Tourniquet use in ankle arthroscopy: A systematic review

BACKGROUND

Ankle arthroscopy is commonly performed using a thigh tourniquet and is thought to improve visibility and reduce operative time. However, the current evidence is unclear as to whether the use of a tourniquet provides these benefits. The aim of this study was to investigate whether there is any clinical benefit of using a tourniquet in ankle arthroscopy.

METHODS

A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, PubMed and the Cochrane Library Database from inception until January 2023 reporting on the use of a tourniquet in ankle arthroscopy were included.

RESULTS

180 studies were identified of which 3 (164 patients) met the inclusion criteria. All studies showed no statistically significant difference in mean surgical time and complication rate between the tourniquet and non-tourniquet groups. Overall, the quality of the evidence was moderate to poor without data in favour or against the routine use of tourniquets in ankle arthroscopy.

CONCLUSION

The current literature suggests that there are no significant differences in mean surgical time and complication rate between the tourniquet and non-tourniquet groups.

Effects of copper and zinc oxide nanoparticles on German cockroach development, indoxacarb resistance, and bacterial load

BACKGROUND

The German cockroach, Blattella germanica, is a ubiquitous and medically significant urban pest. The ongoing development of insecticide resistance in global populations of B. germanica has complicated control efforts and created a need for improved tools. We previously reported that disruption of the gut microbiota by oral administration of the antimicrobial doxycycline reduced resistance in an indoxacarb resistant field strain and also delayed nymphal development and reduced adult fecundity. However, the application of doxycycline for cockroach control in the field is impractical. Here, we sought to determine whether two metal nanoparticles with known antimicrobial properties, copper (Cu) and zinc oxide (ZnO), have similar effects to doxycycline on the physiology of B. germanica and could provide more practical alternatives for control.

RESULTS

We found that dietary exposure to 0.1% Cu nanoparticles, but not ZnO, significantly delays the development of nymphs into adults. However, neither of the nanoparticles altered the fecundity of females, and ZnO surprisingly increased resistance to indoxacarb in a resistant field strain, in contrast to doxycycline. Semi-quantitative polymerase chain reaction (qPCR) further revealed that prolonged dietary exposure (14 days) to Cu or ZnO nanoparticles at the low concentration readily consumed by cockroaches (0.1%) does not reduce the load of the bacterial microbiota, suggesting alternative mechanisms behind their observed effects.

CONCLUSIONS

Together, our results indicate that ingestion of Cu nanoparticles can impact German cockroach development through an undetermined mechanism that does not involve reducing the overall load of the bacterial microbiota. Therefore, Cu may have some applications in cockroach control as a result of this activity but antagonistic effects on insecticide resistance should be considered when evaluating the potential of nanoparticles for cockroach control. © 2023 Society of Chemical Industry.

The Learning Curve of Third-Generation Percutaneous Chevron and Akin Osteotomy (PECA) for Hallux Valgus

The learning curve to reach technical proficiency for third-generation percutaneous or minimally invasive chevron and Akin osteotomies (PECA/MICA) is recognized to be steep however it is poorly defined in the literature. This study is a retrospective review of the first 58 consecutive PECA cases of a single surgeon. The primary outcome was the number of cases required to reach technical proficiency as defined by the operation time. Secondary outcomes included radiation exposure, radiographic deformity correction, and complication rates. Between November 2017 and March 2019, 61 consecutive PECA cases were performed with outcome data available for 58 of these (95%). Technical proficiency was reached after 38 cases. Operation time and radiation exposure significantly decreased after this transition point (p < .05). There was no difference in complication rate or radiographic deformity correction regardless of position along the learning curve (p > .05). In conclusion, the mean number of cases required to reach technical proficiency in third-generation PECA is 38 cases. The complication rate does not correlate to the number of cases performed, therefore surgeons interested in learning minimally invasive surgery can be reassured that there is unlikely to be an additional risk of harm to a patient during the learning curve.

Prevalence and Implications of Shiga Toxin-Producing E. coli in Farm and Wild Ruminants

Shiga-toxin-producing Escherichia coli (STEC) is a food-borne pathogen that causes human gastrointestinal infections across the globe, leading to kidney failure or even death in severe cases. E. coli are commensal members of humans and animals' (cattle, bison, and pigs) guts, however, may acquire Shiga-toxin-encoded phages. This acquisition or colonization by STEC may lead to dysbiosis in the intestinal microbial community of the host. Wildlife and livestock animals can be asymptomatically colonized by STEC, leading to pathogen shedding and transmission. Furthermore, there has been a steady uptick in new STEC variants representing various serotypes. These, along with hybrids of other pathogenic E. coli (UPEC and ExPEC), are of serious concern, especially when they possess enhanced antimicrobial resistance, biofilm formation, etc. Recent studies have reported these in the livestock and food industry with minimal focus on wildlife. Disturbed natural habitats and changing climates are increasingly creating wildlife reservoirs of these pathogens, leading to a rise in zoonotic infections. Therefore, this review comprehensively surveyed studies on STEC prevalence in livestock and wildlife hosts. We further present important microbial and environmental factors contributing to STEC spread as well as infections. Finally, we delve into potential strategies for limiting STEC shedding and transmission.

Time to maximum clinical improvement following minimally invasive chevron and Akin osteotomies (MICA) in hallux valgus surgery

BACKGROUND

There is increasing evidence of positive improvement in clinical and radiological outcomes following minimally invasive hallux valgus deformity correction surgery (MIS). This study investigated the rate of improvement in clinical patient reported outcome measures (PROMs) following MIS as this is not well understood.

METHODS

Between July 2014 and July 2019, data was prospectively collected from consecutive patients pre-operatively and at 6, 12, and 24 months following third-generation minimally invasive chevron and Akin osteotomies (MICA). Radiographic deformity and correction was assessed using weight-bearing radiographs pre-operatively and 6 weeks post-operatively. The primary outcome measure was the change in Manchester Oxford Foot Questionnaire (MOXFQ) score at each time point. Secondary outcomes include radiographic deformity correction, health-related quality of life PROMs and exploration of cases where PROMs did not improve.

RESULTS

There were 202 feet with complete PROM data for every time point. There was a statistically significant improvement in MOXFQ Index score at each time point (p < 0.05) following MICA surgery. The majority of the improvement occurred within the first 6 months. A subgroup of 17 feet (8.4%) were identified which had worse MOXFQ Index scores 6 months following MICA. For 14 feet in this subgroup (82.4%), the MOXFQ Index score subsequently improved over time such that by two years, their score had significantly improved compared to their pre-operative score.

CONCLUSION

The majority of PROM improvement with MICA is gained by 6 months post-operatively but further significant improvement can be seen up to 2 years. Those patients who have not improved at 6 months, are likely to do so with time.

LEVEL OF EVIDENCE

IV.

A holistic molecular modelling approach to design novel indole-2-carboxamide derivatives as potential inhibitors of MmpL3

Tuberculosis is an infectious air-borne disease and one of the leading causes of death globally among all infectious diseases. There is an urgent need to develop antitubercular drugs that would be highly efficient and less toxic than the presently available marketed drugs. Mycobacterium membrane protein large 3 (MmpL3) is an emerging drug target in tuberculosis with various classes of molecules that have been known to inhibit it. In this study, a dataset of indole-2-carboxamides showing antitubercular activity by inhibiting MmpL3 was utilized. Initially, a chimera-based homology model was developed and docking was performed with the filtered dataset to analyse the interactions. Thereafter, molecular dynamics simulations were run with representative molecules to gain a better insight on the binding patterns. To attain a more quantitative correlation, an atom-based 3D QSAR model was developed which complemented the results from the previous models. A library of novel indole-2-carboxamides was then generated using core hopping-based ligand enumeration and upon screening on our workflow model it predicted three molecules as potent antitubercular compounds. This work not only helps to gain new insights on the interactions at the MmpL3 binding site but also provides novel indole-2-carboxamides having the potential to become antitubercular drugs in future.

Minimally invasive surgery for severe hallux valgus in 106 feet

BACKGROUND

There is widespread variation in the optimal procedure for correction of severe hallux valgus deformity defined as hallux valgus angle (HVA) (≥40°) and/or 1-2 intermetatarsal angle (IMA) (≥20°). There is limited evidence investigating the clinical or radiological outcomes following treatment of severe hallux valgus deformity with third-generation minimally invasive chevron and Akin osteotomies (MICA).

METHODS

This was a prospective observational single surgeon series of consecutive patients who underwent primary third-generation MICA with screw fixation for severe hallux valgus. The primary outcome was a validated patient reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ), assessed minimum 2 years following MICA. Secondary outcomes were radiographic deformity correction (assessed 6 weeks post-operatively), complication rates and other quality of life PROMs (EQ-5D and Visual Analogue Pain Scale).

RESULTS

Between September 2014 and November 2018, 106 consecutive feet (n = 78 patients; 73 female, 5 male) met the inclusion criteria. Prospectively collected pre-operative and 2 year PROM MOXFQ data was available for 86 feet (81.1%). At two years following surgery, the MOXFQ score significantly improved for the Pain, Walking and Standing and Social Interaction domains from 39.2 to 7.5, 38.2 to 5.9 and 48.6 to 5.5, respectively (p < 0.001). Pre- and 6 week post-operative radiographic data was available for all 106 feet. Mean IMA improved from 18.2° to 6.3° (p < 0.001) whilst mean HVA improved from 45.3° to 10.9° (p < 0.001). The complication rate was 18.8% and the screw removal rate was 5.6%.

CONCLUSION

This study has demonstrated third-generation MICA for the treatment of severe hallux valgus deformity enables substantial deformity correction and is associated with significant improvements in clinical PROMs 2 years following surgery.

The impact of hallux valgus on function and quality of life in females

BACKGROUND

The effect of hallux valgus (HV) on health-related quality of life (HRQOL) and the relationship between radiographic severity of deformity and patient reported outcome measures (PROMs) is poorly understood. The aim of this study was to compare the HRQOL of female patients with HV to the UK population. The secondary aim was to assess the correlation between PROMs, including HRQOL, with radiographic severity of deformity.

METHODS

Weight bearing radiographic data (hallux valgus (HVA) angle; intermetatarsal (IM) angle) were measured in consecutive female patients presenting with HV. Each patient prospectively completed the Euroqol EQ-5D-5L questionnaire (EQ-5D), Visual Analogue Scale for Pain (VAS-Pain) and Manchester Oxford Foot Questionnaire (MOXFQ). Data were stratified into age ranges and compared with an EQ-5D United Kingdom general population reference dataset. Pearson R correlation values were calculated for the PROMs and radiographic deformity.

RESULTS

Between July 2015 and March 2020, 425 consecutive female patients presented with HV for consideration for surgery. EQ-5D-5L data were prospectively collected for 396 of these patients (93.2%). Females less than 65 years with HV had a statistically significantly worse quality of life compared with females of the same age group in the general population. Above the age of 65, there was no statistically significant difference in EQ-5D-5L Index score between the two groups. Younger females reported higher VAS-Pain scores compared to older patients with 91% of patients reporting some degree of pain symptoms. There was a moderate correlation with MOXFQ Index score and EQ-5D-5L Index (R = -0.51, p < 0.001) and VAS-Pain scores (R = 0.54, p < 0.001). There was no correlation between radiographic HV deformity and HRQOL measures or MOXFQ scores although it was noted that there was a trend of increasing HVA/IMA with age.

CONCLUSION

Female patients presenting with HV deformity have a significantly reduced quality of life compared with the UK general population. The radiographic severity of deformity did not correlate with HRQOL measures or foot and ankle specific PROMs. Foot and ankle specific clinical PROMsmoderately correlate with HRQOL and may be a better marker of the negative effect of symptomatic hallux valgus deformity on quality of life.

LEVEL OF EVIDENCE

III.

Hallux valgus surgery in children with cerebral palsy: A systematic review

BACKGROUND

Children with cerebral palsy are highly likely to develop foot deformities, some of which may require surgical intervention. Hallux valgus is a common forefoot deformity which can cause issues with pain, footwear, orthotic splints and soft tissues. It remains unclear what the optimal surgical treatment is for children with cerebral palsy and hallux valgus deformity.

OBJECTIVE

To systematically review studies reporting the clinical and radiological outcomes of surgical correction of hallux valgus deformity in children with cerebral palsy.

METHODS

A systematic review of studies published in electronic databases (Medline, Embase, Pubmed and Cochrane library) from inception until January 2021. Keywords related to hallux valgus and cerebral palsy were included.

RESULTS

58 studies were identified of which 7 met the criteria for inclusion. 200 feet in 134 patients with a mean age of 13.5 years were included, with a mean follow up period of 43 months. A range of clinical and radiographic outcomes were assessed. A treatment framework for the assessment and management of hallux valgus in children with cerebral palsy based on the published evidence is presented.

CONCLUSION

Non-ambulant children with cerebral palsy with symptomatic hallux valgus should primarily undergo first MTPJ arthrodesis whilst those who are ambulant should undergo first metatarsal osteotomy± soft tissue correction.

A public health approach for addressing recidivism and addiction using European concepts in Alaska

Problem

Criminal activity attributed to substance misuse is a tremendous challenge to public health and public safety. Over 80% of Alaska's incarcerated population has an addiction disorder. These individuals are 129 times more likely to die of a drug overdose within two weeks after reentry. Nearly 83% will likely be rearrested. This complex problem has a costly impact. In 2017, 25,450 Alaskans were victims of crimes directly attributed to substance misuse for a total cost of over $2.3 billion.

Description

The Alaska Recidivism Reduction and Recovery Project is a comprehensive intervention addressing the primary risk factors of ongoing criminal activity and substance misuse within an innovative therapeutic campus model and a mobile health platform. The intervention uses a conceptual framework derived from the European Union's Triple-R Model and the Norway Model of Restorative Justice. Living on a therapeutic campus for an average of 6-18 months, formerly incarcerated adults engage in a suite of services designed to transform criminogenic needs. Services also employ an innovative mobile health platform using Oracle's Intelligent Advisor technology. The project aims to increase access to critical community care, improve participants' quality of life, and improve public health and safety by reducing crime related to substance misuse.

Results

Preliminary results suggest the intervention may significantly improve access to care upon reentry while creating meaningful changes in criminogenic needs. Early indications also suggest substantial cost savings may be achieved. For every 80 successful participants in Alaska, data suggests cost savings and net economic benefits may reach $20 million.

Lessons

European concepts can be successfully replicated in Alaska to create an impactful intervention addressing criminal recidivism and addiction. Given the correlation between crime and addiction, this practice may provide a critical pathway for improving public health and safety.

Key messages

European conceptual frameworks can be successfully replicated in Alaska to create a meaningful community-based intervention for reducing criminal recidivism and substance misuse. An innovative intervention in Alaska addressing the primary risk factors of criminal activity and substance misuse demonstrates the potential to achieve significant social impact and cost savings.

Storage and recycling of major and trace element in mangroves

The role of mangroves in sequestering metal and nutrients in sediment has been described in the past, but knowledge gaps still exist on storage capacity and recycling fluxes of elements in plant biomass, notably concerning their magnitude in root uptake and loss by litterfall. This study addresses the storage and transport pathways of 16 elements, classified as macro-nutrients (Ca, Mg, Na, K), micro-nutrients (Fe, Mn, Ni, Co, Cu, Cr, Zn, Mo), and potential toxicants (Al, Cd, Sn, Pb) in the world's largest mangroves, the Sundarbans. Elemental concentrations in plant organs were generally lower than in the sediment. The stock of macro and micro-nutrients in plant biomass varied from 60 to 2717 and 0.003 to 37.7 Mg ha^-1 respectively, with highest values observed for Na and lowest for Cd. The Avicennia species exhibited the maximal accumulation of all elements. Translocation of major elements to different plant organs increased with increasing their concentrations in the sediment. Elemental loss via litterfall indicated that Sundarbans mangrove could act as a source, particularly of Mn, to the Bay of Bengal. Moreover, belowground uptake of the 16 elements showed 2-3 fold higher fluxes than their loss via litterfall. There was a significant retention of some trace elements (notably Mo, Cd, and Sn) in plant biomass, which might allow one to use these mangroves for phytoremediation and restoration purposes. We conclude that mangroves efficiently store and remobilize major and trace elements from the sediments by root uptake and recycle back to sediment surface via litterfall.

Modified Broström repair with suture tape augmentation for lateral ankle instability: A systematic review

BACKGROUND

There is increasing interest in augmentation of modified Broström repairs for lateral ankle instability with a prosthetic reconstruction using suture tape internal bracing. The aim of this study was to investigate if suture tape augmentation resulted in improved clinical and radiological outcomes compared to a standard modified Broström repair alone.

METHODS

A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, Pubmed and the Cochrane Library Database from inception until January 2020 reporting on the use of suture tape augmentation to a modified Broström repair for lateral ankle instability.

RESULTS

78 studies were identified of which 10 (assessing 333 patients) met the criteria for inclusion. Mean follow up was 24.8 months (range 6-52 months). All studies showed a statistically significant improvement across multiple clinical outcome measures post-surgery in both suture tape augmentation and modified Broström groups, however there were no statistically significant inter-group differences. Pooled results suggested there may be a reduction in recurrence of instability with suture tape augmentation when compared to modified Broström repair alone (p < 0.05). Overall quality of evidence was moderate to poor with limited data to support use of suture tape augmentation.

CONCLUSION

Clinical and radiographic outcomes using a suture tape internal bracing for lateral ankle instability are excellent, and are equivalent to standard treatment across multiple clinical and radiographic assessment measures. There is minimal evidence to suggest functional outcomes are better, or recurrence rates are lower than modified Broström repair alone.

PROSPERO REGISTRY

CRD42020169876.

LEVEL OF EVIDENCE

II.

The Persistence of Escherichia coli Infection in German Cockroaches (Blattodea: Blattellidae) Varies Between Host Developmental Stages and is Influenced by the Gut Microbiota

The German cockroach, Blatella germanica (L.), is a suspected vector of several enteric bacterial pathogens, including Escherichia coli, among livestock and humans. However, little is known about the factors that influence bacterial transmission by cockroaches. Here, we orally infected B. germanica with various laboratory and field strains of E. coli and examined bacterial titers over time to shed new light on the factors that influence the dynamics of infection. Our results reveal that a laboratory strain of E. coli is largely cleared within 48 h while one field isolate can persist in a majority of cockroaches (80-100%) for longer than 3 d with minimal impact on cockroach longevity. We also find that the ability to clear some strains of E. coli is greater in cockroach nymphs than adults. Notably, no differential expression of the antimicrobial gene lysozyme was observed between nymphs and adults or in infected groups. However, clearance of E. coli was significantly reduced in gnotobiotic cockroaches that were reared in the absence of environmental bacteria, suggesting a protective role for the microbiota against exogenous bacterial pathogens. Together, these results demonstrate that the interactions between cockroaches and enteric bacterial pathogens are highly dynamic and influenced by a combination of microbial, host, and environmental parameters. Such factors may affect the disease transmission capacity of cockroaches in nature and should be further considered in both lab and field studies.

Consensus and development of document for management of stabilized acute decompensated heart failure with reduced ejection fraction in India

Aim

Ensuring adherence to guideline-directed medical therapy (GDMT) is an effective strategy to reduce mortality and readmission rates for heart failure (HF). Use of a checklist is one of the best tools to ensure GDMT. The aim was to develop a consensus document with a robust checklist for stabilized acute decompensated HF patients with reduced ejection fraction. While there are multiple checklists available, an India-specific checklist that is easy to fill and validated by regional and national subject matter experts (SMEs) is required.

Methodology

A total of 25 Cardiology SMEs who consented to participate from India discussed data from literature, current evidence, international guidelines and practical experiences in two national and four regional meetings.

Results

Recommendations included HF management, treatment optimization, and patient education. The checklist should be filled at four time points- (a) transition from intensive care unit to ward, (b) at discharge, (c) 1st follow-up and (d) subsequent follow-up. The checklist is the responsibility of the consultant or the treating physician which can be delegated to a junior resident or a trained HF nurse.

Conclusion

This checklist will ensure GDMT, simplify transition of care and can be used by all doctors across India. Institutions, associations, and societies should recommend this checklist for adaptability in public and private hospital. Hospital administrations should roll out policy for adoption of checklist by ensuring patient files have the checklist at the time of discharge and encourage practice of filling it diligently during follow-up visits.

A simplified protocol for in vitro rearing of human body lice

Human body lice (Pediculus humanus) are neglected ectoparasites and pathogen vectors. Difficulties in raising and maintaining colonies of body lice in a laboratory setting remain a barrier to fundamental studies of physiology and vector-pathogen interactions in these insects. Several in vivo and in vitro rearing systems have been previously described and used by multiple research groups. However, these methods suffer from drawbacks that still complicate the rearing of body lice relative to many other commonly studied hematophagous insects. Here, a simplified protocol for raising and maintaining body lice in vitro using the commercially available Hemotek apparatus is described. This protocol draws from published methods for rearing body lice as well as other hematophagous insect species to further reduce labor, time, costs, and regulatory requirements typically associated with keeping human body lice in the laboratory. Using this protocol, the insects consistently fed on commercially available rabbit blood with little mortality, reached adulthood at a high rate, and produced a significant number of viable eggs, resulting in a 4.8-fold increase in population over a period of 40 days. The data suggest that the process described here can propagate modest populations for ongoing laboratory experiments and is a useful alternative to existing methods. The use and further optimization of in vitro rearing systems may facilitate dynamic studies of body lice by a wider range of investigators, enabling new progress in combating lice infestations, and louse-borne infections.

Patient-reported functional outcomes and health-related quality of life following fractures of the talus

INTRODUCTION

The primary aim of this study was to investigate patient-reported outcomes following talar fractures. Secondary aims were to investigate health-related quality of life and to determine whether it is influenced by functional outcome.

MATERIALS AND METHODS

This retrospective study identified 56 talar fractures over eight years. Patients were contacted by post and the Olerud and Molander score (OMS), Manchester-Oxford Foot and Ankle scores (MOXFQ) and Euroqol-5D-3L collected.

RESULTS

The mean age was 35.2 years (range 13-78 years). There were four cases (7.1%) of avascular necrosis and one (1.8%) non-union occurred. Data from patient-reported outcome measures were available for 42 patients (75.0%) with a median follow-up of 67.1 months (range 23.2-111.8 months). Mean OMS was 60.0 (standard deviation ± 29.51) and median MOXFQ was 30.33 (interquartile range 47.13). Median Euroqol-5D-3L index was 0.74 (interquartile range 0.213) and median Euroqol-5D-3L visual analogue score was 80 (interquartile range 21). Older age, open fractures, multiple injuries and subsequent avascular necrosis were associated with worse patient-reported outcomes (P < 0.05), with older age, avascular necrosis and open fractures found to be independent predictors of poor OMS, and avascular necrosis and open fractures independently predicting MOXFQ score on regression analysis (P < 0.05). Poor self-reported function, measured by OMS and MOXFQ, correlated with worse health-related quality of life as measured by the Euroqol-5D-3L index (OMS: r = 0.764, P < 0.001; MOXFQ: r = 0.824, P < 0.001) and visual analogue score (OMS: r = 0.450, P = 0.003; MOXFQ: r=0.559, P < 0.001).

CONCLUSIONS

Older age, avascular necrosis and open fractures predict poorer functional outcomes following talar fractures. Patients with worse limb-specific functional outcomes are more likely to have a worse perception of health-related quality of life.

Tuberculosis among the elderly in Tanzania: disease presentation and initial response to treatment

BACKGROUND

Reports on tuberculosis (TB) presentation among the elderly in sub-Sahara Africa are scarce at a time when the elderly population is increasing. This dearth of information is likely to lead to an increase in the number of undetected TB cases in the region.

OBJECTIVE

To describe TB presentation and response to anti-tuberculosis treatment at 2 months among elderly patients.

METHODS

Consecutive patients referred to TB centres in Dar es Salaam, Tanzania, underwent clinical, microbiological and chest X-ray (CXR) evaluations at baseline and after 2 months of anti-tuberculosis treatment. Patients aged 60 years were considered elderly and those aged 18-59 years formed the comparison group.

RESULTS

Elderly patients with TB were more likely to have smear-negative TB (76.7% vs. 49.3%, P < 0.0001) and lower-zone lesions on CXR (41% vs. 17%, P < 0.001), but less likely to have cavities on CXR (77.6% vs. 50.4%, P < 0.0001) than the comparison group. Hypertension and diabetes mellitus were more common among the elderly than among controls. Mortality at 2 months was respectively 18.6% and 8.1% among the elderly and among controls. Human immunodeficiency virus infection and smoking increased mortality, while hypertension was associated with reduced mortality.

CONCLUSION

TB in the elderly was associated with atypical clinical and radiological presentations. A high index of suspicion could minimise delays in diagnosis and treatment.

Spin glass like transition and the exchange bias effect in Co3O4 nanoparticles anchored onto graphene sheets

We have synthesized Co3O4 nanoparticles having 40 nm average size, which are anchored on reduced graphene oxide. X-ray diffraction, FESEM, TEM and Raman spectroscopy are performed for the characterization. The temperature dependence of field cooled (FC) and zero field cooled (ZFC) magnetization curves exhibits antiferromagnetic (AFM) transition around ∼30 K, as observed for bulk Co3O4. The exchange bias effect is observed below ∼30 K. A significant change in the exchange bias effect is noted around ∼8 K, which is close to a spin-glass-like transition. The spin-glass-like phase has been confirmed by the memory effects observed by different experimental protocols. The possible origin of exchange bias is discussed in the manuscript.

Label-Free Biomolecule Detection in Physiological Solutions With Enhanced Sensitivity Using Graphene Nanogrids FET Biosensor

Recently, graphene nanogrid sensor has been reported to be capable of sub-femtomolar sensing of Hepatitis B (Hep-B) surface antigen in buffer. However, for such low concentration of Hep-B in serum, it has been observed during real-time operation that there is an overlap of around 50% in the drain-source current sensitivity values between different concentrations of the target biomolecule, in the range from 0.1 to 100 fM. This has been attributed to the fact that the concentration of non-specific antigen in serum being significantly higher than that of the target antigen, there is a considerable deviation in the number of captured target antigen for the same concentration. Further, this degree of overlap varies from one set to another set of sensor, depending on the statistical variations in the sensor fabrication process. This phenomenon challenges the quantification of target antigen for ultralow limit in physiological analyte. In this paper, we introduce probabilistic neural network (PNN) for quantification of Hep-B down to 0.1 fM in serum using graphene nanogrids field-effect transistor biosensor. The sensor has been operated in heterodyne mode in the frequency range of 100 kHz to 1 MHz applied between drain and source to overcome the problem of Debye screening effect. The application of PNN limits the quantification error within 10% in the range of 0.1 to 100 fM in contrast to 77% and 66% using polynomial fit and static neural network models, respectively. Further, the proposed methodology lowers the detection limit of Hep-B in serum by more than three orders of magnitude compared with the state-of-the-art, real-time, label-free sensors.

Exportation of dissolved (inorganic and organic) and particulate carbon from mangroves and its implication to the carbon budget in the Indian Sundarbans

Mangroves are known for exchanging organic and inorganic carbon with estuaries and oceans but studies that have estimated their contribution to the global budget are limited to a few mangrove ecosystems which exclude world's largest the Sundarbans. Here, we worked in the Indian Sundarbans and in the Hooghly river/estuary in May (pre-monsoon) and December (post-monsoon), 2014. Aims were, i) to quantify the riverine export of particulate organic carbon (POC) and dissolved organic and inorganic carbon (DOC, DIC)) of the Hooghly into the Bay of Bengal (BoB), ii) to estimate the C export (DOC, DIC, POC) from the Sundarbans into the BoB by using a simple mixing model, as well as iii) to revise the existing C budget constructed for the mangroves. The riverine exports of POC, DOC and DIC account for 0.07TgCyr^-1, 0.34TgCyr^-1 and 4.14TgCyr^-1, respectively, and were largest during the monsoon period. Results revealed that mangrove plant derived organic matter and its subsequent degradation is the primary source of DIC and DOC in the Hooghly estuary whereas POC is linked to soil erosion. Mangroves are identified as a major source of carbon (POC, DOC, DIC) transported from the Sundarbans into the BoB, with export rates of 0.58 TgCyr^-1, 3.03TgCyr^-1, and 3.69TgCyr^-1 respectively, altogether amounting to 7.3TgCyr^-1. This C export from the Indian Sundarbans exceeds the 'missing C' of the previous budget, thus necessitating further research to finally resolve the mangrove C budget. However, these first baseline data on C exports from the world's largest deltaic mangrove improves limited global data inventory and signifies the need of acquiring more data from different mangrove settings to reduce uncertainties.

Long-term results and recurrence patterns from SCALOP: a phase II randomised trial of gemcitabine- or capecitabine-based chemoradiation for locally advanced pancreatic cancer

BACKGROUND

SCALOP, a randomised, phase II trial, tested the activity and safety of gemcitabine (GEM)-based and capecitabine (CAP)-based chemoradiation (CRT) for locally advanced pancreatic cancer (LAPC). Here we present the long-term outcomes.

METHODS

Eligibility: histologically proven LAPC ⩽7 cm. Following 12 weeks of induction GEMCAP chemotherapy (three cycles: GEM 1000 mg m-2 days 1, 8, 15; CAP 830 mg m-2 days 1-21 q28 days) patients with stable/responding disease, tumour ⩽6 cm, and WHO Performance Status 0-1 were randomised to receive one cycle GEMCAP followed by CAP (830 mg m-2 b.d. on weekdays only) or GEM (300 mg m-2 weekly) with radiation (50.4 Gy per 28 fractions).

RESULTS

One-hundred fourteen patients (28 UK centres) were registered between 24 December 2009 and 25 October 2011, and 74 were randomised (CAP-RT=36; GEM-RT=38). At the time of this analysis, 105 of the 114 patients had died and the surviving 9 patients had been followed up for a median of 10.9 months (IQR: 2.9-18.7). Updated median OS was 17.6 months (95% CI: 14.6-22.7) in the CAP-CRT arm and 14.6 months (95% CI: 11.1-16.0) in the GEM-CRT arm (intention-to-treat adjusted hazard ratio (HR): 0.68 (95% CI: 0.38-1.21, P=0.185)); median progression-free survival (PFS) was 12.0 months (95% CI: 10.0-15.2) in the CAP-CRT arm and 10.4 months (95% CI: 8.8-12.7) in the GEM-CRT arm (intention-to-treat adjusted HR: 0.60 (95% CI: 0.32-1.14, P=0.120)). In baseline multivariable model, age ⩾65 years, better performance status, CA19.9<613 IU l-1, and shorter tumour diameter predicted improved OS. CAP-CRT, age ⩾65 years, better performance status, CA19.9 <46 IU ml-1 predicted improved OS and PFS in the pre-radiotherapy model. Nine-month PFS was highly predictive of OS.

CONCLUSIONS

CAP-CRT remains the superior regimen. SCALOP showed that patients with CA19.9 <46 IU ml-1 after induction chemotherapy are more likely to benefit from CRT.

Long-term results and recurrence patterns from SCOPE-1: a phase II/III randomised trial of definitive chemoradiotherapy +/- cetuximab in oesophageal cancer

BACKGROUND

The SCOPE-1 study tested the role of adding cetuximab to conventional definitive chemoradiotherapy (dCRT), and demonstrated greater toxicity and worse survival outcomes. We present the long-term outcomes and patterns of recurrence.

METHODS

SCOPE-1 was a phase II/III trial in which patients were randomised to cisplatin 60 mg m-2 (day 1) and capecitabine 625 mg m-2 bd (days 1-21) for four cycles +/- cetuximab 400 mg m-2 day 1 then by 250 mg m-2 weekly. Radiotherapy consisted of 50 Gy/25# given concurrently with cycles 3 and 4. Recruitment was between February 2008 and February 2012, when the IDMC recommended closure on the basis of futility.

RESULTS

About 258 patients (dCRT=129; dCRT+cetuximab (dCRT+C)=129) were recruited from 36 centres. About 72.9% (n=188) had squamous cell histology. The median follow-up (IQR) was 46.2 (35.9-48.3) months for surviving patients. The median overall survival (OS; months; 95% CI) was 34.5 (24.7-42.3) in dCRT and 24.7 (18.6-31.3) in dCRT+C (hazard ratio (HR)=1.25, 95% CIs: 0.93-1.69, P=0.137). Median progression-free survival (PFS; months; 95% CI) was 24.1 (15.3-29.9) and 15.9 (10.7-20.8) months, respectively (HR=1.28, 95% CIs: 0.94-1.75; P=0.114). On multivariable analysis only earlier stage, full-dose RT, and higher cisplatin dose intensity were associated with improved OS.

CONCLUSIONS

The mature analysis demonstrates that the dCRT regimen used in the study provided useful survival outcomes despite its use in patients who were largely unfit for surgery or who had inoperable disease. Given the competing risk of systemic and local failure, future studies should continue to focus on enhancing local control as well as optimising systemic therapy.

High mortality in younger patients with major osteoporotic fractures

Data were gathered with regard to mortality after fractures in 1006 younger patients. Results revealed that major osteoporotic fractures of the hip and humerus and drinking alcohol to excess were related to an increased risk of mortality.

INTRODUCTION

Major osteoporotic fractures are known to be associated with increased mortality in older individuals. It is less clear whether this also applies to younger patients.

METHODS

Date were gathered regarding patient demographics, fracture pattern, mechanism of injury, as well as smoking and alcohol intake at the time of injury in consecutive patients aged between 40 and 55 who presented to a UK trauma centre over a 12-month period. Mortality data was taken from the electronic patient records and was cross referenced with data from the General Registrar Office of Scotland. Cox regression analysis was used to identify independent predictors of mortality after adjusting for confounding factors.

RESULTS

The study cohort consisted of 1006 patients, of which 53% were male. The commonest mechanism of injury was a fall. We obtained complete data regarding mortality for all patients at a median of 5.4 years (inter-quartile range 5.1 to 5.6). During this period, 46 patients were identified as being deceased. The overall standardised mortality ratio for the cohort was substantially increased relative to the age and sex matched general population with a ratio of 3.89 (95% confidence intervals (CI) 1.59 to 6.19). Alcohol excess and fractures involving the humerus and the neck of femur were independent predictors of mortality.

CONCLUSIONS

Young individuals with hip and humerus fractures have a significantly increased mortality risk after their injury relative to the general population. The results of our study suggest that this may be in part due to a high prevalence of alcohol excess.

Multiple sources driving the organic matter dynamics in two contrasting tropical mangroves

In this study, we have selected two different mangroves based on their geological, hydrological and climatological variations to investigate the origin (terrestrial, phytobenthos derived, and phytoplankton derived) of dissolved organic carbon (DOC), particulate organic carbon (POC) in the water column and the sedimentary OC using elemental ratios and stable isotopes. Qeshm Island, representing the Iranian mangroves received no attention before this study in terms of DOC, POC biogeochemistry and their sources unlike the Sundarbans (Indian side), the world's largest mangrove system. Slightly higher DOC concentrations in the Iranian mangroves were recorded in our field campaigns between 2011 and 2014, compared to the Sundarbans (315±25μM vs. 278±42μM), owing to the longer water residence times, while 9-10 times greater POC concentration (303±37μM, n=82) was linked to both suspended load (345±104mgL(-1)) and high algal production. Yearlong phytoplankton bloom in the mangrove-lined Persian Gulf was reported to be the perennial source of both POC and DOC contributing 80-86% to the DOC and 90-98% to the POC pool. Whereas in the Sundarbans, riverine input contributed 50-58% to the DOC pool and POC composition was regulated by the seasonal litter fall, river discharge and phytoplankton production. Algal derived organic matter (microphytobenthos) represented the maximum contribution (70-76%) to the sedimentary OC at Qeshm Island, while mangrove leaf litters dominated the OC pool in the Indian Sundarbans. Finally, hydrographical settings (i.e. riverine transport) appeared to be the determinant factor in differentiating OM sources in the water column between the dry and wet mangroves.

Use of an Innovative Simple Method for Anaerobiosis in the Diagnosis and Management of Infections in Two Unusual Cases

Technical limitations restrict routine anaerobe isolation from clinical materials in resource-limited laboratories. An innovative two steps combustion candle jar technique may be suitable for such setup. This system was tried with one case of chronic osteomyelitis developed on supracondyler compound fracture. Porphyromonas spp. was isolated and identified. Vancomycin was recommended based on in vitro sensitivity test, but the leg was amputed after receiving a resistant drug gentamycin. While in another child with hydrocephalous, V-P shunt associated infection by Peptostreptococcus anaerobius was successfully controlled by sensitive drug vancomycin. These two eye-opener cases insisted us for large scale application of the technique.

First Measurement of Electron Neutrino Appearance in NOvA

We report results from the first search for ν_{μ}→ν_{e} transitions by the NOvA experiment. In an exposure equivalent to 2.74×10^{20} protons on target in the upgraded NuMI beam at Fermilab, we observe 6 events in the Far Detector, compared to a background expectation of 0.99±0.11(syst) events based on the Near Detector measurement. A secondary analysis observes 11 events with a background of 1.07±0.14(syst). The 3.3σ excess of events observed in the primary analysis disfavors 0.1π<δ_{CP}<0.5π in the inverted mass hierarchy at the 90% C.L.

Determination of a safe INR for joint injections in patients taking warfarin

INTRODUCTION

With an increase in life expectancy in 'developed' countries, the number of elderly patients receiving joint injections for arthritis is increasing. There are legitimate concerns about an increased risk of thromboembolism if anticoagulation is stopped or reversed for such an injection. Despite being a common dilemma, the literature on this issue is scarce.

METHODS

We undertook 2,084 joint injections of the knee and shoulder in 1,714 patients between August 2008 and December 2013. Within this cohort, we noted 41 patients who were taking warfarin and followed them immediately after joint injection in the clinic or radiology department, looking carefully for complications. Then, we sought clinical follow-up, correspondence, and imaging evidence for 4 weeks, looking for complications from these joint injections. We recorded International Normalised Ratio (INR) values before injection.

RESULTS

No complications were associated with the procedure after any joint injection. The radiologists who undertook ultrasound-guided injections to shoulders re-scanned the joints looking for haemarthroses: they found none. A similar outcome was noted clinically after injections in the outpatient setting.

CONCLUSION

With a mean INR of 2.77 (range, 1.7-5.5) and a maximum INR within this group of 5.5, joint injections to the shoulder and knee can be undertaken safely in primary or secondary care settings despite the patient taking warfarin.

Patient-reported outcomes during and after definitive chemoradiotherapy for oesophageal cancer

BACKGROUND

Limited data describe patient-reported outcomes (PROs) of localised oesophageal cancer treated with definitive chemoradiotherapy(CRT). The phase 2/3 SCOPE-1 trial assessed the effectiveness of CRT±cetuximab. The trial for the first time provided an opportunity to describe PROs from a multi-centre group of patients treated with CRT that are presented here.

METHODS

Patients undergoing CRT±cetuximab within the SCOPE-1 trial (258 patients from 36 UK centres) completed generic-, disease- and treatment-specific health-related quality of life (HRQL) questionnaires (EORTC QLQ-C30, QLQ-OES18, Dermatology Life-Quality Index (DLQI)) at baseline and at 7, 13, 24, 52 and 104 weeks. Mean EORTC functional scale scores (>15 point change significant), DLQI scores (>4 point change significant) and proportions of patients (>15% significant) with 'minimal' or 'severe' symptoms are presented.

RESULTS

Questionnaire response rates were good. At baseline, EORTC functional scores were high (>75%) and few symptoms were reported except for severe problems with fatigue, insomnia and eating-related symptoms (e.g., appetite loss, dysphagia, dry mouth) in both groups(>15%). Functional aspects of health deteriorated and symptoms increased with treatment and by week 13 global quality of life, physical, role and social function significantly deteriorated and more problems with fatigue, dyspnoea, appetite loss and trouble with taste were reported. Recovery occurred by 6 months (except severe fatigue and insomnia in >15% of patients) and maintained at follow-up with no differences between groups.

CONCLUSIONS

CRT for localised oesophageal cancer has a significant detrimental impact on many aspects of HRQL; however, recovery is achieved by 6 months and maintained with the exception of persisting problems with severe fatigue and insomnia. The data suggest that the HRQL recovery after definitive CRT is quicker, and there is little lasting deficit compared with treatment including surgery. These data need to be compared with HRQL data from studies evaluating treatments including surgery for oesophageal cancer.

Magnetic memory in nanocrystalline α-Fe2O3 embedded in reduced graphene oxide

Single phase iron oxide (α-Fe₂O₃) of nearly regular ellipsoidal shape, embedded in reduced graphene oxide (RGO) has been prepared by the chemical route. Memory effect is observed in magnetization study.

Mitral valve disease

In industrially developed countries, moderate or severe mitral valve disease is relatively common and is usually caused by prolapse or is secondary to left ventricular disease. Mitral stenosis (MS), however, is uncommon and usually a sequela of rheumatic fever. This article discusses the natural history of mitral regurgitation and MS and their medical and surgical management.

Benefits and limitations of fine needle aspiration cytology in the diagnosis and classification of leprosy in primary and secondary healthcare settings

OBJECTIVES

The goal of the World Health Organization (WHO) is to eliminate leprosy as a public health problem. This will only be possible when all patients are detected and cured using multidrug therapy, which requires accurate diagnosis prior to treatment. The objective of this study was to evaluate the possibility of the diagnosis of leprosy lesions by fine needle aspiration cytology according to a modification of the Ridley-Jopling scale, as it can be used in primary and secondary healthcare centres, especially in low-resource settings in which leprosy is prevalent.

METHODS

A prospective study comprising 54 cases with cardinal features of leprosy was performed. Among the 54 cases, 27 patients consented to a histopathological biopsy procedure. The slides were stained with Giemsa, modified Ziehl-Neelsen, Papanicolaou and haematoxylin and eosin methods.

RESULTS

Among the 54 cases, 34 were reported as tuberculoid leprosy, five as mid-borderline (BB), three as borderline lepromatous (BL) and eight as lepromatous leprosy (LL); four were unsatisfactory. Histopathological study was performed in 27 cases, which showed cyto-histological correlation in 21 cases (78%). Agreement between histological and cytological diagnosis was achieved in 12 of the 15 tuberculoid cases, one of the three BB cases, one of the two BL cases and all seven LL cases.

CONCLUSION

With the implementation of the WHO classification based on patch counting, there is the possibility of the over-treatment of paucibacillary cases and under-treatment of multibacillary cases. Cytology in terms of cellular type morphology and bacteriological study can complement the WHO classification.

Quantitative study of As (V) and As (III) interaction with mangrove DNA by molecular fluorescence spectroscopy

This study describes the in vitro study of (1:1) one step nucleophilic displacement ([Formula: see text]) of phosphate by heavier anion arsenate and arsenite in the DNA of arsenic ridden Sundarban mangroves. Mangrove DNA was found to give rise to a broad fluorescence and its integrated fluorescence intensity was enhanced on addition of As (V) and As (III), respectively. Analyses of the fluorescence parameter showed adequacy of 1:1 model to describe substitution of phosphate of mangrove DNA chain exiplex by arsenate and arsenite with equilibrium constant (log Kc) ranging between 4.19 and 4.32 for As (V), and between 3.77 and 3.89 for As (III) at pH 7 and 25°C. In the cases, the melting temperature (Tm) and reassociation rate constant of mangrove DNA was increased on treatment with As (V) and As (III). It is suggested that heavier ion arsenate and arsenite may substitute phosphate in natural DNA.

Predictors of weight loss during conformal radiotherapy for head and neck cancers - how important are planning target volumes?

AIMS

Nutritional compromise is common during high dose radiotherapy (RT) or chemoradiotherapy (CRT) for head and neck cancers. We aimed to identify the factors that determine nutritional outcome for head and neck cancer patients during radiotherapy.

METHODS

Data from 103 patients with head and neck cancer treated with highly conformal radiotherapy to doses of 60 Gy or more in 30-33 fractions in the adjuvant or definitive setting was analyzed. All patients received complex 3D conformal radiotherapy (3DCRT) or intensity modulated radiotherapy (IMRT). Patients received regular nutritional counseling and need-based interventions. Their weight was recorded at the beginning and end of radiotherapy. Using univariate and multivariate models we tested possible predictors of weight loss of >5% and NG tube requirement.

RESULTS

The mean weight loss was 3.8%. The incidence of weight loss >5% was 37.9% and NG tube placement was 24.3%. The factors significantly associated with >5% weight loss in the univariate analysis were tumor site (oro-hypopharyngeal vs. others), definitive vs. adjuvant RT; prescription dose of >60 Gy vs. 60 Gy; CRT vs. RT alone; prescription dose planning target volume (PTV) volume >235 cc and total PTV volume >615 cc. Age, sex, T stage, N stage and modality (3DCRT/IMRT) were not significant. In multivariate analysis, the total PTV volume, prescription dose PTV volume and use of chemotherapy were significant after controlling for other factors. Patients could be risk stratified based on the use of CRT and large PTV volumes. Patients with none, one or both factors had a likelihood of >5% weight loss of 0%, 30.3%, and 56.9% (p < 0.001) and likelihood of NG tube placement of 5.3%, 15.2% and 37.3% (p = 0.007).

CONCLUSIONS

It is possible to predict weight loss and NG tube requirements from disease and treatment related factors. PTV volumes are important predictors of nutritional compromise. Risk stratification may enable more focused counseling and identification of patients who require preventive interventions.

Implication of organic matter on arsenic and antimony sequestration in sediment: evidence from Sundarban mangrove forest, India

This study reports the measurement of stability constants for the interaction of As (V and III) and Sb (V and III) with humic substances extracted from aquatic sediments of the Sundarban mangrove forest ecosystem. It was observed that As and Sb formed a slightly more stable association with fulvic acid (FA) than with its humic acid (HA) counterpart. Quenching of fluorescence at increasing As (III and V) or Sb (III and V): FA or HA ratios was obtained that ideally correspond to a 1:1 complexation model. Quite strong complexation of As and Sb by FA and HA occurs at neutral pH, indicating that HA and FA probably markedly affect the mobility of As and Sb in the mangrove environment.