Acceptability, feasibility and cost of point of care testing for sexually transmitted infections among South African adolescents where syndromic management is standard of care

BACKGROUND

Young people (YP) in southern Africa are at substantial risk of HIV and sexually transmitted infections (STIs). Despite the epidemiological and biological link between STIs and HIV transmission and acquisition, infections such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) remain widely undiagnosed. Syndromic STI management is the standard of care in low- and middle-income countries (LMICs) despite a high prevalence of asymptomatic infections. We conducted an observational study to explore the acceptability, feasibility, and cost of a STI test-and-treat service for YP in Cape Town.

METHODS

YP attending a mobile clinic (MC) and a youth centre clinic (YC) were offered STI screening. Urine testing for CT and NG using a 90-min molecular point-of-care (POC) test on the GeneXpert platform was conducted and treatment provided. Data were collated on demographics, sexual behaviour, presence of symptoms, uptake of same-day treatment, prevalence of CT/NG, and service acceptability.

RESULTS

Three hundred sixty six participants were enrolled (median age 20, 83% female).57% (209/366) of participants tested positive for either CT (126/366, 34%) or NG (57/366, 16%) or co-infection (26/366, 7%). Clinical symptoms were a poor predictor of GeneXpert diagnosed CT or NG, with a sensitivity of 46.8% and 54.0% for CT and NG respectively. Although half of participants initially chose to receive same day results and treatment, only a third waited for results on the day. The majority of participants (91%) rated the service highly via a post-visit acceptability questionnaire.

CONCLUSION

Curable STIs are highly prevalent in this population. STI screening using POC testing was feasible and acceptability was high. The study provides further impetus for moving policy beyond syndromic management of STIs in South Africa.

Hypofractionated Radiotherapy for Hematological Malignancies during COVID-19 Pandemic and Beyond

PURPOSE/OBJECTIVE(S)

Conventionally fractionated radiotherapy (RT) has shown to have excellent local control in hematological malignancies (HM). Up to date there is none or scant literature about the use of hypofractionated radiotherapy (HFRT) for the treatment of HM, this single institution study analyzed the efficacy of HFRT in HM. We hypothesized that HFRT in HM will result in a similar local tumor control that has been reported with standard fractionated RT.

MATERIALS/METHODS

In this retrospective study, we analyzed the data from patients within the provincial cancer registry diagnosed with HM treated with a curative intent using HFRT regimens suggested by International Lymphoma Radiation Oncology Group between 2020-2022 during the COVID-19 pandemic. Primary outcome of the study was overall response rate (ORR), measured as complete response (CR), partial response (PR) or stable disease (SD) within the irradiated field determined radiologically or clinically post completion of RT. Secondary end point was freedom from local progression (FFLP), calculated from the date of initiation of RT to the first date among in-field progression, death, and last follow-up. Summary statistics were used to describe cohort and treatment characteristics. FFLP was calculated by 1 minus cumulative incidence accounting for competing risk (i.e., death).

RESULTS

Of the 36 patients included for analysis, 18 were aggressive non-Hodgkin lymphoma (NHL), 9 were indolent NHL, 6 were Hodgkin lymphoma (HL) and 3 were other HM. Among them 25 had consolidation RT and 11 had definitive RT. HFRT daily dose per fraction ranged from 2.67 Gy to 5 Gy and total dose regimens ranged from 18 Gy to 42.5 Gy in 6 - 17 fractions and median equivalent dose in 2 Gy fractions (EQD2) for alpha/beta = 10Gy was 36 Gy (±7.5). ORR for the entire cohort was 94.4%. With a median follow up of 13.2 months, FFLP at one year for the entire cohort was 91.5% and death without infield progression was 8.7%. Among the 4 patients who had in radiation field recurrence, 2 had aggressive NHL and 2 had HL. No grade 3 or 4 acute toxicities were reported.

CONCLUSION

This retrospective study using HFRT showed an ORR and FFLP comparable to historical studies using standard fractionation. Further long-term follow-up is warranted to confirm these findings.

Long-Term Toxicity in Patients Receiving Radiotherapy for Ultracentral Stage I Non-Small Cell Lung Cancer - A Secondary Analysis of the LUSTRE Randomized Trial

PURPOSE/OBJECTIVE(S)

Hypofractionated and stereotactic body radiotherapy (SBRT) are increasingly used in the treatment of centrally located, early-stage non-small cell lung cancer (NSCLC), though there are concerns of increased morbidity and mortality in patients with ultracentral tumors (UC). We report on the long-term toxicity of patients with UC lung cancer treated on a prospective randomized clinical trial of SBRT versus conventionally hypofractionated radiotherapy (CRT) for stage I NSCLC (NCT01968941).

MATERIALS/METHODS

Patients with UC tumors, defined as those where the planning target volume directly overlaps with the proximal bronchial tree (PBT), were identified from the larger cohort of patients treated on the trial. These patients received either SBRT with 60 Gy in 8 fractions or CRT with 60 Gy in 15 fractions. The primary endpoint of this secondary analysis was development of any grade 3 or higher toxicity defined using CTCAE version 3.0. Secondary endpoints included local control, as well as dosimetric analysis of the PBT, using EQD2 with α/β ratio of 3 to assess the relationship between dose to the PBT and toxicity.

RESULTS

Twenty-nine patients were identified with UC tumors; 21 received SBRT and 8 received CRT. Median age was 72 years (range 55-88 years) and 59% were female. Median FEV1 was 1.46L (range 0.64-2.37L). Patients had either T1 (59%) or T2 (41%) lesions, with median tumor size 2.5cm (range 1.1-4.9cm). Most patients had histologically confirmed disease (squamous cell, n = 10; adenocarcinoma, n = 8; radiographically suspicious, n = 11). The median follow-up was 2.9 years (range 0.7-5.2 years). The 3-year local control rate of all patients was 88.3% (95% confidence interval: 75.7-100%). There were 3 patients with late (>3 months) grade 3 toxicity (bronchial stricture, chest pain, and atelectasis) and 1 patient with late grade 5 toxicity (bleeding/hemorrhage), all treated in the SBRT arm. Median EQD2 dose to PBT in patients with grade ≥3 late toxicity compared to the rest of the cohort was: Dmax, 132 vs 129 Gy; D0.1cc, 129 vs 119 Gy; D1cc, 124 vs 80 Gy; and D5cc, 83 vs 41 Gy. Median EQD2 volumetric doses in grade ≥3 patients (compared to the rest) to PBT were: V65 Gy, 9.7 vs 2.2cc; V80 Gy, 7.9 vs 1.1cc; V90 Gy, 6.2 vs 0.4cc; and V100 Gy, 4.8 vs 0.3cc. The single patient with grade 5 toxicity had the highest D5cc (116 Gy) and V100 Gy (7cc) among all patients.

CONCLUSION

Stereotactic radiation with 60 Gy in 8 fractions for UC lung cancer provides good local control but carries an approximately 15-20% rate of late grade ≥3 toxicity. There appears to be a dosimetric association between toxicity and dose to the PBT. It may be more important to minimize volumetric PBT dose rather than maximum point dose to reduce risk of severe late toxicity.

Goals for girls: a cluster-randomized trial to investigate a school-based sexual health programme amongst female learners in South Africa

The delivery of comprehensive sexuality education to adolescents at school is recognized as a long-term strategy to support adolescent health. Suboptimal sexual and reproductive health (SRH) outcomes among South African adolescents necessitate the ongoing development and optimization of SRH education and promotion models. We conducted a cluster-randomized controlled trial amongst secondary schools (n = 38) in Cape Town, South Africa, to evaluate a sport-based, near-peer-led SRH curriculum, SKILLZ, amongst female learners (n = 2791). Biomedical (sexually transmitted infections [STIs], human immunodeficiency virus [HIV] and pregnancy) and socio-behavioural (social support, gender norms and self-concept) outcomes were assessed pre and post intervention. Attendance at SKILLZ was low and intervention participants did not show an improvement in SRH outcomes, with HIV and pregnancy incidence remaining stable and STI prevalence remaining high and increasing in both control and intervention arms. Although evidence of positive socio-behavioural measures was present at baseline, participants with high attendance showed further improvement in positive gender norms. SKILLZ did not demonstrate the capacity to significantly impact clinical SRH outcomes. Modest improvements in outcomes amongst high attenders suggest that the impact may be possible with improved attendance; however, in the absence of optimal attendance, alternative intervention strategies may be required to improve SRH outcomes amongst adolescents.

Role of White Blood Cell Count, Immature to Total Ratio and C-Reactive Protein in Early Detection of Clinically Suspected Neonatal Sepsis

Despite recent advances in neonatal care, early detection of neonatal sepsis still remains challenging. Positive blood culture is the gold standard for definitive diagnosis of neonatal sepsis but is time consuming and demands a well equipped laboratory setting. Therefore, it becomes imperative to evaluate usefulness of white blood cell count, Immature to total (IT) ratio and C-reactive protein as potential markers in the early diagnosis of neonatal sepsis. The objective of the study was to evaluate role of white blood cell count, IT ratio and C-reactive protein in early detection of clinically suspected neonatal sepsis. This cross-sectional descriptive study was conducted from January 2017 to December 2018 at Special Care Newborn Unit (SCANU) of Rangpur Medical College Hospital, Rangpur, Bangladesh. After parental permission and ethical clearance, a total of 70 eligible neonates were included into the study. Estimation of total white blood cell count, IT ratio and C-reactive protein as well as blood culture were done for each case. Significance for Chi-Square test and Pearson's correlation coefficient test was predetermined as p<0.05. Of the total 70 neonates studied, 19(27.14%) were blood culture positive and most common organism was Escherichia coli (7/14, 37.0%). Among individual and combination tests, CRP was highly sensitive (100%) followed by WBC count (74.94%). Highly specific tests in diagnosing sepsis were combination test of IT ratio and CRP (88.23%) followed by combination test of WBC count and CRP (82.35%). Positive predictive value (PPV) was high for combination test of WBC count and CRP (90.90%) followed by combination test of IT ratio and CRP (90.47%). Negative predictive value (NPV) was high in CRP (100.0%) followed by WBC count (89.19%). IT ratio positively correlated with CRP (p=0.002) and there was significant association between raised CRP and WBC count (p=0.005) in neonatal sepsis. Diagnostic role of both individual and combination tests were significant in early detection of clinically suspected neonatal sepsis while awaiting results of blood culture. However, none of the combination tests were able to achieve 100.0% sensitivity.

The lipid-lowering efficacy of rosuvastatin is associated with variations in SLCO1B1: a 12-month prospective cohort study

OBJECTIVE

Statins' efficacy and safety are subject to wide inter-individual variability, partly due to genetic predisposition. Studies have shown that the genetic variations in the common solute carrier organic anion transporter family member 1B1 (SLCO1B1) gene polymorphisms affect the transport of statins' transport into hepatocytes, their plasma concentration, and circulation time. The ultimate result is variable and personalized statins response and statin-associated muscular symptoms (SAMS). Here we report an update on the differential response to rosuvastatin therapy in the Pakistani population.

PATIENTS AND METHODS

A total of 166 hyperlipidemic patients on rosuvastatin were prospectively followed for 24 weeks. Muscle symptoms were recorded after 6-8 weeks of therapy, and assessment was done according to the SAMS-clinical index tool. Patients were genotyped for SLCO1B1 c.521T>C and c.388A>G polymorphisms, for association with lipid-lowering response and statin-associated muscle symptoms. The plasma level of rosuvastatin was determined through Liquid chromatography-mass spectrometry (LCMS) for possible correlation with adverse effects and lipid-lowering efficacy.

RESULTS

Mean reduction in low-density lipoprotein cholesterol (LDL-C) was 42.34 mg/dl (p<0.001), 35.66 mg/dl (p<0.001), and 24.47 mg/dl (p=0.202) in reference, heterozygous and mutant homozygous groups of SLCO1B1 c.521T>C, respectively. A 15.70% and 42.14% diminished LDL-C reduction was observed in c.521TC and c.521CC, respectively, compared to the reference c.521TT genotype. Similarly, for SLCO1B1 c.388A>G, 20.50% and 29.40% less LDL-C lowering effect was observed in heterozygous and mutant homozygous carriers, respectively. SAMS were observed in 37% and 33% of heterozygous and minor homozygous, respectively, (p=0.059). The rosuvastatin plasma level was 1.89-fold higher in the c.521CC genotype than in the reference homozygous type.

CONCLUSIONS

Differential lipid-lowering response and muscular symptoms due to rosuvastatin are associated with the SLCO1B1 common polymorphisms. Further studies are needed to validate dose adjustment and rationalization.

In Vitro and In Silico Analysis of Epithelial-Mesenchymal Transition and Cancer Stemness as Prognostic Markers of Clear Cell Renal Cell Carcinoma

The process of epithelial-mesenchymal transition (EMT) involves the phenotypic transformation of cells from epithelial to mesenchymal status. The cells exhibiting EMT contain features of cancer stem cells (CSC), and the dual processes are responsible for progressive cancers. Activation of hypoxia-inducible factors (HIF) is fundamental to the pathogenesis of clear cell renal cell carcinoma (ccRCC), and their role in promoting EMT and CSCs is crucial for ccRCC tumour cell survival, disease progression, and metastatic spread. In this study, we explored the status of HIF genes and their downstream targets, EMT and CSC markers, by immunohistochemistry on in-house accrued ccRCC biopsies and adjacent non-tumorous tissues from patients undergoing partial or radical nephrectomy. In combination, we comprehensively analysed the expression of HIF genes and its downstream EMT and CSC-associated targets relevant to ccRCC by using publicly available datasets, the cancer genome atlas (TCGA) and the clinical proteome tumour analysis consortium (CPTAC). The aim was to search for novel biological prognostic markers that can stratify high-risk patients likely to experience metastatic disease. Using the above two approaches, we report the development of novel gene signatures that may help to identify patients at a high risk of developing metastatic and progressive disease.

Evaluation of gingival displacement, bleeding and ease of application for polytetrafluoroethylene (PTFE) and conventional retraction cord - a clinical trial

OBJECTIVE

Conventional use of retraction cord in soft tissue management is effective only when the non-resilient nature of material does not jeopardize gingival health. Therefore this study aims to clinically evaluate the gingival displacement, ease of application and bleeding from polytetrafluoroethylene (PTFE) retraction cord.

PATIENTS AND METHODS

This study is a single-center, parallel-group, randomized controlled clinical trial (1:1). Sixty patients indicated for full coverage metal-ceramic restoration for first molars were enrolled and randomly allocated to experimental (PTFE Cord) and control (conventional plain retraction cord) groups. After crown preparation and isolation, a pre-displacement impression was made. Assigned gingival displacement material was applied for 5 minutes, followed by post-displacement impression. Casts were prepared and used for assessment of mean horizontal gingival displacement by measuring displacement using a stereomicroscope (20 x). Post-displacement gingival bleeding and ease of application were also assessed clinically. t-test and Chi-square tests were used for statistical assessment of gingival displacement, gingival bleeding and ease of application.

RESULTS

Gingival displacement, bleeding and ease of application were similar among study groups (p > 0.05). Mean gingival displacement in the experimental group was 197.1 µm, and 167.7 µm in the control group. Bleeding was observed in 30% and 20% of cases of experimental and control group, respectively. Ease of application was 'difficult' in 53.3% and 43.3% of cases of experimental and control group, respectively. Non-impregnated gingival retraction cord and PTFE cord displayed similar outcomes of gingival displacement, ease of placement and bleeding after cord removal.

CONCLUSIONS

Post-displacement bleeding and discomfort for PTFE cord placement suggest that this technique needs improvement. Therefore further studies are warranted to improve and investigate the physical and biological response to PTFE retraction cord.

Damage control surgery of the critical Jehovah's Witness patient - a narrative review

SUMMARY

South Africa has a high burden of trauma related injuries with haemorrhage remaining a leading treatable complication of trauma. Expedient management of haemorrhage serves to reduce patient morbidity and mortality. Damage control surgery aims to minimise haemorrhage, contain contamination, and allow restoration of physiology in an intensive care unit (ICU) before proceeding to definitive surgery. Over time, damage control surgery has found favour in non-traumarelated surgeries in unstable patients. The Jehovah's Witness (JW) religion believes that blood is sacred and strictly do not consent to blood or blood product transfusions, including in emergency settings. Thus, the management of a bleeding or bled-out JW patient proves to be a unique challenge in modern medicine. For the JW patient who is undergoing damage control surgery, the primary goal is to win time for recovery of the haemoglobin level by maintaining adequate oxygen delivery to tissues. We review the multiple methods available to optimise haemodynamic stability in a bleeding JW patient. These include techniques aimed at (i) minimising blood loss, (ii) optimising oxygen delivery (DO2), (iii) optimising oxygen consumption (VO2), and (iv) correction of coagulopathy. The management of haemorrhage in the JW patient remains challenging. It is imperative for healthcare professionals to be aware of all options available when treating these patients in order to provide optimal treatment whilst maintaining respect for their beliefs.

Mental Disorders and Oral Diseases: Future Research Directions

The poor physical health (including oral health) of people with mental disorders is a global problem. The burden of oral diseases among this group is substantial given their high prevalence and ability to increase the personal, social, and economic impacts of mental disorders. This article summarizes causes of mental disorders and oral diseases, critically reviews current evidence on interventions to reduce the burden of oral diseases in people with mental disorders, and suggests future research directions. The relationship between mental disorders and oral diseases is complex due to the shared social determinants and bidirectional interaction mechanisms that involve interconnected social, psychological, behavioral, and biological processes. Research has, to date, failed to produce effective and scalable interventions to tackle the burden of oral diseases among people with mental disorders. Transformative research and actions informed by a dynamic involvement of biological, behavioral, and social sciences are needed to understand and tackle the complex relationship between mental disorders and oral diseases, as well as inform the design of complex interventions. Examples of future research on complex public health, health service, and social care interventions are provided. The design and testing of these interventions should be carried out in real-world settings, underpinned by the principles of coproduction and systems thinking, and conducted by a transdisciplinary team. We propose this starts with setting research priorities and developing complex intervention theory, which we report to support future research to improve oral health and hence physical and mental health in this disadvantaged group.

Knock down of TIMP-2 by siRNA and CRISPR/Cas9 mediates diverse cellular reprogramming of metastasis and chemosensitivity in ovarian cancer

BACKGROUND

The endogenous tissue inhibitor of metalloproteinase-2 (TIMP-2), through its homeostatic action on certain metalloproteinases, plays a vital role in remodelling extracellular matrix (ECM) to facilitate cancer progression. This study investigated the role of TIMP-2 in an ovarian cancer cell line in which the expression of TIMP-2 was reduced by either siRNA or CRISPR/Cas9.

METHODS

OVCAR5 cells were transiently and stably transfected with either single or pooled TIMP-2 siRNAs (T2-KD cells) or by CRISPR/Cas9 under the influence of two distinct guide RNAs (gRNA1 and gRNA2 cell lines). The expression of different genes was analysed at the mRNA level by quantitative real time PCR (qRT-PCR) and at the protein level by immunofluorescence (IF) and western blot. Proliferation of cells was investigated by 5-Ethynyl-2'-deoxyuridine (EdU) assay or staining with Ki67. Cell migration/invasion was determined by xCELLigence. Cell growth in vitro was determined by 3D spheroid cultures and in vivo by a mouse xenograft model.

RESULTS

Approximately 70-90% knock down of TIMP-2 expression were confirmed in T2-KD, gRNA1 and gRNA2 OVCAR5 ovarian cancer cells at the protein level. T2-KD, gRNA1 and gRNA2 cells exhibited a significant downregulation of MMP-2 expression, but concurrently a significant upregulation in the expression of membrane bound MMP-14 compared to control and parental cells. Enhanced proliferation and invasion were exhibited in all TIMP-2 knocked down cells but differences in sensitivity to paclitaxel (PTX) treatment were observed, with T2-KD cells and gRNA2 cell line being sensitive, while the gRNA1 cell line was resistant to PTX treatment. In addition, significant differences in the growth of gRNA1 and gRNA2 cell lines were observed in in vitro 3D cultures as well as in an in vivo mouse xenograft model.

CONCLUSIONS

Our results suggest that the inhibition of TIMP-2 by siRNA and CRISPR/Cas-9 modulate the expression of MMP-2 and MMP-14 and reprogram ovarian cancer cells to facilitate proliferation and invasion. Distinct disparities in in vitro chemosensitivity and growth in 3D culture, and differences in tumour burden and invasion to proximal organs in a mouse model imply that selective suppression of TIMP-2 expression by siRNA or CRISPR/Cas-9 alters important aspects of metastasis and chemosensitivity in ovarian cancer.

Platinum-resistance in epithelial ovarian cancer: an interplay of epithelial-mesenchymal transition interlinked with reprogrammed metabolism

BACKGROUND

Epithelial ovarian cancer is the most lethal gynaecological cancer worldwide. Chemotherapy resistance represents a significant clinical challenge and is the main reason for poor ovarian cancer prognosis. We identified novel expression of markers related to epithelial mesenchymal transitions (EMT) in a carboplatin resistant ovarian cancer cell line by proteomics. This was validated in the platinum resistant versus sensitive parental cell lines, as well as platinum resistant versus sensitive human ovarian cancer patient samples. The prognostic significance of the different proteomics-identified marker proteins in prognosis prediction on survival as well as their correlative association and influence on immune cell infiltration was determined by public domain data bases.

METHODS

We explored the proteomic differences between carboplatin-sensitive OVCAR5 cells (parental) and their carboplatin-resistant counterpart, OVCAR5 CBPR cells. qPCR and western blots were performed to validate differentially expressed proteins at the mRNA and protein levels, respectively. Association of the identified proteins with epithelial-mesenchymal transition (EMT) prompted the investigation of cell motility. Cellular bioenergetics and proliferation were studied to delineate any biological adaptations that facilitate cancer progression. Expression of differentially expressed proteins was assessed in ovarian tumors obtained from platinum-sensitive (n = 15) versus platinum-resistant patients (n = 10), as well as matching tumors from patients at initial diagnosis and following relapse (n = 4). Kaplan-Meier plotter and Tumor Immune Estimation Resource (TIMER) databases were used to determine the prognostic significance and influence of the different proteomics-identified proteins on immune cell infiltration in the tumor microenvironment (TME).

RESULTS

Our proteomics study identified 2422 proteins in both cell lines. Of these, 18 proteins were upregulated and 14 were downregulated by ≥ twofold (p < 0.05) in OVCAR5 CBPR cells. Gene ontology enrichment analysis amongst upregulated proteins revealed an overrepresentation of biological processes consistent with EMT in the resistant cell line. Enhanced mRNA and/or protein expression of the identified EMT modulators including ITGA2, TGFBI, AKR1B1, ITGAV, ITGA1, GFPT2, FLNA and G6PD were confirmed in OVCAR5 CBPR cells compared to parental OVCAR5 cell line. Consistent with the altered EMT profile, the OVCAR5 CBPR cells demonstrated enhanced migration and reduced proliferation, glycolysis, and oxidative phosphorylation. The upregulation of G6PD, AKR1B1, ITGAV, and TGFβ1 in OVCAR5 CBPR cells was also identified in the tumors of platinum-resistant compared to platinum-sensitive high grade serous ovarian cancer (HGSOC) patients. Matching tumors of relapsed versus newly diagnosed HGSOC patients also showed enhanced expression of AKR1B1, ITGAV, TGFβ1 and G6PD protein in relapsed tumors. Among the identified proteins, significant enhanced expression of GFPT2, FLNA, TGFBI (CDGG1), ITGA2 predicted unfavorable prognosis in ovarian cancer patients. Further analysis suggested that the expression of TGFBI to correlate positively with the expression of identified and validated proteins such as GFPT2, FLNA, G6PD, ITGAV, ITGA1 and ITGA2; and with the infiltration of CD8⁺ T cells, macrophages, neutrophils, and dendritic cells in the TME.

CONCLUSIONS

Our research demonstrates proteomic-based discovery of novel EMT-related markers with an altered metabolic profile in platinum-resistant versus sensitive ovarian cancer cell lines. The study also confirms the expression of selected identified markers in the tumors of platinum-resistant versus sensitive, and in matching relapsed versus newly diagnosed HGSOC patients. The study provides insights into the metabolic adaptation of EMT-induced carboplatin resistant cells that confers on them reduced proliferation to provide effective migratory advantage; and the role of some of these identified proteins in ovarian cancer prognosis. These observations warrant further investigation of these novel target proteins in platinum-resistant patients.

Implementation and Safety of a Single Fraction Peripheral Lung SBRT during the Global COVID-19 Pandemic, a Single Institution's Experience

Purpose/Objective(s)

In response to the COVID-19 pandemic, a single fraction peripheral lung SBRT program was established to minimize potential COVID-19 exposures. This analysis aims to review clinical and treatment characteristics and associated toxicities in appropriately selected patients for this newly implemented technique.

Materials/Methods

From May 2020 until Feb 2022, patients with peripheral lung tumors who met eligibility for 3400cGy in a single-fraction SBRT were treated at a tertiary academic cancer center. Patient, treatment, and toxicity parameters were retrospectively collected. Radiation dosimetric parameters were tabulated. Toxicities were quantified using CTCAE v5.0. Fisher's exact test was used to assess the differences in toxicities with clinical and dosimetric parameters. P-value < 0.05 was considered significant.

Results

23 patients were analyzed with a median age of 72 years (IRQ: 67-80) and 61% were females. 96% were smokers and 43% had COPD. All patients were ECOG ≤ 2. Majority of patients (96%) had early-stage primary lung cancer while 4% had pulmonary oligometastatic cancer. 39% of patients were treated on SABR-BRIDGE protocol while another 35% were medically inoperable and 26% refused surgery. A total of 23 peripheral lesions were treated with median greatest dimension of 1.7 cm (IQR: 1.4-2), ITV 4.9 cm³ (IQR: 3.6-8.4) and PTV 18.1 cm³ (IQR: 12.8-26). 87% had PTV within 1 cm form chest wall. After median follow-up of 6 months (IQR: 2-12), 52% of patients experienced grade ≤ 2 toxicities and no patients experienced ≥ grade 3. Radiation pneumonitis was the most common toxicity (35%; 5/8 with asymptomatic radiographic) followed by fatigue (30%) and chest wall pain (30%; 3/7 with grade 2). Two patients (9%) had rib fractures. Chest wall pain was significantly higher in patients with tumor diameter >1.5 cm (p = 0.02). No other significant difference was observed between clinical or dosimetric parameters and development of radiation pneumonitis or chest wall pain (p > 0.05). On the other hand, patients with ribs fractures were observed to have larger tumors (mean 3.2 vs. 1.7 cm), ITVs (mean 30 vs. 11 cm³), PTVs (mean 61 vs. 16 cm³), chest wall V30_Gy (mean 4.8 vs. 0.4 cm³), and ribs V30_Gy (mean 1.1 vs. 0.1 cm³). Only 1 patient had local failure after 12 months while another patient on SABR-BRIDGE underwent surgical resection after 6 months in which there were 20% viable tumor cells.

Conclusion

Single fraction peripheral lung SBRT is a practical and safe option with no grade ≥ 3 toxicity. Our observed toxicities are within previously reported ranges. We observed that patients with rib fractures had larger tumors and higher V30_Gy to chest wall and ribs. Careful patient selection and dosimetric efforts to limit high fall-off dose to chest wall and ribs may limit these toxicities.

Community- vs. hospital-based management of multidrug-resistant TB in Pakistan

BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

Precision Medicine: An Optimal Approach to Patient Care in Renal Cell Carcinoma

Renal cell cancer (RCC) is a heterogeneous tumor that shows both intra- and inter-heterogeneity. Heterogeneity is displayed not only in different patients but also among RCC cells in the same tumor, which makes treatment difficult because of varying degrees of responses generated in RCC heterogeneous tumor cells even with targeted treatment. In that context, precision medicine (PM), in terms of individualized treatment catered for a specific patient or groups of patients, can shift the paradigm of treatment in the clinical management of RCC. Recent progress in the biochemical, molecular, and histological characteristics of RCC has thrown light on many deregulated pathways involved in the pathogenesis of RCC. As PM-based therapies are rapidly evolving and few are already in current clinical practice in oncology, one can expect that PM will expand its way toward the robust treatment of patients with RCC. This article provides a comprehensive background on recent strategies and breakthroughs of PM in oncology and provides an overview of the potential applicability of PM in RCC. The article also highlights the drawbacks of PM and provides a holistic approach that goes beyond the involvement of clinicians and encompasses appropriate legislative and administrative care imparted by the healthcare system and insurance providers. It is anticipated that combined efforts from all sectors involved will make PM accessible to RCC and other patients with cancer, making a tremendous positive leap on individualized treatment strategies. This will subsequently enhance the quality of life of patients.

Isolation and In Silico Characterization of Defensin Genes from Some Indigenous Plant Species of Pakistan

Aims: Damage of crop plants due to pathogenic attacks, postharvest crops spoilage and lethal effects of chemical pesticides has enforced scientists to find some potential natural alternative. Plants produce different types of antimicrobial peptides including defensins in response to biotic and abiotic stresses. Defensins are small cysteine rich, cationic peptide with 40-45 amino acid residues with a variety of biological activities. Hence defensins have pharmaceutical and agricultural significance especially wide range of antifungal activities. Methodology: Nine plant species viz Brassica napus, Brassica nigra, Conyza bonariensis, Alhagi marorum, Sonchus arvensis, Brassica compestris, Eruca sativa, Cirsium arvensis and Brassica juncea were selected for the study. Four set of primers were applied on extracted genomic DNAs and four amplified genes were isolated from different plants species by PCR. The amplified genes were cloned via pTZ57R/T in E.coli. The cloned fragments were sequenced and characterized by different bioinformatics tool such as coding length and peptide sequence, site of cell aggregation, peptide physico-chemical properties, antimicrobial properties and gene expression pattern. Result: The amplified products from B. napus, B. nigra, B. compestris, E. sativa and B. juncea were about 330 bp in length and showed upto 85% nucleotide homology to the reported defensins. Deduced amino acid sequence from Bn-Def, Es-Def Bj-Def and Bc- Def showed the conserved defensin domain. These sequences were also characterized for different characteristic like charged amino acids, pI value, shelflife and stability.  Sonchus arvensis didn’t give any specific product by prescribed set of primers. However the products from Alhagi marorum was about 770 bp and B. napus was of 270 bp but both give homology below 30%. Conclusion: This study showed that in silico characterization of deduced antimicrobial peptides from different plant species has depicted these as an effective alternative to communal therapeutics. However, further work is needed to verify defensins specific activity at protein level.

Prevalence of insect pests on maize crop in District Mansehra, Khyber Pakhtunkhwa, Pakistan

The maize crop is used as food for humans, livestock and poultries forms, it is also used in bread making, corn flakes, corn syrup, corn starch and corn oils. The field study consisted of one experimental trial, about the incidence of that insect pest complex on maize cultivar Azam during the Kharif season 2020 at the Agricultural, Research Station, Baffa, Mansehra. The trial was laid out in the Randomized Complete Block Design (RCBD), and then it was divided into three replications. The result obtained from the trial showed that a number of the pest species were recorded during the experimental period; however, the population was noticed at a low level. The obtained insect species were corn leaf aphid (6.90 ± 5.5) per square inch, corn leafhopper (1.32 ± 0.63), maize stem borer (0.63 ± 0.29), corn flea beetle (0.43 ± 0.28), Thrips (0.38 ± 0.22), Hairy caterpillar (0.21 ± 0.22), Grasshopper (0.17 ± 0.11) and shoot fly (0.11 ± 0.08) throughout the season.

The landscape of neurophysiological outcome measures in ALS interventional trials: A systematic review

OBJECTIVE

We collated all interventional clinical trials in amyotrophic lateral sclerosis (ALS), which utilised at least one neurophysiological technique as a primary or secondary outcome measure. By identifying the strengths and limitations of these studies, we aim to guide study design in future trials.

METHODS

We conducted and reported this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight databases were searched from inception. In total, 703 studies were retrieved for screening and eligibility assessment.

RESULTS

Dating back to 1986, 32 eligible interventional clinical trials were identified, recruiting a median of 30 patients per completed trial. The most widely employed neurophysiological techniques were electromyography, motor unit number estimation (including motor unit number index), neurophysiological index and transcranial magnetic stimulation (including resting motor threshold and short-interval intracortical inhibition). Almost 40% of trials reported a positive outcome with respect to at least one neurophysiological measure. The interventions targeted either ion channels, immune mechanisms or neuronal metabolic pathways.

CONCLUSIONS

Neurophysiology offers many promising biomarkers that can be utilised as outcome measures in interventional clinical trials in ALS. When selecting the most appropriate technique, key considerations include methodological standardisation, target engagement and logistical burden.

SIGNIFICANCE

Future trial design in ALS would benefit from a standardised, updated and easily accessible repository of neurophysiological outcome measures.

796 THE IMPORTANCE OF CHEST X RAYS AS AN INITIAL INVESTIGATION IN ROUTINE ACUTE ELDERLY CARE ADMISSIONS

Introduction

The Chest X-Ray (CXR) is a common and central initial investigation for any patient that has been admitted via Accident and Emergency (A&E). In the context of elderly care, it is a useful measure of a patient’s baseline functional status as well as a tool for cancer surveillance and other aspects of clinical care. Accurate documentation of CXR review is also imperative for closed loop communication of clinical information amongst a multi-disciplinary team.

Methods

Twenty-eight random inpatients in a local NHS Trust Healthcare of Older People (HCOP) department were selected to be part of this two-cycle study. Using hospital database records, the CARESTREAM imaging system and patient clinical documentation, data including the following was collected: whether a CXR was completed, was CXR review documented in patient notes and initial reason for admission. As per local practice, all acute HCOP admissions should undergo a CXR and have an image review clearly documented in patients’ clinical noting. The established target was 95% compliance for both. Following intervention by way of ward poaters and presentation at a local quality improvement meeting the cycle was repeated to ascertain improvement in compliance.

Results

22 (79%) HCOP patients had a CXR on admission. Of those completed CXRs, only 6 (27%) of these showed evidence of review (documentation in clinical noting). Following the above mentioned interventions, 25 (89%) of HCOP patients had a CXR on admission, showing an improvement. Of those completed CXRs, 20 (80%) showed evidence of documented clinical review– once again showing improvement.

Conclusions

CXRs and their accurate documentation is an important aspect of the holistic care of the HCOP patient. Ensuring that compliance for completing the scan and documenting results should be a priority in clinical quality and safety. Our interventions have shown an improvement in compliance and resulted in sustainable change.

Expression of TIMPs and MMPs in Ovarian Tumors, Ascites, Ascites-Derived Cells, and Cancer Cell Lines: Characteristic Modulatory Response Before and After Chemotherapy Treatment

Background

The tissue inhibitors of metalloproteinase (TIMPs) and their associated metalloproteinase (MMPs) are essential regulators of tissue homeostasis and are essential for cancer progression. This study analyzed the expression of TIMP-1,-2,-3 and the associated MMPs (MMP-2,-9,-11,-14) in different Stages, Grades and World Health Organization (WHO) classifications of serous ovarian tumors, ascites, ascites-derived cells from chemo-naïve (CN) and relapsed (CR) patients, and in ovarian cancer cell lines. The status of TIMPs and associated MMPs in response to chemotherapy treatment was assessed in cancer cell lines; TCGA data was interrogated to gauge TIMPs and associated MMPs as prognostic and platinum-response indicators.

Methods

The levels of TIMP-1, -2 and -3 were assessed by immunohistochemistry. The mRNA expression of TIMPs and MMPs was quantified by real time PCR (qRT-PCR). The chemosensitivity (IC₅₀ values) to Cisplatin or Paclitaxel in cell lines was evaluated by MTT assay. The levels of TIMPs in ascites and cell lysates were analyzed by an ELISA assay.

Results

The expression of TIMP-2 was significantly upregulated in Type 2 compared to Type 1 tumors and normal/benign ovarian tissues. TIMP-3 expression was significantly enhanced in Stage III, Grade 3 and Type 2 tumors compared to normal/benign ovarian tissues. The mRNA expression of MMP-9,-11 and -14 was significantly upregulated in Stage IV compared to normal/benign ovarian tissues. The expression of TIMP-1 was highest, followed by TIMP-2 and then TIMP-3 in CN ascites. At the cellular level, TIMP-2 mRNA expression was significantly higher in CN compared to CR epithelial cells in patients. The expression of TIMP-1 and -2, MMPs and cancer stem cells (CSCs) were upregulated in response to chemotherapy treatments in cancer cell lines. Interrogation of the TCGA dataset suggests shifts in platinum responses in patients consistent with genetic alterations in TIMP-2, -3 and MMP-2, -11 genes in tumors; and decreased overall survival (OS) and progression-free survival (PFS) in patients with altered MMP-14 genes.

Conclusions

TIMPs and related MMPs are differentially expressed in serous ovarian tumors, ascites, ascites-derived cells and ovarian cancer cell lines. Chemotherapy treatment modulates expression of TIMPs and MMPs in association with increased expression of genes related to cancer stem cells.

Refeeding syndrome in surgical patients post initiation of artificial feeding, a prospective cohort study in a low-income country

BACKGROUND & AIMS

South Africa's inequitable history has contributed to a malnourished population, further aggravated by high levels of violence and economic uncertainty culminating in a population suffering the sequelae of poverty. The perceived notion is that malnutrition places the South African population at greater risk for development of refeeding syndrome. This study aimed to identify the incidence of refeeding syndrome in the South African population.

METHODS

All patients admitted into the surgical intensive care unit from 1 November 2019 to 30 September 2020, were screened using the National Institute for Health and Care Excellence (NICE) refeeding risk criteria. Patients started on artificial feeds with one or more risk factors were included in the study. The syndrome was confirmed using the King's College criteria and compared with the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria for refeeding syndrome.

RESULTS

200 Patients were included in this study. The median age of the sample population was 41 years (IQR 30-58) with a male predominance (63%). All patients included had one or more risk factors and 62 (31%) of patients fulfilled the NICE criteria. The sensitivity of the NICE criteria was 33% and specificity was 70%. The most common risk factors identified were little or no nutritional intake for >5 days (55%) followed by a history of alcohol abuse, drugs including insulin, chemotherapy, diuretics or antacids (18%). Specificity values for all risk factors were >80% apart from little or no nutritional intake for >5 days which had a specificity of 64.2%. Sensitivity values for all risk factors were low. 84.5% of patients received artificial nutritional support in the form of enteral feeds, 9% parenteral and 6.5% both enteral and parenteral feeds. A total of 146 patients required electrolyte supplementation. Three patients fulfilled the King's College criteria and one subsequently died. In comparison, 25 patients fulfilled the ASPEN criteria and 3 demised.

CONCLUSION

Due to the low sensitivity and specificity of the NICE criteria, we advise that it be used merely as a guideline to identify patients at risk of refeeding syndrome and one should remain vigilant in patients with any risk factors present. Due to the small number of patients who fulfilled the King's College criteria and significant difference in incidence when compared to the ASPEN definition, a conclusion regarding the accuracy of both diagnostic criteria could not be made. We recommend a review of the current definition and a global adoption of an agreed criteria for the estimation of the true prevalence.

Global epidemiology of Equine Influenza viruses; "A possible emerging zoonotic threat in future" an extensive systematic review with evidence

There are different opinions around the World regarding the zoonotic capability of H3N8 equine influenza viruses. In this report, we have tried to summarize the findings of different research and review articles from Chinese, English, and Mongolian Scientific Literature reporting the evidence for equine influenza virus infections in human beings. Different search engines i.e. CNKI, PubMed, ProQuest, Chongqing Database, Mongol Med, and Web of Knowledge yielded 926 articles, of which 32 articles met the inclusion criteria for this review. Analyzing the epidemiological and Phylogenetic data from these articles, we found a considerable experimental and observational evidence of H3N8 equine influenza viruses infecting human being in different parts of the World in the past. Recently published articles from Pakistan and China have highlighted the emerging threat and capability of equine influenza viruses for an epidemic in human beings in future. In this review article we have summarized the salient scientific reports published on the epidemiology of equine influenza viruses and their zoonotic aspect. Additionally, several recent developments in the start of 21st century, including the transmission and establishment of equine influenza viruses in different animal species i.e. camels and dogs, and presumed encephalopathy associated to influenza viruses in horses, have documented the unpredictable nature of equine influenza viruses. In sum up, several reports has highlighted the unpredictable nature of H3N8 EIVs highlighting the need of continuous surveillance for H3N8 in equines and humans in contact with them for novel and threatening mutations.

Safety and outcomes of routine endovascular thrombectomy in large artery occlusion recorded in the SITS Register: An observational study

BACKGROUND AND OBJECTIVE

We aimed to evaluate the safety and outcomes of thrombectomy in anterior circulation acute ischaemic stroke recorded in the SITS-International Stroke Thrombectomy Register (SITS-ISTR) and compare them with pooled randomized controlled trials (RCTs) and two national registry studies.

METHODS

We identified centres recording ≥10 consecutive patients in the SITS-ISTR with at least 70% of available modified Rankin Scale (mRS) at 3 months during 2014-2019. We defined large artery occlusion as intracranial internal carotid artery, first and second segment of middle cerebral artery and first segment of anterior cerebral artery. Outcome measures were functional independence (mRS score 0-2) and death at 3 months and symptomatic intracranial haemorrhage (SICH) per modified SITS-MOST.

RESULTS

Results are presented in the following order: SITS-ISTR, RCTs, MR CLEAN Registry and German Stroke Registry (GSR). Median age was 73, 68, 71 and 75 years; baseline NIHSS score was 16, 17, 16 and 15; prior intravenous thrombolysis was 62%, 83%, 78% and 56%; onset to reperfusion time was 289, 285, 267 and 249 min; successful recanalization (mTICI score 2b or 3) was 86%, 71%, 59% and 83%; functional independence at 3 months was 45.5% (95% CI: 44-47), 46.0% (42-50), 38% (35-41) and 37% (35-41), respectively; death was 19.2% (19-21), 15.3% (12.7-18.4), 29.2% (27-32) and 28.6% (27-31); and SICH was 3.6% (3-4), 4.4% (3.0-6.4), 5.8% (4.7-7.1) and not available.

CONCLUSION

Thrombectomy in routine clinical use registered in the SITS-ISTR showed safety and outcomes comparable to RCTs, and better functional outcomes and lower mortality than previous national registry studies.

Knowledge attitude and practice of safety measures for corona virus disease - 19 (COVID-19) among general population

Objective

To evaluate the knowledge, attitude, and practice of general population for Corona virus disease 19 (COVID-19).

Methods

A total of 950 participants submitted an online self-administered questionnaire, which was developed through literature search and validated. The online survey link was distributed through various social media platforms (WhatsApp, Instagram, Facebook, LinkedIn, Twitter, Snapchat, Pinterest, and Tumblr). And 861 forms were included in the study after checking for completion of relevant response from participants, whereas 89 forms were excluded. The data were analyzed through Statistical Package for Social Sciences. Descriptive statistics were performed for percentage and frequency determination of quantitative and qualitative variables. Spearman's correlation and Chi square test were performed to control confounders and association of knowledge, attitude, and practices with gender and education level. The P value <0.05 was considered as statistically significant.

Results

More than two third of the population was aware of COVID-19 and three fourth had had bachelor's degrees, whereas 18% had master level education. 85% have not attended any courses, awareness campaigns, and lectures to inculcate recent and updated knowledge. 83% believed that COVID-19 is a serious threat to the community; hence, prevention strategies should be adopted. There was no significant relationship (p = 0.23) between knowledge, attitude, and practice levels with gender, whereas a significant relationship (p = 0.01) was noted with education of participant. Similarly, a significant relationship (p = 0.00) was seen between knowledge and practices of participants toward COVID-19.

Conclusion

The studied population displayed adequate knowledge, attitude, and practice to combat COVID-19. However, we also find a knowledge gap between information source and perception of COVID-19 among our study participants. Therefore, there is a critical need for effective education and widespread public campaigns aiming to enhance relevant and contemporary information related to prevention and management of COVID-19.

Distribution and abundance of dinoflagellates from the coastal waters of Karachi, Pakistan, northern part of the Arabian Sea

The present study reports on seasonal and spatial variations in diversity, distribution and abundance of dinoflegellates and indicates the presence of HAB species in Pakistan waters. A total of 179 taxa, recorded in this study from offshore and near-shore waters, belong to 41 genera in 26 families and 10 orders. The high species count (149 species) was recorded from Manora Island offshore station (MI-1) and 105 spp, 109 spp and 115 spp were encountered from the Mubarak village offshore station (MV-1), Manora near shore station (MI-2) and Mubarak Village near-shore station (MV-2) respectively. Tripos furca was the dominant and frequently occurring species (> 1 x103 to > 25 x103 cells L-1 from coastal and >1x 105 cells L-l from near-shore stations) in addition to less abundant Alexandrium catenella, Alexandrium sp., Alexandrium minutum, and Prorocentrum micans (>103 to 25x 103cells/L). Another 44 species occurred in relatively low numbers (<103 cell L-l). Seventy species were found throughout the study period at all four stations. High number of species in three genera (Tripos (38), Protoperidinium (34) and Prorocentrum (20) was recorded. Potently toxic (16 genera 43 species) and HAB related (19 genera and 30 species) dinoflagellate taxa were also recorded. The percent contribution of dinoflagellates in total phytoplankton population generally remained below 20% except for a few instances. Manora Island stations had comparatively higher Shannon index and equitability and slightly lower dominance index. The PCA plot showed strong positive correlation among chlorophyll-a concentration, dissolved oxygen, total number of phytoplankton and dinoflagellates.

Determinants of resistance to VEGF-TKI and immune checkpoint inhibitors in metastatic renal cell carcinoma

Vascular endothelial growth factor tyrosine kinase inhibitors (VEGF-TKIs) have been the mainstay of treatment for patients with advanced renal cell carcinoma (RCC). Despite its early promising results in decreasing or delaying the progression of RCC in patients, VEGF-TKIs have provided modest benefits in terms of disease-free progression, as 70% of the patients who initially respond to the treatment later develop drug resistance, with 30% of the patients innately resistant to VEGF-TKIs. In the past decade, several molecular and genetic mechanisms of VEGF-TKI resistance have been reported. One of the mechanisms of VEGF-TKIs is inhibition of the classical angiogenesis pathway. However, recent studies have shown the restoration of an alternative angiogenesis pathway in modulating resistance. Further, in the last 5 years, immune checkpoint inhibitors (ICIs) have revolutionized RCC treatment. Although some patients exhibit potent responses, a non-negligible number of patients are innately resistant or develop resistance within a few months to ICI therapy. Hence, an understanding of the mechanisms of VEGF-TKI and ICI resistance will help in formulating useful knowledge about developing effective treatment strategies for patients with advanced RCC. In this article, we review recent findings on the emerging understanding of RCC pathology, VEGF-TKI and ICI resistance mechanisms, and potential avenues to overcome these resistance mechanisms through rationally designed combination therapies.

The attributes of plakins in cancer and disease: perspectives on ovarian cancer progression, chemoresistance and recurrence

The plakin family of cytoskeletal proteins play an important role in cancer progression yet are under-studied in cancer, especially ovarian cancer. These large cytoskeletal proteins have primary roles in the maintenance of cytoskeletal integrity but are also associated with scaffolds of intermediate filaments and hemidesmosomal adhesion complexes mediating signalling pathways that regulate cellular growth, migration, invasion and differentiation as well as stress response. Abnormalities of plakins, and the closely related spectraplakins, result in diseases of the skin, striated muscle and nervous tissue. Their prevalence in epithelial cells suggests that plakins may play a role in epithelial ovarian cancer progression and recurrence. In this review article, we explore the roles of plakins, particularly plectin, periplakin and envoplakin in disease-states and cancers with emphasis on ovarian cancer. We discuss the potential role the plakin family of proteins play in regulating cancer cell growth, survival, migration, invasion and drug resistance. We highlight potential relationships between plakins, epithelial-mesenchymal transition (EMT) and cancer stem cells (CSCs) and discuss how interaction of these processes may affect ovarian cancer progression, chemoresistance and ultimately recurrence. We propose that molecular changes in the expression of plakins leads to the transition of benign ovarian tumours to carcinomas, as well as floating cellular aggregates (commonly known as spheroids) in the ascites microenvironment, which may contribute to the sustenance and progression of the disease. In this review, attempts have been made to understand the crucial changes in plakin expression in relation to progression and recurrence of ovarian cancer.

An online forum to support consultant psychiatrists in their first five years of practice, introduced during the COVID-19 pandemic

Introduction

In the United Kingdom, the move from trainee to consultant psychiatrist can be both exciting and daunting. Trainee psychiatrists have access to support and weekly supervision that is not available to consultants. Having an organised meeting for new consultants could help bridge this gap with peer-led support.

Objectives

Improving support and guidance to new consultants Networking with peers Promoting wellbeing, good clinical practice and career development

Methods

We identified a group of 85 consultants in their first five years of practice. Meetings were held online using videoconference. Senior leaders presented at each meeting, with a group discussion at the end. We surveyed attendees using an online platform.

Results

We had excellent attendance rates from the group, with 30 to 45 consultants attending each webinar. Over 60% of attendees had been a consultant for less than a year. For 90%, this was their first experience of a new consultant forum. Attendees gave excellent feedback (Table). Being able to meet consultants from different specialties, hearing career stories from senior leaders and how they have managed the COVID-19 pandemic were cited as benefits.

Table: Feedback scores (0 = not useful to 100 = very useful)
Statement	Score
The forum helped me feel supported	75
Topics covered are relevant to me	79
I feel more connected with colleagues	71

Conclusions

The forum was popular and the feedback was excellent. Using an online format worked well and made it easier to organise and plan sessions. There is potential to implement similar fora for other senior psychiatrists across Europe.

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South African guidelines on the determination of death

Summary

Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence. The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment (https://criticalcare.org.za/resource/death-determination-checklists/).

Key points

Brain death and circulatory death are the accepted terms for defining death in the hospital context.

Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met.

The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks’ corrected gestation.

Brain-death testing while on extra-corporeal membrane oxygenation is outlined.

Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation.

The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.

South African guidelines on the determination of death

Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence. The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment (https://criticalcare.org.za/resource/death-determination-checklists/). Key points • Brain death and circulatory death are the accepted terms for defining death in the hospital context. • Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met. • The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks' corrected gestation. • Brain-death testing while on extra-corporeal membrane oxygenation is outlined. • Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation. • The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.

The impact of COVID-19 on transfusion-dependent thalassemia patients of Karachi, Pakistan: A single-center experience

Objectives

With the advent of COVID-19 in Pakistan, the already fragmented blood transfusion services (BTS) received a severe blow, putting the lives of transfusion-dependent thalassemia children on stake. This study aimed to assess the impact of the COVID-19 on blood transfusion therapy (BTT) of thalassemia patients and suggest ways to ensure safe and reliable blood supplies amid such health crises.

Material and methods

A retrospective, cross-sectional study was conducted from October 2019 (before COVID-19) to July 2020 (during COVID-19) based on the data provided by a thalassemia center, named Help International Welfare Trust, Karachi, Pakistan. SPSS version 24.0 was used for the data analysis. Data were described in the form of means and percentages.

Results

There was a significant reduction in the consumption of PRBCs bags after the emergence of COVID-19 (P = 0.002). Moreover, the number of thalassemia patients receiving BTT was dropped by 10.56% during the pandemic. There was a strong negative correlation observed between the rising cases of COVID-19 in Pakistan and the number of patients missing their therapy sessions (r = −0.914, P = 0.030). A considerable decline in the reserves of all Rhesus-negative blood groups amid the COVID-19 outbreak was also observed.

Conclusion

The COVID-19 pandemic adversely affected the already suboptimal care catered to thalassemia patients in Karachi, Pakistan. The fear of the virus contraction coupled with the lockdown and restricted mobility has disrupted the entire transfusion chain from donor to the recipient. Collaborated efforts by the government and healthcare authorities are essential to ensure sufficient blood for thalassemia patients amid the pandemic.

A simple adaptation of a handheld ECG recorder to obtain chest lead equivalents

Hand held ECG recorders are transforming the way we detect and diagnose heart rhythm disorders. The Kardia 6 L was launched in 2019 to detect and diagnose heart rhythm disorders recording a six lead (limb lead) ECG. Recording and analysis of precordial leads are currently not supported by the Kardia 6 L. In this study we aim to assess if reliable chest lead data can be obtained using a simple modification to the recording system.

Urinalysis in dog and cat: A review

Urinalysis is the examination of normal and abnormal constituents of urine. It is an easy, cheap, and vital initial diagnostic test for veterinarians. Complete urinalysis includes the examination of color, odor, turbidity, volume, pH, specific gravity, protein, glucose, ketones, blood, erythrocytes, leukocytes, epithelial cells, casts, crystal, and organisms. Semi-quantitative urine analysis with urine dipsticks, as well as an automatic analyzer, provides multiple biochemical data. Contamination is almost entirely avoided if the protocols for ensuring a proper sample have been followed, as mentioned still consideration must be given to the likelihood of contamination, even if the sample is correctly obtained. Interpretation of urinalysis will be doubtful if the knowledge of the interference is limited. Well-standardized urinalysis, when correlated in the context of history, clinical findings, and other diagnostic test results, can identify both renal and non-renal disease. This paper reviews significance of different components of urinalysis of dog and cat, such as collection, storage, examination, interpretation, and common causes of error in the result.

TIMP-2 regulates proliferation, invasion and STAT3-mediated cancer stem cell-dependent chemoresistance in ovarian cancer cells

BACKGROUND

The metzincin family of metalloproteinases and the tissue inhibitors of metalloproteinases (TIMPs) are essential proteins required for biological processes during cancer progression. This study aimed to determine the role of TIMP-2 in ovarian cancer progression and chemoresistance by reducing TIMP-2 expression in vitro in Fallopian tube secretory epithelial (FT282) and ovarian cancer (JHOS2 and OVCAR4) cell lines.

METHODS

FT282, JHOS2 and OVCAR4 cells were transiently transfected with either single or pooled TIMP-2 siRNAs. The expression of different genes after TIMP-2 knock down (T2-KD) or in response to chemotherapy was determined at the mRNA level by quantitative real time PCR (qRT-PCR) and at the protein level by immunofluorescence. Sensitivity of the cell lines in response to chemotherapy after TIMP-2 knock down was investigated by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and 5-Ethynyl-2'-deoxyuridine (EdU) assays. Cell invasion in response to TIMP-2 knockdown was determined by xCELLigence.

RESULTS

Sixty to 90 % knock down of TIMP-2 expression was confirmed in FT282, OVCAR4 and JHOS2 cell lines at the mRNA and protein levels. TIMP-2 knock down did not change the mRNA expression of TIMP-1 or TIMP-3. However, a significant downregulation of MMP-2 in T2-KD cells occurred at both the protein and activation levels, compared to Control (Cont; scrambled siRNA) and Parental cells (P, transfection reagent only). In contrast, membrane bound MT1-MMP protein levels were significantly upregulated in T2-KD compared to Cont and P cells. T2-KD cells exhibited enhanced proliferation and increased sensitivity to cisplatin and paclitaxel treatments. Enhanced invasion was observed in the T2-KD-JOSH2 and OVCAR4 cells but not in T2-KD-FT282 cells. Treatment with cisplatin or paclitaxel significantly elevated the expression of TIMP-2 in Cont cells but not in T2-KD cells, consistent with significantly elevated expression of chemoresistance and CSC markers and activation of STAT3. Furthermore, a potent inhibitor of STAT3 activation, Momelotinib, suppressed chemotherapy-induced activation of P-STAT3 in OVCAR4 cells with concomitant reductions in the expression of chemoresistance genes and CSC markers.

CONCLUSIONS

The above results suggest that TIMP-2 may have a novel role in ovarian cancer proliferation, invasion and chemoresistance.

The Incidence and Associated Factors of Early Neurological Deterioration After Thrombolysis

Background and purpose:

Early neurological deterioration (END) after stroke onset may predict severe outcomes. Estimated rates of END after intravenous thrombolysis among small patient samples have been reported up to 29.8%. We studied the incidence and factors associated with END among patients following intravenous thrombolysis.

Methods:

We analyzed SITS-International Stroke Thrombolysis registry patients with known outcomes enrolled in 2010 to 2017. END was defined as an increase in National Institutes of Health Stroke Scale score ≥4 or death within 24 hours from baseline National Institutes of Health Stroke Scale. We determined the incidence of END and used logistic regression models to inspect its associated factors. We adjusted for variables found significant in univariate analyses ( P <0.05). Main outcomes were incidence of END, associated predictors of END, ordinal day-90 mRS, and day-90 mortality.

Results:

We excluded 53 539 patients and included 50 726 patients. The incidence of END was 3415/50 726 (6.7% [95% CI, 6.5%–7.0%]). Factors independently associated with END on multivariate analysis were intracerebral hemorrhage (OR, 3.23 [95% CI, 2.96–3.54], P <0.001), large vessel disease (LVD) with carotid stenosis (OR, 2.97 [95% CI, 2.45–3.61], P <0.001), other LVD (OR, 2.41 [95% CI, 2.03–2.88], P <0.001), and ischemic stroke versus transient ischemic attack (TIA)/stroke mimics (OR, 16.14 [95% CI, 3.99–65.3], P <0.001). END was associated with worse outcome on ordinal mRS: adjusted OR 2.48 (95% CI, 2.39–2.57, P <0.001) by day-90 compared with no END. The adjusted OR for day-90 mortality was 9.70 (95% CI, 8.36–11.26, P <0.001).

Conclusions:

The routinely observed rate of END reflected by real-world data is low, but END greatly increases risk of disability and mortality. Readily identifiable factors predict END and may help with understanding causal mechanisms to assist prevention of END.

A pilot study on the rational use of medicines in four tertiary care hospitals through validated World Health Organization prescribing drugs indicators

BACKGROUND

Appropriate utilization of therapeutic agents is a basic component of the quality of health outcomes for the patients and the community. A pilot study was conducted to evaluate the rational use of medicines and antibiotics, based on World Health Organization (who) prescribing indicators.

STUDY DESIGN

We performed a retrospective, descriptive, cross-sectional pilot study in the medical outpatient departments in four tertiary care hospitals of Islamabad, Pakistan, in order to verify the correct prescribing of medicines according to the validated indicators prepared by the World Health Organization (who).

METHODS

The Registries of all the prescriptions formulated during the period April 02 2017 - April 01 2018 by the outpatient departments of four tertiary care hospitals (two government funded hospitals (GH-A and GH-B) and two private funded hospitals (PH-C and PH-D) were considered. According to the World Health Organization recommendations, during the following month (April 02 2018 to May 1 2018), 600 prescriptions (150 per hospital) were collected by a random sampling method, verified and analyzed through a statistical tool (SPSS version 22.0).

RESULTS

Mean number of medicines per prescription were 4.6 (Optimal value ≤ 2), with the highest value observed in GH-B hospital. Out of these, 350 (58.3%) (Optimal value < 30%) prescriptions consisted of antibiotics and 340 (56.6%) (Optimal value < 25%) prescriptions consisted of injectable medicines, with marked differences between hospitals. About 550 (19.6%) medicines were prescribed by generic name in all selected prescriptions with the lowest value observed in PH-D (9.9%) (Optimal value = 100%). Overall, 88% medicines were prescribed from National essential medicine list/formulary (Optimal value = 100%). All the prescribing core indicators showed significant difference between hospitals (P = 0.001). The most commonly prescribed antibiotic was ceftriaxone (37.4%), followed by ciprofloxacin (15.1%).

CONCLUSIONS

Poor adherence to WHO prescribing indicators were observed in all medical outpatient departments in selected hospitals. WHO recommended core interventions should be implemented on trial basis to develop strategies to achieve long-lasting benefits.

Critical Care Society of Southern Africa adult patient blood management guidelines: 2019 Round-table meeting, CCSSA Congress, Durban, 2018

The CCSSA PBM Guidelines have been developed to improve patient blood management in critically ill patients in southern Africa. These consensus recommendations are based on a rigorous process by experts in the field of critical care who are also practicing in South Africa (SA). The process comprised a Delphi process, a round-table meeting (at the CCSSA National Congress, Durban, 2018), and a review of the best available evidence and international guidelines. The guidelines focus on the broader principles of patient blood management and incorporate transfusion medicine (transfusion guidelines), management of anaemia, optimisation of coagulopathy, and administrative and ethical considerations. There are a mix of low-middle and high-income healthcare structures within southern Africa. Blood products are, however, provided by the same not-for-profit non-governmental organisations to both private and public sectors. There are several challenges related to patient blood management in SA due most notably to a high incidence of anaemia, a frequent shortage of blood products, a small donor population, and a healthcare system under financial strain. The rational and equitable use of blood products is important to ensure best care for as many critically ill patients as possible. The summary of the recommendations provides key practice points for the day-to-day management of critically ill patients. A more detailed description of the evidence used to make these recommendations follows in the full clinical guidelines section.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.