Perceptions of theatre team members to robotic assisted surgery and the aid of technology in colorectal surgery

The implementation of robotic assisted surgery (RAS) has brought in a change to the perception and roles of theatre staff, as well as the dynamics of the operative environment and team. This study aims to identify and describe current perceptions of theatre staff in the context of RAS. 12 semi-structured interviews were conducted in a tertiary level university hospital, where RAS is utilised in selected elective settings. Interviews were conducted by an experienced research nurse to staff of the colorectal department operating theatre (nursing, surgical and anaesthetics) with some experience in operating within open, laparoscopic and RAS surgical settings. Thematic analysis on all interviews was performed, with formation of preliminary themes. Respondents all discussed advantages of all modes of operating. All respondents appreciated the benefits of minimally invasive surgery, in the reduced physiological insult to patients. However, interviewees remarked on the current perceived limitations of RAS in terms of logistics. Some voiced apprehension and anxieties about the safety if an operation needs to be converted to open. An overarching theme with participants of all levels and backgrounds was the 'Teamwork' and the concept of the [robotic] team. The physical differences of RAS changes the traditional methods of communication, with the loss of face-to-face contact and the physical 'separation' of the surgeon from the rest of the operating team impacting theatre dynamics. It is vital to understand the staff cultures, concerns and perception to the use of this relatively new technology in colorectal surgery.

Correction of curvature in single stage hypospadias repair with foreskin reconstruction

INTRODUCTION

Many surgeons offer foreskin reconstruction (FR) as a routine part of hypospadias repair. We present a step-by-step video of the procedure of Tubularised Incised Plate (TIP) repair, FR and dorsal plication through a ventral skin incision.

MATERIALS AND METHODS

A ventral incision is made between the inner preputial mucosa and the outer skin extending below the meatus. Ventral degloving is carried out. The dissection is extended laterally around the corporal bodies. The point of maximal curvature (PMC) is marked on the dorsal midline. A vertical incision is made and closed transversely with 5-0 prolene suture in a Heineke- Mikulicz fashion. Urethroplasty is performed in 2 layers using 7-0 polydioxanone (PDS). Spongioplasty and ventral dartos are used as barrier layers. Glansplasty is performed in 2 layers.FR is carried out in 3 layers.

DISCUSSION

Curvature correction is key to good outcome. Dorsal degloving can be achieved through a ventral incision allowing exposure of the dorsal midline for plication sutures.

RESULTS

The patient had good cosmetic and functional outcome at 1 month follow up.

CONCLUSION

FR can be safely performed during TIP repair for distal hypospadias repair. Curvature of less than 30° can be corrected through a ventral incision only.

A consensus process to identify research priorities in paediatric urology in the United Kingdom

INTRODUCTION

Paediatric urologists manage a spectrum of conditions, much of the evidence for relevant treatment pathways is of low quality. For many conditions treatment varies according to location and surgeon; children with the same condition might have surgery in one unit but watchful waiting in another. Underlying this variation are differences in opinion, and insufficient high-level evidence with few prospective randomized studies. Such studies may be challenging to design, fund and recruit into, and are more likely to succeed if there is a collaborative approach. Research prioritization is a tool to identify the research of most value. Delphi methodology is an interpretive technique aiming to gain the consensus view of interested parties. The British Association of Paediatric Urologists (BAPU) set out to ascertain consensus on what paediatric urologists, working in the UK, consider to be areas of priority for research. This paper describes the process used, and the resulting list of research questions.

METHODS

A scoping survey of paediatric urologists in the UK was undertaken to identify an initial set of research questions. These were refined by the BAPU research committee (BAPU RC), then prioritized using a modified Delphi process. During Stage 1a multiple new research questions were submitted leading to Stage 1b, an interim process. All UK paediatric urologists were invited to take part in Stage 2 of the prioritization process.

RESULTS

Sixty-five questions were submitted to the scoping survey by 24 paediatric urologists. The BAPU RC refined these to 60 questions, which were submitted to Stage 1a of the modified Delphi process. Sixty-seven people completed Stage 1a, at the same time submitting 224 additional research questions. The BAPU RC revised the entire question set, ensuring the key subject of the original question was not altered and novel questions were retained. The BAPU RC undertook interim scoring of the resultant 79 questions, the top scoring 25 questions plus 5 lower scoring 'wild card' questions (to ensure the breadth of the specialty was represented) were put forward to Stage 2. A total of 65 people completed Stage 2, including a lay representative. A list of 30 priority research questions was generated; the top 10 includes management of neuropathic bladder, posterior urethral valves, antibiotic prophylaxis, DSD & CAH, continence, male external genitalia, VUR and transition care (Table).

CONCLUSION

This process has provided BAPU, paediatric urologists in the UK, and funders with areas of research considered a priority in the specialty.

Can paediatric surgical registrars safely perform supervised hypospadias surgery?

INTRODUCTION

Hypospadias repair is regarded as a technically demanding, complex procedure, with variable outcomes. Therefore, it tends to be performed by consultants, with limited trainee involvement. We aimed to study the clinical outcomes of supervised registrars performing proximal and distal hypospadias repairs, compared to their consultant mentors.

METHODS

We undertook a retrospective review of all primary hypospadias repairs performed between April 2013-April 2022 at our tertiary paediatric urology centre. Redo repairs and patients lost to follow-up were excluded. Pre-operative anatomy, theatre time, grade of primary surgeon (registrar (trainees and non-training middle grades) or consultant), operative technique, follow-up duration, complications, and reoperation rates were recorded. The procedures were assessed in two groups according to the primary operator: registrar or consultant. The Zwisch scale is used to describe level of consultant support. Registrars as primary operators received "passive help" or "supervision" (Zwisch levels 3/4). Consultants as primary operators provided registrars with "show-and-tell" or "active help" (Zwisch levels 1/2).

RESULTS

270 procedures performed on 228 patients met the inclusion criteria. 109 were performed by registrars and 161 by consultants. In both groups, median age was two years (p = 0.23). Median theatre time was similar (registrars 2.8 h vs. consultants 2.7 h, p = 0.88), as was median follow-up (registrars 25months, vs. consultants 21months, p = 0.99). Operations performed by registrars were 76% distal and 24% proximal; and by consultants were 62% distal and 38% proximal. The overall urethroplasty complication rate was similar, at 24% for registrars and 23% for consultants (p = 0.89). The summary table shows the distribution of different complications. Re-operation rate was 16% in both groups (p = 0.99). Complications were further assessed according to operation type (TIP vs. two-stage repair).

DISCUSSION

Contrary to popular belief amongst hypospadiologists, we found complication rates were similar for registrar and consultant surgeons. We question that involvement of registrars increases complications. The literature demonstrates safety of trainee performance of limited steps of the procedure. However our institution permits registrars to perform up to the whole hypospadias repair under direct supervision, with no predefined limit to their involvement.

CONCLUSION

Paediatric surgical registrars can be safely supervised to have substantial involvement in proximal and distal hypospadias repair, without compromising the duration or outcomes of surgery. We hope that allowing more registrar involvement can lead to faster acquisition of surgical skills, whilst remaining under the safety of senior supervision. Increasing opportunities for those with an aptitude for hypospadias repair can equip them with skills and confidence for entering fellowship training.

Highly Stable MWCNT@NVP Composite as a Cathode Material for Na-Ion Batteries

A 3D framework with Nasicon structured polyanionic Na₃V₂(PO₄)₃ (NVP) has been emphasized as a leading cathode material for sodium-ion batteries (SIBs) due to its high working voltage plateau, structural stability, and good rate performance. Herein, pristine NVP and MWCNT@NVP composite synthesized via a facile solid-state method are examined and compared as cathode materials for Na-ion batteries. The morphological study confirms the uniform distribution of MWCNTs in the pristine NVP structure. Impedance spectroscopy clearly confirms more diffusion of Na ions for the MWCNT@NVP composite as compared to pristine NVP, considering its diffusion coefficient which directly implies on an increase in specific capacity. MWCNT@NVP (FNV-2) showed specific discharge capacity 110 mAhg-1 at 0.1C current rate which is almost stable at higher current rates with marginal fading. However, the pristine NVP shows capacity loss at a higher current rate. It is noteworthy that the MWCNT@NVP composite shows stable performance with marginal specific capacity fading (1%) compared to pristine (15%). This is because of the mechanical integrity and stability afforded to the composite by the intertwined MWCNT framework in the MWCNT@NVP composite matrix against electrode degradation during the electrochemical reaction. More significantly, even at a higher current rate, that is, at 10 C, the composite recorded a very stable and excellent Columbic efficiency of 97% with a reversible specific capacity of 94 mAhg^-1 after 2000 cycles. An enhanced electrochemical performance, that is, rate capability and cycling stability, demonstrates the high potential of the MWCNT@NVP composite for Na-ion storage. Moreover, a sodium-ion full cell with hard carbon demonstrated a reversible capacity of 103 mAhg^-1 at C/20 current rate, which clearly demonstrates that MWCNT@NVP is a promising cathode material for sodium-ion batteries.

Evaluation of immunogenicity post two doses of inactivated SARS-CoV-2 vaccine, Covaxin after six months

We have evaluated the immunogenicity of two dose of Covaxin given at a one-month interval to two adult populations, i.e. COVID-19 naïve-vaccinated individuals (n = 118) and COVID-19 recovered individuals (n = 128) with the vaccination. The immune response in the study population were assessed at three follow-ups, namely at one month post first dose, one and six months after the second dose. The persistence of S1RBD IgG and neutralizing antibodies for six months post vaccination was observed at different time intervals. The enhanced immune response was observed in both the participant groups. The study emphasizes the need for a booster dose post six months of vaccination.

Results of in situ fixation of Andersson lesion by posterior approach in 35 cases

STUDY OBJECTIVE

Due to the rarity of the Andersson lesion (AL), the literature is ambiguous regarding the type of surgical fixation, need for debridement and deformity correction. The purpose of this retrospective study is to evaluate the efficacy, feasibility and functional outcome of posterior fixation in AL.

MATERIALS AND METHODS

This study included 35 patients having thoracolumbar AL operated for in situ fixation and fusion with minimum of 24-month follow-up. VAS (Visual Analogue Score) back pain, ODI (Oswestry Disability Index), Frankel's grade were compared and analyzed. Union status was noted with complications.

RESULTS

The mean age of 35 patients was 56.34(± 11.3) years with average follow-up of 51.49 months. Two patients had AL at two levels. 27/37 AL were at discal level. Average estimated blood loss (EBL) was 276.43 ml and duration of surgery was 130.43 min. On an average, operated segments needed 7.77 screws. There were ten minor complications without long-term sequel. Neurological improvement was noted in 30 patients. Average preoperative VAS score improved from 8.69 to 3.14, ODI score improved from 68.76 to 18.77 at final follow-up which were significant (p < 0.05). There was significant improvement in Frankel's grading (Z = - 4.354, P = 0.00).

CONCLUSIONS

Surgical management of AL by posterior approach and posterior stabilization can give satisfactory results without the need of extensive anterior reconstruction, bone grafting or deformity correction procedures without added morbidity and complications.

A study on stock market investors during COVID phase – prospect theory approach

At the macro-level, behavioral finance challenges classic financial theories. It shows that investor behavior in the real world is incompatible with the fundamental assumption of rationality in traditional finance, as studied by Sedaghati. While taking decisions, including financial decisions, rational thoughts are not involved, as suggested by modern theory. Additionally, these decisions are taken by them are also often inconsistent. Contrarily, human decisions are subject to several irrational principles, as in an evaluator study by Kannadhasan. These decisions are taken by considering the risks and returns involved. Prospect theory is one of the many theories derived from behavioral finance was first invented in a 1979 paper by Daniel Kahneman and Amos Tversky. It is commonly seen as the best explanation of how people evaluate risk in experimental settings, as researched by Barberis. This theory mainly includes how individuals or groups of investors decide between the alternatives under the umbrella of risk and uncertainty. This research evaluates the stock investors’ behaviors during the COVID-19 phase in India using prospect theory; many factors affect the decision of stock investors, such as loss aversion, risk aversion, certainty effect, reflective effect, etc., observed by Kahneman & Tversky. This study explores the possibility of factors of prospect theory on investors’ decisions about their investments during the COVID-19 phase. The results provide insights into how individual investors’ decisions vary during this pandemic situation.

A Phase IV Study on Safety, Tolerability and Efficacy of Dolutegravir, Lamivudine, and Tenofovir Disoproxil Fumarate in Treatment Naïve Adult Indian Patients Living with HIV-1

Purpose

WHO recommends dolutegravir (DTG) based regimens as first-line treatment for HIV-1 infection. However, few studies have been conducted in Indian population. Hence, our study evaluated the safety, tolerability, and efficacy of DTG 50 mg with Tenofovir and Lamivudine (300/300mg) fixed dose combination in treatment naïve adult Indian patients.

Methods

This was an open label, multicenter, prospective, interventional, phase IV study conducted across 14 sites between February 2019 and July 2020. 24 weeks was the treatment duration for each subject. The primary end point was to assess the incidence of adverse events (AEs) and secondary end points were to assess the proportion of patients achieving plasma HIV-1 RNA levels <50 copies/mL at week 24 and change in CD4+ cell count from the baseline. Safety analysis was conducted using Safety Analysis Set and efficacy analysis was carried out using Full Analysis Set and Per protocol set.

Results

A total of 288 patients were screened; 250 were enrolled; and 229 completed the study. 389 AEs were reported from 58% of patients. Of these, 61 were related to study treatment. One event of decreased creatinine clearance led to study discontinuation. One serious event of pyrexia was reported, which was unrelated to the study drug. The most common AEs were headache (18%), pyrexia (14%), vomiting (6.4%) and upper respiratory tract infections (6%). No deaths were reported. At week 24, 86.8% of the patients achieved plasma HIV-1 RNA levels <50 copies/mL and the mean CD4 cell count increased from 350.2 (SD, 239.73) at baseline to 494.6 (SD, 261.40) with an average increase of 143.2 (SD, 226.14) cells.

Conclusion

This study demonstrated the safety and efficacy of DTG based regimen in treatment naïve HIV-1 patients in Indian population and support use of DTG as first-line treatment regimen.

Gap Statistics for Confined Particles with Power-Law Interactions

We consider the N particle classical Riesz gas confined in a one-dimensional external harmonic potential with power-law interaction of the form 1/r^{k}, where r is the separation between particles. As special limits it contains several systems such as Dyson's log-gas (k→0^{+}), the Calogero-Moser model (k=2), the 1D one-component plasma (k=-1), and the hard-rod gas (k→∞). Despite its growing importance, only large-N field theory and average density profile are known for general k. In this Letter, we study the fluctuations in the system by looking at the statistics of the gap between successive particles. This quantity is analogous to the well-known level-spacing statistics which is ubiquitous in several branches of physics. We show that the variance goes as N^{-b_{k}} and we find the k dependence of b_{k} via direct Monte Carlo simulations. We provide supporting arguments based on microscopic Hessian calculation and a quadratic field theory approach. We compute the gap distribution and study its system size scaling. Except in the range -1<k<0, we find scaling for all k>-2 with both Gaussian and non-Gaussian scaling forms.

Conflict situation in a suburban hospital, India: Reasons and measures to minimize

Health care has a prominent place in society and as a settingrequired to serve and care for its public and stimulate overallphysical, psychological, and social health. It has a distinctobligation to generate a healthy workplace. Conflict and diversityare intrinsic in health care, and conflict in interdisciplinaryteams is an accepted norm and unescapable. Thus, astudy was conducted to understand reasons for the conflictamongst varied levels of healthcare staff in a 150 bedded multispecialtyhospital in an Indian city. A Survey of 200 respondents(Healthcare and managerial staff) revealed that lack ofappreciation, job stress, and competition within the department(32%) were the major reasons for differences amongstthe employees. Concerning approaches adopted, compromisingand collaborating methods scored more (38% and38.6%, respectively). The results have shown that, in general,managers are familiar with conflict resolution techniques andbelieve in motivating their staff to increase their levels of performanceand retain them with the hospital. However, thereis a need to make the human resource system more robustand accommodating to ensure varied healthcare professionalsfrom different qualification backgrounds and job roles aretreated equitably

1160 LEARN (Urological Teaching in British Medical Schools Nationally): A Multicentre Cross-Sectional Study

Introduction

Urology is a common rotation for UK Foundation Year (FY) doctors, and accounts for &gt;25% of acute surgical referrals. In 2012, the British Association of Urological Surgeons (BAUS) produced ‘An Undergraduate Syllabus for Urology’, advising on common clinical areas of urology to be covered during medical school. However, its national uptake remains unknown. LEARN aims to assess undergraduate urology teaching across UK medical schools.

Method

LEARN is the largest ever multicentre cross-sectional study of undergraduate urology teaching. Year 2-5 medical students and FY1 doctors were invited to complete a survey between 3rd October-20th December 2020. The primary objective is to compare current undergraduate urology teaching against the BAUS syllabus. Secondary objectives investigate the type and quantity of teaching provided, the reported performance rate of GMC mandated urological procedures, and the proportion of those considering urology as a career.

Results

A total of 7,611/8,346 (91.2%) responses from 39 medical schools that met the inclusion criteria were analysed. 16.5% of responses were newly appointed FY1 doctors. In their undergraduate training, the most commonly taught topics were urinary tract infection, acute kidney injury and haematuria; the least taught topics were male urinary incontinence, male infertility and erectile dysfunction. 90.6% and 86.3% had reported performing catheterisation as undergraduates on male and female patients respectively, and 16.9% had considered a career in urology.

Conclusion

LEARN provides the largest evaluation of any undergraduate specialty teaching. It has identified areas to improve teaching, to equip the future workforce with the competencies to manage urological pathology, irrespective of future career choice.

764 Human Factors in Operative Theatres During the Covid-19 Pandemic: A Cross-sectional Analysis of Operating Theatre Staff Experiences in a Regional Centre

Introduction

In the already high-risk, high-stress environment of the operating theatre, operating during Covid-19 has brought its own unique challenges. Communication, teamwork and anxiety related new operating practices secondary to Covid-19 are hypothesised to have a negative impact on patient care.

Method

We conducted a single-centre online survey of operating theatre staff from 22nd June–6th July 2020. Respondents completed 18 human factors questions related to COVID-19 precautions including communication, teamwork, situational awareness, decision making, stress, fatigue, work environment and organisational culture. Questions consisted of yes/no responses, multiple choice and Likert items. Kruskall-Wallis tests, Chi-Squared, Mann Whitney U tests, Spearman’s correlation coefficient, lambda and Cramer’s V tests were used. Free-text responses were also reviewed.

Results

116 theatre staff responded. Visual (90.5%), hearing/ understanding (96.6%) difficulties, feeling faint/lightheaded (66.4%) and stress (47.8%) were reported. Decreased situational awareness was reported by 71.5% and correlated with visors (r = 0.27 and p = 0.03) and FFP2/3 mask usage (r = 0.29 and p = 0.01). Reduced efficiency of theatre teams was reported by 75% of respondents and 21.5% felt patient safety was at greater risk due to Covid-19 precautions in theatre.

Conclusions

Organisational adjustments are required, and research focused on development of fit-for-purpose personal protective equipment (PPE).

P73 LEARN: uroLogical tEAching in bRitish medical schools Nationally - a national retrospective multi-centre audit of urology teaching across British medical schools

Introduction

Urological conditions account for approximately 25% of acute surgical referrals and 10-15% of general practitioner appointments. In 2012, the British Association of Urological Surgeons (BAUS) produced ‘An Undergraduate Syllabus for Urology’, advising on common clinical areas of urology that must be covered during undergraduate medical training. However, its uptake nationally remains unknown. This project aims to assess undergraduate urology teaching across UK medical schools.

Methods

A targeted advertising drive using social media, medical school societies, websites and newsletters was performed over 4 weeks. Collaborators are responsible for recruiting survey respondents (year 2 medical students to foundation year 1 (FY1) doctors). Survey respondents will complete a REDCap survey retrospectively assessing their urology teaching to date. The primary objective is to compare current urology teaching in medical schools across the United Kingdom with the BAUS undergraduate syllabus.

Results

Currently, 522 collaborators have registered from 36 medical schools nationally. Of these collaborators, 6.32% (33/522) are FY1s and 93.68% (489/522) are medical students. Each collaborator will be responsible for recruiting at least 15 survey respondents to be eligible for PubMed-indexed collaborator authorship.

Conclusion

LEARN has recruited successfully to date, with all collaborators from the medical student and FY1 cohort. With the role of collaborators to further recruit survey respondents, LEARN will provide the most representative and thorough evaluation of UK undergraduate urological teaching to date. It will provide evidence to support changes in the medical school curriculum, and allow re-evaluation of the current national undergraduate BAUS syllabus.

P57 Global recruitment for the RESECT study (transurethral REsection and Single-instillation intravesical chemotherapy Evaluation in bladder Cancer Treatment) - an international observational cohort study aiming to improve the quality of surgery for non-muscle invasive bladder cancer

Introduction

Non-muscle invasive bladder cancer (NMIBC) is one of the most expensive cancers to treat, driven by high recurrence rates and disease progression. Mortality rates in the UK for all bladder cancers have remained relatively stable over the past decade. NMIBC can be curatively treated with transurethral resection of the bladder tumour (TURBT). Despite international evidence-based guidelines on the TURBT procedure and postoperative single instillation of mitomycin-C, TURBT quality continues to vary widely. RESECT will be the first ever international study of TURBT surgery evaluating the achievement of TURBT quality indicators globally and assessing if audit and performance feedback can improve surgical outcomes.

Methods

RESECT is a prospective, multicentre international observational cohort study. Collaborators at each site will collect data using REDCap about local TURBT practice, early recurrence rates and the experience of local TURBT surgeons. The primary outcome is the rate of achievement of key TURBT quality indicators. Advertisement for the study launched in 2020.

Results

As of October 1st, 2020, 524 collaborators have registered to participate. Collaborators represent 334 centres from 54 countries, with the highest number of centres from the United Kingdom (133), Spain (17), and India (16). 50.8% are trainees, 30.3% consultants, and 17.2% medical students. Based on current registrations, patient recruitment will far exceed initial projections and considerably improve statistical power.

Conclusion

RESECT has attracted many collaborators internationally from consultants and trainees at all stages. RESECT has significant potential to positively impact TURBT practice, health economics and ultimately improve outcomes for patients with NMIBC globally.

Employment of medical and physician associate students in an NHS trust during the COVID-19 pandemic

We present a model of employment of healthcare professional students successfully used during the COVID-19 pandemic to support and increase the local workforce. Following recruitment, students from multiple year groups, with varying experience, were deployed to many areas within the trust. The model used allowed overseeing staff to re-deploy students as required in response to changing demand. We received positive feedback from staff and students throughout and present the analysis of a student survey performed towards the end of their roles. We hope the model provides vital insight and an example for other trusts should future need arise during the COVID-19 pandemic and beyond.

Unveiling barriers and facilitators to physical activity participation among urban Indian men

Purpose

Regular participation in physical activity is critical for nurturing optimum health and well-being. It also prevents the onset of obesity and associated non-communicable diseases. Indeed, urban Indian men are more prone to these chronic illnesses as most of them lead a very sedentary lifestyle. Thus, a public health priority is to increase physical activity levels among sedentary urban Indian men. With this objective in mind, an exploratory study was designed to understand men's perspective of physical activity and the factors influencing physical activity participation.

Methods

Five focus group discussions (FGDs) were conducted with adult men (n = 26; age: 20-60 years) between August and November 2019. The participants were recruited from Mumbai Metropolitan Area through snowballing. All the FGDs were audio-recorded and conducted in both Hindi and English. The audio recordings were transcribed and translated. Content analysis was used to obtain frequencies of different barriers and facilitators. Thematic analysis was applied to cluster responses, identify themes in the data, and build an explanation from the FGDs.

Results

All the participants perceived the need to participate in physical activity as it was associated with a better quality of life. Commonly identified facilitators were health benefits, physical appearance, and adequate facilities in the neighbourhood to engage in physical activity. Self-reported barriers included lack of time because of hectic work schedules and commuting, laziness, physical activity not viewed as a priority, and engagement with mobile phones.

Conclusions

The emerging findings can inform the development of a physical activity intervention to support behaviour change as well as ensure its sustainability among inactive urban Indian men. This qualitative inquiry contributes to the body of knowledge on physical activity in a culture that is relatively underrepresented in the current literature.

Key messages

Physical activity was influenced by multiple factors at multiple levels i.e. intrapersonal level, interpersonal level, and community level. There is a need to design effective public health interventions to increase physical activity and thereby control the prevailing disease burden.

Efficacy and safety of a single-tablet regimen containing tenofovir disoproxil fumarate 300 mg, lamivudine 300 mg and efavirenz 400 mg as a switch strategy in virologically suppressed HIV-1-infected subjects on nonnucleoside reverse transcriptase inhibitor-containing first-line antiretroviral therapy in Pune, India

OBJECTIVES

As per National AIDS Control Organization (NACO) estimates, there are 2.1 million people living with HIV (PWH) in India, of whom 1.2 million are on first-line antiretroviral therapy (ART). This study explored the use of a single-tablet regimen containing tenofovir disoproxil fumarate 300 mg + lamivudine 300 mg + efavirenz 400 mg (TLE400 STR) as a first-line switch strategy in PWH in Pune, India.

METHODS

This retrospective cohort study was conducted in private sector ART clinics in three tertiary-level hospitals in Pune, India. PWH > 12 years of age (n = 502) who initiated first-line ART (predominantly TLE600 STR), completed ≥ 6 months of follow-up and achieved virological suppression [plasma viral load (VL) < 1000 HIV-1 RNA copies/mL] were identified and switched to TLE400 STR. The virological and immunological efficacy of TLE400 STR at 6 and 12 months of follow-up were noted. Grade 3/4 adverse events (especially efavirenz-related neuropsychiatric adverse events) leading to regimen discontinuation were also noted.

RESULTS

Of 502 PWH who switched to TLE400 STR, complete virological suppression (VL < 20 copies/mL) was maintained in more than 97% of patients at follow-up. TLE400 STR was successful in maintaining CD4 counts within the range observed at the start of the regimen. Grade 3/4 adverse events leading to TLE400 STR discontinuation were seen in 11 (2.2%) patients. Virological failure (VL > 1000 copies/mL) and treatment regimen failure were seen in six (1.2%) and 49 (9.8%) subjects, respectively.

CONCLUSIONS

TLE400 STR exhibits excellent efficacy and safety as a switch strategy and should be introduced in the Indian National ART Program, especially for PWH who are virologically suppressed on TLE600 STR.

Insulin resistance and intestinal integrity in children with and without HIV infection in Uganda

OBJECTIVES

The risk of cardiometabolic complications in children with perinatally acquired HIV infection (PHIVs) and in perinatally HIV-exposed but uninfected children (HEUs) and its relationship to systemic inflammation and markers of gut integrity are not well established. In this current study, we assed insulin resitance in PHIV compared to HEUs and HIV unexposed uninfected children and explored potential association with intestinal damage biomarkers.

METHODS

This was a cross-sectional study in PHIVs, HEUs and HIV-unexposed, uninfected children (HUUs) aged 2-10 years enrolled in Uganda. PHIVs were on stable antiretroviral therapy (ART) with HIV viral load  < 400 HIV-1 RNA copies/mL. Insulin resistance was estimated using the homeostasis model assessment of insulin resistance (HOMA-IR). We measured markers of systemic inflammation, monocyte activation and gut integrity. Kruskal-Wallis tests were used to compare markers by HIV status; Pearson correlation and multiple linear regressions were used to assess associations of the HOMA-IR index with biomarkers of intestinal damage and translocation.

RESULTS

Overall, 172 participants were enrolled in the study (57 PHIVs, 59 HEUs and 56 HUUs). The median age was 7.8 [interquartile range (IQR) 6.39, 8.84] years, 55% were female and the median body mass index (BMI) was 15 (IQR 14.3, 15.8) kg/m² . Among PHIVs, the median CD4% was 37%, and 93% had viral load ≤ 20 copies/mL. PHIVs had higher waist:hip ratio, high-density lipoprotein (HDL) cholesterol, triglycerides and HOMA-IR index than the other groups (P ≤ 0.02). Factors correlated with insulin resistance included higher BMI and HDL cholesterol and lower soluble tumour necrosis factor receptor I (sTNFRI) (P ≤ 0.02). There was no correlation between any of the other inflammatory or gut biomarkers and HOMA-IR index (P ≥ 0.05). After adjusting for age and sTNFRI, BMI remained independently associated with the HOMA-IR index (β = 0.16; P < 0.01).

CONCLUSIONS

Despite viral suppression, Ugandan PHIVs have disturbances in glucose metabolism. Higher BMI, and not immune activation or alteration of gut integrity, was associated with insulin resistance in this population.

Harmonically Confined Particles with Long-Range Repulsive Interactions

We study an interacting system of N classical particles on a line at thermal equilibrium. The particles are confined by a harmonic trap and repel each other via pairwise interaction potential that behaves as a power law ∝∑[under i≠j][over N]|x_{i}-x_{j}|^{-k} (with k>-2) of their mutual distance. This is a generalization of the well-known cases of the one-component plasma (k=-1), Dyson's log gas (k→0^{+}), and the Calogero-Moser model (k=2). Because of the competition between harmonic confinement and pairwise repulsion, the particles spread over a finite region of space for all k>-2. We compute exactly the average density profile for large N for all k>-2 and show that while it is independent of temperature for sufficiently low temperature, it has a rich and nontrivial dependence on k with distinct behavior for -2<k<1, k>1 and k=1.

Incidence of tuberculosis among HIV infected individuals on long term antiretroviral therapy in private healthcare sector in Pune, Western India

Background

Despite rapid scale up of antiretroviral therapy (ART), Tuberculosis (TB) remains the commonest opportunistic infection and cause of death among HIV infected individuals in resource limited settings like India. Incidence of TB in individuals on ART in private healthcare sector in India is infrequently studied.

Methods

This retrospective cohort study conducted between 1st March 2009 and 1st March 2017 aimed to evaluate rate of incident TB in individuals initiated on ART at 3 private sector ART clinics in Pune, India. Individuals more than 12 years of age with ART duration of atleast 6 months were included. Patients were classified as having prevalent TB if they had a TB episode within the year prior to ART initiation or if they developed TB within 6 months of starting ART. Individuals who were diagnosed with TB after 6 months of starting ART were classified as incident TB cases. A recurrent episode of TB after treatment completion or cure of prevalent TB was also regarded as incident TB. Patients were classified as definitive TB if Mycobacterium tuberculosis was grown in culture from a biological sample or a positive rapid molecular test. Patients were classified as probable TB if there was radiologic evidence of TB in absence of confirmatory culture or PCR.

Results

1904 patients with a median duration of follow up on ART of 57 (IQR = 32.0, 84.0) months were included. Of these, 182 developed incident TB (22% definitive TB, 38% recurrent cases). TB incidence at 6–12 months, 13–24 months, 25–60 months and > 60 months of ART was 24.32, 5.46, 2.54 and 0.75 cases per 100 person years respectively. Current time updated CD4 count < 500 cells/mm³ (p < 0.0001), virologic failure on ART (adjusted Hazard Ratio (aHR): 3.05 (95% CI: 2.094, 4.454), p < 0.0001) and receipt of ART without IPT (aHR: 8.24 (95% CI, 3.358, 20.204), p < 0.0001) were associated with higher risk of incident TB.

Conclusion

Starting ART early in treatment naïve individuals, prompt detection of virologic failure on ART and providing IPT along with ART will be useful in reducing incident TB. Efforts from private sector are crucial in achieving Sustainable Development Goals set by Government of India and attaining the vision of a TB free India.

Free radical-decellularized tissue promotes enhanced antioxidant and anti-inflammatory macrophage response

Oxidative stress leads to the progression of many diseases including chronic wounds, atherosclerosis, stroke and cancer. The modification of biomolecules with reactive nitrogen or oxygen species has been shown to trigger oxidative stress pathways that are beneficial for healing. Extracellular matrix scaffolds have been used successfully in reconstructive applications due to the beneficial host response they induce. To tailor extracellular matrix scaffolds to enhance antioxidant response, ECM were prepared using reactive nitrogen or oxygen species. These scaffolds were shown to be effectively decellularized and possess oxidative or nitroxidative protein modifications. Macrophage responses in vitro and in an in vivo muscle injury model were shown to have enhanced antioxidant phenotypes without impairment of long-term remodeling. These observations suggest that ECM decellularized with reactive oxygen or nitrogen species could provide better outcomes for the treatment of ischemic diseases.

Phenotypic Prenatal Diagnosis of Chronic Granulomatous Disease: A Useful Tool in The Absence Of Molecular Diagnosis

Chronic granulomatous disease (CGD) is an inherited immunodeficiency disorder affecting the microbicidal function of the phagocytes. It is characterized by susceptibility to recurrent infections leading to significant morbidity and mortality. Antibacterial and antifungal prophylaxis, though, has significantly reduced the rate and severity of the infections; the breakthrough infections still remain a challenge. Currently, allogenic haematopoietic stem cell transplantation is the only curative option which is very expensive and unavailable for many due to lack of suitable donor. Thus, prenatal diagnosis (PND) forms an important component of management in the affected families. PND is challenging in families approaching late in pregnancy with an uncharacterized molecular defect. In such cases, PND can be performed by analysis of NADPH activity of fetal blood (FB) neutrophils at 18-20 weeks of gestation. Cord blood samples at 18 weeks of gestation from healthy control were used to establish normal ranges for NBT and DHR. PND was offered for six pregnancies (NBT: n = 3, DHR: n = 6) with index cases of CGD confirmed by abnormal NBT and DHR analysis. NBT and DHR tests were found to be negative for all the six cases, confirming the same on samples post-delivery. NBT and DHR tests offer a rapid and sensitive PND of CGD in the absence of facilities for molecular diagnosis. It was observed that addition of CD15 along with CD45 led to an accurate DHR analysis. It is recommended to perform the diagnosis with adequate precautions only at centres with considerable experience and expertise in the diagnosis of CGD.

Swift tuning from spherical molybdenum microspheres to hierarchical molybdenum disulfide nanostructures by switching from solvothermal to hydrothermal synthesis route

Herein, we report the synthesis of metallic molybdenum microspheres and hierarchical MoS₂ nanostructures by facile template-free solvothermal and hydrothermal approach, respectively. The morphological transition of the Mo microspheres to hierarchical MoS₂ nanoflower architectures is observed to be accomplished with change in solvent from ethylenediamine to water. The resultant marigold flower-like MoS₂ nanostructures are few layers thick with poor crystallinity while spherical ball-like molybdenum microspheres exhibit better crystalline nature. This is the first report pertaining to the synthesis of Mo microspheres and MoS₂ nanoflowers without using any surfactant, template or substrate in hydro/solvothermal regime. It is opined that such nanoarchitectures of MoS₂ are useful candidates for energy related applications such as hydrogen evolution reaction, Li ion battery and pseudocapacitors. Inquisitively, metallic Mo can potentially act as catalyst as well as fairly economical Surface Enhanced Raman Spectroscopy (SERS) substrate in biosensor applications.

The Significance of Extensor Tendon Tethering and Dorsal Joint Capsule Tightening After Injury to the Hand

This paper examines the clinical problem of extensor tendon tethering and/or dorsal joint capsule tightening secondary to hand injury. One hundred and forty-one patients were examined 13 to 51 months after hand injuries of varying severity. Fifty-six patients (40%) had suffered simple and eighty-five patients (60%) complex injuries. Seventy-four (52%) of the 141 patients had no extensor tendon tethering and/or dorsal joint capsule tightening. In 30 (21%), the extensor tendon tethering and/or dorsal joint capsule tightening was considered to be “obvious” in that it was easily seen on examination using various commonly used clinical tests of finger flexion and extension. In 37 (26%), the extensor tendon tethering and/or dorsal joint capsule tightening was considered to be of “lesser degree” because it was only evident on application of specific tests which are described in this paper. Of the 37, 21 (56%) described themselves as being unable to make a “proper” fist with the injured hand, 33 (89%) had pain or discomfort on the dorsum of the injured hand and/or fingers on gripping ( P < 0.01) and 25 (70%) had weakness of power of gripping ( P < 0.01). Thirty-two (87%) complained of functional problems at work, with activities of daily living or with the pursuit of their hobbies.

Stabilizing Entanglement via Symmetry-Selective Bath Engineering in Superconducting Qubits

Bath engineering, which utilizes coupling to lossy modes in a quantum system to generate nontrivial steady states, is a tantalizing alternative to gate- and measurement-based quantum science. Here, we demonstrate dissipative stabilization of entanglement between two superconducting transmon qubits in a symmetry-selective manner. We utilize the engineered symmetries of the dissipative environment to stabilize a target Bell state; we further demonstrate suppression of the Bell state of opposite symmetry due to parity selection rules. This implementation is resource efficient, achieves a steady-state fidelity F=0.70, and is scalable to multiple qubits.

Educational survey of regional general practitioner's management of paediatric patients with undescended testis

INTRODUCTION

Recent recommendations have lowered the ideal age of surgery for undescended testis (UDT) to 3-6 months of age. However, many publications demonstrate that age at surgery is still above the recommended age of 1 year as originally suggested in 1996.

AIM

Through a web-based educational survey, we aimed to combine questions regarding General Practioner's (GPs) management of these patients with educational slides with advice to update them with current recommendations.

METHODS

The regional GPs were invited by email and letter to undertake the web-based questionnaire devised using SurveyMonkey(®). Educational slides were shown after each questionnaire slide. Feedback was immediate and a one-page summary was emailed to the GP on completion. A pre- and post-educational intervention audit was undertaken to ascertain the change in age of referral for patients <5 years of age.

RESULTS

144 (36%) of 401 GPs undertook this survey. 84% were happy assessing infants (<1year) with UDT. 16% were unhappy discussing management with parents for palpable UDT. 52% were happy discussing malignant risk with parents. 80% thought that ultrasonography was routinely used. Optimal referral time was thought to be 6-12 months (42%) and time of surgery was 1-2 years (50%). 72% would refer a patient with palpable UDT after 6 months of age. Only 41% were happy to assess testicular size at puberty. 98% found this format of an educational survey was helpful. The average age of referral for patients <5 years improved significantly after educational intervention from 2.8 years in 2010 to 1.25 years in 2013 (p < 0.01).

DISCUSSION

With an interactive survey, we were able assess and also educate the regional GPs with regard to management of paediatric patients with UDT. There is a varied range of knowledge and practice demonstrated which we hoped to standardise and thereby increase efficiency and decrease the age of referral. A large majority would refer patients with UDT after 6 months of age that would make the target of surgery <6 months unachievable unless they are aware of current recommendations. This study is limited by a 36% response rate but that is comparable to other surveys. Also, referrals come from other sources that were not included. The causal effect of the educational survey is hypothesised.

CONCLUSION

This educational survey has confirmed the varied management by GPs. The referral age was demonstrated to be reduced after this intervention and this process was widely accepted by GPs that undertook the educational survey.

Abstract P2-12-13: Modified pectoral nerves block for postoperative analgesia after modified radical mastectomy: A comparative study

Background: The modified pectoral nerves block (Pecs II) as a method of analgesia for breast cancer surgery has shown excellent results in recent publications. This technique blocks the long thoracic nerve, thoracic intercostal nerves from T2-T6 & thoracodorsal nerve.

Aims: To evaluate the effectiveness of the Pecs II block for pain relief in the postoperative period of patients undergoing modified radical mastectomy (MRM).

Methods: A prospective comparative study was conducted at our instituition between November 2014 and March 2015. Patients scheduled to undergo MRM were randomly assigned to the test group (endotracheal anaesthesia along with Pecs II) and the control group (endotracheal anaesthesia only). In the postoperative period the patients were evaluated using a visual analogue scale to determine pain scores at 6, 12 & 24 hours.

Results: Fifty patients (25 in each group), between the ages of 24 to 76 years (54.76 ± 10) were included in the study. There was no significant difference in ages between test & control groups. In the postoperative period, the test group had significantly lower median pain scores at 6, 12 & 24 hours as compared to the control group.

Table 1: Comparative analysis for Pecs II block TestControlp valueeffect size (r)Average age (years)54.44 ± 10.7855.08 ± 9.370.824-Median postoperative pain scores  6 hours2 (1)6 (2)&lt;0.001*- 0.8312 hours3 (1)5 (2)&lt;0.001*- 0.6224 hours3 (1)0.034*- 0.30* statistically significant

Conclusion: The modified pectoral nerves block (Pecs II) is a novel & effective technique for postoperative analgesia in patients undergoing modified radical mastectomy.

Citation Format: Kanitkar R, Mane A, Agashe A, Kulkarni M, Deshmukh S. Modified pectoral nerves block for postoperative analgesia after modified radical mastectomy: A comparative study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-13.

A case of acquired Gitelman syndrome presenting as hypokalemic paralysis

We report a case of a young female patient who presented with weakness of upper and lower limbs. On evaluation, she had hypokalemia, hypomagnesemia, metabolic alkalosis and hypocalciuria. Anti-Ro (SSA) antibody was positive. She had an acquired Gitelman syndrome due to primary Sjögren's syndrome (SS). SS presenting with features of Gitelman syndrome is very rare.

Titanium nanostructures for biomedical applications

Titanium and titanium alloys exhibit a unique combination of strength and biocompatibility, which enables their use in medical applications and accounts for their extensive use as implant materials in the last 50 years. Currently, a large amount of research is being carried out in order to determine the optimal surface topography for use in bioapplications, and thus the emphasis is on nanotechnology for biomedical applications. It was recently shown that titanium implants with rough surface topography and free energy increase osteoblast adhesion, maturation and subsequent bone formation. Furthermore, the adhesion of different cell lines to the surface of titanium implants is influenced by the surface characteristics of titanium; namely topography, charge distribution and chemistry. The present review article focuses on the specific nanotopography of titanium, i.e. titanium dioxide (TiO2) nanotubes, using a simple electrochemical anodisation method of the metallic substrate and other processes such as the hydrothermal or sol-gel template. One key advantage of using TiO2 nanotubes in cell interactions is based on the fact that TiO2 nanotube morphology is correlated with cell adhesion, spreading, growth and differentiation of mesenchymal stem cells, which were shown to be maximally induced on smaller diameter nanotubes (15 nm), but hindered on larger diameter (100 nm) tubes, leading to cell death and apoptosis. Research has supported the significance of nanotopography (TiO2 nanotube diameter) in cell adhesion and cell growth, and suggests that the mechanics of focal adhesion formation are similar among different cell types. As such, the present review will focus on perhaps the most spectacular and surprising one-dimensional structures and their unique biomedical applications for increased osseointegration, protein interaction and antibacterial properties.