Exploration of a Potential DOOR Endpoint for Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia Using Six Registrational Trials for Antibacterial Drugs

BACKGROUND

Desirability of outcome ranking (DOOR) is an innovative approach to clinical trial design and analysis that uses an ordinal ranking system to incorporate the overall risks and benefits of a therapeutic intervention into a single measurement. Here, we derived and evaluated a disease-specific DOOR endpoint for registrational trials for hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia (HABP/VABP).

METHODS

Through comprehensive examination of data from nearly 4,000 participants enrolled in six registrational trials for HABP/VABP submitted to the FDA between 2005-2022, we derived and applied a HABP/VABP specific endpoint. We estimated the probability that a participant assigned to the study treatment arm would have a more favorable overall DOOR or component outcome than a participant assigned to comparator.

RESULTS

DOOR distributions between treatment arms were similar in all trials. DOOR probability estimates ranged from 48.3% to 52.9% and were not statistically different. There were no significant differences between treatment arms in the component analyses. Though infectious complications and serious adverse events occurred more frequently in ventilated participants compared to non-ventilated participants, the types of events were similar.

CONCLUSIONS

Through a data-driven approach, we constructed and applied a potential DOOR endpoint for HABP/VABP trials. The inclusion of syndrome-specific events may help to better delineate and evaluate participant experiences and outcomes in future HABP/VABP trials and could help inform data collection and trial design.

Characterization of new cellulose fiber extracted from second generation Bitter Albizia tree

The present work examines the physical, thermal tensile, and chemical properties of wood skin fibers obtained from second generation Bitter Albizia (BA) tree skin. Chemical characterization of BA fibers showed the presence of various chemical contents such as cellulose of 74.89 wt. %, hemicellulose of 14.50 wt. %, wax of 0.31 wt. %, lignin of 12.8 wt. %, moisture of 11.71 wt. %, and ash of 19.29 wt. %. The density of BA fibers (BAFs) was showed 1285 kg/m3. XRD analysis of BAFs showed a crystallinity index (CI) of 57.20% and size of crystallite of 1.68 nm. Tensile strength and strain to failure of BAFs examined through tensile test were 513-1226 MPa and 0.8-1.37% respectively. TGA portrayed the thermal steadiness of BAFs as 339 °C with 55.295 kJ/mol kinetic activation energy, its residual mass was 23.35% at 548 °C. BAFs with high CI, less wax content, and better tensile strength make more suitable for making polymer matrix composites. SEM images of the BAFs surface depicted that the fiber outer surface has more rough which shows that they can contribute to hige fiber-matrix adhesion during composites preparation.

Seroprevalence of Various Viral Diseases in Tamil Nadu, India

Introduction

Virus-borne diseases have recently gained significant public health importance. Viruses infect several hosts, including animal reservoirs, evolve quickly, and recombine emerging and reemerging to pose recurring dangers to humans. The Viral Research and Diagnostic Laboratory (VRDL) located at Government Theni Medical College, Theni, Tamil Nadu, conducts the diagnosis of common virus infections.

Methods

From January 2018 to December 2022, the VRDL received whole blood sera samples from 84,059 patients suspected of having various viral illnesses. The enzyme-linked immunosorbent assay was used to detect viral infections in all of the samples.

Results

A total of 84,059 individuals suspected for various viral infections have been tested and out of these 4948 (5.88%) cases have been reported to be positive and among them, the dengue virus is predominantly followed by, hepatitis B virus, chikungunya virus, hepatitis C virus, hepatitis A virus, hepatitis E virus, hepatitis B virus, herpes simplex virus, cytomegalovirus, and rubella virus.

Conclusion

The issue of emerging and re-emerging infectious illnesses, particularly those caused by viruses, has grown in importance in public health. Timely action combined with proper information and the ability to diagnose infections may save many lives.

Exploration of a Potential Desirability of Outcome Ranking Endpoint for Complicated Intra-Abdominal Infections Using 9 Registrational Trials for Antibacterial Drugs

BACKGROUND

Desirability of outcome ranking (DOOR) is a novel approach to clinical trial design that incorporates safety and efficacy assessments into an ordinal ranking system to evaluate overall outcomes of clinical trial participants. Here, we derived and applied a disease-specific DOOR endpoint to registrational trials for complicated intra-abdominal infection (cIAI).

METHODS

Initially, we applied an a priori DOOR prototype to electronic patient-level data from 9 phase 3 noninferiority trials for cIAI submitted to the US Food and Drug Administration between 2005 and 2019. We derived a cIAI-specific DOOR endpoint based on clinically meaningful events that trial participants experienced. Next, we applied the cIAI-specific DOOR endpoint to the same datasets and, for each trial, estimated the probability that a participant assigned to the study treatment would have a more desirable DOOR or component outcome than if assigned to the comparator.

RESULTS

Three key findings informed the cIAI-specific DOOR endpoint: (1) a significant proportion of participants underwent additional surgical procedures related to their baseline infection; (2) infectious complications of cIAI were diverse; and (3) participants with worse outcomes experienced more infectious complications, more serious adverse events, and underwent more procedures. DOOR distributions between treatment arms were similar in all trials. DOOR probability estimates ranged from 47.4% to 50.3% and were not significantly different. Component analyses depicted risk-benefit assessments of study treatment versus comparator.

CONCLUSIONS

We designed and evaluated a potential DOOR endpoint for cIAI trials to further characterize overall clinical experiences of participants. Similar data-driven approaches can be utilized to create other infectious disease-specific DOOR endpoints.

An Electronic Algorithm to Identify Vancomycin-Associated Acute Kidney Injury

Background

The burden of vancomycin-associated acute kidney injury (V-AKI) is unclear because it is not systematically monitored. The objective of this study was to develop and validate an electronic algorithm to identify cases of V-AKI and to determine its incidence.

Methods

Adults and children admitted to 1 of 5 health system hospitals from January 2018 to December 2019 who received at least 1 dose of intravenous (IV) vancomycin were included. A subset of charts was reviewed using a V-AKI assessment framework to classify cases as unlikely, possible, or probable events. Based on review, an electronic algorithm was developed and then validated using another subset of charts. Percentage agreement and kappa coefficients were calculated. Sensitivity and specificity were determined at various cutoffs, using chart review as the reference standard. For courses ≥48 hours, the incidence of possible or probable V-AKI events was assessed.

Results

The algorithm was developed using 494 cases and validated using 200 cases. The percentage agreement between the electronic algorithm and chart review was 92.5% and the weighted kappa was 0.95. The electronic algorithm was 89.7% sensitive and 98.2% specific in detecting possible or probable V-AKI events. For the 11 073 courses of ≥48 hours of vancomycin among 8963 patients, the incidence of possible or probable V-AKI events was 14.0%; the V-AKI incidence rate was 22.8 per 1000 days of IV vancomycin therapy.

Conclusions

An electronic algorithm demonstrated substantial agreement with chart review and had excellent sensitivity and specificity in detecting possible or probable V-AKI events. The electronic algorithm may be useful for informing future interventions to reduce V-AKI.

Evaluation of the Diagnostic Performance of F18-Fluorodeoxyglucose-Positron Emission Tomography, Dynamic Susceptibility Contrast Perfusion, and Apparent Diffusion Coefficient in Differentiation between Recurrence of a High-grade Glioma and Radiation Necrosis

Background

Differentiation between recurrence of brain tumor and radiation necrosis remains a challenge in current neuro-oncology practice despite recent advances in both radiological and nuclear medicine techniques.

Purpose

The purpose of this study was to compare the diagnostic performance of dynamic susceptibility contrast (DSC) perfusion magnetic resonance imaging (MRI), apparent diffusion coefficient (ADC) derived from diffusion-weighted imaging, and F18-fluorodeoxyglucose-positron emission tomography (F18-FDG-PET) in the differentiation between the recurrence of a high-grade glioma and radiation necrosis.

Materials and Methods

Patients with a diagnosis of high-grade glioma (WHO Grades III and IV) who had undergone surgical resection of the tumor followed by radiotherapy with or without chemotherapy were included in the study. DSC perfusion, diffusion-weighted MRI, and PET scan were acquired on a hybrid PET/MRI scanner. For each lesion, early and delayed tumor-to-brain ratio (TBR), early and delayed maximum standardized uptake value (SUVmax), normalized ADC ratio, and normalized relative cerebral blood volume (rCBV) ratio were calculated and the pattern of lesional enhancement was noted. The diagnosis was finalized with either histopathological examination or the characteristics on follow-up imaging. The statistical analysis using the receiver operator characteristic curves was done to determine the diagnostic performance of DSC perfusion, 18-F FDG-PET, and ADC in differentiation between tumor recurrence and radiation necrosis.

Results

Fifty patients were included in the final analysis, 32 of them being men (64%). A cutoff value of early TBR >0.8 (sensitivity of 100% and specificity of 80%), delayed TBR >0.93 (sensitivity of 92.3% and specificity of 80%), early SUVmax >10.2 (sensitivity of 76.9% and specificity of 80%), delayed SUVmax >13.2 (sensitivity of 61.54% and specificity of 100%), normalized rCBV ratio >1.21 (sensitivity of 100% and specificity of 60%), normalized ADC ratio >1.66 (sensitivity of 38.5% and specificity of 80%), and Grade 3 enhancement (sensitivity of 100% and specificity of 60%) were found to differentiate recurrence from radiation necrosis. Early TBR had the highest accuracy (94.44%), while ADC ratio had the lowest accuracy (50%). A combination of early TBR (cutoff value of 0.8), late TBR (cutoff value of 0.93), and rCBV ratio (cutoff value of 1.21) showed a sensitivity of 100%, specificity of 92.3%, positive predictive value of 88.9%, negative predictive value of 93.7%, and an accuracy of 96.6% in discrimination between radiation necrosis and recurrence of tumor.

Conclusion

F18-FDG-PET and DSC perfusion can reliably differentiate tumor recurrence from radiation necrosis, with early TBR showing the highest accuracy. ADC demonstrates a low sensitivity, specificity, and accuracy in differentiating radiation necrosis from recurrence. A combination of early TBR, delayed TBR, and rCBV may be more useful in discrimination between radiation necrosis and recurrence of glioma, with this combination showing a better diagnostic performance than individual parameters or any other combination of parameters.

223. Development and Analysis of a Novel DOOR Endpoint for Complicated Intra-abdominal Infections (cIAI) Using 10 Registrational Trials for Antibacterial Drugs

Background

Desirability of outcome ranking (DOOR) uses an ordinal ranking system to evaluate global outcomes in clinical trial participants by incorporating safety and efficacy assessments into a single endpoint. In this study, we developed and applied a DOOR endpoint for cIAI clinical trials.

Methods

We reviewed 10 Phase 3 noninferiority trials for cIAI with electronic patient-level data (n=5473 participants) submitted to the FDA between 2005-2021. Extending previous work [CID. 2019:68(10):1691-8)], we developed an expanded cIAI-specific DOOR endpoint based on clinically meaningful events captured in trial datasets and those that were unique to patients with cIAI. Using this DOOR endpoint, we assigned each participant a DOOR rank, estimated the probability that a participant in the study treatment arm in each trial would have a more desirable DOOR rank than if assigned to the comparator arm, and analyzed individual components of clinical experience in each trial.

Results

Based on analysis of available data, we noted heterogeneity in definitions of “indeterminate” clinical outcomes, and significant diversity and increased incidence of infectious complications (ICs), serious adverse events (SAEs), and surgical/percutaneous procedures in participants without clinical cure. These informed the expansion of the DOOR endpoint for cIAI to include clinical efficacy outcomes, ICs, SAEs, and additional procedures (Table 1). The DOOR distributions between treatment and comparator arms in all 10 trials were similar. DOOR probability estimates for the 10 trials ranged from 44.5% to 50.3% but were not nominally statistically significant. Component analyses in two trials showed that the study treatment was nominally statistically inferior to the comparator with regard to SAEs and clinical failure, respectively (Fig. 1b, 1c). Table 1.

Experimental study on total coliform violations in the complied NH2CL, O3, and UV treated municipal water supply system

Water quality has become a severe concern on a global scale, owing mostly to the rapid increase of the nation's development. According to Malaysia's Natural Resources and Environment Ministry, poor water management is the primary cause of the country's water quality problems. Many river systems are polluted by home and industrial pollutants, according to the findings of research in Malaysia and comparable difficulties in a few other nations. Hence, the following are the research's goals: (1) To look into what is causing the infractions. (2) To undertake the inquiry, develop a thorough hypothesis. (3) To detect dangerous germs by sampling the most usually infected regions. (4) To develop a test for Total Coliform violations in chlorine-treated water at the water treatment plant and in water distribution systems. As a result, the most major barrier to ensuring the safe delivery of treated water to consumers and protecting human health from water-related diseases is the drinking water treatment process. As a result, practically all water treatment systems around the world, including those in the USA, use a chlorine-based procedure to disinfect the water system during treatment. According to studies, the ideal way of disinfecting treated water is both safe and beneficial. Any sort of pandemic or biologically caused disease has no societal implications. Many countries began to suffer in 2009 as a result of e-coli and total coliform contamination in their water systems, leading to ambiguity in disinfection methods. Some water from UNMC's coolers was within the guidelines, while some exceed them. Water coolers at Block E (614 m) and Block B (605 m), for example, measured 12 CFU/100 ml and 11 CFU/100 ml, respectively. Water coolers should be cleaned regularly to ensure that they perform correctly. Further, the microbial population was found to be higher at water storage tanks than that is at the water cooler. This demonstrates how a water cooler fulfils its purpose of filtering and trapping germs to provide clean drinking water.

Microbiological profile of canaliculitis and their antibiotic susceptibility patterns: A 11-year review at a referral eye care centre

PURPOSE

To analyze the microbiological profile and in vitro antibiotic susceptibility patterns of bacterial isolates in canaliculitis, an infection of the lacrimal drainage system of the eye.

METHODS

The laboratory records of patients presenting with canaliculitis from whom specimens were obtained for microbiological investigations at our tertiary eye care centre in South India from January 2010 to December 2020, were reviewed.

RESULTS

A total of 130 canalicular pus samples were collected from 112 patients and submitted for microbiological studies during the study period. A total of 183 micro-organisms were isolated from 115 culture-positive specimens. The micro-organisms isolated were predominantly aerobic Gram-positive bacteria (83.44%), with Coagulase-negative Staphylococci (CoNS/Other Staphylococcus spp) (31.69%), Corynebacterium spp (15.3%), Staphylococcus aureus (9.84%) and Viridans Streptococci (9.84%) accounting for a majority of the isolates. Actinomycesspp (6.56%) was the most common anaerobic bacterium isolated. Our study revealed several bacteria not previously associated with canaliculitis namely Ottowia spp, Elizabethkingiameningoseptica, Aeromonassalmonicida, Capnocytophagaochracea and Campylobacter gracilis. Polymicrobial aetiology was observed in 39.13% of culture-positive samples. Analysis of antibiotic susceptibility patterns of the isolates revealed a high proportion of Gram-positive bacteria susceptible to chloramphenicol (90.16%) compared to fluoroquinolones including ciprofloxacin (74.42%), norfloxacin (64.15%) and gatifloxacin (60.49%).

CONCLUSION

This study represents the largest series of canaliculitis reporting the microbiological profile and antibiotic susceptibilities of the isolated micro-organisms, till date. Gram-positive bacteria accounted for a majority of isolates, predominated by Staphylococcus spp. The increasing resistance of Gram-positive bacteria to fluoroquinolones warrants antibiotic treatment in canaliculitis is based on in vitro antimicrobial susceptibility patterns.

Comparison between Dexmedetomidine, Ketamine and Tramadol for Prevention of Perioperative Shivering under Spinal Anaesthesia: A Randomised Clinical Trial

Introduction: Perioperative shivering after spinal anaesthesia is a common complication. Ketamine and tramadol are routinely used to prevent perioperative spinal shivering. Ketamine has the side-effect of delirium while tramadol causes nausea and vomiting. Dexmedetomidine an alpha2 agonist is superior to tramadol and ketamine in view of better central vasoconstrictor tone regulation and less sympathetic activity. Aim: To compare the efficacy, effect on haemodynamics, and any adverse effects of tramadol, ketamine and dexmedetomidine when used prophylactically to prevent perioperative shivering after spinal anaesthesia. Materials and Methods: This, randomised, clinical study recruited adult patients aged 18 to 65 years, of American Society of Anaesthesiologists (ASA) I and II, of both genders undergoing surgery under spinal anaesthesia between February 2018 and August 2018. A total of 120 patients were assigned to four groups: T, D, K, and N, to receive Tramadol 0.5 mg/kg or Dexmedetomidine 0.5 μg/kg or Ketamine 0.25 mg/kg or normal saline 5 mL, respectively. Each study drug was diluted to 5 mL using normal saline and administered as a slow intravenous (iv) bolus injection five minutes before spinal anaesthesia. Patients received subarachnoid block in L3-4 or L4-5 space in sitting position with 0.5% hyperbaric bupivacaine 15 mg. Patients were monitored for shivering, (using a four-point scale), level of consciousness, heart rate, SpO2 , respiratory rate, non invasive blood pressure, nausea and vomiting, at intervals of every five minutes for the first 30 minutes and every 15 minutes for the remaining observation period. Results: Dexmedetomidine (n=0) offered lower incidence of shivering prevention after spinal anaesthesia than ketamine (n=2,6.6%), tramadol (n=10,33%) and normal saline groups (n=11,36.6%). Dexmedetomidine also provided the advantages of maintaining haemodynamics, respiratory rate, and consciousness, similar to ketamine or tramadol (p-value>0.05). Conclusion: Dexmedetomidine is superior to ketamine and tramadol for the prevention of shivering after spinal anaesthesia.

Audit of operation theater time utilization with perspective to optimize turnaround times and theater output

Background and Aims

Operation theater (OT) complex is an important area for a hospital as it needs expensive infrastructure, disposable, and reusable resources and a multidisciplinary highly qualified and efficient team, the metrics of which are key in generating revenue, and improved productivity. The efficient utilization of OT ensures maximum output in view of the investment of highly qualified doctors, equipment, and outcomes. Our study aimed to evaluate the utilization of OT functioning stepwise, reasons for delays, case cancellations, and areas of improvement if any.

Material and Methods

This prospective observational study was planned in three phases; in phase 1 audit of OT functioning was carried out for 1 month and based on data analysis recommendations were given for improvement. In phase 2, the recommendations would be implemented over 3 months and in phase 3 re-audit will be carried out for 1 month. Data analysis was done on IBM SPSS version 26 software. Descriptive statistics measures were calculated by the mean and standard deviation.

Results

The total available resource time was 52920 min and the total time utilized was 37740 min. Overall, raw utilization was 71.31%. OT was started late 63.50% times. Case cancellation occurred on 8.99% occasions.

Conclusion

We conclude that utilization of operating room time can be maximized by proper planning and realistic scheduling of elective lists, communication among team members, and resource management. Audit of OT utilization is an important tool to identify problem areas and formulate protocols accordingly.

A Regulatory Review Approach for Evaluation of Micafungin for Treatment of Neonatal Candidiasis

Pathogenesis of neonatal candidiasis (NC) is distinct from systemic candidiasis in adults and older pediatric patients due to the significant incidence of central nervous system (CNS) involvement in neonates. Thus, although adequate and well-controlled trials in NC are often unfeasible due to difficulty enrolling patients, extrapolation of efficacy from antifungal drug trials in adults is generally not appropriate. However, treatment of NC is an area of great unmet need. We describe a regulatory review approach that combined the assessment of limited clinical efficacy, pharmacokinetics, and safety data from neonates and young infants along with microbiology outcomes and pharmacokinetic data from relevant nonclinical models of candidemia/invasive candidiasis to inform the use of micafungin in pediatric patients younger than 4 months of age, while communicating areas of remaining uncertainty in labeling.

Comparison of hemodynamic responses to laryngoscopy and intubation using Macintosh or McCoy or C-MAC laryngoscope during uniform depth of anesthesia monitored by entropy

Background and Aims:

Laryngoscopy forms an important part of general anesthesia and endotracheal intubation. The aim of the present study was to compare the hemodynamic responses to Laryngoscopy and Intubation using Macintosh or McCoy or C-MAC Laryngoscope with M-Entropy module monitoring to ensure uniform and adequate depth of anesthesia, during and after intubation.

Material and Methods:

A prospective, randomised, comparative study was done and patients included were of 18 to 60 years, ASA (American Society of Anesthesiologist) physical status I and II of both sexes undergoing elective surgery under general anesthesia. They were assigned to three groups using simple randomisation, after securing IV (intravenous) access, standard monitoring and Entropy leads were attached. General anesthesia was administered with glycopyrrolate 0.1 mg, fentanyl 2 ug/kg and intravenous thiopentone, 4 mg/kg. Adequate muscle relaxation was achieved with atracurium 0.6 mg/kg IV. By titrating isoflurane concentration, Entropy maintained between 40 and 60, orotracheal intubation done, with Macintosh or McCoy or C-MAC blades according to simple randomisation. Size of laryngoscope blade, time taken for laryngoscopy and intubation were noted. Heart rate, blood pressure, RE (Response Entropy) and SE (State Entropy) were noted before and during induction and laryngoscopy and post intubation up to 5 minutes. Statistical analysis done using NCSS 9 version 9.0.8 statistical software.

Results:

Hemodynamic responses during laryngoscopy and intubation using Macintosh or McCoy or C-MAC laryngoscope were statistically insignificant (p > 0.05) between the three groups, provided the depth of anesthesia is maintained constant.

Conclusions:

It is the depth of anesthesia that decides the magnitude of hemodynamic responses and not the choice of laryngoscope.

Concordance of early and late endpoints for community-acquired bacterial pneumonia trials

BACKGROUND

While there are ongoing regulatory convergence efforts, differences remain in primary endpoints recommended for community-acquired bacterial pneumonia (CABP) trials. The US Food and Drug Administration recommends assessing CABP symptom resolution at an early time point (3-5 days after randomization). Other regulatory agencies recommend assessing overall clinical response at a later time point (5-10 days after therapy ends).

METHODS

We analyzed participant-level data from six recent CABP trials submitted to the FDA (n=4,645 participants) to evaluate concordance between early and late endpoint outcomes. We used multivariate logistic regression to identify factors associated with discordance.

RESULTS

Early and late endpoint outcomes were concordant for 85.6% of participants. The proportions of early endpoint responders that ultimately failed and early endpoint non-responders that ultimately succeeded were similar (6.0% vs 8.4%, respectively). Early endpoint response was highly predictive of late endpoint success (positive predictive value 92.9%). Multivariate logistic regression identified early endpoint responders/late endpoint failures as less likely to be obese and more likely to be infected with Chlamydophila pneumoniae or Staphylococcus aureus, have received antibacterial drug therapy prior to randomization, and have severe chest pain at baseline. The most common investigator-provided reasons for failure among early endpoint responders/late endpoint failures were receipt of non-study antibacterial drug therapy and loss to follow-up.

CONCLUSION

Early and late endpoint outcomes were highly concordant. These data may be useful in the continuing efforts to reach international regulatory convergence on CABP clinical trial design recommendations.

A sensitive liquid chromatography-tandem mass spectrometry method for quantitative bioanalysis of fingolimod in human blood: Application to pharmacokinetic study

A simple and sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) method has been developed and validated for the determination of fingolimod in human blood. The analyte and internal standard fingolimod-d4 were extracted from 300 μl of human blood using protein precipitation coupled with solid-phase extraction method. The chromatographic separation was achieved with a Kinetex biphenyl column (100 × 4.6 mm, 2.6 μm) under isocratic conditions at the flow rate of 0.8 ml/min and column temperature was maintained at 45°C. The detection of analyte and internal standard was carried out by tandem mass spectrometry, operated in positive ion and multiple reaction monitoring acquisition mode. The method was fully validated for its selectivity, precision, accuracy, linearity, stability, detection and quantification limit. The extraction recovery of fingolimod in human blood ranged from 98.39 to 99.54%. The developed method was linear over the concentration range of 5-2500 pg/ml with a detection limit of 1 pg/ml. The developed method was validated and successfully applied for pharmacokinetic study after oral administration of fingolimod capsules.

Development and validation of a liquid chromatography-tandem mass spectrometric method for the determination of lenalidomide in human plasma and its application on bioequivalence studies

A simple, sensitive, and specific liquid chromatography-tandem mass spectrophotometry (LC-MS/MS) method was developed and validated for the quantification of lenalidomide in human plasma. The separation was carried out on a symmetry, C18, 5-μm (50 × 4.6 mm) column as stationary phase and with an isocratic mobile phase of 0.1% formic acid in water-methanol in the ratio of (15:85, v/v) at a flow rate of 0.5 mL/min. Protonated ions formed by electrospray ionization in the positive mode were used to detect analyte and fluconazole (internal standard). The mass detection was made by monitoring the fragmentation of m/z 260.1/148.8 for lenalidomide and m/z 307.1/238.0 for internal standard on a triple quadrupole mass spectrometer. The developed method was validated over the concentration range of 10–1000 ng/mL for lenalidomide in human plasma with a correlation coefficient (r2) was 0.9930. The accuracy and precision values obtained from six different sets of quality control samples analyzed on separate occasions ranged from 99.41 to 106.97% and 2.88 to 4.22%, respectively. Mean extraction recoveries were 98.06% and 88.78% for the analyte and IS, respectively. The developed method was successfully applied for analyzing lenalidomide in human plasma samples.

Stabilized red soil-an efficient liner system for landfills containing hazardous materials

In recent decades, disposal of hazardous material has become a challenging task especially in case of landfills where leaching out of waste is possible. In such cases, an efficient and economical liner system using locally available material is very essential. In this paper, an attempt has been made to study the suitability of red soil stabilized using lime and Prosopis juliflora fibers as liner material for landfills. Prosopis is a woody weed available abundantly in tropical and subtropical regions of the world. The fibers were used at 0.0%, 0.25%, 0.50%, 0.75%, and 1.0% by weight of the soil and the amount of lime used was kept constant as 4%. Tests results revealed decrease in plasticity index, increase in UCC strength, ductile behavior, decrease in consolidation settlement, reduction in permeability and shrinkage, and increase in CBR resistance in soils treated with both lime and Prosopis fibers. SEM images of stabilized soil revealed adherence of hydrated products of lime on the fiber surface, which facilitate efficient stress transfer between the soil and fibers. A single composite liner system was modeled using Visual MODFLOW by replacing the compacted clay layer with the stabilized red soil below the HDPE liner and the model was simulated. The simulation result showed that the performance of liner system with stabilized red soil is good and could prevent the aquifer from contamination. From the study, it can be concluded that stabilized red soil possesses the geotechnical properties required for an efficient liner system.

Effect of perineural dexmedetomidine on the quality of supraclavicular brachial plexus block with 0.5% ropivacaine and its interaction with general anaesthesia

Background and Aims:

The effect of perineural dexmedetomidine on the time to onset, quality and duration of motor block with ropivacaine has been equivocal and its interaction with general anaesthesia (GA) has not been reported. We assessed the influence of dexmedetomidine added to 0.5% ropivacaine on the characteristics of supraclavicular brachial plexus block and its interaction with GA.

Methods:

In a randomised, double blind study, 36 patients scheduled for orthopaedic surgery on the upper limb under supraclavicular block and GA were divided into either R group (35 ml of 0.5% ropivacaine with 0.5 ml of normal saline [n - 18]) or RD group (35 mL of 0.5% ropivacaine with 50 μg dexmedetomidine [n - 18]). The onset time and duration of motor and sensory blockade were noted. The requirement of general anaesthetics was recorded.

Results:

Both the groups were comparable in demographic characteristics. The time of onset of sensory block was not significantly different. The proportion of patients who achieved complete motor blockade was more in the RD group. The onset of motor block was earlier in group RD than group R (P < 0.05). The durations of analgesia, sensory and motor blockade were significantly prolonged in group RD (P < 0.00). The requirement of entropy guided anaesthetic agents was not different in both groups.

Conclusions:

The addition of dexmedetomidine to 0.5% ropivacaine improved the time of onset, quality and duration of supraclavicular brachial plexus block but did not decrease the requirement of anaesthetic agents during GA.

Infection Prevention Considerations Related to New Delhi Metallo-β-Lactamase Enterobacteriaceae A Case Report

A 60-year-old American man who was hospitalized in India for 4 weeks after an intracranial bleed was transferred by air ambulance to a 249-bed community hospital in Maryland in January 2011. His clinical course is described elsewhere. Here, we describe the infection prevention considerations surrounding his care in the hospital. A sputum sample obtained from the patient grew a New Delhi metallo-β-lactamase-producing (NDM) Klebsiella pneumoniae (NDM-KP) strain and panresistant Acinetobacter species, among other pathogens. Two weeks later, a perirectal swab sample grew an NDM-1 Salmonella Senftenberg (NDM-SS) isolate, described elsewhere. Gut decolonization was attempted with rifaximin 300 mg every 12 hours for 12 days. The patient was discharged home 4.5 months later. He was readmitted to the hospital within 1 week and died shortly thereafter.

In recognition of his epidemiological risk factors, empiric contact isolation was instituted by the infectious disease physician who was consulted when the patient experienced a fever 24 hours after hospital admission. Once the NDM-KP strain was identified, a 1:1 nursing protocol was instituted for the patient; respiratory therapists, however, continued to care for other Patients. The patient's nurses were empowered to enforce strict contact isolation. Visitors were restricted to the patient's immediate family members. The hospital implemented an intensive education and communication program for the professional staff, nurses, respiratory therapists, ancillary personnel, and the patient's family.

Anaesthetic management of a patient with deep brain stimulation implant for radical nephrectomy

A 63-year-old man with severe Parkinson's disease (PD) who had been implanted with deep brain stimulators into both sides underwent radical nephrectomy under general anaesthesia with standard monitoring. Deep brain stimulation (DBS) is an alternative and effective treatment option for severe and refractory PD and other illnesses such as essential tremor and intractable epilepsy. Anaesthesia in the patients with implanted neurostimulator requires special consideration because of the interaction between neurostimulator and the diathermy. The diathermy can damage the brain tissue at the site of electrode. There are no standard guidelines for the anaesthetic management of a patient with DBS electrode in situ posted for surgery.

Designing a Low-Cost Multifunctional Infant Incubator

Every year, an unacceptably large number of infant deaths occur in developing nations, with premature birth and asphyxia being two of the leading causes. A well-regulated thermal environment is critical for neonatal survival. Advanced incubators currently exist, but they are far too expensive to meet the needs of developing nations. We are developing a thermodynamically advanced low-cost incubator suitable for operation in a low-resource environment. Our design features three innovations: (1) a disposable baby chamber to reduce infant mortality due to nosocomial infections, (2) a passive cooling mechanism using low-cost heat pipes and evaporative cooling from locally found clay pots, and (3) insulated panels and a thermal bank consisting of water that effectively preserve and store heat. We developed a prototype incubator and visited and presented our design to our partnership hospital site in Mysore, India. After obtaining feedback, we have determined realistic, nontrivial design requirements and constraints in order to develop a new prototype incubator for clinical trials in hospitals in India.

Towards enhancing the performance of multi-parameter patient monitors

Multi-parameter patient monitors (MPMs) have become increasingly important in providing quality healthcare to patients. It is well known in the medical community that there exists an intrinsic relationship between different vital parameters in a healthy person, these include heart rate, blood pressure, respiration rate and oxygen saturation. For example, an increase in blood pressure would lead to a decrease in the heart rate, and vice versa. Although it is likely to improve the performance of MPM systems, this fact is not explored in engineering research. In this work, experiments show that deriving additional features to capture the intrinsic relationship between the vital parameters, the alarm accuracy (sensitivity), no-alarm accuracy (specificity) and the overall performance of MPMs can be improved. The geometric mean of the product of all the vital parameters taken in pairs of two was used to capture the intrinsic relationship between the different parameters. An improvement of 10.55% for sensitivity, 0.32% for specificity and an overall performance improvement of 1.03% was obtained, compared to the baseline system using classification and regression tree with the four vital parameters.

An E-learning System Based on Secure Data Storage Services in Cloud Computing

Abundant reasonable computers, web resources and education content are identified to transform educational usage on-demand in the field of cloud infrastructure. Therefore, there comes a necessity to redesign the educational system to meet the needs better. The appearance of cloud based services supports the creation of latest generation e-learning systems for storing multimedia data within the cloud; it draws attention for academia and research area, which may be able to use high quality of resources. Even though the merits of cloud service are more attractive, the physical possession of users data is under security risk with respect to data correctness. This poses many new security challenges which have not been well explored. This paper focuses mainly on distributed data storage security for e-learning system, which has always been an important aspect of quality service. To make sure the correctness of users data within the cloud, an adaptable and effective auditing mechanism hitches the challenges and distributes erasure-coded data for e-learning web application. This extensive analysis shows that the auditing result achieves quick data error correction and localization of servers for malicious data modification attacks.

Role of hydrocortisone in prevention of pain on propofol injection

Background and Objectives:

Pain following intravenous injection of propofol continues to be an intriguing problem. None of the commonly used methods completely attenuate the pain. Inflammatory response to propofol contributes to the pain. Role of hydrocortisone in attenuating pain has not been evaluated. This study was conducted to compare the efficacy of lignocaine and hydrocortisone in attenuation of pain following intravenous injection of propofol.

Materials and Methods:

A prospective randomized double-blind, placebo-controlled study was conducted on 72 adult patients belonging to American Society of Anesthesiologists (ASA) physical status I or II, scheduled to undergo elective surgery. They were randomly assigned to four groups of 18 each. Group NS, group LG, group HC10, and group HC25. The groups received 2 ml normal saline, 2 ml 2% lignocaine, 10 mg/2 ml hydrocortisone, and 25 mg/2 ml hydrocortisone, respectively, as pretreatment. Propofol was injected 30 sec later. A blinded researcher assessed the patient's pain level using a four point verbal rating scale.

Results:

The four groups were comparable in respect to patient's characteristics. There was no significant difference of hemodynamics changes during propofol induction between all the groups. There was no statistically significant difference in the incidence of pain between patients who received hydrocortisone and the placebo group. The incidence of pain was significantly less in group LG than other three groups.

Conclusion:

Use of intravenous low dose hydrocortisone pretreatment of the vein does not attenuate pain following propofol injection.

Development of calibration techniques for ultrasonic hydrophone probes in the frequency range from 1 to 100 MHz

The primary objective of this work was to develop and optimize the calibration techniques for ultrasonic hydrophone probes used in acoustic field measurements up to 100 MHz. A dependable, 100 MHz calibration method was necessary to examine the behavior of a sub-millimeter spatial resolution fiber optic (FO) sensor and assess the need for such a sensor as an alternative tool for high frequency characterization of ultrasound fields. Also, it was of interest to investigate the feasibility of using FO probes in high intensity fields such as those employed in HIFU (high intensity focused ultrasound) applications. In addition to the development and validation of a novel, 100 MHz calibration technique the innovative elements of this research include implementation and testing of a prototype FO sensor with an active diameter of about 10 microm that exhibits uniform sensitivity over the considered frequency range and does not require any spatial averaging corrections up to about 75 MHz. The results of the calibration measurements are presented and it is shown that the optimized calibration technique allows the sensitivity of the hydrophone probes to be determined as a virtually continuous function of frequency and is also well suited to verify the uniformity of the FO sensor frequency response. As anticipated, the overall uncertainty of the calibration was dependent on frequency and determined to be about +/-12% (+/-1 dB) up to 40 MHz, +/-20% (+/-1.5 dB) from 40 to 60 MHz and +/-25% (+/-2dB) from 60 to 100 MHz. The outcome of this research indicates that once fully developed and calibrated, the combined acousto-optic system will constitute a universal reference tool in the wide, 100 MHz bandwidth.

Filarial/human immunodeficiency virus coinfection in urban southern India

The disease course of human immunodeficiency virus (HIV) is often altered by existing or newly acquired coinfections. Treatment or prevention of these concomitant infections often improves the quality and duration of life of HIV-infected persons. The impact of helminth infections on infections with HIV is less clear. However, HIV is frequently most problematic in areas where helminth infections are common. In advance of the widespread distribution of drugs for elimination of lymphatic filariasis, we assessed the prevalence of active Wuchereria bancrofti infection among HIV-positive patients in Chennai, India at two time points separated by four years. We found that the overall prevalence of W. bancrofti infections among HIV-positive persons was 5-9.5%, and there were no quantitative differences in circulating filarial antigen levels between HIV-positive and HIV-negative filarial-infected patients.

Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC)

We sought to determine the rate of healthcare-associated infection (HCAI), microbiological profile, bacterial resistance, length of stay (LOS) and excess mortality in 12 ICUs of the seven hospital members of the International Infection Control Consortium (INICC) of seven Indian cities. Prospective surveillance was introduced from July 2004 to March 2007; 10 835 patients hospitalized for 52 518 days acquired 476 HCAIs, an overall rate of 4.4%, and 9.06 HCAIs per 1000 ICU-days. The central venous catheter-related bloodstream infection (CVC-BSI) rate was 7.92 per 1000 catheter-days;the ventilator-associated pneumonia (VAP) rate was 10.46 per 1000 ventilator-days; and the catheter-associated urinary tract infection (CAUTI) rate was 1.41 per 1000 catheter-days. Overall 87.5% of all Staphylococcus aureus HCAIs were caused by meticillin-resistant strains, 71.4% of Enterobacteriaceae were resistant to ceftriaxone and 26.1% to piperacillin-tazobactam; 28.6% of the Pseudomonas aeruginosa strains were resistant to ciprofloxacin, 64.9% to ceftazidime and 42.0% to imipenem. LOS of patients was 4.4 days for those without HCAI, 9.4 days for those with CVC-BSI, 15.3 days for those with VAP and 12.4 days for those with CAUTI. Excess mortality was 19.0% [relative risk (RR) 3.87; P < or = 0.001] for VAP, 4.0% (RR 1.60; P=0.0174) for CVC-BSI, and 11.6% (RR 2.74; P=0.0102) for CAUTI. Data may not accurately reflect the clinical setting of the country and variations regarding surveillance may have affected HCAI rates. HCAI rates, LOS, mortality and bacterial resistance were high. Infection control programmes including surveillance and antibiotic policies are a priority in India.

In vitro and in vivo studies on HPMC-K-100 M matrices containing naproxen sodium

Controlled release (CR) matrix tablets of naproxen sodium were prepared by wet granulation using hydroxypropyl methyl cellulose (HPMC-K-100 CR) as the hydrophilic rate controlling polymer. The effect of the concentration of the polymer and different fillers on the in vitro drug release rate was studied. The studies indicated that the drug release can be modulated by varying the concentration of the polymer and the fillers. An optimized formulation subjected to accelerated stability studies for 3 months revealed that the developed CR tablets are stable. A complete cross-over bioavailability study of the optimized formulation of the developed CR tablets and marketed immediate release tablets was performed in 6 healthy male volunteers. The extent of absorption of drug from the CR tablets was significantly higher than that for the marketed naproxen sodium tablet due to lower elimination rate and longer half-life.