated using the GRADE approach.

Results

Some 48 studies involving 5644 participants were included. Most interventions were pharmacological strategies to prevent PO‐UR. Based on GRADE, there was high‐certainty evidence to support replacing morphine in a regional anaesthetic regimen, using alpha‐blockers (number needed to treat to prevent one case of PO‐UR (NNT) 5, 95 per cent c.i. 5 to 7), the antispasmodic drug drotaverine (NNT 9, 7 to 30) and early postoperative mobilization (NNT 5, 4 to 8) for prevention, and employing hot packs or gauze soaked in warm water for treatment (NNT 2, 2 to 4). Very few studies reported on secondary outcomes of pain, incidence of urinary tract infection or duration of hospital stay.

Conclusion

Promising interventions exist for PO‐UR, but they need to be evaluated in randomized trials investigating comparative clinical and cost effectiveness, and acceptability to patients.

Cutaneous metastases as initial presentation of malignancy

We describe a case of 73-year-old female who presented with dry cough, chest pain and light-headedness. On examination, multiple subcutaneous masses were noticed on the chest wall, bilateral breast, anterior abdomen and both arms. Subsequent CT-TAP and CT-brain showed multiple subcutaneous nodules in scalp, neck, anterior chest wall, breast and abdomen. A biopsy taken from breast revealed metastatic malignant melanoma; however there was no evidence of primary cutaneous malignant melanoma. We also describe a case of 72-year-old male who presented with tender mass on his lower back and posterior neck. He was known to have COPD and was a heavy smoker. A CT-TAP showed right lower lung mass with soft tissue masses near lumbar spine and lower cervical spine. While awaiting bronchoscopy, biopsy taken from the mass on lower back showed features of metastatic lung adenocarcinoma. In fact, presence of cutaneous metastasis is heraldsign and indicates advanced malignancy with poor prognosis regardless of type of primary malignancy.

Operative versus Non operative treatment of displaced intraarticular fracture of calcaneum: a meta-analysis of randomized controlled trials

Various studies comparing operative and non-operative intervention for displaced intrarticular calcaneal fractures have reported conflicting findings in the past. The objective of this meta-analysis was to compare the efficacy and safety of open reduction and internal fixation (ORIF) vis-a-vis conservative management. Relevant randomized controlled trials (RCTs) comparing operative and non-operative intervention for displaced intraarticular calcaneal fractures were assessed and included in this meta-analysis. Data was extracted independently and methodological quality was further assessed. The inclusion criteria of this meta-analysis were: randomized controlled trials comparing operative with non-operative intervention for displaced intra-articular fractures of calcaneum and reporting atleast one of the main outcomes as failure to resume pre-injury work, residual pain and other complications. Eight randomized controlled trials fulfilled the criteria for this meta-analysis. Pooled results showed that patients managed conservatively failed to resume pre-injury work (RR 0.60, 95% CI = 0.37-0.98, P = 0.04). However operative intervention was associated with more complications (RR 1.74, 95% CI = 1.28 to 2.37, P = 0.0005). There was no statistically significant difference in residual pain (RR 0.73 95% CI = 0.40-1.36, P = 0.33) and reoperation (RR = 0.75, 95% CI = 0.48-1.16, P = 0.20) between the two groups. Surgery can benefit patients with calcaneal fracture and increases their likelihood to resume pre-injury work. However, the complication rates are significantly higher in the operative group. Since the included trials have used different scores to measure patient outcomes, hence little effective data could.

Retrospective analysis of four-year injury data from the Infantry Training Centre, Catterick

Introduction

Musculoskeletal injury (MSKI) represents a considerable threat to the effectiveness and productivity of military organisations globally. The impact on the medical chain, occupational disposal with associated loss of working days and associated financial burden have far-reaching consequence. The moral and legal responsibility to reduce avoidable injuries through risk assessment and prevention strategies is fundamental to governance and a key component of best practice.

Methods

A retrospective observational analysis was performed of 4101 MSKIs presenting from a total inflow of 10 498 British Army Infantry recruits recorded over four consecutive training years between 2012 and 2016. Injury incidence, site, type and week of training were recorded and analysed.

Results

The total incidence of all MSKI was observed as 39.1%. Overuse injuries were the most common subclassification of injury type (24.5%), followed by trauma (8.8%) and then stress fractures (5.7%). Causes of medical discharge over a four-year cumulative incidence were from overuse injuries (59.3%), stress fractures (21.5%) and trauma (19.2%). 45.5% of all MSKIs presented within the first eight weeks of training.

Conclusions

MSKI data highlighted the requirement for a comprehensive service evaluation of the Combat Infantryman’s Course and subsequent justification for the introduction of an injury prevention intervention — Project OMEGA.

Tracking referrals to early intervention in psychosis team: An audit

Aims

To monitor if the early intervention services (EIS) in Sandwell meet the standard of assessing all patients referred to the team within the set target. To monitor factors that affects the outcome including the source of referral, whether the patients, are known to another team, and the demographic features of the patient.

Background

Providing timely, appropriate and coordinated care for patients presenting with a first episode of psychosis has been a focus for EIS teams to improve outcomes, experiences and in reducing costs. In April 2016, new target times of 5–10 days for referral-to-assessment and 14 days for referral-to-treatment were introduced by the government.

Method

All the referrals that were made since 01/04/2016 were followed up. A comparison was made with the referral-to-assessment and referral-to-treatment target for referrals made before the 01/04/16.

Results

There has been an increase in referrals. Preliminary evidence gathered suggests that there has been a marked improvement in the referral-to-assessment pathway and referral-to-management pathway. Patients referred to the EIS are offered an earlier assessment. Majority of the referrals made are however not appropriate to receive care from the EIS, and are not taken on by the team. All the patients that are accepted by the team are offered a NICE treatment package. Most of the referrals that come from other EIS teams or wards, are accepted by the team, at least for an extended assessment. Referrals from Children services are usually at the point when they are due to turn 18, for a second opinion.

Disclosure of interest

The author has not supplied his/her declaration of competing interest.

Interdisciplinary onsite team-based simulation training in the neonatal intensive care unit: a pilot report

OBJECTIVE

Simulation training improves individual clinician confidence, performance and self-efficacy in resuscitation and procedural training experiences. The reality of resuscitation experiences in the neonatal intensive care unit (NICU) is that they are team-accomplished events. However, limited data exist on team-based simulation training (TBST) in the NICU. We report the experience of TBST over a 4-year period.

STUDY DESIGN

This is a retrospective report of 65 TBST events in a 71-bed Level IV NICU at a regional subspecialty children's hospital. Participants were more than 500 NICU staff, including neonatal/cardiac/surgical attendings, neonatal fellows, neonatal nurse practitioners, pediatric residents, registered nurses and respiratory therapists. Background work, common case scenarios, training objectives and learning opportunities were reported, along with discipline-specific, and team and system areas for improvement. Qualitative, subjective data were tracked and efforts at collecting quantitative, objective data are ongoing.

RESULTS

Seventy-five TBST events were scheduled from November 2010 through December 2014; 10 of these were canceled. TBST events occurred both night (n=23) and day (n=42), and also on weekends (n=19), using high-fidelity (n=42) and low-fidelity (n=23) systems. Resuscitation team participants at each TBST were 12-30 providers and staff. The duration of each TBST event was 30-65 min including debriefing. Systems issues were identified and corrected, including problems activating the code pathway, issues using a pager activation system and confusion over resuscitation team roles and responsibilities. Educational needs were addressed, focused on topic areas that included arrhythmias and use of extracorporeal cardiopulmonary resuscitation.

CONCLUSION

With appropriate planning and implementation, TBST is feasible and realistic in a busy NICU.

Newborn healthcare in urban India

The rapid population growth in urban India has outpaced the municipal capacity to build essential infrastructures that make life in cities safe and healthy. Local and national governments alike are grappling with the challenges of urbanization with thousands migrating from villages to cities. Thus, urbanization in India has been accompanied by a concentration of poverty and urban public healthcare has emerged as one of the most pressing priorities facing our country. Newborn mortality rates in urban settings are lower than rural areas, early neonatal deaths account for greater proportion than late neonatal deaths. The available evidence suggests that socio-economic inequalities and poor environment pose major challenges for newborn health. Moreover, fragmented and weak public health system, multiplicity of actors and limited capacity of public health planning further constrain the delivery of quality and affordable health care service. Though healthcare is concentrated in urban areas, delay in deciding to seek health care, reaching a source of it and receiving appropriate care affects the health outcomes disproportionately. However, a few city initiatives and innovations piloted in different states and cities have brought forth the evidences of effectiveness of different strategies. Recently launched National Urban Health Mission (NUHM) provides an opportunity for strategic thinking and actions to improve newborn health outcomes in India. There is also an opportunity for coalescence of activities around National Health Mission (NHM) and Reproductive, Maternal, Newborn and Child Health+Adolescent (RMNCH+A) strategy to develop feasible and workable models in different urban settings. Concomitant operational research needs to be carried out so that the obstacles, approaches and response to the program can be understood.

Inpatient care of small and sick newborns in healthcare facilities

Neonatal units in teaching and non-teaching hospitals both in public and private hospitals have been increasing in number in the country since the sixties. In 1994, a District Newborn Care Programme was introduced as a part of the Child Survival and Safe Motherhood Programme (CSSM) in 26 districts. Inpatient care of small and sick newborns in the public health system got a boost under National Rural Health Mission with the launch of the national programme on facility-based newborn care (FBNC). This has led to a nationwide creation of Newborn Care Corners (NBCC) at every point of child birth, newborn stabilization units (NBSUs) at First Referral Units (FRUs) and special newborn care units (SNCUs) at district hospitals. Guidelines and toolkits for standardized infrastructure, human resources and services at each level have been developed and a system of reporting data on FBNC created. Till March 2015, there were 565 SNCUs, 1904 NBSUs and 14 163 NBCCs operating in the country. There has been considerable progress in operationalizing SNCUs at the district hospitals; however establishing a network of SNCUs, NBSUs and NBCCs as a composite functional unit of newborn care continuum at the district level has lagged behind. NBSUs, the first point of referral for the sick newborn, have not received the desired attention and have remained a weak link in most districts. Other challenges include shortage of physicians, and hospital beds and absence of mechanisms for timely repair of equipment. With admission protocols not being adequately followed and a weak NBSU system, SNCUs are faced with the problem of admission overload and poor quality of care. Applying best practices of care at SNCUs, creating more NBSU linkages and strengthening NBCCs are important steps toward improving quality of FBNC. This can be further improved with regular monitoring and mentoring from experienced pediatricians, and nurses drawn from medical colleges and the private sector. In addition there is a need to further increase such units to address the unmet need of facility-based care.

State of newborn health in India

About 0.75 million neonates die every year in India, the highest for any country in the world. The neonatal mortality rate (NMR) declined from 52 per 1000 live births in 1990 to 28 per 1000 live births in 2013, but the rate of decline has been slow and lags behind that of infant and under-five child mortality rates. The slower decline has led to increasing contribution of neonatal mortality to infant and under-five mortality. Among neonatal deaths, the rate of decline in early neonatal mortality rate (ENMR) is much lower than that of late NMR. The high level and slow decline in early NMR are also reflected in a high and stagnant perinatal mortality rate. The rate of decline in NMR, and to an extent ENMR, has accelerated with the introduction of National Rural Health Mission in mid-2005. Almost all states have witnessed this phenomenon, but there is still a huge disparity in NMR between and even within the states. The disparity is further compounded by rural-urban, poor-rich and gender differentials. There is an interplay of different demographic, educational, socioeconomic, biological and care-seeking factors, which are responsible for the differentials and the high burden of neonatal mortality. Addressing inequity in India is an important cross-cutting action that will reduce newborn mortality.

Hysteroscopy in Abnormal Uterine Bleeding vs Ultrasonography and Histopathology Report in Perimenopausal and Postmenopausal Women

INTRODUCTION

Abnormal uterine bleeding is one of the most common morbidity landing women to attend medical attention in gynecology outpatient department. This study aims to evaluate the hysteroscopy finding in diagnosis of AUB and its correlation with ultrasonography finding and histopathological reports.

METHODS

This was a prospective comparative study in which ultrasonography was performed in fifty patients with abnormal uterine bleeding attending OPD then hysteroscopy was performed.After removing hysteroscopy dilation and curettage was done and sample sent for histopathology.At the end reports of hysteroscopy finding were compared with sonograhic and pathological results.

RESULTS

In the study women aged from 45 to 64 years with the symptoms duration of 15 days to 6 months. Post menopausal women seek medical attention more early then the menstruating women.Common symptoms are menorrhagia, metrorrhagia and postmenopausal bleeding. Most common abnormality was menorrhagia (32%) followed by post menopausal bleeding 28 %. Ultrasonography showed 46% of abnormal finding in which 17 (47%) menstruating women and 6 (43%) women were postmenopausal women. Among 50 women 17 (34%) had negative finding and 43 (66%) had abnormal finding in which most common finding of hyperplastic endometrium. Hysteroscopy correctly diagnose atrophic endometrium, polyp and endometrial Ca which is also confirmed by histopathology finding.

CONCLUSIONS

Hysteroscopy is reliable method for evaluating cases of AUB and it can be used as first line diagnostic method for benign lesions. Hysteroscopy guided biopsy has most accurate in diagnosing pathology.

Colloidosome like structures: self-assembly of silica microrods

Self-assembly of micron-sized silica rods is demonstrated using a Pickering emulsion based strategy.

Genetic polymorphisms associated with sulphadoxine-pyrimethamine drug resistance among Plasmodium falciparum field isolates in malaria endemic areas of Assam

Background:

The emergence of antimalarial drug resistance malaria parasite is widespread in North eastern region of India. During January 2012-December 2013, we conducted active surveillance for detection of antifolate resistance-associated genetic polymorphisms in Plasmodium falciparum malaria parasite from different malaria endemic areas of Assam.

Materials and Methods:

A total of 281 field samples were collected from suspected malaria patients of which 106 malaria P. falciparum positive cases were detected in microscopic slide examination. A nested PCR was done for amplification of a 648 bp portion of the dhfr gene and 710 bp portion of the dhps gene.

Results:

Mutation analysis revealed existence of three different haplotypes of the P. falciparum dhfr gene of which ANRNI was highly prevalent (90%). Triple mutant haplotypes AIRNI (N51I + C59R + S108N) of the dhfr gene associated with pyrimethamine resistance were prevalent in Chirang district of Assam. Whereas, dhps mutation study revealed that triple mutant haplotype AGEAA (S436A + A437G + K540E) associated with Sulphadoxine resistance was found among 26% of P. falciparum field isolates. However, P. falciparum dhfr-dhps two locus mutation analysis showed that there were a total of nine dhfr-dhps genotypes.

Conclusion:

It was noticed that 93.62% (88/94) isolates had mutations in the sequences of both enzymes, which is an indication of prevalence of high grade of Sulphadoxine — pyrimethamine resistance in P. falciparum malaria parasites in Assam.