Azithromycin therapy for prevention of chronic lung disease of prematurity (AZTEC): a multicentre, double-blind, randomised, placebo-controlled trial

BACKGROUND

Systematic reviews have reported conflicting evidence on whether macrolide antibiotics reduce rates of chronic lung disease of prematurity (CLD) in at-risk preterm infants born at less than 30 weeks' gestation, including in those colonised with pulmonary Ureaplasma spp. Since an adequately powered trial has been lacking, we aimed to assess if the macrolide azithromycin improved survival without the development of physiologically defined moderate or severe CLD in preterm infants.

METHODS

AZTEC was a multicentre, double-blind, randomised, placebo-controlled trial conducted in 28 tertiary neonatal intensive care units in the UK. Infants were eligible if they were born at less than 30 weeks' gestation and had received at least 2 h of either non-invasive (continuous positive airway pressure or humidified high flow nasal cannula therapy) or invasive respiratory support (via endotracheal tube) within 72 h of birth. Eligible infants were randomly allocated in a 1:1 ratio using random permuted blocks of four to receive either intravenous azithromycin at 20 mg/kg per day for 3 days followed by 10 mg/kg for 7 days, or to placebo. Allocation was stratified by centre and gestational age at birth (<28 weeks vs ≥28 weeks). Azithromycin and placebo vials were encased in tamper-evident custom cardboard cartons to ensure masking for clinicians, parents, and the research team. The primary outcome was survival without development of physiologically defined moderate or severe CLD at 36 weeks' postmenstrual age. Outcomes and safety were analysed on an intention-to-treat basis (all randomly allocated infants, regardless of any post-randomisation events). The study was registered with ISRCRN (11650227) and is closed.

FINDINGS

Infants were recruited between Oct 9, 2019, and March 22, 2022. 799 (53·1%) of 1505 eligible infants underwent random allocation; three infants were withdrawn, including consent to use their data, leaving 796 infants for analysis. Survival without moderate or severe CLD occurred in 166 (42%) of 394 infants in the intervention group and 179 (45%) of 402 in the placebo group (three-level adjusted OR [aOR] 0·84, 95% CI 0·55-1·29, p=0·43). Pulmonary Ureaplasma spp colonisation did not influence treatment effect. Overall, seven serious adverse events were reported for the azithromycin group (five graded as severe, two as moderate), and six serious adverse events were reported in the placebo group (two severe, two moderate, and two mild), as assessed by the local principal investigators.

INTERPRETATION

Since prophylactic use of azithromycin did not improve survival without development of physiologically-defined CLD, regardless of Ureaplasma spp colonisation, it cannot be recommended in clinical practice.

FUNDING

UK National Institute for Health and Care Research.

Assessment of cyclone risk and case study of Gaja cyclone using GIS techniques and machine learning algorithms in coastal zone of Tamil Nadu, India

Cyclones can cause devastating impacts, including strong winds, heavy rainfall, storm surges, and flooding. The aftermath includes infrastructure damage, loss of life, displacement of communities, and ecological disruptions. Timely response and recovery efforts are crucial to minimize the socio-economic and environmental consequences of cyclones. To accelerate the time-consuming risk assessment process, particularly in geographically diverse regions, a blend of multi-criteria decision-making and machine learning models was utilized. This novel approach swiftly assessed cyclone risk and the impact of the Gaja cyclone in Nagapattinam, India. The method involved assigning weights to distinct criteria, unveiling notable vulnerability aspects like elevation, slope, proximity to the coast, distance from cyclone tracts, Lu/Lc, population density, proximity to cyclone shelters, household density, accessibility to healthcare facilities, NDVI, and levels of awareness. Daddavari, Ettugudi, Kodikarai, Vedharanyam, Velankanni, and Thirupoondi face high/extreme cyclone risk. Nagore, Nagapattinam, Pillai, Enangudi, and Sannanllur have low/no threat. To further enhance the precision of the study, machine learning algorithms like SVM, SAM, and MLC were deployed. These models were instrumental in generating pre- and post-cyclone land use maps. The influence of Gaja cyclones effects shows decreasing of agriculture land from 34% to 30%, aquaculture increase 1%, barren land decrease from 8% to 6%, Built-up land decrease from 15% to 13%, land with scrub and salt pan also decrease from 21% to 17% and 10%-8%. Mostly effect of Gaja cyclone is dramatic increase of water body from 8% to 21%. Conducting cyclone risk zone analysis and pre/post-cyclone Land Use Land Cover (LULC) detection in Nagapattinam offers valuable insights for disaster preparedness, infrastructure planning, and climate resilience. This study can enhance understanding of vulnerability and aid in formulating strategies to mitigate cyclone impacts, ensuring sustainable development in the region.

Can we predict urethral length of boys? - An observational study

INTRODUCTION

An additional knowledge about normal anatomy of urethra in boys can improve clinical outcome of any urological interventions. This will also reduce catheter related complications like intra vesical knotting and urethral injuries. At present there is no systematic data available which has studied the urethral length of boys. We have done this study to analyse the length of urethra in boys.

AIM

The aim of the study is to measure the urethral length in Indian children from the age of 1 year till 15 years and plot a nomogram. Furthermore to analyse the influence of anthropometry on urethral length and derived a formula to predict the urethral length in boys.

STUDY DESIGN

This is a single institution prospective observational study. After obtaining clearance from the institutional review board, a total of 180 children from the age of 1-15 were recruited for the study. The urethral length was measured during Foley's catheter removal. Other data like age, weight, and height of the patient are collected and the obtained values were analysed with SPSS software. The acquired figures were further used to derive formulae to predict urethral length.

RESULTS

A nomogram of urethral length based on age was plotted. With collected figures, five separate formulae were derived to calculate the urethral length based on the age, height and weight. Furthermore for day-to-day use we have deduced a formulas to calculate urethral length which are simplified forms of original formulae.

DISCUSSION

The length of urethra of a new-born male is 5 cm, which attains 8 cm by three years of age and to 17 cm by adulthood. There were attempts to measure the urethral length in adults using cystoscopy, Foley's catheter and different imaging techniques like Magnetic Resonance Imaging and dynamic retrograde urethrography. Simplified formulae which has been derived from this study for clinical use is Urethral length = 8.7 + Age (in year) × 0.55 CONCLUSION: Our results will complement the current anatomical understanding of the urethra. This evades some rare complications of catheterisation and facilitate reconstructive procedures.

Reduction in prevalence of spousal physical violence against women in India: evidence from three national surveys

Spousal physical violence (PV) against women is considered to be major health issue in developing countries. Lifetime physical violence is a composite outcome consists of hit, kick, beat, slap and threatened with weapon, perpetrated by the husband. The study aims to examine changes in prevalence and specific risk factors for PV from 1998 to 2016 in India. This study analyzed data from a cross sectional epidemiological survey in 1998-1999, NFHS-3 (2005-2006) and NFHS-4 (2015-2016) data. There was a significant decline of about 10% (95% CI: 8.8%-11.1%) in PV. Major risk factors for change in PV were husband's use of alcohol, illiteracy and socio-economic status of the household. The Protection of Women from Domestic Violence Act may have played a role in reducing the PV. Even though there was a decline in PV, actions have to be implemented from the root level to ensure women empowerment.

A Site-Based Analysis of Relationship Between Clinicopathological Factors and Their Influence on Locoregional Recurrence in Oral Squamous Cell Carcinoma

In India, oral cancers are the major cause of cancer-related death. Tongue and buccal mucosa being the major subsites in oral cancer have varying clinicopathological presentations. This study is intended to know the difference in clinicopathological behavior of these two subsites. This retrospective study included 474 patients of which 232 patients had tongue cancer and 242 patients had buccal alveolar complex (BAC) cancer. Comparison between the pathological characters including pattern of nodal involvement was analyzed. Disease-free survival (DFS) and factors influencing the DFS were analyzed and compared using Cox regression analysis. Mean age of the study population was 52.7 years. Tongue oral squamous cell carcinoma (OSCC) differed significantly from BAC OSCC in terms of age of presentation, tumor staging, and perineural invasion. Among neck nodal involvement, tongue OSCC commonly involved level IIa (p < 0.001) whereas BAC involved level Ib (p < 0.001). At a median follow-up of 27 months, 141 patients had disease recurrence, tongue OSCC commonly recurred in neck (p = 0.008), and BAC OSCC relapsed at primary site (p = 0.001). Patients older than 45 years with BAC cancer had lesser risk of recurrence (HR, 0.30; 95% CI, 0.2-0.5; p < 0.0001). Pathological tumor stage in tongue cancer (HR, 14.9; 95% CI, 2.6-84.8; p = 0.002) and grade of tumor differentiation in BAC OSCC (HR, 9.2; 95% CI, 1.9-43.3; p < 0.005) were the most significant factors that influenced tumor recurrence. There was a significant difference in factors influencing disease recurrence among tongue and BAC OSCC. Also, pattern of nodal metastasis and pattern of recurrence were different. Hence, further research on OSCC may be done site specific.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-023-01750-8.

Trends in prevalence and determinants of severe and moderate anaemia among women of reproductive age during the last 15 years in India

BACKGROUND

Anaemia is a serious global public health problem that disproportionally affects children, adolescent girls, and women of reproductive age, especially pregnant women. Women of reproductive age are more vulnerable to anaemia, particularly severe and moderate anaemia leads to adverse outcomes among pregnant women. Despite continuous Government efforts, anaemia burden still poses a serious challenge in India. The objective of this study is to assess the trends in prevalence and determinants of severe and moderate anaemia among women of reproductive age between 15 and 49 years.

METHOD

We used three rounds of the large-scale National Family Health Survey (NFHS) India, conducted on a representative sample of households using a cross-sectional design across the country in 2005-06, 2015-16 and 2019-2021. We included all the women aged 15 to 49 years in our analysis. We used the same haemoglobin (Hb) cut-off values for all the three rounds of surveys to ensure comparability. Generalized linear regression analyses with log link were done. Survey weights were incorporated in the analysis.

RESULTS

The prevalence of severe or moderate Anaemia (SMA) in non-pregnant women was 14.20%, 12.43% and 13.98%; it was 31.11%, 25.98% and 26.66% for pregnant women in 2006, 2016 and 2021 respectively. The decline in SMA prevalence was 1.54% in non-pregnant women, whereas it was 14.30% in pregnant women in 15 years. Women who were poor, and without any formal education had a higher risk for severe and moderate Anaemia.

CONCLUSION

Despite the intensive anaemia control program in India, SMA has not declined appreciably in non-pregnant women during the last two decades. Despite the decline, the prevalence of SMA was about 26% in pregnant women which calls for a comprehensive review of the existing anaemia control programmes and there must be targeted programmes for the most vulnerable and high-risk women such as rural, poor and illiterate women of reproductive age to reduce the burden of anaemia among them.

Exact correction factor for estimating the OR in the presence of sparse data with a zero cell in 2 × 2 tables

In case-control studies, odds ratios (OR) are calculated from 2 × 2 tables and in some instances, we observe small cell counts or zero counts in one of the cells. The corrections to calculate the ORs in the presence of empty cells are available in literature. Some of these include Yates continuity correction and Agresti and Coull correction. However, the available methods provided different corrections and the situations where each could be applied are not very apparent. Therefore, the current research proposes an iterative algorithm of estimating an exact (optimum) correction factor for the respective sample size. This was evaluated by simulating data with varying proportions and sample sizes. The estimated correction factor was considered after obtaining the bias, standard error of odds ratio, root mean square error and the coverage probability. Also, we have presented a linear function to identify the exact correction factor using sample size and proportion.

Assess the Risk Level of Acute Coronary Syndrome (ACS) Among Patients with Chest Pain in Emergency Department

Background: Fast and accurate chest pain risk stratification in the Emergency Department (ED) is critical. The HEART score predicts the short-term incidence of major cardiac events (MACE) in this population and divides them into three risk categories. Our aim was to describe the chest pain population, to characterize the subset of patients with acute coronary syndrome (ACS), and to assess the prognostic value of the Manchester triage system and the HEART score.Chest pain is a common symptom in all health care settings and may be due to a extensive variety of disease conditions. Some of those will be because of treatable causes, including musculoskeletal problems with favorable outcomes; others will be because of probably deadly life-threatening conditions, inclusive of acute coronary syndrome. Methods: Descriptive research design was adopted to conduct the study with( n=60) samples who met the inclusion criteria at Saveetha Medical College and Hospital. Samples were selected by convenience sampling Saveetha Medical College and Hospital, Chennai. A total of 60 Samples who met the inclusion criteria is selected by using convenience sampling technique. After selecting the sample, the investigator introduced him-self and explained the purpose of the study to the participants. Informed consent was obtained from the participants after assured confidentiality. The demographic and clinical variables were collected by using multiple choice questionnaires. Assess the risk level of acute coronary syndrome (ACS) by using HEART score immediately after receiving the chest pain patients with emergency. The data were collected, and score evaluation will take 10 -15 minutes after The data were tabulated and analyzed by descriptive and inferential statistics Result: The risk level of acute coronary syndrome (ACS) among patients with chest pain in emergency department. Study finding shows that out of 60 samples in risk level of acute coronary syndrome (ACS) among patients with chest pain in emergency department by using HEART Score 36(60%) had high risk, 13(21.7%) had intermediate risk and11(18.3%)had low risk. Conclusion: The chest pain is the most associate feature of major adverse cardiac events in the conditions. Chest pain is a common presentation at the Emergency Room. Rapid identification level of risk acute coronary syndrome (ACS)isacrucial component of thetriage. HEART Score is an efficient score in triaging acute chest pain patients at the Emergency Department

Difference in clinical presentation and their significance in oral squamous cell carcinoma: A retrospective analysis

BACKGROUND

Oral squamous cell carcinoma (OSCC) remains the most common cancer among Indian men. OSCC involving the tongue and bucco alveolar complex (BAC) behaves differently. Nevertheless, the differences in clinical features and symptoms between the two subsites and their relation to pathology remain largely unexplored.

STUDY DESIGN

The study compared various clinical parameters and pathological factors between tongue cancer patients and patients with BAC cancer.

RESULTS

Among 474 patients, 232 had tongue cancer and 242 had BAC cancer. Except for the ulcer, 30% of patients with OSCC were asymptomatic at presentation. Compared to tongue cancers, lesions confined to BAC present at an advanced stage (P = 0.006). Multivariate analysis showed that dysphagia in tongue cancer (P = 0.020) and external swelling or lesion in BAC cancers (P = 0.002) were significant predictors of an advanced stage of the disease. On histopathology, perineural invasion (PNI) was significantly associated with tongue (P = 0.008) compared to BAC cancers (P = 0.015). Cancers of the tongue with pain and referred otalgia had a significantly higher depth of invasion (DOI), compared to those without pain (DOI - no pain 6.9 mm, pain 9.9 mm, and referred otalgia 11.4 mm).

CONCLUSIONS

Patients with OSCC present late and in an advanced stage of the disease. Among tongue cancers, clinical history of pain was significantly associated with DOI and PNI, the significance of which needs to be prospectively analyzed. Clinical history in OSCC can be used as predicting factor for an advanced pathological stage of the disease. It also had an influence on various pathological characters, which is subsite specific.

OP0187 COMPARATIVE EFFICACY OF NON-BIOLOGIC IMMUNOSUPPRESSANTS IN TAKAYASU ARTERITIS

Background

The choice of immunosuppressant (IS) in patients with Takayasu arteritis (TAK) is often arbitrary due to lack of comparison studies.

Objectives

In this retrospective, we aimed to compare the efficacy of 3 non biologic IS including azathioprine (AZA), mycophenolate mofetil (MMF) and methotrexate (MTX) in inducing and maintaining sustained remission in patients with TAK.

Methods

Patients with a diagnosis of TAK, attending our clinics between Jan 2000 and May 2019 were identified. Those who satisfied either ACR or Sharma’s classification or EULAR PRINTO PRES criteria and/or had angiographic evidence of Takayasu arteritis with a minimum 2 follow up visits were included. Patients who received upfront biologics were excluded. The patients were matched for parameters statistically different among three groups using propensity score analysis. Clinical details at the index visit defined as the time of initiation of first IS and follow up visits were prospectively recorded and retrospectively noted from electronic medical records. The primary outcomes were attainment of complete remission and relapses. Disease activity was assessed by Indian Takayasu arteritis score (ITAS), C-reactive protein and angiograms. Relapse was defined as ITAS-A(CRP) >=2 and/or progression in angiograms and/or escalation of steroid dose and/or switching of IS due to active disease. The baseline variables of patients receiving AZA, MMF and MTX were compared using chi square test or Mann Whitney U test. The comparative efficacy of IS to induce complete remission was calculated using logistic regression and presented as odds ratio (95% CI). The cumulative risk of relapse was calculated using Cox-proportional hazards model with hazards ratio and 95% confidence interval (CI) after adjusting for duration of symptoms and juvenile onset disease. The patients were censored at the time of relapse or time of switching to another IS or last follow up whichever was the earliest. AZA was arbitrary chosen as the reference drug for all the analysis. The missing values (visits) were not included in analysis and the last observation was carried forwards. Data after switching of immunosuppressant of interest till the last follow up visit was analysed descriptively. All analysis were done for matched and unmatched patient groups. The results of matched and unmatched cohort were similar, hence the results of unmatched groups are presented here.

Results

Overall, 234 patients satisfying inclusion criteria including 53 (22.6%), 156 (66.7%) and 25 (10.7%) patients receiving AZA, MMF, Mtx respectively were studied. Complete remission (CR) was attained in 183 (78.2%) patients after initiating steroids and IS. 79.2%, 77.6% and 80% of patients receiving AZA, MMF or MTX respectively achieved CR yielding an odds ratio of 1.10 (0.52-2.37), p= 0.80 and 0.96 (0.29-3.12), p= 0.94 for MMF and MTX as compared with AZA. CR was sustained in 22 (52.4%), 80 (66.1%) and 11 (55%) of patients on AZA, MMF and MTX respectively. When compared with AZA, adjusted hazards ratio (AHR) of relapse was 1.51 (0.79-2.89), p=0.21 and 2.45 (1.00-5.99), p= 0.05 with MMF and MTX after adjusting for juvenile onset disease, type 1 and type 4 disease by angiography. The frequency of remission in patients who received MMF was significantly higher in patients who presented with type 4 disease (96%) as compared with the patients who had other types on angiography (74%), p= 0.017. Conversely, 63.6% of patients with type 1 disease responded to MMF which was significantly lower than 81.3% of patients with other angiographic types (p=0.037) while no such differential response was observed for AZA or MTX. Retrospective design and small number of patients in AZA and Mtx group were the major limitations of the study.

Conclusion

In our patients with TAK, all the three IS were comparable in inducing remission. Azathioprine was equal to MMF but superior to MTX in maintaining relapse free sustained response. The efficacy of MMF differed across various angiographic types of disease.

References

None

Disclosure of Interests

None declared

ZFTA-fusion in supratentorial ependymomas: low prevalence in South Asians and no correlation with survival

BACKGROUND

- Supratentorial ependymomas (STEs) are an aggressive group of ependymoma, topographically distinct from their posterior fossa and spinal counterparts. ZFTA fusion-positive cases have been reported to account for the majority of STEs, although data on its association with poorer outcomes is inconsistent.

MATERIALS AND METHODS

- We assessed the prevalence of the ZFTA-fusion by RT PCR and FISH in a cohort of 61 patients (68 samples) with STE. Our primary outcome was to determine the role of the ZFTA-fusion on progression-free and overall survival of patients with STE. Our secondary objectives were to assess the impact of ZFTA-fusion on NF-kB pathway signalling via surrogate markers of this pathway, namely COX-2, CCND1 and L1CAM.

RESULTS

- ZFTA-fusion was noted in 21.3% of STEs in our cohort. The presence of this rearrangement did not significantly impact the PFS or OS of patients with STEs and was not associated with upregulation of markers of the NF-kB pathway. Only gross total resection was significantly associated with better progression-free survival.

CONCLUSION

- In contradiction to prior reports from across the world, the ZFTA-fusion is far less prevalent among our population. It does not appear to drive NF-kB signaling or significantly affect outcomes. Gross total resection (GTR) must be attempted in all cases of STE and adjuvant radiation and/or chemotherapy employed when GTR is not achieved.

Simulation with a colour indicator to help reduce contamination during airway management in COVID-19 times: An experience from a tertiary centre in India

BACKGROUND AND AIMS

The coronavirus disease 2019 (COVID-19) pandemic has initiated modified protocols for aerosol-generating procedures. A simulation study using dye was conducted to highlight contamination at intubation and extubation and to encourage adherence to the new COVID-19 protocol among anaesthesia personnel in our institution.

METHODS

A video demonstrating the new COVID-19 protocols was circulated in the Department of Anaesthesiology a week prior to the study. Thirty teams, each comprising an anaesthesia resident and a staff technician, were enroled. Each team was asked to demonstrate the steps of preparation, intubation and extubation on a mannequin in a COVID-19 scenario. Checklists were used to assess points of contamination and adherence to the protocols. Following debriefing, a repeat simulation was conducted. The use of a dye highlighted the points of contamination. The study subjects provided feedback on the usefulness of the session and practical difficulties encountered in adapting to the new protocols.

RESULTS

The average contamination scores decreased by 3.4 (95% confidence interval (CI): 2.4-4.4, P < 0.001) in the post-debrief session. Adherence to the steps of the modified protocol improved by a score of 2.7 (CI: 3.6-1.83) among anaesthesiologists and by 4.3 (CI: 5.3-3.3) among technicians. Further, 93% felt that the use of the colour indicator reinforced awareness of the possible points of contamination.

CONCLUSION

Simulation with a low-fidelity mannequin by using colour indicator for secretions is an effective teaching tool to reduce health hazards during airway management in COVID-19 times.

Analysis of Early Impact of COVID-19 on Presentation and Management of Oral Cancers - an Experience from a Tertiary Care Hospital in South India

Oral cancers are the leading cause of cancer-related death in Indian men. Currently steps to contain the transmission and treatment of COVID-19 pandemic have crippled the entire health care system. With hospitals running short of resources, the oncological practice became standstill, especially during the initial phase. This is a retrospective study among patients who presented to our tertiary care hospital in early 3 months of COVID-19 era(ECE) with respect to pre-COVID-19 era(PCE). The study includes patients discussed in multidisciplinary tumor board(MDT)(421 in ECE Vs 31 in PCE) and those who underwent surgery(192 in ECE Vs 26 in PCE). The presentation and outcomes of oral carcinoma were compared between the two eras. There was a significant drop in the number of patients who presented during ECE. Though mean age and gender remained comparable between groups, there was a statistical difference in relation to demographic profile of patient (p value < 0.001). Among operated during ECE, 80% had a significantly advanced tumor stage (p value < 0.034) and advanced composite stage (p value < 0.049). Among patients discussed in MDT during ECE, 38.7% were deemed inoperable which is double the number when compared with PCE (p value < 0.009). Results of our study showed a higher incidence of advanced stage disease during ECE, with many patient turning inoperable. Thus, the survival of newly diagnosed oral carcinoma patients will be worser. In the management of oral cancer both early stage and advanced stage should have the same priority. Immediate resumption of safe oncology services is mandatory to curtail the current issues.

Apnoeic oxygenation during simulated difficult intubation in obese patients: comparison of buccal ring, adair and elwyn tube versus nasal cannula: A prospective randomized controlled trial

Background:

Apnoeic oxygenation is an established method of increasing safe apnoea times during intubation and this is of more importance in obese patients. The usefulness of buccal Ring, Adair and Elwyn (RAE) oxygenation has been established in previous studies, however a head-to-head comparison with nasal cannula (NC) is lacking.

Aim:

The aim of this study was to compare apnoea time with buccal RAE (BR) versus NC in obese patients.

Setting and Design:

This was a prospective, nonblinded randomized controlled trial conducted in a tertiary hospital where fifty American Society of Anaesthesiologists Physical Status Class I and II, obese patients with body mass index ≥30, posted for elective surgery were included.

Materials and Methods:

Following adequate preoxygenation and standard induction of anaesthesia, a prolonged simulated difficult laryngoscopy was performed during which oxygen was provided via either BR or NC. The primary outcome was time to desaturation to <95% or 10 min, which ever occurred first. Other outcomes recorded were lowest saturation, time to resaturation and highest end tidal carbon di oxide.

Statistical Analysis:

Mean with standard deviation (SD) or median with inter quartile range were used for continuous variables and absolute number with percentage were used for categorical variables. The primary outcome was analyzed using Kaplan-Meier survival curves, and log-rank tests were applied.

Results:

Patient characteristics were similar in both arms. The mean apnoea time in seconds (SD) in the BR group, 375.3 (116.6) was higher than the NC group 316.1 (94.1), P = 0.054. From the Kapan Meier curves the probability of desaturating to <95% was earlier in the NC group than the BR group (P = 0.092). The other outcomes were similar in both groups.

Conclusion:

This is the first study that demonstrates that oxygenation via a BR is better than NC in providing apnoeic oxygenation in obese patients and can safely be used when NC are contraindicated.

Concurrent T790M and L858R mutations in treatment-naïve metastatic non-small-cell lung cancer: A therapeutic challenge – Current treatment strategies and promising therapies of the future in a nutshell

De novo (pretreatment) epidermal growth factor receptor T790M mutation in non-small-cell lung cancer (NSCLC) is rare when detected by standard genotyping methods. We present a case of concurrent de novo T790M and L858R mutations detected by direct sequencing in treatment-naïve metastatic NSCLC. This case is worthy of mention as the presence of this mutation has a bearing on the choice of treatment. This article aims to evaluate the clinical outcome for metastatic NSCLC with de novo T790M mutation and formulate an optimum treatment plan in this clinical scenario. The novel targeted therapy agents have also been reviewed.

A Rare Survival in Celphos Poisoning

Aluminium phosphide poisoning releases phosphine gas which causes inhibition of cytochrome oxidase, inhibition of electron transport chain and thereby myocardial suppression. It is known to cause various electric abnormalities in the heart from ST-T depression to fatal tachyarrhythmias. Here we present a case of celphos poisoning presenting with both supraventricular tachycardia and ventricular tachycardia.

Medical Image Reliability Verification Using Hash Signatures and Sequential Square Encoding

Increased growth of information technology in healthcare has led to a situation where the security of patient information is more important and is a critical issue. The aim of the proposed algorithm is to provide a framework to verify the integrity of the medical images. In this paper, the integrity of the medical images is verified by embedding hash signatures using the sequential square embedding technique. This technique is as efficient as the diamond encoding technique but with increased payload capability. The medical image is first divided into the region of interest (ROI) block and the signature block. The hash signatures are determined by dividing the ROI into nonoverlapping blocks. During the data hiding stage, the hash signatures are embedded in randomly chosen pixel pairs in the signature block using the sequential square encoding (SSE) technique. In the experimental results, the data hiding capacity of the proposed SSE technique is verified in terms of peak signal-to-noise ratio. Also, the medical image integrity is substantiated by comparing the L2 norm between computed and extracted hash signatures. Modifications such as contrast enhancement, rotation, scaling, and changing the image information result in increased L2 norm; thus, the integrity of the medical images can be verified. The parameters required for embedding, such as the embedding parameter and the seed for random sequence generation, are encrypted and communicated to the receiving end. Hence, the proposed algorithm provides a secure framework for medical image integrity verification.

Study on biofilm formation in burn wound infection in a pediatric hospital in Chennai, India

Infection is one of the major causes of death in pediatric burns in India. This work was conducted in an exclusive Children's Hospital (KKCTH) with a total of 220 beds, of which ten beds in the burn unit and two isolation beds in the 28-bed PICU are for burns patients (more than 20% TBSA burns) with sepsis. In this study, 30 burn wound swab isolates obtained from 14 pediatric burns patients (admitted to the burns ward and transferred to PICU) from November 2013 to March 2014 were investigated. Cultures were done on the first day for all patients and empirical antibiotic administration was started for those with septic burns (14 in total) with piperacillin-tazobactam and vancomycin. Antibiotics were changed according to antibiotic sensitivity reports. Cultures were repeated for culture positive cases on the fifth day. Further antibiotic treatment was based on this culture report. When the general condition of the patient did not respond to highlevel antibiotics, biofilm formation was suspected and evaluated as the possible cause of antibiotic resistance. For these patients, an enhanced method of wound debridement and albumin transfusions were used to improve their general condition. Microbial identification and antimicrobial sensitivity testing was done for all 30 isolates. The predominant bacteria were Pseudomonas aeruginosa, Acinetobacter and Staphylococcus aureus. Most of the Acinetobacter and Staphylococcus aureus showed multidrug resistance. Biofilm formation was studied using the Tissue Culture Plate (TCP) method for all bacterial isolates, and results showed that most of the MDR isolates formed biofilm.

Response of keloid fibroblasts to Vitamin D3 and quercetin treatment - in vitro study

Keloid scars continue to pose a challenge to clinicians as the treatment armamentarium lacks a formidable agent to tackle them. We have undertaken an in vitro study based on the mechanism of action of Vitamin D3 and quercetin on isolated keloid fibroblasts. Dose-dependent action on the reduction of cellular proliferation, collagen synthesis and induction of apoptosis by Vitamin D3 and quercetin are analyzed and probable mechanism of action is elaborated. This study thus opens up newer avenues in tackling keloid scars effectively.

High voltage electrical burn injuries in teenage children: case studies with similarities (an Indian perspective)

From 1992 to 2012, a total of 911 paediatric burns were admitted and treated at Kanchi Kamakoti Childs Trust Hospital Intensive Burn Care Unit, of these 28 children had suffered electrical injuries and burns. 7 teenagers suffered high voltage electrical burn injuries: 2 were involved in train accidents which caused fatal electrical injuries, and 5 had electrical burn injuries caused by similar types of accidents, requiring Paediatric Intensive Care Unit (PICU) care, repeated surgeries and extensive rehabilitation. A common factor among these latter 5 patients was that they were injured by overhead high electrical voltage cables. Their management was labour intensive and highly costly. In this report, the type of accident, the electrical voltage that produced burns and the treatment details are elaborated. Findings included similarities in age and type of accident, and failure to implement safety procedures and apply standard norms of high voltage transmission feeder lines.

Advantages of collagen based biological dressings in the management of superficial and superficial partial thickness burns in children

Collagen based dressings for acute burn wound management have been extensively used in India, particularly in the city of Chennai. Due to the high levels of humidity in our city, closed dressings become infected and treatment with topical antimicrobials, like Silver Sulfadiazine cream, quickly become desiccated. Collagen membrane dressings were manufactured by the biomaterial laboratory of the Central Leather Research Institute (CLRI), Government of India in Chennai, and then the process was patented. Collagen was extracted from bovine skin and Achilles tendons, and then reconstituted. This was used on burn wounds as dressings after clearance from the Institutional Review Board and Ethics Committees of the Hospital and CLRI. Continued research in this field to enable resulted in the design of silver sulphadiazine loaded alginate microspheres which were embedded in the reconstituted collagen. Controlled delivery of silver sulphadiazine. This collagen membrane was used in chronic infected burns. Low molecular weight heparin was given subcutaneously to improve wound healing in burn injuries and collagen membrane dressings were also applied. After several trials the process technology was patented. The advantages and disadvantages of the collagen membrane cover is elaborated in a group of 487 pediatric burn patients. The trial was conducted at the burn unit of Kanchi Kamakoti Childs Trust Hospital (KKCTH) in Chennai, India.

Expression of fibrocyte markers by keloid fibroblasts: an insight into fibrosis during burn wound healing - a preliminary study

In extensive burns it becomes difficult for fibroblasts to migrate from the periphery of the healthy tissue and colonize the injured area. Even under such circumstances healing takes place, and this is attributed to the differentiation of circulating fibrocytes which enter the wound site. This normal cell type is identified in keloid fibroblasts: it expresses fibrocyte markers and secretes extra cellular matrix proteins. In-vitro collagen contraction assay reveals that fibrocytes contract collagen gels with an efficacy similar to normal fibroblasts. The contribution of fibrocytes to the formation of keloid fibroblasts in post-burn healing is discussed.

2,3-Dibromo-3-(4-chloro-phen-yl)-1-(4-nitro-thio-phen-2-yl)propan-1-one

The title compound, C(13)H(8)Br(2)ClNO(3)S, exhibits whole-mol-ecule disorder over two orientations in a 0.805 (6):0.195 (6) ratio. The dihedral angles between the thio-phene ring [maximum deviations = 0.017 (4) and 0.033 (9) Å for the major and minor components, respectively] and the chloro-substituted phenyl ring are 32.1 (5) (major component) and 26.3 (18)° (minor component). In the crystal, C-H⋯Cl and C-H⋯O hydrogen bonds link the mol-ecules into sheets lying parallel to the bc plane. Aromatic π-π stacking inter-actions [centroid-centroid distance = 3.550 (7) Å] are also observed.

(E)-N′-(4-Chlorobenzylidene)-1-benzofuran-2-carbohydrazide monohydrate

The title compound, C₁₆H₁₁ClN₂O₂·H₂O, exists in an E conformation with respect to the N=C bond. The benzofuran ring system forms a dihedral angle of 1.26 (4)° with the benzene ring. In the crystal, mol­ecules are linked via (N,C)—H⋯O bifurcated acceptor hydrogen bonds and (O,O,C)—H⋯O trifurcated acceptor hydrogen bonds, forming layers parallel to the bc plane.

3-Methyl-4-[2-(4-nitro-phen-yl)hydrazin-1-yl-idene]-5-oxo-4,5-dihydro-1H-pyrazole-1-carbothio-amide

The asymmetric unit of the title compound, C(11)H(10)N(6)O(3)S, contains two independent mol-ecules, each of which is stabilized by an intra-molecular N-H⋯O hydrogen bond, forming an S(6) ring motif. In one mol-ecule, the pyrazole ring forms a dihedral angle of 10.93 (14)° with the benzene ring. The corresponding dihedral angle in the other mol-ecule is 7.03 (14)°. In the crystal, mol-ecules are linked via pairs of (N,N)-H⋯O bifurcated acceptor bonds which, together with C-H⋯O hydrogen bonds, form sheets parallel to (001).

N'-[(E)-4-Bromo-benzyl-idene]-1-benzofuran-2-carbohydrazide monohydrate

The title compound, C₁₆H₁₁BrN₂O₂·H₂O, exists in a trans conformation with respect to the N=C bond [1.2815 (14) Å] and the benzofuran ring system forms a dihedral angle of 2.96 (5)° with the benzene ring. In the crystal, the ketone O atom accepts two O—H⋯O and one C—H⋯O hydrogen bond, and the water O atom accepts an N—H⋯O inter­action. Together, these lead to infinite layers lying parallel to (100).

Current scenario in chemical burns in a developing country: Chennai, India

Chemical burns are not uncommon in India. Both accidental and non-accidental chemical burns are encountered in our setting. In the paediatric age group, chemical burns are mainly accidental. Analysis of chemical burn admissions to the Burn Units of a medical college hospital, and to an exclusively tertiary care children's hospital in Chennai, India, from 2001 to 2010 is described. A total number of 75 adults and 38 children are included in the study. Detailed analysis of age, sex, percentage of burn total body surface area (TBSA %), causative agents, aetiology (accidental or non-accidental), treatment instituted, mortality, and outcome are reported.

Profile of burn sepsis challenges and outcome in an exclusive children's hospital in Chennai, India

A group of 273 paediatric patients admitted to Kanchi Kamakoti Childs Trust Hospital Burn Unit, Chennai, India between the years 2004 to 2010 were analysed retrospectively. Of these, 89 were suffering from sepsis and septic shock and 15 died. Strict adherence to antibiotic administration and to the Paediatric Intensive Care Unit (PICU) and management protocol improved the outcome, especially in 2009 and 2010.

Low molecular weight heparin mediated regulation of nitric oxide synthase during burn wound healing

Nitric oxide (NO) is an important signal molecule in many types of cells and tissues. Efficiently balanced NO production was noted to play an important role in the healing of burns. Inducible nitric oxygen synthase (iNOS) is responsible for the discontinuous synthesis of high amounts of NO. Dysregulation of nitric oxygen synthase (NOS) activity has been associated with multiple organ failure in burn patients and may therefore represent a novel therapeutic target in such circumstances. Heparin and low molecular weight heparin (LMWH) derivatives may offer therapeutic benefit for inflammatory diseases, whereas NO plays a protagonist role. Burn injury in humans has been associated with a significant increase in NO(2)/NO(3) (nitrite/nitrate) plasma levels. In this prospective study burn patients were treated with and without LMWH to provide evidence that LMWH has NOS-reducing activity. This was proved by colorimetric and immunohistological studies. There was a significantly different NOS activity between the treated and the control group and our results suggest that LMWH was more effective in the treatment of burn patients through iNOS inhibition. Treatment with LMWH was initiated within 6 h post-burn.

2,2'-Dithio-dianiline: a redetermination at 100 K

Structural studies of the title compound [systematic name: 2,2′-(disulfanedi­yl)dianiline], C₁₂H₁₂N₂S₂, were previously performed at room temperature [Gomes de Mesquita (1967 ▶). Acta Cryst.23, 671; Lee & Bryant (1970 ▶). Acta Cryst. B26, 1729; Ribar et al. (1975 ▶). Bull. Yugoslav. Crystallogr. Centre, A10, 68]. The results of the current redetermination allow a clarification of the nature of the intra- and inter­molecular N—H⋯S hydrogen bonding described in the literature for this compound. On cooling to 100 K, the unit cell contracts most in the c axis, and it changes rather less in the directions involving the strongly hydrogen-bonded chains, which are the a and b axes. In the crystal structure, N—H⋯N hydrogen bonds link neighbouring mol­ecules into two-dimensional frameworks parallel to the ab plane. An additional inter­molecular N—H⋯S hydrogen bond has also been established, based on freely refined H-atom positions. Inter­molecular C—H⋯π inter­actions further stabilize the crystal structure.

Ethyl 4-[3,5-bis-(trifluoro-meth-yl)phen-yl]-6-methyl-2-oxo-1,2,3,4-tetra-hydro-pyrimidine-5-carboxyl-ate

In the title compound, C₁₆H₁₄F₆N₂O₃, the dihydro­pyrimid­in­one ring adopts an envelope conformation. In the crystal, mol­ecules are linked by N—H⋯O and C—H⋯O hydrogen bonds into a ribbon-like structure along the b axis. In the ribbon, a pair of bifurcated acceptor N—H⋯O and C—H⋯O bonds generate an R₂¹(6) ring motif. Adjacent ribbons are linked via C—H⋯F hydrogen bonds.

Ethyl 4-(2,4-difluoro-phen-yl)-6-methyl-2-oxo-1,2,3,4-tetra-hydro-pyrimidine-5-carboxyl-ate

In the title compound, C₁₄H₁₄F₂N₂O₃, the dihydro­pyrimidin­one ring adopts a flattened boat conformation. The difluoro­phenyl group is disordered over two orientations with occupancies of 0.544 (3) and 0.456 (3). The methoxy­carbonyl group is disordered over two positions with occupancies of 0.580 (8) and 0.420 (8). In the crystal, mol­ecules are linked into centrosymmetric dimers by paired N—H⋯O hydrogen bonds and the dimers are linked into a ribbon-like structure along [100] by further N—H⋯O hydrogen bonds.

Ethyl 4-(2,4-difluoro-phen-yl)-6-methyl-1-phenyl-2-thioxo-1,2,3,4-tetra-hydro-pyrimidine-5-carboxyl-ate

The asymmetric unit of the title compound, C₂₀H₁₈F₂N₂O₂S, contains four independent mol­ecules, two of which are paired into a dimer by way of two N—H⋯S hydrogen bonds. The other two independent mol­ecules are paired into two centrosymmetric dimers via pairs of inter­molecular N—H⋯S hydrogen bonds. In one mol­ecule, the carboxyl­ate O atoms, methyl­ene and methyl groups attached to the benzene ring are disordered between two positions in a 0.908 (3):0.092 (3) ratio. In two of the independent mol­ecules, the F and H atoms of the diflourophenyl ring are flip-flop disordered (i.e. by 180° about the C—C bond axis linking the ring to the rest of the molecule) in a 3:2 ratio. The crystal packing is stabilized by weak inter­molecular C—H⋯O hydrogen bonds.

A molecular method for typing Herpes simplex virus isolates as an alternative to immunofluorescence methods

BACKGROUND

Typing of Herpes simplex virus (HSV) isolates is required to identify the virus isolated in culture. The methods available for this include antigen detection by immunofluorescence (IF) assays and polymerase chain reaction (PCR). This study was undertaken to standardize a molecular method for typing of HSV and compare it with a commercial IF reagent for typing.

OBJECTIVES

To compare a molecular method for typing HSV isolates with a monoclonal antibody (MAb) based IF test.

STUDY DESIGN

This cross-sectional study utilized four reference strains and 42 HSV isolates obtained from patients between September 1998 and September 2004. These were subjected to testing using an MAb-based IF test and a PCR that detects the polymerase ( pol ) gene of HSV isolates.

RESULTS

The observed agreement of the MAb IF assay with the pol PCR was 95.7%. Fifty four point eight percent (23/42) of isolates tested by IF typing were found to be HSV-1, 40.5% (17/42) were HSV-2, and two (4.8%) were untypable using the MAb IF assay. The two untypable isolates were found to be HSV-2 using the pol PCR. In addition, the cost per PCR test for typing is estimated to be around Rs 1,300 (USD 30), whereas the cost per MAb IF test is about Rs 1,500 (USD 35) including all overheads (reagents, instruments, personnel time, and consumables).

CONCLUSION

The pol PCR is a cheaper and more easily reproducible method for typing HSV isolates as compared to the IF test. It could replace the IF-based method for routine typing of HSV isolates as availability of PCR machines (thermal cyclers) is now more widespread than fluorescence microscopes in a country like India.