Long COVID-19 and primary care: Challenges, management and recommendations

Long COVID-19, also known as post-acute sequelae of SARS-CoV-2 infection (PASC), is characterized by persistent symptoms after COVID-19 onset. This article explores the challenges, management strategies, and recommendations for addressing long COVID-19 in primary care settings. The epidemiology of long COVID-19 reveals significant variability, with a substantial portion of COVID-19 survivors experiencing post-acute symptoms. Pathophysiological mechanisms include viral persistence, endothelial dysfunction, autoimmunity, neurological dysregulation, and gastrointestinal dysbiosis. Multiple risk factors, including age, sex, pre-existing comorbidities, smoking, BMI, and acute COVID-19 severity, influence the development of long COVID-19. Effective management requires proactive measures such as vaccination, identification of high-risk populations, public awareness, and post-infection vaccination. Collaboration of primary care physicians with specialists is essential for holistic and individualized patient care. This article underscores the role of primary care physicians in diagnosing, managing, and mitigating the long-term effects of COVID-19.

A simple technical innovation to prevent needle stick injuries among dental professionals

OBJECTIVE

Dental healthcare personnel face the potential danger of being exposed to infectious patients while administering local anesthesia injections during dental operations. This could lead to unintentional transfer of infectious diseases from patients to physicians. Although safety measures such as the One-hand-scoop technique and the use of safety syringes, plastic needle cap holders, and needles with safety caps are in place, there have been instances of needle stick injuries reported in clinics. This might be due to the lack of adherence to conventional safety measures or the impracticality of safety techniques and safety syringes. This article aims to demonstrate the utilization of dental tweezers, specifically London College tweezers or dental forceps, for the secure recapping of needles, eliminating the requirement for extra equipment or devices.

SUBJECTS AND METHODS

After obtaining ethical approval (Approval No.: 024-01-2024) from the College of Dentistry, Dar Al Uloom University, 67 dental professionals, with consent for participation in the study, were included. They were requested to use dental tweezers/London College tweezers and dental extraction forceps such as maxillary anterior, mandibular anterior, and maxillary bayonet root forceps individually to recap the local anesthetic needles. The efficacy of these techniques was evaluated against the one-hand scoop technique for its ease, convenience, and reliability in preventing needle stick injuries.

RESULTS

The evaluation of dental professionals regarding the ease of using dental tweezers to recap needles, compared to the one-hand scoop technique (p=0.592), maxillary bayonet root forceps (p=0.746), mandibular anterior forceps (p=0.380), and maxillary anterior forceps (p=0.808), did not yield statistically significant results. The assessment of the procedural simplicity of the one-hand scoop technique showed a satisfaction rate of over 40%, whereas the application of dental tweezers resulted in a satisfaction rate of 30%. However, the use of dental tweezers for needle recapping resulted in a satisfaction rate of over 50%, compared to a satisfaction rate of 30% for the one-handed scoop technique.

CONCLUSIONS

There is no statistically significant difference in the assessment of the efficacy of dental tweezers and the one-hand scoop technique, bayonet root forceps, mandibular anterior forceps, maxillary anterior forceps, and dental tweezers for the needle capping technique. Therefore, dental forceps can be used instead of the one-handed scoop approach. The needle recapping procedure outlined in our study, aimed at preventing needle stick injuries, is simple to implement, and all dental specialties have convenient access to the required instruments.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Tracing probiotic producing bacterial species from gut of buffalo (Bubalus bubalis), South-East-Asia

Abstract Due to extensive application of antibiotics as growth promoters in animal feed, antimicrobial resistance has been increased. To overcome this challenge, rumen microbiologists search for new probiotics to improve the rate of livestock production. The present study was aimed to isolate and evaluate breed-specific lactic acid bacteria (LAB) as potential animal probiotics. The current study was conducted during 10 months from July 2020 to April 2021, in which a total of n=12 strains were isolated from different samples including milk, rumen, and feces of Nilli Ravi Buffaloes. These isolates were evaluated for their antimicrobial potential against common animal pathogens (Bacillus spp., E. coli, Staphylococcus aureus, Salmonella spp., Listeria spp.). All the isolates were identified using 16S rRNA gene sequencing and the phylogenetic analyses inferred that these strains showed close relations to the species of various genera; Enterococcus lactis, Pediococcus pentosaceus, Bacillus subtilis Weissella cibaria, Weissella soli, Bacillus tequilensis, Weissella bombi, Bacillus licheniformis, Lactococcus lactis, Bacillus megaterium, Lactobacillus ruminis, and Lactococcus lactis. NMCC-Ru2 has exhibited the enormous potential of antimicrobial activity, 28 mm, for Salmonella typhimurium;23 mm for Listeria monocytogenes 21 mm for E.coil. Highest resistance was seen in NMCC-Ru2 agasint test antbiotic, like 25.5 mm for Tetracycline. Overall results revesl that the probiotic profile of isolates was achieved using standard criteria, particularly with animal probiotic properties

Outcomes with Bridging Radiation Therapy Prior to CAR-T Cell Therapy in Pts with Aggressive B Cell Lymphomas

PURPOSE/OBJECTIVE(S)

Select patient (pts) with relapsed/refractory aggressive B cell lymphoma may benefit from bridging radiation (bRT) prior to anti-CD19-directed chimeric antigen receptor T cell therapy (CART). Here, we examined pt and treatment factors associated with outcome after bRT and CART.

MATERIALS/METHODS

We retrospectively reviewed adults with DLBCL who received bRT prior to axicabtagene ciloleucel 11/2017-12/2022. Clinical/treatment characteristics, response, and toxicity were extracted. Progression free survival (PFS), disease specific survival (DSS) and overall survival (OS) were modeled using Kaplan-Meier for events distributed over time, or binary logistic regression for disease response. Fisher's Exact Test or Mann-Whitney U methods were used.

RESULTS

Among 40 pts, 11 (28%) had limited stage disease at apheresis, and 14 (35%) received bRT in addition to bridging systemic therapy. Thirty-two (80%) pts received bRT post-leukapheresis. bRT was delivered with a median dose of 30 Gy (range: 4-46) in 10 fractions (range: 2-23). Eighteen (45%) pts received <30 Gy. Twenty-two pts (55%) received bRT comprehensively to all sites of disease, including 9 pts who had limited stage. Eleven pts had bulky disease (≥ 10 cm) at the time of bRT. After CART, 4 pts (10%) experienced Grade ≥3 cytokine release syndrome (CRS), 16 (40%) had Grade ≥2 CRS, and 16 (38%) had Grade ≥3 neurotoxicity. Twenty-three pts (57.5%) had CR at 30 days post-CART infusion. Nine had PR (22.5%), of whom 2 pts eventually developed CR at three months and 1 at nine months. Eight pts (20%) had either PD or SD. Of 23 pts who experienced CR, 11 relapsed-6 at three months and 5 at six months. At a median follow up of 9.6 months (95% CI: 6.6-16.2), 22 pts relapsed: 6 (27.3%) in-field, 10 (5.5%) out-of-field, 4 (18.2%) both, and 2 (9.1%) unknown. The median PFS was 8.87 months and median OS was 22 months. PFS at 1 year was 70% (53-82) and at 2 years was 42% (27-57). OS at 1 and 2 years was 72.5% (56-84) and 51% (34-65), respectively. Seventeen pts (42.5%) remain alive at last follow-up, 13 (76.5%) of whom have no evidence of disease (NED). On univariate analysis, OS and PFS at 1 year were 67% (43-83) and 49% (27-68) for those who received RT comprehensively (n = 22), and 41.9% (19-64) and 33.3% (14-54) for those who did not (n = 18; both p≤0.03). Disease bulk (≥10 cm) was associated with significant decrement in DSS (p = 0.03), but not PFS (p = 0.16) or OS (p = 0.24). Among pts treated comprehensively with bRT (n = 22), there was no association of tumor bulk with OS, PFS, or DSS (p>0.2). IPI ≥3 was associated with worse DSS (p = 0.045) and trended towards worse PFS (p = 0.054), but not OS (p = 0.23). There was no difference in PFS, OS, or DSS between pts who received bRT or chemoRT (p>0.3).

CONCLUSION

bRT and CART is a good treatment strategy for select pts with aggressive B cell lymphoma. When feasible, and with a caveat that other variables influence patient disposition, bRT for CART is associated with improved outcomes after comprehensive RT to all sites of disease.

Lack of skeletal muscle contraction disrupts fibrous tissue morphogenesis in the developing murine knee

Externally applied forces, such as those generated through skeletal muscle contraction, are important to embryonic joint formation, and their loss can result in gross morphologic defects including joint fusion. While the absence of muscle contraction in the developing chick embryo leads to dissociation of dense connective tissue structures of the knee and ultimately joint fusion, the central knee joint cavitates whereas the patellofemoral joint does not in murine models lacking skeletal muscle contraction, suggesting a milder phenotype. These differential results suggest that muscle contraction may not have as prominent of a role in the growth and development of dense connective tissues of the knee. To explore this question, we investigated the formation of the menisci, tendon, and ligaments of the developing knee in two murine models that lack muscle contraction. We found that while the knee joint does cavitate, there were multiple abnormalities in the menisci, patellar tendon, and cruciate ligaments. The initial cellular condensation of the menisci was disrupted and dissociation was observed at later embryonic stages. The initial cell condensation of the tendon and ligaments were less affected than the meniscus, but these tissues contained cells with hyper-elongated nuclei and displayed diminished growth. Interestingly, lack of muscle contraction led to the formation of an ectopic ligamentous structure in the anterior region of the joint as well. These results indicate that muscle forces are essential for the continued growth and maturation of these structures during this embryonic period.

Outcomes and Toxicities in Patients with Diffuse Large B-Cell Lymphoma of the Gastrointestinal Tract

PURPOSE/OBJECTIVE(S)

Diffuse large B-cell lymphoma (DLBCL) involving the gastrointestinal (GI) tract is rare and long-term outcomes are not well defined. Combined modality therapy (CMT) with radiotherapy (RT) in addition to systemic therapy in this setting is not commonly pursued. We aim to characterize outcomes in patients with GI DLBCL treated with systemic therapy, with or without RT.

MATERIALS/METHODS

Patients diagnosed with DLBCL of the GI tract (with or without mesenteric involvement) treated at a single institution from 1988-2022 were retrospectively reviewed on an IRB-approved protocol. Clinical and treatment data were collected including adverse events (AE; acute vs late defined as before or 4 weeks after therapy end). Kaplan-Meier and Cox regression models were used to estimate survival.

RESULTS

Of 207 patients, 62% were male and median age at diagnosis was 63 (IQR 52-73). Gastric involvement was most common (n = 130, 63%), followed by small intestines (n = 48, 23%) and colon/rectum (n = 24, 12%). Most presented with early-stage disease (n = 124, 60%), with a median IPI score of 1. All patients received chemotherapy. Of 182 treated with CHOP/EPOCH, 36 (20%) were treated in the pre-rituximab era while 146 (80%) received rituximab. 66 patients (32%) were treated with RT, 89% as part of first line CMT. 50 cases (76%) received consolidative RT, while 10 (15%) targeted residual gross disease and 4 (6%) targeted distant sites. Median dose and fractionation were 36Gy (IQR 30.6-39.6) in 18 fractions (IQR 17-22). Over half (n = 132, 64%) developed grade 3+ acute chemotherapy AEs, and the most common were anemia (n = 64), febrile neutropenia (n = 40), and neutropenia (n = 20). Grade 3+ late chemotherapy AEs occurred in 14 patients (7%). Acute grade 3+ radiation AEs were uncommon (n = 2, 3%; colitis, emesis). No grade 3+ late radiation AEs were noted. Median follow-up was 46 months (IQR 16-97). 169 (81.6%) had a complete response (CR), with 154 (91%) after first line chemotherapy, 9 (5%) after second line, and 6 (4%) after RT. CR was defined by PET (62%), endoscopy (22%), CT (9%), or other methods (7%). The 5-year progression-free survival for those treated with one line of chemotherapy with or without RT was 95%. Median overall survival (OS) was not reached. Improved OS was associated with early-stage disease (p = 0.003), low IPI (p = 0.001), fewer chemotherapy lines (p<0.001), and CR (p<0.001). OS did not differ by gender, age, immunophenotype, GI site, SUVmax, or RT. Patients with early stage DLBCL treated with RT in the post-rituximab era received fewer chemotherapy cycles compared to those treated without RT (p = 0.02; median of 4 (IQR 3-6) vs 6 cycles (IQR 4-6)), with no OS difference.

CONCLUSION

GI DLBCL patients have favorable outcomes after CMT with minimal late toxicity. CMT with RT to the GI tract is well tolerated with no OS difference compared to chemotherapy alone, and may mitigate risks from additional chemotherapy cycles for selected early-stage patients.

Perspectives and challenges in lip rejuvenation: a systematic review

OBJECTIVE

There is an abundance of information on facelifts, blepharoplasties, rhinoplasty, and other cosmetic surgical procedures for the upper third of the face, but little is known about perioral lip rejuvenation. The aim of this article is to examine the existing literature on lip rejuvenation and perioral procedures related to lip rejuvenation. Additionally, this article aims to highlight the importance of addressing perioral areas alongside lip rejuvenation procedures, rather than solely focusing on lip rejuvenation. We also discussed the extensive procedures and materials used for lip rejuvenation, such as hyaluronic acid, botulinum toxin A, abobotulinum, onabotulinum, incobotulinum, prabobotulinum, fat grafts, silicone fillers, human collagen, collagen stimulating procedures such as derma pens and derma rolls, radiation frequency, stem cells, and plasma therapy, as well as the underlying factors that contribute to varying success rates.

MATERIALS AND METHODS

A thorough literature search was done using PubMed, Cochrane, Ebsco search, Google Scholar, Scopus, and Web of Science for the articles pertaining to facial and lip cosmetic surgeries 1995-2020. Keywords for the search included anatomy of the face, facial aging, perioral areas, lip rejuvenation, botox, grafts, facelift, plastic surgery, stem cell therapy, plasma treatment, and cosmetic surgery.

RESULTS

37 articles met the study criteria. 14 out of 37 studies included procedures for lip and perioral region rejuvenation. The remaining 23 studies either involved lip procedures alone or lip procedures in conjunction with facial cosmetic procedures. Lip rejuvenation with perioral enhancement with hyaluronic acid gel demonstrated a 94.3% improvement on the lip fullness scale (LFS) one month after re-treatment. The amalgamation of lip and perioral region rejuvenation produces a synergistic effect. Whereas, sole lip rejuvenation procedures showed short-term results with less patient satisfaction, calling for secondary lip rejuvenation procedures. It was also observed that hyaluronic acid was the most commonly used agent for lip rejuvenation procedures with minimal or no side effects.

CONCLUSIONS

In conjunction with perioral rejuvenation, lip rejuvenation procedures produce more aesthetically appealing results. However, any cosmetic surgical or non-surgical procedure is limited by the nature and composition of the products used. The use of FDA-approved products for rejuvenation is strongly advised to avoid undesirable side effects. Further extensive research is required on the long-term outcomes and adverse effects of stem cell transplants, such as tumor development.

Detection of Oncogenic Human Papillomavirus (HPV-16 and HPV-18) from Bacterial Vaginosis Positive Patient Attending at Tertiary Care Hospital in Mymensingh

Cervical cancer is the fourth most common cancer in women in the world and is the second leading malignancy among Bangladeshi women. Persistent infection with high risk human papillomavirus (HPV) is an important cause of development of cervical intraepithelial neoplasia (CIN) followed by cancer. Bacterial vaginosis (BV), a common treatable vaginal infection which can disrupt the balanced vaginal ecosystem and its innate protective mechanisms against infection, can play an essential role in the acquisition and persistence of high risk human papillomavirus (HR-HPV) infection. This cross sectional study was conducted to detect the HR-HPV (HPV-16 and HPV-18) infection among bacterial vaginosis positive patient in the Department of Microbiology, Mymensingh Medical College (MMC), Bangladesh, from March 2018 to February 2019. A total of 300 endocervical swabs and high vaginal swabs were collected from the VIA (Visual inspection with acetic acid) outdoor clinic of Obstetrics and Gynaecology Department of Mymensingh Medical college Hospital. HPV DNA was tested among all 300 cases by nested PCR. Typing of HPV 16 and HPV 18 was done among HPV DNA positive cases with BV and intermediate flora by multiplex PCR. BV was diagnosed according to Nugent criteria by using the gram stained smear of high vaginal swab. A total of 57/300 (19.0%) samples were positive for HPV DNA by nested PCR. Of the total 300 cases 78(26.0%) had BV, 38(13.0%) had intermediate flora and 184(61.0%) had normal vaginal flora. HPV DNA was more positive in patients having intermediate flora 08/38 (21.05%) followed by the patients having normal vaginal flora 37/184 (20.11%) and BV 12/78 (15.38%). Among the 12 BV patients who were also HPV DNA positive (83.33%) were belong to high risk HPV (type 16 and 18) group and among them 08(66.67%) were HPV-16 and 02(16.67%) were HPV-18. But among 08 HPV DNA positive intermediate flora containing patients only 01(12.5%) were belong to HR-HPV (type 16 and no type 18 was detected).

A Prospective Study of Machine Learning-Assisted Radiotherapy Planning for Patients Receiving 54 Gy to the Brain

PURPOSE/OBJECTIVE(S)

Radiotherapy (RT) planning is presently a semi-manual, iterative, labor-intensive process which may result in unnecessary variation in plan quality. To improve treatment plan quality and decrease RT planning time, we conducted a prospective, blinded study to compare machine learning-assisted planning with conventional manual planning for patients receiving 54 Gy in 30 fractions for a primary brain tumor.

MATERIALS/METHODS

From January 31, 2022 to January 10, 2023, 40 patients receiving 54 Gy for primary CNS tumors were prospectively enrolled (median age 50 years, range 4-78 years). Patients underwent standard CT/MR simulation and target/OAR delineation by the treating radiation oncologist. Each patient had one ML plan and 1-2 manual RT plans created by different planners. The reviewing oncologist was blinded to planning method by removing optimization and IMRT/VMAT beam arrangement details from all plans, which were then rated based on clinical acceptability, target coverage, OAR sparing, conformity, and dose-fall off. One preferred plan was chosen and used for clinical treatment.

RESULTS

A total of 115 plans for 40 patients were evaluated: 40 ML plans (35% of all plans), and 75 manual plans (65% of all plans; 5 and 35 patients had 1 and 2 manual plans created, respectively). ML plans required a mean planning time of 65 min as compared to 107 min for manual plans, with a mean time savings of 41 min per patient (paired t-test p = 0.002). 97% of ML plans (95% confidence interval [CI] 85-100) and 96% of manual plans (95% CI 87-99) were designated clinically acceptable by the treating radiation oncologist. While ML-assisted plans represented 35% of plans evaluated, they were chosen as preferred for clinical treatment in 43% of cases (17/40, 95% CI 29-58, p = 0.32). Median doses to the brain (10.8 Gy vs. 11.3 Gy, Wilcoxon rank-sum p = 0.012) and brain minus PTV (9.2 Gy vs 10.0 Gy, Wilcoxon rank-sum p = 0.009) were lower with ML planning versus manual planning, respectively. Doses to other structures, including hippocampi, cochlea, pituitary and hypothalamus were not statistically different.

CONCLUSION

In this prospective study with blinded oncologist evaluation, ML-assisted RT planning for primary CNS tumors was faster than manual planning, and produced a very high rate of acceptable plans with similar or superior OAR sparing. Future work will be undertaken to iteratively refine the ML model using the preferred cases from this study.

Characterization of Lymphopenia during Bridging Radiation Therapy Prior to CAR-T Cell Therapy in Patients with Aggressive B Cell Lymphomas

PURPOSE/OBJECTIVE(S)

Bridging RT (bRT) may be used as a strategy for disease control in patients with relapsed/refractory aggressive B cell lymphoma treated with anti-CD19-directed chimeric antigen receptor T-cell therapy (CART). The correlation of treatment-related lymphopenia with adverse outcomes in patients has been widely documented in several malignancies. Here, we assessed lymphocyte kinetics during bRT and impact on clinical outcome.

MATERIALS/METHODS

After IRB-approval, records were retrospectively reviewed for adults with DLBCL who received bRT for axicabtagene ciloleucel 11/2017-12/2022. Clinical/treatment characteristics, lab values, and outcomes were extracted. ALC Δ RT was computed by subtracting pre-RT ALC from post-RT ALC count. Survival was modeled using Kaplan-Meier for events distributed over time, or binary logistic regression for disease response. Fisher's Exact Test or Mann-Whitney U methods were used.

RESULTS

Forty patients met inclusion criteria. Fourteen (35%) received bRT with systemic therapy. Thirty-two (80%) patients received bRT that started post-leukapheresis. bRT was delivered with a median dose of 30 Gy (range: 4-46) in 10 fractions (range: 2-23). Twenty-three patients (57.5%) had CR at 30 days post-CART infusion. Nine had PR (22.5%), and 8 patients (20%) had PD or SD. Median PFS was 8.9 months and median OS was 22 months. The pre-RT ALC mean ± SD was 0.74 ± 0.49 K/µL, and post-RT was 0.43 ± 0.35 K/µL. The absolute ALC Δ RT was 0.31 ± 0.43 K/µL, and ratio post-RT/pre-RT was 0.74 ± 0.64. Stratifying by receipt of bRT alone or with systemic therapy, there was no statistically significant difference in ALC count post-RT (chemoRT: 0.33 ± 0.23 vs. RT: 0.48 ± 0.4, p = 0.2), but there was a lower ALC count pre-RT in the chemoRT group (0.5 ± 0.3 vs. 0.87 ± 0.52 for RT alone, p = 0.02). Post-RT ALC was not significantly associated with CR/PR vs. PD/SD, or with DSS, PFS, or OS. A greater drop in ALC Δ RT trended towards association with improved 90-day response (p = 0.066), without correlation with DSS, OS, or response at 30 days. Median dose per fraction was lower among patients that got pre-leukapheresis RT (2.25 vs. 2.5, p = 0.04), but total dose of bRT or number of fractions was not significantly different. Otherwise, the groups were similar in terms of stage, disease bulk, or comprehensive vs. focal bRT. The average decrease in ALC post-RT for patients who received bRT prior to apheresis was 0.215 K/µL, compared to 0.268 K/µL for patients who received bRT post-apheresis (p = 0.75). Treatment with pre-leukapheresis bRT or ALC Δ RT among these patients were not associated with worse DFS, PFS, or OS (p>0.15).

CONCLUSION

Post-bRT ALC and reduction in ALC during bRT is not associated with worse treatment response or survival outcomes after CAR-T cell treatment in aggressive B cell lymphoma. Pre-leukapheresis bRT did not appear to substantially impact ALC, and ALC Δ RT among these patients were not associated with worse outcomes.

Management and Outcomes of Hodgkin Lymphoma Patients Who Achieve Partial Metabolic Response on PET Scans Post-Chemotherapy

PURPOSE/OBJECTIVE(S)

Optimal management of patients with Hodgkin Lymphoma (HL) who do not achieve PET (positron emission tomography) complete metabolic response after primary systemic therapy is unclear. Options vary significantly and include radiation therapy (RT) to localized sites of PET avid disease, salvage chemotherapy followed by autologous stem-cell transplantation (ASCT), or observation with serial imaging. This multi-center study sought to investigate the management approaches and outcomes for HL patients who achieved partial metabolic response after primary systemic therapy.

MATERIALS/METHODS

In this retrospective study, patients diagnosed with HL were identified from the electronic medical records database of two large academic centers between January 2009 and September 2021. PET scan results following initial chemotherapy were reviewed and responses were categorized using International Working Group (IWG) criteria, with the initial staging imaging being used as the reference against which response was evaluated. We performed descriptive analysis of demographic and clinical characteristics of the population and Kaplan-Meier estimates were used to determine progression-free survival (PFS).

RESULTS

The charts of 1,093 HL patients were reviewed. A total of 765 patients had a post chemotherapy PET scan with 57 of those showing partial metabolic response. Among these 57 patients, 31 (54%) were male, the median age at diagnosis was 31 (range:18-74), and the median length of follow up was 1.6 years (average 2.9 years). Five percent stage I, 32% stage II, 23% stage III, and 40% stage IV. Typical initial chemotherapy included ABVD, ABVD switched to BEACOPP due to abnormal interim PET, and AVD with Brentuximab. Among all patients with metabolic partial response to chemotherapy, the 2-year PFS was 72.8% (95% CI = 60.9-87%). Thirty-three of these patients (58%) were treated with planned radiation therapy alone, and 2-year PFS was 80.7% (95% CI = 66.6-97.9%). For those who did not receive radiation as part of their treatment, progression rate was 38% at 2 years.

CONCLUSION

To our knowledge, this is the largest series of HL patients with partial metabolic response following primary chemotherapy. Our preliminary analysis showed that treatment with radiation was associated with good PFS at 2 years and many of those treated with radiation alone were cured.

Role of Serum Triglyceride to Detect Severity and Outcome in Acute Pancreatitis

Though hypertriglyceridemia is an established risk factor for acute pancreatitis, the relationship between hypertriglyceridemia and pancreatitis-associated complications remains controversial. Serum triglyceride could be a simple, routinely available investigation if predictability of the outcome can be validated. Due to scarcity of related studies in Bangladesh, this study aimed to evaluate the role of serum triglyceride to detect severity and outcome in acute pancreatitis. This prospective observational study was conducted in the Department of Gastrointestinal, Hepatobiliary and Pancreatic Disorders (GHPD), BIRDEM General Hospital, Dhaka from April 2019 to January 2021. A total of 153 patients with confirmed diagnosis of acute pancreatitis were selected as study cases according to selection criteria. Detailed clinical and demographic history of each patient was taken along with physical examination and relevant investigations. Developed complications and mortality were also assessed during hospital stay. Collected data were checked for errors and analyzed by using the statistical software SPSS 23.0. The mean age ±SD of the study population was 46.72±13.43 years with a majority in age group 41-50 years (30.10%). About 51.60% patients were male and 48.40% patients were female. Higher frequency of severe cases of acute pancreatitis (according to Glasgow score, BISAP score and Ranson score) was observed in patients with hypertriglyceridemia than patients with normal triglyceride with statistical significance (p<0.05). Mortality and complications were also more frequent in patients with acute pancreatitis with statistical significance (p<0.05). With a cut off value of 218mg/dl, serum triglyceride showed 68.66% sensitivity, 66.28% specificity and 67.32% accuracy for predicting outcome of acute pancreatitis. Findings of this study suggest that serum triglyceride might play a recommendable role in predicting the severity and outcome of patients with acute pancreatitis. However, further extensive study is recommended.

Success of Liquid Tumor Biopsy in Men with Metastatic Prostate Cancer According to Self-Identified Race

PURPOSE/OBJECTIVE(S)

Liquid biopsy using cell-free DNA (cfDNA) is increasingly used to identify somatic prostate cancer (PrCa) alterations when tissue biopsy of a metastatic lesion is infeasible or impractical. High-risk somatic alterations identified by cfDNA have been recently shown to predict the benefit of metastasis-directed therapy with stereotactic body radiation therapy in PrCa. However, given the older age of PrCa patients, liquid biopsy is often contaminated with alterations related to clonal hematopoiesis of indeterminate potential (CHIP), generating uncertainty in the clinical utility of the results. Given the higher incidence and aggressiveness of metastatic PrCa in Black men, we sought to determine if the success of cfDNA testing varied by race in a large and diverse cohort of United States Veterans with metastatic PrCa, hypothesizing that race would not influence the success of cfDNA testing.

MATERIALS/METHODS

Veterans with metastatic PrCa underwent next-generation sequencing of cfDNA biopsy specimens through the VA National Precision Oncology Program from February 2019 to November 2022. Successful identification of PrCa with cfDNA testing was defined as the identification of an alteration in one or more PrCa-related related genes in the gene panel tested (AR, CDK12, SPOP, MED12, CCND1, BRAF, AKT1, TMPRSS2, ERG, ETV1, and ETV4). Univariate logistic regression was employed to explore the association between patient self-identified race, as well as other patient and disease-specific factors at the time of cfDNA biopsy, with the likelihood of yielding a successful cfDNA biopsy result.

RESULTS

A total of 2066 cfDNA tests from 1985 Veterans were related to a diagnosis of PrCa, passed quality control measures, and were linkable to patient-level demographics. Median age at testing was 74, median PSA at testing was 22.7, median PSA doubling time (PSADT) was 3.6 months, and median Gleason score was 8. 57% of Veterans self-identified as White, 33% as Black, and 10% as Other. Eight hundred fourteen (39%) tests were deemed successful by finding a PrCa related gene alteration. Among successful tests, the most frequently encountered alterations were AR alterations in 60.4% White men and 33.9% Black men (p = 0.72), followed by TMPRSS2 alterations in 70.3% White men and 22.0% Black men (p<0.001). Despite a lower rate of PrCa-specific alterations in Black men, on univariate analysis, Veteran self-identified race was not associated with successful cfDNA testing (OR 0.95, 95% CI 0.78-1.14, p = 0.6), whereas PSA in quintiles 2-4, PSADT <12 months, and unit increase in Gleason score were associated with successful cfDNA testing (p<0.01 for all).

CONCLUSION

Successful cfDNA biopsy in metastatic PrCa is associated with PSA and PSADT, but not related to patient self-identified race. In appropriate clinical scenarios, patients who self-identify as Black or White are equally likely to have PrCa-specific alterations detected on cfDNA testing when evaluating metastatic PrCa patients for local and systemic therapies.

Estimation of 10-Year Fracture Risk with and without Bone Mineral Density in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common inflammatory arthritis affecting 0.5-1.0% of the general population worldwide and although RA is properly considered a disease of the joints, it can cause a variety of extra-articular manifestations. This study was performed to find out any discrepancy in fracture risk estimates with and without bone mineral density (BMD) in rheumatoid arthritis (RA) patients. This observational cross-sectional study was carried out in the Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from July 2013 to July 2015. Total 65 consecutive patients with RA fulfilling ACR/EULAR criteria aged 40-90 year were recruited. Ten year fracture risk of these patients was evaluated by the FRAX score with and without BMD and differences were observed. FRAX score without BMD revealed that major fracture risk was low in 58(89.2%) patients, moderate in 7(10.8%) patients but re-estimation with BMD revealed that 55(84.6%) patients remained in low risk group, 8(12.3%) patients in moderate risk group and 2(3.1%) patients went to the high risk group. In case of hip fracture risk without BMD, risk was low in 58(89.2%) patients, high in 7(10.8%) patients; but with BMD, 50(76.9%) patients remained in low risk group but risk of 15(23.1%) patients became high. Almost all the high risk patients (93.3%) were ≥55 years of age. Increasing age, female sex, disease duration and use of steroid were positively correlated with increased FRAX score where as high BMI and high BMD were associated with low FRAX score. But in multivariate analysis it was found that only relation with age was at statistically significant level. Significant numbers of patients with rheumatoid arthritis have high risk of fracture especially hip fracture. The mean of FRAX score increased in both major & hip osteoporotic fracture risk after adding BMD. More than half of the patients above fifty five years or more had high risk of fracture. So, BMD should be done in patients aged more than fifty five.

Search for Λ[over ¯]-Λ Baryon-Number-Violating Oscillations in the Decay J/ψ→pK^{-}Λ[over ¯]+c.c

We report on the first search for Λ[over ¯]-Λ oscillations in the decay J/ψ→pK^{-}Λ[over ¯]+c.c. by analyzing 1.31×10^{9}  J/ψ events accumulated with the BESIII detector at the BEPCII collider. The J/ψ events are produced using e^{+}e^{-} collisions at a center of mass energy sqrt[s]=3.097  GeV. No evidence for hyperon oscillations is observed. The upper limit for the oscillation rate of Λ[over ¯] to Λ hyperons is determined to be P(Λ)=[B(J/ψ→pK^{-}Λ+c.c.)/B(J/ψ→pK^{-}Λ[over ¯]+c.c.)]<4.4×10^{-6} corresponding to an oscillation parameter δm_{ΛΛ[over ¯]} of less than 3.8×10^{-18}  GeV at the 90% confidence level.

Clinical outcomes following COVID-19 infection in ethnic minority groups in the UK: a systematic review and meta-analysis

OBJECTIVES

This study evaluated the differences in clinical outcomes of COVID-19 infection between ethnic minorities and the White ethnic group in the UK.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

This study included adult residents in the UK with confirmed COVID-19 infection. The outcomes evaluated in this study were mortality, intensive care unit (ICU) admission and invasive mechanical ventilation (IMV). Outcome data were compared between individuals from ethnic minority groups and individuals from a White ethnic background. MEDLINE, Embase, Cochrane, medRxiv and PROSPERO were searched for articles published between May 2020 and April 2021. The risk of bias was evaluated using the Newcastle-Ottawa Scale checklist.

PROSPERO ID

CRD42021248117.

RESULTS

Fourteen studies (767,177 participants) were included in the current review. In the adjusted analysis, the pooled odds ratio (OR) for mortality following COVID-19 infection was higher for Black (OR 1.83, 95% confidence interval [CI]: 1.21-2.76, number of studies [k] = 6), Asian (OR 1.16, 95% CI: 0.85-1.57, k = 6) and Mixed and Other (MO) ethnic groups (OR 1.12, 95% CI: 1.04-1.20, k = 5) compared with the White ethnic group. The adjusted and unadjusted ORs of ICU admission for many of the ethnic minority groups were more than double the OR values for the White ethnic group (Black ethnic group = OR 2.32, 95% CI: 1.73-3.11, k = 5; Asian ethnic group = OR 2.34, 95% CI: 1.89-2.90, k = 5; and MO ethnic group = OR 2.26, 95% CI: 1.64-3.11, k = 4). In the adjusted analysis for IMV, the ORs were similarly significantly raised in ethnic minority groups compared with the White ethnic group (Black ethic group = OR 2.03, 95% CI: 1.80-2.29, k = 3; Asian ethnic group = OR 1.84, 95% CI: 1.20-2.80, k = 3; and MO ethnic group = OR 2.09, 95% CI: 1.35-3.22, k = 3).

CONCLUSION

This review found that in the UK, Black, Asian and MO ethnic groups experienced increased COVID-19-related disease severity and mortality compared with the White ethnic group majority.

Combined osmotic pretreatment and hot air drying: Evaluation of drying kinetics and quality parameters of adajamir (Citrus assamensis)

Adajamir (Citrus assamensis) is a highly perishable but nutritional fruit. Hot air drying is ubiquitous in food preservation but not quality friendly. However, drying pretreatments play an indispensable role preserving fruits and vegetables. The aim of this study was, therefore, to reveal the hot air drying kinetics of osmotically pretreateated adajamir and investigate the quality parameters (total phenolic contents, antioxidant capacity, and vitamin C). Adajamir slices were subjected to osmotic pretreatment (10% sucrose, 10% fructose, and 2% NaCl), subsequently, dried in a hot air dryer at 50 °C, 30% relative humidity (RH), and with a velocity of 1 ms-1. The drying kinetics were studied using three mathematical models: Newtonian model, Henderson and Pabis model, and Page model. The result depicted that effective diffusivity was highest (9.5 ± 0.2a × 10-6 m2s-1) in untreated samples compared to the treated samples, and the Page model was the one with the best fitness to explain the drying behavior. Regarding quality, the pretreatments provided better retention of all quality parameters compared to the untreated samples. In addition, osmotic treatment with sucrose had the best quality retention capability. The study will contribute to the optimization of thermal processing parameters in fruit dehydration. Eventually, this research will expedite future research pertinent to innovative combined drying techniques of citrus fruit.

Hydrodynamic performance assessment of photocatalytic reactor with baffles and roughness in the flow path: A modelling approach with experimental validation

Purification of wastewater is essential for human being as well as for the flora and fauna, and sustainable environment. Photocatalytic reactor with TiO2 coated layer can be used to degrade the pollutants but without proper pollutant mass transfer in the reactive surface, photocatalytic reactor decreases its effectiveness. The baffles and rough surface in the flow path can improve the fluid mixing to enhance pollutant mass transfer to improve the reactor's performance. In this study, a computational fluid dynamics (CFD) model has been developed to investigate the effect of four top baffles and three rough surfaces (semi-circular, triangle, and rectangle) on pressure drops, mass transfer and the hydrodynamic performance of the reactor. The experimental investigation was carried out using Formic Acid (FA) as pollutant in feed water for model validation. The simulated result varies only within 5% with the experimental data of FA concentration versus feed flow rate and fluid velocity. The model was run at fluid velocity of 0.15 m/s and 0.5 m/s (Reynolds number of 2150 (laminar flow) and 7500 (turbulent flow), respectively. The simulation result shows that the addition of baffles and roughness on the reactive surfaces increases the turbulent kinetic energy (minimum increase 8%) and consequently increases the mass transfer (maximum increase 37%) of the pollutant. The highest wall shear was observed to be 40 Pa when both square and triangular elements were used as roughness elements at turbulent flow condition. The results also shows that the highest pressure-drop of 8 kPa was found when the square roughness element was used at turbulent flow condition. Overall, the photocatalytic reactor performance is significantly enhanced by the application of combined baffles and roughness elements in the reactive surface.

Use of tobramycin-impregnated antibiotic beads in frontal sinus osteomyelitis

OBJECTIVE

Osteomyelitis of the frontal bone is a rare but devastating complication of frontal sinusitis. Treatment involves aggressive surgery to remove all sequestra in combination with long-term antibiotic therapy. However, systemic antibiotics may struggle to penetrate any remaining infection in devascularised areas, and the morbidity associated with surgical resection of some areas of the skull base is too high. In contrast, locally implanted antibiotics provide a reliable, high concentration of treatment to these areas while also minimising potential systemic side effects. The clinical application of tobramycin beads has primarily been used in orthopaedics as an adjunct to the treatment of tibial osteomyelitis or prosthetic joint infection.

CASE REPORT

To the best of the authors' knowledge, the two cases discussed here represent the first use of tobramycin antibiotic beads in frontal sinus osteomyelitis secondary to chronic rhinosinusitis.

CONCLUSION

These cases show promising use of tobramycin beads in recalcitrant frontal osteomyelitis.

Identifying domains of health-related quality of life: the perspective of individuals with low back pain

BACKGROUND

Identifying the most relevant HRQOL domains for LBP from the perspective of individuals with lived experience with LBP is necessary to prioritize domains that will be most informative for evaluating the impact of pain and interventions while overcoming the burden of using long-form assessment tools. This study aimed to identify which domains of HRQOL are most important from the perspective of individuals with chronic LBP.

METHODS

Semi-structured interviews were conducted with 26 individuals with LBP. Participants first responded to questions related to the impact of their LBP on their HRQOL. Then, using a card sorting method, they were asked to select and indicate HRQOL domains that were most relevant to them from a list of 18 cards that represented different HRQOL domains. Participants were asked to explain the reasoning for their selection.

RESULTS

Participants identified physical activity restriction (50%), severity of pain (31%), social activity restriction (23%), and work performance restriction (23%) as the most important domains. The most frequently selected HRQOL domains during card sorting were social function (69%), pain intensity (62%), physical function (58%), fatigue (58%), and pain interference (42%).

CONCLUSION

The most important domains of HRQOL perceived by participants were pain intensity, social function, physical function, fatigue, and pain interference. Identifying these domains will inform clinical decision-making and guide treatment choices for health care providers.

Species Identification and Antifungal Susceptibility Pattern of Candida Isolates in Patients with Vulvovaginitis from Mymensingh, Bangladesh

Vulvovaginal Candidiasis (VVC), a frequent and cumbersome reproductive tract infection affects women's physical and mental health. Although Candida albicans was reported as the most common agent of VVC yet, recently there are significant changes in the pattern of Candida species causing VVC with varying antifungal susceptibility pattern. Therefore this cross-sectional, descriptive type of observational study conducted to identify the spectrum of Candida species associated with VVC and assesses their antifungal susceptibility pattern from March 2021 to February 2022. High vaginal swabs from 175 patients clinically suspected of VVC were collected and cultured on Sabouraud dextrose agar with Chloramphenicol. Species were identified by phenotypic methods like- germ tube test, sub-culture in chromogenic agar media and genotypic methods like- Polymerase chain reaction (PCR), Restriction fragment length polymorphism (RFLP). Antifungal susceptibility was done by disk diffusion method. Out of 175 patients, 52(29.7%) were positive for Candida species. Of the isolates- C. albicans 34(65.0%), Non albicans Candida (NAC) 18(35.0%). Among NAC, C. glabrata 5(9.6%), C. tropicalis 5(9.6%), C. parapsilosis 4(7.7%) and each of C. krusei, C. kefyr, C. ciferrii, C. dubliniensis were 1(1.9%). On susceptibility testing highest resistance was to Clotrimazole 31.0% followed by Nystatin 13.0%, Itraconazole 12.0% and Fluconazole 10.0%. Resistance to azole was higher in NAC than in albicans. Of these patients, 16(31.0%) had history of recurrent VVC (RVVC) of which 12(75.0%) were by NAC, predominantly C. glabrata 5(32.0%). The results showed the increasing incidence of NAC associated vaginitis with higher resistance and recurrence that should be considered in gynecology clinics.

[Inactivation of Ras1 in Fission Yeast Aggravates the Oxidative Stress Response Induced by Tert Butyl Hydroperoxide (tBHP)]

Ras proteins are small GTPases and function as molecular switches to regulate cellular homeostasis. Ras-dependent signalling pathways regulate several essential processes such as cell cycle progression, growth, migration, apoptosis, and senescence. The dysregulation of Ras signaling pathway has been linked to several pathological outcomes. A potential role of RAS in regulating the redox signalling pathway has been established that includes the manipulation of ROS levels to provide a redox milieu that might be conducive to carcinogenesis. Reactive oxygen species (ROS) and mitochondrial impairment have been proposed as major factors affecting the physiology of cells and implicated in several pathologies. The present study was conducted to evaluate the role of Ras1, tert Butyl hydroperoxide (tBHP), and antimycin A in oxidative stress response in Schizosaccharomyces pombe cells. We observed decreased cell survival, higher levels of ROS, and mitochondrial dysfunctionality in ras1Δ cells and tBHP as well as respiratory inhibitor, antimycin A treated wild type cells. Furthermore, these defects were more profound in ras1Δ cells treated with tBHP or antimycin A. Additionally, Ras1 also has been shown to regulate the expression and activity of several antioxidant enzymes like glutathione peroxidase (GSH-Px), glutathione-S-transferase (GST), and catalase. Together, these results suggest the potential role of S. pombe Ras1 in mitigating oxidative stress response.

Molecular docking-based interaction studies on imidazo[1,2-a] pyridine ethers and squaramides as anti-tubercular agents

Development of new anti-tubercular agents is required in the wake of resistance to the existing and newly approved drugs through novel-validated targets like ATP synthase, etc. The major limitation of poor correlation between docking scores and biological activity by SBDD was overcome by a novel approach of quantitatively correlating the interactions of different amino acid residues present in the target protein structure with the activity. This approach well predicted the ATP synthase inhibitory activity of imidazo[1,2-a] pyridine ethers and squaramides (r = 0.84) in terms of Glu65b interactions. Hence, the models were developed on combined (r = 0.78), and training (r = 0.82) sets of 52, and 27 molecules, respectively. The training set model well predicted the diverse dataset (r = 0.84), test set (r = 0.755), and, external dataset (r_ext = 0.76). This model predicted three compounds from a focused library generated by incorporating the essential features of the ATP synthase inhibition with the pIC₅₀ values in the range of 0.0508-0.1494 µM. Molecular dynamics simulation studies ascertain the stability of the protein structure and the docked poses of the ligands. The developed model(s) may be useful in the identification and optimization of novel compounds against TB.

Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021

OBJECTIVE

To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021.

POPULATION

Liveborn infants.

METHODS

Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study.

RESULTS

Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%).

CONCLUSIONS

Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

Best practices for the care of pregnant people living with TB

BACKGROUND: Each year more than 200,000 pregnant people become sick with TB, but little is known about how to optimize their diagnosis and therapy. Although there is a need for further research in this population, it is important to recognize that much can be done to improve the services they currently receive.METHODS: Following a systematic review of the literature and the input of a global team of health professionals, a series of best practices for the diagnosis, prevention and treatment of TB during pregnancy were developed.RESULTS: Best practices were developed for each of the following areas: 1) screening and diagnosis; 2) reproductive health services and family planning; 3) treatment of drug-susceptible TB; 4) treatment of rifampicin-resistant/multidrug-resistant TB; 5) compassionate infection control practices; 6) feeding considerations; 7) counseling and support; 8) treatment of TB infection/TB preventive therapy; and 9) research considerations.CONCLUSION: Effective strategies for the care of pregnant people across the TB spectrum are readily achievable and will greatly improve the lives and health of this under-served population.

Effect of Duration of Hemostatic Compression on Radial Artery Occlusion after Transradial Percutaneous Coronary Intervention

Radial artery occlusion (RAO) is now a major concern in transradial approach (TRA). RAO limits future radial artery use for further TRA, for as a conduit during CABG, for invasive hemodynamic monitoring and for creation of arteriovenous fistula for hemodialysis in Chronic Kidney Disease (CKD) patients through same vascular approach. The effect of duration of hemostatic compression of RAO is unknown in Bangladesh. This prospective observational study was conducted in the department of Cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh (NICVD) from September 2018 to August 2019, to evaluate the effect of duration of hemostatic compression on the incidence of radial artery occlusion (RAO) after transradial percutaneous coronary intervention. A total of 140 patients underwent percutaneous coronary intervention (PCI) through TRA. RAO was defined as an absence of antegrade flow or monophasic flow or invert flow on Duplex study. In this study 70 patients (Group I) received 2 hours hemostatic compression after transradial PCI. Another 70 patients (Group II) received 6 hours hemostatic compression after transradial PCI. Radial arterial blood flow assessed at early (24 hours) and late (30 days) by color duplex study after the procedure in both groups. Early radial artery occlusion occurred in 4.3% of patients in Group I and 12.8% of patients in Group II, (p=0.04). Late radial artery occlusion occurred in 2.8% of patients in Group I and 11.4% of patients in Group II, the difference was statistically significant (p=0.04). From multivariate logistic regression analysis duration of hemostatic compression time 6 hours (p=0.01), post-procedural nitroglycerine use (p=0.03) and procedure time (p=0.03) were predictors of RAO. Shorter duration of hemostatic compression is associated with a lower incidence of early and late radial artery occlusion after transradial intervention.

Suitability of memory aids and strategies for people with posterior cortical atrophy: protocol for a scoping review

Background

Posterior cortical atrophy (PCA) is a neurodegenerative syndrome characterised by progressive visuospatial and visuoperceptual impairment. Recent research shows that memory impairment can also occur as an early symptom of the condition and that the impairment can be ameliorated by providing support in the memory recall phase, for example, by presenting a related cue. In Alzheimer’s disease (AD), which is defined by an amnestic syndrome, memory aids and strategies have been used to help support everyday memory, which in turn can have a positive impact on patient and carer outcomes. Similar support for PCA could be achieved by using memory aids and strategies which help to encode and/or retrieve information, yet there are currently no guidelines for memory strategies that may be suitable in PCA. Due to the central visual disorder that defines PCA, careful consideration is needed when making recommendations.

Methods

A scoping review will be conducted of published studies that have assessed memory aids and strategies in people with AD and related dementias where memory is considered a core or supplementary feature, with the aim of distinguishing those that may be suitable or adaptable for PCA. The systematic search will include the electronic databases MEDLINE, PsycINFO and CINAHL, using search terms for dementia and memory aids and strategies identified in pilot searches. Findings will be mapped and described based on methods used, population, clinical data and memory aids and strategies identified.

Discussion

The scoping review will give an overview of the memory aids and strategies used in people with AD and related dementias and identify characteristics, modality and pragmatics to evaluate their suitability and adaptability for a PCA population. Tailored memory support strategies for people living with PCA could improve memory performance, with knock-on positive effects on patient and carer outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-023-02187-4.

The financial and quality of life impact of urgent dental presentations: A cross-sectional study

AIM

This study aimed to: (i) calculate personal financial costs associated with urgent dental attendance; and (ii) investigate the pain-related disability and quality of life impact of dental conditions which result in urgent dental attendance.

METHODOLOGY

Data were collected from those presenting with urgent dental conditions to an out-of-hours dental service, a dental emergency clinic and five primary care general dental practices across North-East England. A pre-operative questionnaire explored the impact of urgent dental conditions on oral health-related quality of life (OHRQoL) using Oral Health Impact Profile-14 (OHIP-14) and modified Graded Chronic Pain Scale (GCPS). OHIP-14 yields a maximum score of 56, with a higher score indicating a lower OHRQoL. Personal financial costs were summed to provide a total. These included travel, appointment fees, childcare costs, medication use and time away from work. Data were analysed using one-way ANOVA and multivariable modelling.

RESULTS

In total, 714 participants were recruited. Mean OHIP-14 score was 25.73; 95% CI [24.67, 26.79], GCPS CPI was 71.69; 95% CI [70.09, 73.28] and GCPS interference was 49.56; 95% CI [47.24, 51.87]. Symptomatic irreversible pulpitis was the most frequently managed dental emergency and was associated with the highest mean OHIP-14 score (31.67; 95% CI [30.20, 33.15]). The mean personal financial cost of urgent dental care was £85.81; 95% CI [73.29, 98.33]. Differences in travel time (F[2, 691] = 10.24, p<.001), transport costs (F[2, 698] = 4.92, p=.004), and appointment time (F[2, 74] = 9.40, p<.001) were significant between patients attending an out-of-hours dental service, dental emergency clinic and dental practices for emergency care, with a dental emergency clinic being associated with the highest costs and dental practices the lowest.

CONCLUSIONS

Diseases of the pulp and associated periapical disease were the most common reason for patients to present for urgent dental care and were the most impactful in terms of OHRQoL and pain in the present sample. Personal financial costs are significant from urgent dental conditions, with centralised services increasing the burden to patients of attending appointments.

Task-based measures of sensitivity to physical activity predict daily life pain and mood among people living with back pain

BACKGROUND

Clinical interventions aim to improve the daily life experiences of patients. However, past research has highlighted important discrepancies between commonly used assessments (e.g. retrospective questionnaires) and patients' daily life experiences of pain. These gaps may contribute to flawed clinical decision-making and ineffective care. Recent work suggests that real-time, task-based clinical assessments may help reduce these discrepancies by adding predictive value in explaining daily life pain experiences. This study aimed to investigate these relationships by evaluating whether task-based measures of sensitivity to physical activity (SPA) predict daily life pain and mood, beyond traditional pain-related questionnaires.

METHODS

Adults with back pain (<6-month onset) answered pain-related questionnaires and completed a standardized lifting task. SPA-Pain, SPA-Sensory and SPA-Mood were, respectively, assessed as task-evoked changes in pain intensity, pressure pain threshold (back, hands), situational catastrophizing. Over the next 9 days, daily life pain and mood were assessed using smartphone-based ecological momentary assessment (EMA-Pain and EMA-Mood, respectively) with stratified random sampling. Data analyses estimated fixed effects (b) using multilevel linear modelling with random intercepts.

RESULTS

Median EMA completion per participant was 66.67% (n = 67 participants). After controlling for covariates, SPA-Pain was associated with EMA-Pain (b = 0.235, p = 0.002) and SPA-Psych approached significance with EMA-Mood (b = -0.159, p = 0.052).

CONCLUSIONS

Task-based assessment of SPA helps explain daily life pain and mood among adults with back pain, beyond traditional questionnaires. Adding task-based assessment of SPA may achieve a more complete picture of pain and mood in daily life, offering clinicians better guidance when prescribing activity-based interventions that are designed to modify daily life behaviour, such as graded activity.

SIGNIFICANCE

This study found that, among people with back pain, task-based measures of sensitivity to physical activity contribute additional predictive value for daily life pain and mood beyond self-report questionnaires. Findings suggest that real-time, task-based measures may help mitigate some of the shortcomings that are commonly associated with retrospective questionnaires.

Analytic similarity solutions for fully resolved unsteady laminar boundary layer flow and heat transfer in the presence of radiation

In this paper, we have compared a new type of similarity transformation derived systematically by using Lie point symmetries with the existing similarity transformations for unsteady fluid flow and heat transfer in the boundary layer in the presence of radiation. It is observed that the existing transformations map the steady and marginally accelerating flows only, while the Lie similarity transformations provide solutions for all types of accelerating flows and are independent of unsteadiness in the fluid. The previous transformations are valid for a specific time interval which depends on a range of unsteadiness parameter, however the Lie similarity transformations provide valid solutions at any given time. This implies that the Lie similarity transformations yield solutions for previously unexplored ranges of unsteadiness in the fluid. Boundary layer flow physics for both types of transformations is discussed by employing the Homotopy analysis method. We show that for accelerating fluids, in the developing region, the boundary layer thickness first increases and than starts to decrease with increase in unsteadiness for fully developed flow. Detailed comparison of velocity and temperature profiles in the boundary layer is made using the tables and graphs which show that with Lie similarity transformations the region of study of the considered flow extends significantly for the unsteadiness parameter. The effect of the Prandtl number and radiation parameter on temperature distribution is also compared for both types of similarity transformations. The Lie symmetry similarity transformations are shown to explain the unsteady laminar boundary layer flow and heat transfer to an extent where the existing similarity transformations do not work.

Clinical research coordinators' role in knowledge translation activities in rehabilitation: a mixed methods study

BACKGROUND

Clinical research coordinators (CRCs) facilitate the interaction between researchers and knowledge users in rehabilitation centres to promote and sustain evidence-informed practices. Despite their presence in rehabilitation settings in Quebec for over 20 years, little is known about their profiles and knowledge translation (KT) activities nor how they can best enact their role. This study explored CRCs' roles and perspectives on the barriers, enablers, and strategies for improving KT activities in rehabilitation settings.

METHODS

We conducted a multi-centre, participatory sequential mixed methods study. In the descriptive quantitative phase, we collected data via an online survey to determine CRCs' role in research and KT. In the subsequent qualitative phase, we conducted an in-person focus group to elicit CRCs' perspectives regarding factors influencing their work in KT, and potential solutions for overcoming these challenges. We used a descriptive and an inductive content analysis approach for the data analysis. The data synthesis was inspired by the Promoting Action on Research Implementation in Health Services framework.

RESULTS

All nine CRCs from five partner health regions of a large rehabilitation research centre agreed to participate in the study. The data suggest that CRCs are like knowledge brokers and boundary spanners. As information managers, linkage agents and facilitators, CRCs play a pivot role in diffusion, dissemination, synthesis and tailoring of knowledge to improve evidence informed practices and quality of care in rehabilitation. The factors influencing CRCs' KT activities are mostly linked to the context such as the receptivity of the organization as well as the lack of time and resources, and limited understanding of their roles by stakeholders. Two main suggestions made to enhance CRCs' contribution to KT activities include the harmonisation of expectations between the large research centre and their partner health regions, and better promotion of their role to clinical and research teams.

CONCLUSIONS

This study provides valuable insights into the scope of CRCs' role. The results shed light on the challenges that they face and potential solutions to overcome them. The knowledge generated in this study can be used to implement this role with similar duties in rehabilitation settings or other health care domains.

Long-term survival with first-line nivolumab plus ipilimumab in patients with advanced non-small-cell lung cancer: a pooled analysis

BACKGROUND

First-line nivolumab plus ipilimumab prolongs survival versus chemotherapy in advanced non-small-cell lung cancer (NSCLC). We further characterized clinical benefit with this regimen in a large pooled patient population and assessed the effect of response on survival.

PATIENTS AND METHODS

Data were pooled from four studies of first-line nivolumab plus ipilimumab in advanced NSCLC (CheckMate 227 Part 1, 817 cohort A, 568 Part 1, and 012). Overall survival (OS), progression-free survival (PFS), objective response rate, duration of response, and safety were assessed. Landmark analyses of OS by response status at 6 months and by tumor burden reduction in responders to nivolumab plus ipilimumab were also assessed.

RESULTS

In the pooled population (N = 1332) with a minimum follow-up of 29.1-58.9 months, median OS was 18.6 months, with a 3-year OS rate of 35%; median PFS was 5.4 months (3-year PFS rate, 17%). Objective response rate was 36%; median duration of response was 23.7 months, with 38% of responders having an ongoing response at 3 years. In patients with tumor programmed death-ligand 1 (PD-L1) <1%, ≥1%, 1%-49%, or ≥50%, 3-year OS rates were 30%, 38%, 30%, and 48%. Three-year OS rates were 30% and 38% in patients with squamous or non-squamous histology. Efficacy outcomes in patients aged ≥75 years were similar to the overall pooled population (median OS, 20.1 months; 3-year OS rate, 34%). In the pooled population, responders to nivolumab plus ipilimumab at 6 months had longer post-landmark OS than those with stable or progressive disease; 3-year OS rates were 66%, 22%, and 14%, respectively. Greater depth of response was associated with prolonged survival; in patients with tumor burden reduction ≥80%, 50% to <80%, or 30% to <50%, 3-year OS rates were 85%, 72%, and 44%, respectively. No new safety signals were identified in the pooled population.

CONCLUSION

Long-term survival benefit and durable response with nivolumab plus ipilimumab in this large patient population further support this first-line treatment option for advanced NSCLC.

1339 IMPROVING INPATIENT MANAGEMENT OF DELIRIUM IN A DISTRICT GENERAL HOSPITAL

Background

Delirium is a common clinical condition associated with increased morbidity and mortality, and prolonged hospital stay. Early detection is vital to improving management of the condition and improving outcomes.

Aims

Improve delirium detection using the 4AT screening tool as a validated approach; Improve delirium management across multiple domains using the PINCH ME approach; documented attempt at collateral history within 24 hours of recognition of delirium; obtain serological confusion screen in patients with recognised delirium. (100% each)

Method

Plan Do Study Act (PDSA) method was used to conduct this Quality Improvement (QI) project over 12 months. Data was obtained from paper and electronic records in the medical wards with regards to 'at risk patients' (i.e. over 65y, acutely unwell, background of cognitive impairment and/or acute fracture). The use of 4AT or alternative delirium screens from the emergency department (ED) and medical teams were noted. Assessment for pain, urinalysis, serological screens, bowel and nutrition review including MUST scores, medication reviews were looked for. Interventions included presentation and education at the medicine grand round, publishing a poster, and a PINCHME alert sticker for the medical notes to use at time of assessment. 2 PDSA cycles were completed and post sticker results obtained.

Results

Baseline data shows that collateral history was attempted for 70% patients - improved to 100% after sticker use. Use of validated screening test from 15% to 100% after sticker use. Nutrition assessment improved from 15% to 40%. Serological testing improved from 40% to 53%. 100% patients received a medication review after sticker use.

Conclusion

Introduction of PINCHME sticker serves as a prompt to ensure holistic management. Currently delirium management is clinician dependent as there is lack of formal delirium management pathway. Further plan includes involving nursing staff and 'delirium champions' to bring about a formal pathway for lasting change.

Concordance of three approaches for operationalizing outcome definitions for multidrug-resistant TB

BACKGROUND: The WHO provides standardized outcome definitions for rifampicin-resistant (RR) and multidrug-resistant (MDR) TB. However, operationalizing these definitions can be challenging in some clinical settings, and incorrect classification may generate bias in reporting and research. Outcomes calculated by algorithms can increase standardization and be adapted to suit the research question. We evaluated concordance between clinician-assigned treatment outcomes and outcomes calculated based on one of two standardized algorithms, one which identified failure at its earliest possible recurrence (i.e., failure-dominant algorithm), and one which calculated the outcome based on culture results at the end of treatment, regardless of early occurrence of failure (i.e., success-dominant algorithm).METHODS: Among 2,525 patients enrolled in the multi-country endTB observational study, we calculated the frequencies of concordance using cross-tabulations of clinician-assigned and algorithm-assigned outcomes. We summarized the common discrepancies.RESULTS: Treatment success calculated by algorithms had high concordance with treatment success assigned by clinicians (95.8 and 97.7% for failure-dominant and success-dominant algorithms, respectively). The frequency and pattern of the most common discrepancies varied by country.CONCLUSION: High concordance was found between clinician-assigned and algorithm-assigned outcomes. Heterogeneity in discrepancies across settings suggests that using algorithms to calculate outcomes may minimize bias.

Isolation and characterization of synthetic pyrethroids-degrading bacterial strains from agricultural soil

Pyrethroid pesticides are commonly used for pest control in agriculture setup, veterinary and home garden. They are now posing increased risks to non-targeted organisms associated to human beings due to their considerable use. The present work deals with the isolation of bacteria with tolerance to high concentrations of bifenthrin and cypermethrin from contaminated soil. Enrichment culture technique (bifenthrin concentration = 50-800 mg/L) was used for bacterial isolation. Bacteria that showed growth on minimal media with bifenthrin were also sub-cultured on minimal media with cypermethrin. Bacteria showing luxurious growth on both the pyrethroid, were screened out based on their morphological, biochemical parameters and by API 20NE Kit. Phylogenetic studies revealed that, one bacterial isolate (MG04) belonging to Acinetobacter lwoffii and other five bacterial isolates (MG06, MG05, MG01, MG03 and MG02) cluster with Pseudomonas aeruginosa, Pseudomonas putida respectively. Isolated members of genera Pseudomonas and Acinetobacter could be used for further detailed degradation studies by using FTIR, HPLC-MS or GC-MS analysis.

Health Related Quality of Life in Patients with Pulmonary Tuberculosis

Tuberculosis (TB) is one of the major public health issues in many developing nations especially in Bangladesh. Though most focus is being directed towards mortality and incidence rate, the changes in morbidity and other health status parameters are not been well considered. The aim of the study was a comprehensive assessment of patients with pulmonary tuberculosis by measuring patient's quality of life which may lead to better outcome in patients' health, infection surveillance and prevention programs. This prospective study was conducted in the department of Respiratory and Internal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from September 2015 to March 2017. The quality of life scores of 61 smear positive pulmonary tuberculosis cases were measured by validated Bangla version of SF-36 questionnaire before or at the starting of treatment, after the initial phase and at the end of treatment. Then the score was compared with those of 75 healthy matched controls. The changes of the quality of life with the stage of treatment and with socio-demographic variables were assessed. Before treatment, all domains of HRQoL of the pulmonary TB patients were significantly lower than those of the control group (p<0.001). At the end of six-month treatment period, HRQoL of the pulmonary TB patient had significantly increased compared to before treatment (p<0.001). There was no significant difference of scores after six months of treatment with that of control (p>0.05). The lowest score in tuberculosis patients was related to general health perception and vitality. Patients with low socio economic status, low educational level, prolonged disease duration and increased number of symptoms had lower HRQoL scores.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.