Genomic insights into clostridia in bioenergy production: Comparison of metabolic capabilities and evolutionary relationships

Bacteria from diverse genera, including Acetivibrio, Bacillus, Cellulosilyticum, Clostridium, Desulfotomaculum, Lachnoclostridium, Moorella, Ruminiclostridium, and Thermoanaerobacterium, have attracted significant attention due to their versatile metabolic capabilities encompassing acetogenic, cellulolytic, and C1-metabolic properties, and acetone-butanol-ethanol fermentation. Despite their biotechnological significance, a comprehensive understanding of clostridial physiology and evolution has remained elusive. This study reports an extensive comparative genomic analysis of 48 fully sequenced bacterial genomes from these genera. Our investigation, encompassing pan-genomic analysis, central carbon metabolism comparison, exploration of general genome features, and in-depth scrutiny of Cluster of Orthologous Groups genes, has established a holistic whole-genome-based phylogenetic framework. We have classified these strains into acetogenic, butanol-producing, cellulolytic, CO2-fixating, chemo(litho/organo)trophic, and heterotrophic categories, often exhibiting overlaps. Key outcomes include the identification of misclassified species and the revelation of insights into metabolic features, energy conservation, substrate utilization, stress responses, and regulatory mechanisms. These findings can provide guidance for the development of efficient microbial systems for sustainable bioenergy production. Furthermore, by addressing fundamental questions regarding genetic relationships, conserved genomic features, pivotal enzymes, and essential genes, this study has also contributed to our comprehension of clostridial biology, evolution, and their shared metabolic potential.

Evaluation and deployment of a unified MPPT controller for hybrid Luo converter in combined PV and wind energy systems

This work emphasizes the development and examination of a Hybrid Luo Converter integrated with a unified Maximum Power Point Tracking (MPPT) for both grid and independent hybrid systems. The primary objectives of this hybrid system are to efficiently harness power from intermittent and variable renewable sources while elevating low-voltage energy inputs to utility-grade levels. Unlike previous studies employing specific MPPT algorithms for solar and wind sources, this work aims to simplify the control system by utilizing a unified MPPT controller. This research also introduces a novel approach involving dual-lift hybrid Luo converters to create hybrid systems, operating exclusively or concurrently based on the availability of renewable resources. To maximize power generation from all renewable sources, a unified MPPT algorithm is developed. The hybrid system, incorporates 500 W wind and 560 W PV systems, the innovative Luo converter, and the unified MPPT controller. A comprehensive comparative analysis is presented, comparing the hybrid system's performance with that of traditional control algorithms, such as the Perturb & Observe, and Radial Basis Function Network controllers. The successful prototype of the converter validates the practicality of the proposed approach.

Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a model-based cost-effectiveness analysis of a pragmatic, cluster-randomised trial in seven low-income and middle-income countries

BACKGROUND

Surgical site infection (SSI) is a major burden on patients and health systems. This study assessed the cost-effectiveness of routine change of sterile gloves and instruments before abdominal wall closure to prevent SSI.

METHODS

A decision-analytic model was built to estimate average costs and outcomes of changing gloves and instruments before abdominal wall closure compared with current practice. Clinical data were obtained from the ChEETAh trial, a multicentre, cluster-randomised trial in seven low-income and middle-income countries (LMICs), and costs were obtained from a study (KIWI) that assessed costs associated with SSIs in LMICs. Outcomes were measured as the percentage of surgeries resulting in SSIs. Costs were measured from a health-care provider perspective and were reported in 2021 US$. The economic analysis used a partially split single-country costing approach, with pooled outcomes data from all seven countries in the ChEETAh trial, and data for resource use and unit costs from India (KIWI); secondary analyses used resource use and costs from Mexico and Ghana (KIWI).

FINDINGS

In the base case, the average cost of the intervention was $259∙92 compared with $261∙10 for current practice (cost difference -$1∙18, 95% CI -4∙08 to 1∙33). In the intervention group, an estimated 17∙6% of patients had an SSI compared with 19∙7% of patients in the current practice group (absolute risk reduction 2∙10%, 95% CI 2∙07-2∙84). At all cost-effectiveness thresholds assumed ($0 to $14 000), the intervention had a higher likelihood of being cost-effective compared with current practice, indicating that the intervention was cost-effective. Similar results were obtained when the analysis using data from India was repeated using resource use and unit cost data from Mexico and Ghana.

INTERPRETATION

Routine sterile glove and instrument change before abdominal wall closure is effective and the costs are similar to those for current practice. Routine change of gloves and instruments before abdominal wall closure should be rolled out in LMICs.

FUNDING

National Institute for Health and Care Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, and Mölnlycke Healthcare.

2023 Update of Indian National Association for Study of the Liver Consensus on Management of Intermediate and Advanced Hepatocellular Carcinoma: The Puri III Recommendations

Hepatocellular carcinoma (HCC) presents significant treatment challenges despite considerable advancements in its management. The Indian National Association for the Study of the Liver (INASL) first published its guidelines to aid healthcare professionals in the diagnosis and treatment of HCC in 2014. These guidelines were subsequently updated in 2019. However, INASL has recognized the need to revise its guidelines in 2023 due to recent rapid advancements in the diagnosis and management of HCC, particularly for intermediate and advanced stages. The aim is to provide healthcare professionals with evidence-based recommendations tailored to the Indian context. To accomplish this, a task force was formed, and a two-day round table discussion was held in Puri, Odisha. During this event, experts in their respective fields deliberated and finalized consensus statements to develop these updated guidelines. The 2023 INASL guidelines offer a comprehensive framework for the diagnosis, staging, and management of intermediate and advanced HCC in India. They represent a significant step forward in standardizing clinical practices nationwide, with the primary objective of ensuring that patients with HCC receive the best possible care based on the latest evidence. The guidelines cover various topics related to intermediate and advanced HCC, including biomarkers of aggressive behavior, staging, treatment options, and follow-up care.

Concomitant or sequential pulmonary infection with non-tuberculous mycobacteria and Aspergillus

Non-tuberculous mycobacteria (NTM) and Aspergillus are ubiquitous organisms that have the potential to cause significant pulmonary disease in certain clinical contexts. An association is known to exist between NTM and Aspergillus lung infections. However, it is unclear if NTM infection predisposes to Aspergillus infection or vice versa. It is also unclear whether treatment for one results in a favourable ecological niche that facilitates the growth of the other and promotes subsequent clinical disease. An improved understanding of the link between these two pulmonary pathogens is critical to guide improvements in clinical practice, and ultimately, enhance outcomes among patients who are at risk of experiencing these infections, either concomitantly or sequentially. Here, we discuss the association between pulmonary NTM and Aspergillus infections. We address the frequency with which coinfection or sequential infections are reported to occur, predisposing risk factors that have been identified and the impact on clinical outcomes. Current data on the mechanistic links between NTM and Aspergillus lung infections are also considered. The potential implications for routine clinical practice are explored.

Effectiveness and safety of atezolizumab-bevacizumab in patients with unresectable hepatocellular carcinoma: a systematic review and meta-analysis

Background

Atezolizumab-bevacizumab (atezo-bev) is recommended as first-line therapy for patients with unresectable hepatocellular carcinoma (uHCC). However, its effectiveness and safety in other populations, including those with Child-Turcotte-Pugh (CTP) class B cirrhosis, is unclear.

Methods

For this systematic review and meta-analysis, electronic databases, including PubMed, Embase, and Scopus, were searched from 1st May, 2020 till 5th October, 2022; the last date of access was January 31, 2023. Pooled progression-free survival (PFS), overall survival (OS), and radiological response rate among patients receiving atezo-bev were compared between patients with CTP-A and CTP-B cirrhosis, with tyrosine kinase inhibitors (TKIs) and among those receiving the drug as first-line and later line therapy. The protocol was registered in Prospero (CRD42022364430).

Findings

Among 47 studies (n = 5400 patients), pooled PFS and OS were 6.86 (95% CI, 6.31-7.41) and 13.8 months (95% CI, 11.81-15.8), respectively. Objective response rate (ORR) and disease control rate were 26.7% (24.6-29.1) and 75.3% (73.1-77.4) using RECIST criteria, and 34% (30.3-37.8) and 73.6% (68.8-78) using mRECIST criteria, respectively. Among those receiving atezo-bev, patients with CTP-B cirrhosis had similar ORRs by RECIST (odds ratio [OR], 1.42 [0.77-2.6]; P = 0.25) and mRECIST criteria (OR, 1.33 [0.52-3.39]; P = 0.53) but shorter PFS (mean difference [MD]:3.83 months [1.81-5.84]) than those with CTP-A cirrhosis. Compared to patients receiving TKIs, those receiving atezo-bev had longer PFS (MD: 2.27 months [0.94-3.5]) and higher ORR (RECIST: OR, 1.44 [1.01-2.04] and mRECIST: OR, 1.33 [1.01-1.75]). Compared to first-line therapy, later-line therapy had lower ORR (RECIST: OR, 1.82 [1.3-2.53]; P < 0.001 and mRECIST: OR, 2.02 [1.34-3.05]) but comparable PFS (MD: 0.58 months [-0.18 to 1.35]) among nine studies. The incidence of grade ≥3 adverse events among patients with CTP-A and CTP-B cirrhosis was comparable (OR, 0.89 [0.45-1.74]) as it was for patients receiving atezo-bev and TKIs (OR, 0.86 [0.61-1.2]).

Interpretation

Our findings suggest that atezo-bev is safe and effective as first-line systemic therapy for patients with uHCC and CTP-A or CTP-B cirrhosis.

Funding

An unsolicited grant from ROCHE Products India Pvt Ltd. was received for publication.

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

Background

This study assessed the potential cost-effectiveness of high (80-100%) vs low (21-35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa.

Methods

Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($).

Results

High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was $216 compared with $222 for low FiO2 leading to a -$6 (95% confidence interval [CI]: -$13 to -$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with $195 for low FiO2 leading to a -$11 (95% CI: -$15 to -$6) difference in costs. In South Africa, the average cost for high FiO2 was $1164 compared with $1257 for low FiO2 leading to a -$93 (95% CI: -$132 to -$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a -1.05 (95% CI: -1.14 to -0.90) percentage point reduction in SSIs.

Conclusion

High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this.

Safety and Efficacy of Atezolizumab-Bevacizumab in Real World: The First Indian Experience

Background

Atezolizumab-bevacizumab (atezo/bev) combination is a recommended first-line systemic therapy for unresectable hepatocellular carcinoma (uHCC). There are no studies from India reporting the safety and efficacy of this drug in real-world settings where most patients present in an advanced stage.

Methods

In this retrospective study from two centers in India, we included patients with uHCC who received atezo/bev as first-line systemic therapy. Comparison of overall survival (OS) among the different Child-Turcotte-Pugh (CTP) classes was the primary objective, while progression-free survival (PFS), radiologic response, and adverse events to the therapy were secondary objectives.

Results

The median age of the 67 patients who received atezo/bev therapy was 61 (29-82) years, and 86% were males. Nonalcoholic steatohepatitis (55.2%) was the commonest cause of cirrhosis, and most patients belonged to BCLC-C (74.6%%). There were 24 patients in CTP A, 36 in CTP B, and 7 in CTP C. The median OS was 12 (95%CI, 8.16-15.83) months in the cohort. The median OS in CTP class A, B, and C was 21 (95%CI, 0-42.06) months, 9 (95%CI, 5.46-12.53) months, and 4 (95%CI, 2.14-5.85) months, respectively (P < 0.001). The median PFS in the whole cohort was 8 (95%CI, 6.03-9.96) months. The median PFS in Child A, B, and C was 18 (95%CI, 0.16-35.84) months, 8 (95%CI, 6.14-9.85) months, and 2 (95%CI, 1.77-2.23) months (P < 0.001). On mRECIST evaluation, 12.9% had achieved a complete response, 25.8% had a partial response, 27.41% had stable disease, and the rest had progressed. The objective response rate was 38.7%, and the disease control rate was 66.12%. Of the 64% who developed adverse events, 13.43% discontinued the drug. The incidence of grade ≥3 events was significantly higher in CTP C (85.7%) compared to CTP A (12.5%) and CTP B (14%) (P < 0.001).

Conclusions

Atezolizumab-bevacizumab is safe and effective in uHCC in real-world settings. Candidate selection is of utmost importance in treating uHCC with atezolizumab-bevacizumab to achieve a good response. Current evidence strongly suggests limited use of atezolizumab-bevacizumab in patients with CTP C, and such individuals should not be considered for this combination therapy.

Pathophysiology and management of liver cirrhosis: from portal hypertension to acute-on-chronic liver failure

Cirrhosis transcends various progressive stages from compensation to decompensation driven by the severity of portal hypertension. The downstream effect of increasing portal hypertension severity leads to various pathophysiological pathways, which result in the cardinal complications of cirrhosis, including ascites, variceal hemorrhage, and hepatic encephalopathy. Additionally, the severity of portal hypertension is the central driver for further advanced complications of hyperdynamic circulation, hepatorenal syndrome, and cirrhotic cardiomyopathy. The management of these individual complications has specific nuances which have undergone significant developments. In contrast to the classical natural history of cirrhosis and its complications which follows an insidious trajectory, acute-on-chronic failure (ACLF) leads to a rapidly downhill course with high short-term mortality unless intervened at the early stages. The management of ACLF involves specific interventions, which have quickly evolved in recent years. In this review, we focus on complications of portal hypertension and delve into an approach toward ACLF.

Balloon dissection versus telescopic dissection during laparoscopic totally extraperitoneal (TEP) inguinal hernia repair: a systematic review, meta-analysis, and trial sequential analysis

OBJECTIVES

To compare the outcomes of balloon dissection and telescopic dissection in patients undergoing laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

METHODS

A systematic review in accordance with PRISMA statement standards was conducted. A search of electronic information sources was conducted to identify all studies comparing the outcomes of balloon dissection and telescopic dissection in patients undergoing laparoscopic TEP inguinal hernia repair. Random effects modelling was applied to calculate pooled outcome data.

RESULTS

A total of 936 patients from eight studies were included. The included population in both groups were comparable in terms of baseline characteristics. There was no difference between the two techniques in terms of operation time (MD: - 4.14 min, P = 0.05), conversion to another technique (RD: - 0.02, P = 0.29), recurrence (RD: - 0.00, P = 0.84), haematoma (OR: 1.34, P = 0.61), seroma (OR: 0.63, P = 0.56), surgical site infection (RD: 0.00, P = 1.00), urinary retention (OR: 0.92, P = 0.86), postoperative pain score on day 1 (MD: - 0.16, P = 0.69) and day 7 (MD: - 0.16, P = 0.61). Trial sequential analysis of randomised trials suggested that evidence for operative time and conversion to other technique is subject to type 1 and type 2 error.

CONCLUSIONS

Balloon dissection and telescopic dissection during TEP inguinal hernia repair are comparable in terms of operative and postoperative outcomes. The available evidence for operative time and conversion to other technique is subject to type 1 and type 2 error. In presence of comparative clinical outcomes, the cost-effectiveness analysis in future studies may play an important role in determining the dissection technique of choice.

Immune drivers of HBsAg loss in HBeAg-negative CHB patients after stopping nucleotide analog and administration of Peg-IFN

BACKGROUND

The stoppage of nucleoside analog (NA) can lead to immune flare and loss of HBsAg in a proportion of HBeAg-negative chronic hepatitis B (CHB) patients. HBsAg loss could be improved by instituting Peg-Interferon therapy in those who show an immune flare after the stoppage of NA. We investigated the immune drivers of HBsAg loss in NA-treated HBeAg-negative CHB patients after stopping NAs and administration of Peg-IFN-α2b therapy.

METHODS

Fifty-five NA-treated eAg-ve, HBV DNA not detected CHB patients were subjected to stopping NA therapy. Twenty-two (40%) patients relapsed (REL-CHBV) within 6 months (HBV DNA ≥2000 IU/mL, ALT ≥2XULN) and were started on Peg-IFN-α2b (1.5 mcg/kg) for 48 weeks (PEG-CHBV). Cytokine levels, immune responses, and T-cell functionality were assessed.

RESULTS

Only 22 (40%) of 55 patients clinically relapsed, of which 6 (27%) cleared HBsAg. None of the 33 (60%) nonrelapsers cleared HBsAg. REL-CHBV patients had significantly increased IL-6 (p=0.035), IFN-γ (p=0.049), Th1/17 (p=0.005), CD4 effector memory (EM) (p=0.01), Tfh1/17 (p=0.005), and mature B cells (p=0.04) compared with CHBV. Six months after Peg-IFN therapy, immune resetting with a significant increase in CXCL10 (p=0.042), CD8 (p=0.01), CD19 (p=0.001), and mature B cells (p=0.001) was observed. HBV-specific T-cell functionality showed increased Tfh-secreting IFN-γ (p=0.001), IL-21 (p=0.001), and TNF-α (p=0.005) in relapsers and IFN-γ-secreting CD4 T cell (p=0.03) in PEG-CHBV.

CONCLUSIONS

Stopping NA therapy induces flare in about 40% of HBeAg-negative patients. Peg-IFN therapy given to such patients causes immune restoration with HBsAg loss in one fourth of them.

Strategies to minimise and monitor biases and imbalances by arm in surgical cluster randomised trials: evidence from ChEETAh, a trial in seven low- and middle-income countries

BACKGROUND

Cluster randomised controlled trials (cRCT) present challenges regarding risks of bias and chance imbalances by arm. This paper reports strategies to minimise and monitor biases and imbalances in the ChEETAh cRCT.

METHODS

ChEETAh was an international cRCT (hospitals as clusters) evaluating whether changing sterile gloves and instruments prior to abdominal wound closure reduces surgical site infection at 30 days postoperative. ChEETAh planned to recruit 12,800 consecutive patients from 64 hospitals in seven low-middle income countries. Eight strategies to minimise and monitor bias were pre-specified: (1) minimum of 4 hospitals per country; (2) pre-randomisation identification of units of exposure (operating theatres, lists, teams or sessions) within clusters; (3) minimisation of randomisation by country and hospital type; (4) site training delivered after randomisation; (5) dedicated 'warm-up week' to train teams; (6) trial specific sticker and patient register to monitor consecutive patient identification; (7) monitoring characteristics of patients and units of exposure; and (8) low-burden outcome-assessment.

RESULTS

This analysis includes 10,686 patients from 70 clusters. The results aligned to the eight strategies were (1) 6 out of 7 countries included ≥ 4 hospitals; (2) 87.1% (61/70) of hospitals maintained their planned operating theatres (82% [27/33] and 92% [34/37] in the intervention and control arms); (3) minimisation maintained balance of key factors in both arms; (4) post-randomisation training was conducted for all hospitals; (5) the 'warm-up week' was conducted at all sites, and feedback used to refine processes; (6) the sticker and trial register were maintained, with an overall inclusion of 98.1% (10,686/10,894) of eligible patients; (7) monitoring allowed swift identification of problems in patient inclusion and key patient characteristics were reported: malignancy (20.3% intervention vs 12.6% control), midline incisions (68.4% vs 58.9%) and elective surgery (52.4% vs 42.6%); and (8) 0.4% (41/9187) of patients refused consent for outcome assessment.

CONCLUSION

cRCTs in surgery have several potential sources of bias that include varying units of exposure and the need for consecutive inclusion of all eligible patients across complex settings. We report a system that monitored and minimised the risks of bias and imbalances by arm, with important lessons for future cRCTs within hospitals.

Normal preoperative levels of gamma glutamyltransferase predict absence of common bile duct stones in patients scheduled for laparoscopic cholecystectomy. a retrospective cohort study

Laparoscopic cholecystectomy, nowadays, is considered the gold standard option for management in patients diagnosed with symptomatic cholelithiasis. Nevertheless, some patients may have coexisting choledocholithiasis, which manifests later in life with grave complications such as cholangitis and pancreatitis. The objective of this study is to evaluate the role of preoperative gamma-glutamyltransferase (GGT) in predicting choledocholithiasis in patients undergoing laparoscopic cholecystectomy.

Method

A total of 360 patients with symptomatic cholelithiasis based on diagnosis aided with abdominal ultrasound were included in the study. The study design was a retrospective cohort. Patients were evaluated based on a comparison between findings of per-operative cholangiogram and laboratory measure of GGT.

Result

The mean age of study participants was 47.22 (±28.41) years. Mean GGT levels were 121.54 (±87.91) U/l. One hundred (27.7%) participants had raised GGT. But only 19.4% had been diagnosed with filling defect positive on cholangiogram. The predictability of GGT for positive cholangiogram is statistically significant at less than 0.001 with an area under the curve of 0.922 (0.887-0.957), sensitivity of 95.7%, specificity of 88.6%, and accuracy of 90%. The standard error reported (0.018) was found to be relatively low.

Conclusion

Based on the provided information, it is concluded that GGT plays an important role in predicting the coexistence of choledocholithiasis in symptomatic cholelithiasis and can be used in the setting where the facility of per-operative cholangiogram is not available.

A Supervised Learning-Based Framework for Predicting COVID-19 in Patients

The integration of ML and loT can provide insightful details for critical decision making, automated responses, etc. Predicting future trends and detecting anomalies are some of the areas where loT and ML are being used at a rapid rate. Machine learning can help decode the hidden patterns in IoT data. It may complement or replace manual processes in critical areas with automated systems that use statistically derived behavior. In healthcare, wearable sensors used for tracking patient activity have been continuously producing a staggering amount of data. This paper proposes an IoT-based scalable architecture for detecting COVID-19-positive patients and storing and processing such massive amount of data on the cloud. The proposed architecture also employs machine learning algorithms for correct classification of patients. The proposed architecture employs gradient boosting classifier method for early detection of COVID-19 in the patient's body. In order to make the architecture scalable and faster in terms of computational power, the architecture employs cloud computing for data storage.

Synthesis and upconversion emission studies of CaYF5:Ho3+/Yb3+ phosphor and its applications in optical thermometry, fingerprint detection, and security ink†

In this work, a CaYF₅:Ho³⁺/Yb³⁺ upconversion phosphor was synthesized and its structural, morphological, and optical properties were studied. The upconversion emission study was performed at an excitation pump power density of 5 W cm⁻² and emissions at 544 nm, 650 nm and 747 nm due to the ⁵F₄(⁵S₂) → ⁵I₈, ⁵F₅ → ⁵I₈ and ⁵F₄(⁵S₂) → ⁵I₇ transitions of the Ho³⁺ ion, respectively were observed. From temperature-dependent upconversion spectra temperature sensitivity was calculated and sensitivity is found to be 14 × 10⁻³ K⁻¹ for the synthesized upconversion phosphor. The photothermal conversion efficiency of the prepared sample in ethanol medium was tested. Moreover, the sample was used to develop latent fingerprints on various surfaces and good contrast in recorded images is observed. The invisible ink was prepared using the upconversion phosphor and then written words were recorded in upconversion emission mode.

In this work, a CaYF₅:Ho³⁺/Yb³⁺ upconversion phosphor was synthesized and its structural, morphological, and optical properties were studied. Apart from these studies, latent fingerprint detection and security ink applications were also demonstrated using this phosphor.

Isolated bilateral lateral geniculate body necrosis following acute pancreatitis: A rare cause of bilateral loss of vision in a young female

Sudden bilateral visual loss because of bilateral lateral geniculate body (LGB) necrosis is a very rare entity. The mechanisms causing these isolated lesions have still not been fully understood. We report a case of sudden loss of vision in a 22-year-old female following an attack of acute pancreatitis, just after starting the paleo diet. Neuroimaging revealed bilateral LGB necrosis. Multidisciplinary approach was sought and she was subsequently managed successfully. On follow-up, her visual acuity showed improvement, and neuroimaging revealed resolution of hyperintensities in bilateral LGB with residual blooming suggestive of old hemorrhagic gliosis. The possible reasons for isolated lesions of the LGB are hemorrhagic infarction and osmotic demyelination. In the present case, we postulate a vascular pathology, possibly hypo-perfusion because of shock following acute pancreatitis.

Penetrating Abdominal Trauma: Descriptive Analysis of a Case Series From an Indian Metropolitan City

Introduction Penetrating abdominal trauma (PAT) is a major injury that patients present to the emergency department in developed and developing countries. There are many modes and causes of injury. The aim of this study is to analyse the patterns of presentation and parameters at assessment, including investigations, interventions and outcomes of penetrating abdominal trauma at a major trauma centre in an Indian metropolitan city. Methods This is an observational descriptive study done over 18 months at a major trauma centre in a metropolitan city in India. The study was registered with the institutional ethics committee and the patients were recruited after obtaining consent on admission. The relevant details were collected from the patient's electronic records after admission and analysed. Results Stab wounds in the 21-40-year-old subset were the commonest. The small intestine was the most commonly injured organ. The mortality rates and the duration of the hospital stay were similar to other case series of the same condition. Conclusion The analysis of our case series has highlighted the patterns and outcomes of penetrating abdominal trauma in an urban demographic of a developing economy. Individuals in the prime of their lives, unfortunately, are victims of this mode of injury. Better implementation of standard management protocols can improve outcomes.

Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a pragmatic, cluster-randomised trial in seven low-income and middle-income countries

BACKGROUND

Surgical site infection (SSI) remains the most common complication of surgery around the world. WHO does not make recommendations for changing gloves and instruments before wound closure owing to a lack of evidence. This study aimed to test whether a routine change of gloves and instruments before wound closure reduced abdominal SSI.

METHODS

ChEETAh was a multicentre, cluster randomised trial in seven low-income and middle-income countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, South Africa). Any hospitals (clusters) doing abdominal surgery in participating countries were eligible. Clusters were randomly assigned to current practice (42) versus intervention (39; routine change of gloves and instruments before wound closure for the whole scrub team). Consecutive adults and children undergoing emergency or elective abdominal surgery (excluding caesarean section) for a clean-contaminated, contaminated, or dirty operation within each cluster were identified and included. It was not possible to mask the site investigators, nor the outcome assessors, but patients were masked to the treatment allocation. The primary outcome was SSI within 30 days after surgery (participant-level), assessed by US Centers for Disease Control and Prevention criteria and on the basis of the intention-to-treat principle. The trial has 90% power to detect a minimum reduction in the primary outcome from 16% to 12%, requiring 12 800 participants from at least 64 clusters. The trial was registered with ClinicalTrials.gov, NCT03700749.

FINDINGS

Between June 24, 2020 and March 31, 2022, 81 clusters were randomly assigned, which included a total of 13 301 consecutive patients (7157 to current practice and 6144 to intervention group). Overall, 11 825 (88·9%) of 13 301 patients were adults, 6125 (46·0%) of 13 301 underwent elective surgery, and 8086 (60·8%) of 13 301 underwent surgery that was clean-contaminated or 5215 (39·2%) of 13 301 underwent surgery that was contaminated-dirty. Glove and instrument change took place in 58 (0·8%) of 7157 patients in the current practice group and 6044 (98·3%) of 6144 patients in the intervention group. The SSI rate was 1280 (18·9%) of 6768 in the current practice group versus 931 (16·0%) of 5789 in the intervention group (adjusted risk ratio: 0·87, 95% CI 0·79-0·95; p=0·0032). There was no evidence to suggest heterogeneity of effect across any of the prespecified subgroup analyses. We did not anticipate or collect any specific data on serious adverse events.

INTERPRETATION

This trial showed a robust benefit to routinely changing gloves and instruments before abdominal wound closure. We suggest that it should be widely implemented into surgical practice around the world.

FUNDING

National Institute for Health Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, Mölnlycke Healthcare.

Early Diagnosis and Prevention of Infections in Cirrhosis

Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective β-blocker; PPI, proton pump inhibitors.Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications, and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection; the incremental preventive strategies for infections and sepsi; and the consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors' use, appropriate use of β-blockers, and vaccinations for viral diseases including novel coronavirus disease 2019. Secondary prevention includes early diagnosis and a timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable improved outcomes.

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.

Maximum Likelihood Reconstruction of Water Cherenkov Events With Deep Generative Neural Networks

Large water Cherenkov detectors have shaped our current knowledge of neutrino physics and nucleon decay, and will continue to do so in the foreseeable future. These highly capable detectors allow for directional and topological, as well as calorimetric information to be extracted from signals on their photosensors. The current state-of-the-art approach to water Cherenkov reconstruction relies on maximum-likelihood estimation, with several simplifying assumptions employed to make the problem tractable. In this paper, we describe neural networks that produce probability density functions for the signals at each photosensor, given a set of inputs that characterizes a particle in the detector. The neural networks we propose allow for likelihood-based approaches to event reconstruction with significantly fewer assumptions compared to traditional methods, and are thus expected to improve on the current performance of water Cherenkov detectors.

POS0565 WORSE OUTCOMES LINKED TO ETHNICITY FOR EARLY INFLAMMATORY ARTHRITIS IN ENGLAND AND WALES: A NATIONAL COHORT STUDY

Background

Patients from ethnic minority backgrounds suffer considerable health inequality, with generally poorer health outcomes relative to the rest of the population.1 Further exploration of these differences is essential if we are to deliver the best care for all, and close the health gap for our patients.

Objectives

We used the National Early Inflammatory Arthritis Audit (NEIAA) to assess variability in care quality and treatment outcomes across ethnicities for patients diagnosed with early inflammatory arthritis (EIA) in England and Wales.

Methods

NEIAA is an observational cohort design. Data were from adult patients newly diagnosed with EIA, and seen by rheumatology in England and Wales between May 2018 and March 2020. Quality of care outcomes were assessed against six metrics contained within the National Institute for Health and Clinical Excellence (NICE) Quality Standard for Rheumatoid Arthritis.2 Clinical outcomes were measured using DAS28. Outcomes were compared between ethnic groups (White, Black, Asian, Mixed, Other), and adjusted for confounders (age, sex, smoking, comorbidity, seropositivity and disease severity at presentation) using Logistic regression models with multiple imputation for missing data.

Results

Data for 35,807 eligible patients were analysed, of whom 30,643 (85.6%) were White and 5,164 (14.6%) were from ethnic minority backgrounds: 1,035 (2.8%) Black; 2,617 (7.3%) Asian; 238 (0.6%) Mixed; 1,274 (3.5%) Other. A total of 12,955 patients had confirmed EIA. Of those, 11,315 were White and 1,640 were from ethnic minority backgrounds: 314 (2.4%) Black; 927 (7.1%) Asian; 70 (0.5%) Mixed; 329 (2.5%) Other.

Of 35,160 eligible patients who had data available, 14,803 (42.1%) were assessed by rheumatology within three weeks of referral. Of 9,900 EIA-eligible patients with data available, 5,642 (57.0%) started treatment within six weeks of referral. There were no significant differences in these outcomes by ethnicity. Ethnic minority patients did, however, have lower odds of disease remission at three months, relative to patients of White ethnicity (adjusted odds ratio 0.79; 95% CI: 0.65-0.96; p=0.02). This difference was due to lower odds of disease remission in Black and Asian patients, relative to White patients (Table 1). Ethnic minority patients were significantly less likely to receive initial treatment with methotrexate (0.68; 95% CI: 0.52-0.90; p=0.008) or with glucocorticoids (0.63, 95% CI: 0.49-0.80; p< 0.001).

Table 1.

Associations between ethnicity and disease remission at three months in EIA patients

ModelOdds ratio95% CIP-valueUnadjustedAll ethnic minority0.76(0.62,0.93)0.01backgroundsBlack0.48(0.34,0.67)<0.001Asian0.74(0.59,0.93)0.01Mixed0.61(0.28,1.35)0.22Other1.09(0.71,1.68)0.67Age and sex-adjustedAll ethnic minority0.78(0.63,0.96)0.01backgroundsBlack0.49(0.35,0.69)0.00Asian0.75(0.60,0.94)0.01Mixed0.63(0.28,1.39)0.25Other1.11(0.71,1.71)0.63Fully-adjustedAll ethnic minority0.79(0.65,0.96)0.02backgroundsBlack0.57(0.41,0.79)0.001Asian0.76(0.62,0.93)0.009Mixed0.63(0.27,1.46)0.29Other1.04(0.71,1.54)0.80

Conclusion

The results from this large cohort demonstrate that some minority ethnic groups are less likely to reach disease remission in the early months following an EIA diagnosis. Our results are not explained by delays in referral or treatment. Intitial treatment strategies varied across ethnic groups. These data highlight the need for investigation into the possible drivers of these inequitable outcomes and reappraisal of EIA management pathways.

References

[1]Greenberg JD, Spruill TM, Shan Y, Reed G, Kremer JM, Potter J, et al. Racial and ethnic disparities in disease activity in patients with rheumatoid arthritis. Am J Med. 2013;126(12):1089-98.

[2]NICE quality standard for rheumatoid arthritis in over 16s. Nice.org.uk. 2013 [cited 25 January 2022]. Available from: https://www.nice.org.uk/guidance/qs33/documents/previous-version-of-quality-standard.

Disclosure of Interests

Maryam Adas: None declared, Sathiyaa Balachandran: None declared, Sam Norton: None declared, Edward Alveyn: None declared, Mark Russell Speakers bureau: Has received speaker fees and educational grants from Janssen, Lilly, Menarini, Pfizer and UCB, Tom Esterine Speakers bureau: Patient review of P.I.S and consent form into lay language for KCL that was linked to Pharma company., Paul Amlani-Hatcher: None declared, Sarah Oyebanjo: None declared, Heidi Lempp: None declared, Jo Ledingham: None declared, Kanta Kumar Speakers bureau: Has received training form Pfizer and speaker fees 2021 from Janssen., Paid instructor for: Has received training form Pfizer, James Galloway Speakers bureau: Has received honoraria from AbbVie, Celgene, Chugai, Gilead, Janssen, Eli Lilly, Pfizer, Roche and UCB., Shirish Dubey: None declared.

Tinospora Cordifolia (Giloy)-Induced Liver Injury During the COVID-19 Pandemic-Multicenter Nationwide Study From India

Tinospora cordifolia (Giloy) is an herbal supplement commonly used in the Indian alternative medicine system Ayurveda. This herb has been promoted to the public in India as an immune booster to prevent novel coronavirus disease 2019. However, small reports have recently shown an association between Giloy use and the development of herb-induced liver injury (HILI) with autoimmune features in some patients. This large retrospective Indian multicenter study spanning 13 centers at nine locations was designed to identify features and outcomes of HILI temporally associated with Giloy use. Chemical and toxicological analyses of retrieved Giloy samples using state-of-the-art methods were also performed. We report 43 patients, of whom more than half were female, with a median time from initial Giloy consumption to symptom onset of 46 days. Patients presented with acute hepatitis, acute worsening of chronic liver disease (CLD, the most common clinical presentation), or acute liver failure. Causality assessment revealed probable liver injury in 67.4%. The most common autoantibody detected was anti-nuclear antibody. Liver biopsy in a subset revealed HILI associated with autoimmune features and hepatocyte and canalicular cholestasis and neutrophilic and eosinophilic infiltration. Conclusion: Giloy is associated with acute hepatitis with autoimmune features and can unmask autoimmune hepatitis (AIH) in people with silent AIH-related CLD. Further studies on the safety (and efficacy) of untested but heavily promoted herbals in alternative systems of medicine are an unmet need in the interests of public health and are especially important during this global health emergency.

Air pollution prediction with machine learning: a case study of Indian cities

The survival of mankind cannot be imagined without air. Consistent developments in almost all realms of modern human society affected the health of the air adversely. Daily industrial, transport, and domestic activities are stirring hazardous pollutants in our environment. Monitoring and predicting air quality have become essentially important in this era, especially in developing countries like India. In contrast to the traditional methods, the prediction technologies based on machine learning techniques are proved to be the most efficient tools to study such modern hazards. The present work investigates six years of air pollution data from 23 Indian cities for air quality analysis and prediction. The dataset is well preprocessed and key features are selected through the correlation analysis. An exploratory data analysis is exercised to develop insights into various hidden patterns in the dataset and pollutants directly affecting the air quality index are identified. A significant fall in almost all pollutants is observed in the pandemic year, 2020. The data imbalance problem is solved with a resampling technique and five machine learning models are employed to predict air quality. The results of these models are compared with the standard metrics. The Gaussian Naive Bayes model achieves the highest accuracy while the Support Vector Machine model exhibits the lowest accuracy. The performances of these models are evaluated and compared through established performance parameters. The XGBoost model performed the best among the other models and gets the highest linearity between the predicted and actual data.

An Overview of Vehicular Emission Standards

In India, the ambient air quality has been degrading from past few decades especially in urban areas. Vehicular emissions are amongst one of the major reasons for the deterioration of ambient air quality in such areas. This article is an effort to review the vehicular emission standards of the major countries (USA, Europe, Japan and Australia) and compare with Indian emission standards. However, there exists several differences in present emission standards followed by different countries. For instance, emission standards in USA are fuel neutral, while no separate weight categorization exists among light-duty vehicles (LDVs). In Europe, Japan, Australia and India, separate weight categorization and emission limits for both petrol and diesel vehicles are provided. It was observed that different driving test cycles used by different countries are the reasons for numerical differences in vehicular emission standards. To rectify this, a worldwide harmonized test cycle (WHTC) is introduced by United Nations Economic Committee for Europe (UNECE) that would represent real-world driving and verifies that the statutory emission limits are not exceeded during actual driving. Countries like Japan and Europe have already been following the WHTC, while some other countries may introduce the same in near future. Yet the real-world emissions across the world keeps on diverging. In such situation, harmonization of vehicle emission standards worldwide is a bit challenging, based on dynamics of road conditions, driving patterns, environmental conditions, etc. Thus, more concerted research is needed for evolution of a common universal emission standards implementable worldwide so that the uniformity in information and policies available to the common public could be maintained.

Spontaneous Miscarriage Management Experience: A Systematic Review

Background: The estimated frequency of spontaneous miscarriage is about a quarter of all clinically identified pregnancies in the United States. Women typically go to the emergency department (ED) or outpatient clinic when they experience symptoms, including but not limited to vaginal bleeding, abdominal pain, and contractions. The care that is provided varies from place to place.

Methods: Researchers searched articles from 2010 to 2021 for reports mentioning treatment for spontaneous abortion. Search terms included "miscarriage aftercare" and "spontaneous abortion care," seeking articles addressing the psychological effects of miscarriage and reporting patient experiences in different clinical settings. Data were independently reviewed, graded for evidence quality, and assessed for risk bias using the AMSTAR checklist.

Results: The search strategy yielded 2,275 articles, six of which met the inclusion criteria. Conservative, medical, and surgical management were provided, with surgical management being more common among women with higher education and socioeconomic status. All qualitative studies reported dissatisfaction with care provided in the emergency department, partially due to a lack of emotional support. Structured bereavement intervention was beneficial for women experiencing early pregnancy loss and led to fewer reports of despair. The quantitative studies referenced interventions that aided patients in coping with pregnancy loss and identified several factors influencing the type of treatment received as well as the patient's ability to cope with feeling depressed following a miscarriage.

Conclusion: Psychological management is not regularly addressed in the emergency department, and protocols including bereavement education for healthcare providers as well as patient involvement in management would improve the overall patient experience with spontaneous miscarriage care.

Gender-based differences in primary percutaneous coronary intervention in patients with myocardial infarction from a developing country: A retrospective cohort study

Introduction

Limited data exists about gender's impact on differences in risk factors and outcomes in our setting. Therefore, we sought to ascertain sex-related differences in patients with AMI in our setting.

Material and methods

This retrospective study analyzed data from 247 myocardial infarction patients hospitalized in a tertiary care hospital, between March and October 2020. After hospital admission, all patients underwent ECG, myocardial enzymes, troponin and other biochemical tests followed by primary PCI.

Results

Patients were divided in two groups male (n = 153, mean age 55.2 ± 11.0 years) and female (n = 94, mean age 58.4 ± 12.7 years). The prevalence of smoking was higher in males than females (22.8% vs. 3.1%, p < 0.01) and so was history of three-vessel disease (3VD; 18.9% vs. 7.4%, p = 0.013). History of myocardial infarction was lower in females than males (13.8% vs. 24.8%, p = 0.03) however the age did not vary significantly between the two groups (p = 0.21). Serum creatinine (sCr) levels (1.0 ± 0.77 μmol/L vs. 1.2 ± 0.73 μmol/L, p = 0.28) and body mass index (28.4 ± 5.3 vs 27.4 ± 4.8, p = 0.45) were lower in females as compared to males, however not statistically significant. The incidence of major adverse events, severe arrhythmia and in-hospital outcomes showed no significant difference (p > 0.05) between the two groups. Post-op TIMI score and average length of hospital stay were not statistically different either (3.29 ± 2.9 vs. 2.6 ± 1.7, p = 0.726).

Conclusion

Our study shows that females have a comparable age of onset of major cardiovascular events as that of males. Post-PCI clinical outcomes and in-hospital stay had no significant differences between the two groups.

What is already known on this topic:•

Limited data exists about gender's impact on differences in risk factors and outcomes STEMI in developing countries like Pakistan.

•

Previous analyses on gender disparities have revealed higher mortality in females compared to males when hospitalized for STEMI.

What this study adds:

•

The incidence of major adverse events during in-hospital stay showed no significant difference among gender.

•

The prevalence of smoking and 3VD in males was higher than in females. Despite of differences in co-morbidities between the groups, clinical outcomes remained consistent.

Instruction strategies for drug calculation skills: A systematic review of the literature

BACKGROUND

Medication errors and unsafe medication practices are a leading cause of injury and avoidable harm worldwide.

OBJECTIVES

The aim of this review was to (i) explore and identify evidence-based strategies to teach medication calculation skills by determining the most common errors and assess the quality, level, and role of the evidence, and (ii) describe instruction strategies for drug calculation skills development or improvement based on seven research-based principles for smart teaching.

DESIGN

Systematic review.

DATA SOURCES

CINAHL, PubMed, and PsycINFO.

REVIEW METHODS

The review followed Whittemore and Knafl's framework steps with an assessment of the studies reporting using PRISMA, STROBE, COREQ and categorizing their methods by evidence hierarchy and roles. Two authors independently assessed eligibility and extracted data.

RESULTS

From the total 1793 articles, 51 studies met the eligibility criteria. The studies included 9210 nursing students/nurses and mainly used a quantitative approach (67.5%), followed by qualitative (22.5%) and mixed methods (10.0%), with the students/nurses doing arithmetic and conceptual mistakes. The findings presented were low levels of evidence III (23.5%) and V (41.2%), quality Level B (82.4%), and 47.1% focused on choosing the appropriate teaching and intervention approaches (role of the evidence). The teaching strategies addressed multiple smart teaching principles, but mainly prior knowledge (principle 1, 39.2%). The least used strategies were those addressing the levers that influence motivation and behaviors such as value, expectations, and environment climate (principle 3, 13.7%). Two studies addressed five principles simultaneously.

CONCLUSIONS

Regarding teaching strategies, the most recurring strategies were early diagnostic assessments on knowledge, anxiety and/or self-confidence, considering knowledge organization with scaffolding complex tasks, being explicit about objectives and expectations, and usage of e-learning. However, e-learning was mainly used after 2018. Considering the low levels and quality of evidence, we recommend higher levels of research design for future research. Randomized Controlled Trials could be conducted when randomizing teaching methods per semester or questions embedded in software. Web-base software could be used to support teaching and research approaches.

Comparative Evaluation of Microleakage of Three Different Restorative Materials (Cention N, Zirconomer Improved and Glass Hybrid Restorative System) in Class V Cavity Restoration Using Stereomicroscope: In vitro Study

Aim and Objective: Microleakage is the most important factor responsible for the destruction of restoration margins. The aim of this study was to compare and evaluate the microleakage of three different restorative materials namely glass hybrid restorative system, zirconomer improved and Cention N under stereomicroscope. Materials and Methods: In this in-vitro experimental study, 45 Class V cavities were prepared on the buccal surface of maxillary premolars. The prepared cavities were divided into three groups for restoration with Cention N(group I), Zirconomer Improved(group II), Equiaforte (group III). All the samples were thermocycled for 500 cycles between 5-55°C initially and then immersed in 0.5% methylene blue for 24 hours before sectioning. All the sectioned samples were observed for microleakage under a stereomicroscope. Results: Data was analyzed using one way ANOVA test for comparison between three groups and the result revealed statistically significant difference between the groups(p<0.05). Post hoc Tukey test was used for intergroup comparison and it was observed that both Cention and Equiaforte are inferior to Zirconomer improved in terms of microleakage (p<0.05). Conclusion: Zirconomer improved exhibited lower microleakage when compared to Cention N and Equiaforte cements.

Reinduction of the Temporarily Deferred Donors for Laying the Foundation of Safe and Sustainable Blood Supplies: A Review in the Indian Context

Temporarily deferred donors are a forgotten pool of potential blood source. When dealt appropriately, they can easily be inducted back to the main stream pool of voluntary donors. Although there are multiple studies from India on the deferral rates and patterns; not much has been done with respect to the follow up of these donors and active efforts to bring them back to donate blood. In this narrative review, we discuss the impact of temporary deferral, factors affecting the return and appropriate strategies to improve the return rate of these donors.

Experimental investigations and multi criteria optimization during machining of A356/WC MMCs using EDM

In the current paper, the authors are intended to manufacture the aluminum based metal matrix composite (MMC) employing the stir casting process. Further, the fabricated composite sample is investigated for machining characteristics during the die sink electrical discharge machining process (EDM). EDM is most commonly employed to satisfy the special needs of industry such as developing deep holes and complex contours from high strength materials such as composites, alloys, smart materials, and functionally graded materials. In the current study A356 and 4%, tungsten carbide (WC) powder are considered as matrix and strengthening materials respectively to fabricate the MMCs. During the machining activity, the input factors like discharge current (Ip), Voltage (Vg), Pulse On-Time (Ton), and flushing pressure (P) are optimized for achieving optimum surface roughness (SR), Tool Wear Rate (TWR) and Material Removal Rate (MRR). To estimate the ideal set of process factors grey regression analysis (GRA) is used. From the results, it was observed that the GRA is found to perform better than the RSM.

Prophylactic Perioperative Terlipressin Therapy for Preventing Acute Kidney Injury in Living Donor Liver Transplant Recipients: A Systematic Review and Meta-Analysis

Background

Acute kidney injury (AKI) is common in the perioperative transplant period and is associated with poor outcomes. Few studies reported a reduction in AKI incidence with terlipressin therapy by counteracting the hemodynamic alterations occurring during liver transplantation. However, the effect of terlipressin on posttransplant outcomes has not been systematically reviewed.

Methods

A comprehensive search of electronic databases was performed. Studies reporting the use of terlipressin in the perioperative period of living donor liver transplantation were included. We expressed the dichotomous outcomes as risk ratio (RR, 95% confidence interval [CI]) using the random effects model. The primary aim was to assess the posttransplant risk of AKI. The secondary aims were to assess the need for renal replacement therapy (RRT), vasopressors, effect on hemodynamics, blood loss during surgery, hospital and intensive care unit (ICU) stay, and in-hospital mortality.

Results

A total of nine studies reporting 711 patients (309 patients in the terlipressin group and 402 in the control group) were included for analysis. Terlipressin was administered for a mean duration of 53.44 ± 28.61 h postsurgery. The risk of AKI was lower with terlipressin (0.6 [95% CI, 0.44-0.8]; P = 0.001). However, on sensitivity analysis including only four randomized controlled trials (I² = 0; P = 0.54), the risk of AKI was similar in both the groups (0.7 [0.43-1.09]; P = 0.11). The need for RRT was similar in both the groups (0.75 [0.35-1.56]; P = 0.44). Terlipressin therapy reduced the need for another vasopressor (0.34 [0.25-0.47]; P < 0.001) with a concomitant rise in mean arterial pressure and systemic vascular resistance by 3.2 mm Hg (1.64-4.7; P < 0.001) and 77.64 dyne cm^-1.sec^-5 (21.27-134; P = 0.007), respectively. Blood loss, duration of hospital/ICU stay, and mortality were similar in both groups.

Conclusions

Perioperative terlipressin therapy has no clinically relevant benefit.

Synthesis of NaYF4:Ho3+/Yb3+ colloidal upconversion phosphor and its application for OCT-based imaging, temperature sensing, fingerprinting and security ink

In this work, an NaYF4:Ho3+/Yb3+ upconversion phosphor in colloidal form was synthesized and then its suitability for image contrast enhancement in optical coherence tomography (OCT) and photothermal (PT) OCT imaging was analysed.

Monitoring of Chemical Markers in Extraction of Traditional Medicinal Plants (Piper nigrum, Curcuma longa) Using In Situ ReactIR

BACKGROUND

The fingerprinting and quantification of marker compounds from medicinal plants is a domain of the herbal industry for quality/quantity control parameters.

OBJECTIVE

The main objective of this study is the application of the in situ ReactIR technique for measuring the concentration of different components during the extraction process of different medicinal plants.

METHOD

In this study we have performed the extraction of two-marker compounds, viz. piperine from Piper nigrum and curcumin from Curcuma longa plants, using various solvents (dichloromethane and methanol). The progress of extraction was monitored using an in situ Fourier transform infrared (FTIR) probe instrument and an automated reactor.

RESULTS

In this communication, using the in situ ReactIR technique we developed a method which demonstrates the relative quantification of marker analytes, optimizes extraction time and type of solvents to be used for different analytes during the extraction process.

CONCLUSIONS

To the best of our knowledge, this is the first report of relative quantification and structural information of marker compounds during the process of extraction using in situ FTIR.

HIGHLIGHTS

The present study highlights the real-time monitoring, in situ quantification, and structural information of marker compounds during the process of extraction of medicinal plants using in situ FTIR.

O-172 Metabolic imaging of cumulus cells to predict embryo implantation potential

Study question

Can non-invasive metabolic imaging detect variations in cumulus cell metabolic parameters associated with a viable pregnancy of the corresponding embryo?

Summary answer

Noninvasive metabolic imaging can detect differences in the cumulus cell metabolic signatures between embryos that led to a viable pregnancy and those that did not. 

What is known already

Bidirectional metabolic cooperativity between the human oocyte and its surrounding cumulus cells is essential for the oocyte to acquire full developmental competency. However, the relationship between cumulus cell metabolism and oocyte viability is not well established. Metabolic imaging uses Fluorescence Lifetime Imaging Microscopy (FLIM) to non-invasively measure autofluorescence of the endogenous molecules, NADH and FAD+, which are essential coenzymes for cellular respiration and glycolysis. This technique enables quantitative information for these coenzyme concentrations and regarding metabolite enzyme engagement. We have previously shown that this technique is an effective tool for quantitatively measuring metabolic state of mouse embryos.

Study design, size, duration

Cumulus cell clusters (n = 617 from 193 patients) were dissected from cumulus-oocyte complexes prior to insemination or ICSI, vitrified, warmed and their metabolic function assessed. We conducted a prospective observational study to evaluate to what extent cumulus cells from an oocyte that led to a viable pregnancy (presence of a viable fetus &gt;7 weeks gestation) after transfer of the corresponding embryo metabolically differed from those that did not. We also evaluated the associations with embryo morphology.

Participants/materials, setting, methods

Cumulus cell metabolism was assessed non-invasively using FLIM to measure the autofluorescence of NADH and FAD+. Overall a single FLIM measurement provides a total of 8 metabolic parameters (4 for NADH and 4 for FAD+). An additional parameter, the Redox Ratio was also acquired (NADH intensity / FAD+ intensity). We used multilevel models to investigate the association of cumulus cell metabolic parameters with the morphology of the corresponding embryo and clinical outcome.

Main results and the role of chance

Of the cumulus samples analyzed, 75 corresponded to embryos that did not result in a viable pregnancy, and 24 that did so. Significant associations were observed between cumulus cell FAD+ fraction bound to enzyme (p = 0.007), FAD+ long lifetime (p = 0.01) and FAD+ short lifetime (p &lt; 0.001) and the clinical outcome of the corresponding embryo. These significant associations held up after controlling for age. We used a support vector machine algorithm to distinguish between embryos that led to a viable pregnancy and those that did not. The optimum hyperplane derived from a support vector machine algorithm predicted whether a sample with random cumulus cell metabolic parameters will lead to a viable pregnancy or not with an accuracy of 80%. Embryo morphological assessments were stratified as excellent, good, fair and poor. We found no significant associations between cumulus cell metabolic signatures and embryo morphology evaluated on day 3. Significant associations of FAD+ short lifetime (p &lt; 0.001) and day 5 embryo morphology were found. However, these associations were not significant after controlling for age. 

Limitations, reasons for caution

Although we observed significant variations in metabolic parameters, further studies with larger sample sizes are required. Despite our validation studies showing no significant effect of vitrification on cumulus cell metabolic parameters, analyses with fresh clusters are needed to confirm our results.

Wider implications of the findings

Noninvasive FLIM imaging detects metabolic variations of cumulus masses and their association with embryo viability. The ability to correlate metabolic measurements of cumulus clusters, in combination with embryo morphology assessments and patient clinical characteristics, with embryo fate paves the way for this approach to be used in a clinical setting.

Trial registration number

5RO1HD092559-03