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.

Spurious Hyperphosphatemia in a Patient with Chronic Kidney Disease - a Rare Case of Alteplase Contamination

Spurious hyperphosphatemia, a rare occurrence, typically arises from substances in a patient's blood interfering with the colorimetric method for serum phosphate measurement. We present a case of factitious hyperphosphatemia caused by alteplase-contaminated blood samples in an 88-year-old CKD patient on hemodialysis, leading to misleadingly high phosphorus levels. Thorough investigations ruled out other etiologies, highlighting the necessity of stringent adherence to blood collection protocols to prevent sample contamination and avert erroneous laboratory results. This unique cause of hyperphosphatemia should be considered in the differential diagnosis when encountering unexplained elevations in phosphorus levels, particularly in the context of normal blood calcium levels.

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.

Insights from semi-structured interviews on integrating artificial intelligence in clinical chemistry laboratory practices

BACKGROUND

Artificial intelligence (AI) is gradually transforming the practises of healthcare providers. Over the last two decades, the advent of AI into numerous aspects of pathology has opened transformative possibilities in how we practise laboratory medicine. Objectives of this study were to explore how AI could impact the clinical practices of professionals working in Clinical Chemistry laboratories, while also identifying effective strategies in medical education to facilitate the required changes.

METHODS

From March to August 2022, an exploratory qualitative study was conducted at the Section of Clinical Chemistry, Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan, in collaboration with Keele University, Newcastle, United Kingdom. Semi-structured interviews were conducted to collect information from diverse group of professionals working in Clinical Chemistry laboratories. All interviews were audio recorded and transcribed verbatim. They were asked what changes AI would involve in the laboratory, what resources would be necessary, and how medical education would assist them in adapting to the change. A content analysis was conducted, resulting in the development of codes and themes based on the analyzed data.

RESULTS

The interviews were analysed to identify three primary themes: perspectives and considerations for AI adoption, educational and curriculum adjustments, and implementation techniques. Although the use of diagnostic algorithms is currently limited in Pakistani Clinical Chemistry laboratories, the application of AI is expanding. All thirteen participants stated their reasons for being hesitant to use AI. Participants stressed the importance of critical aspects for effective AI deployment, the need of a collaborative integrative approach, and the need for constant horizon scanning to keep up with AI developments.

CONCLUSIONS

Three primary themes related to AI adoption were identified: perspectives and considerations, educational and curriculum adjustments, and implementation techniques. The study's findings give a sound foundation for making suggestions to clinical laboratories, scientific bodies, and national and international Clinical Chemistry and laboratory medicine organisations on how to manage pathologists' shifting practises because of AI.

Developing and piloting an online course on osteoporosis using a multidisciplinary multi-institute approach- a cross-sectional qualitative study

INTRODUCTION

Postgraduate medical trainees (PGs) in developing nations face various educational hurdles due to limited access to quality resources and training facilities. This study aimed to assess the effectiveness of e-learning, particularly Massive Open Online Courses (MOOCs), within postgraduate medical education. It involved the development of a customized online course focused on osteoporosis for PGs and an examination of their perspectives and preferences concerning online learning methods like Virtual Learning Environment (VLE) platforms.

METHODS

The study was conducted from January 2018 to December 2020. A multi-institutional, multidisciplinary team was assembled to design an osteoporosis course on the VLE platform. PGs (n = 9) from diverse disciplines and institutions were selected with informed consent. Focus group discussions (FGDs) among these PGs identified their preferences for the online course, which subsequently guided the development of the MOOC. The modular MOOC comprised recorded micro-lectures, flashcards, videos, case challenges, and expert interviews. The educational impact of the VLE was assessed using pre- and post-module tests among the participants, and their perceptions of the PGs and course facilitators were gathered via an online survey.

RESULTS

The study identified the involvement of PGs in the course design process as beneficial, as it allowed for content customization and boosted their motivation for peer-to-peer learning. During the FGDs, PGs expressed a strong preference for flexible learning formats, particularly short downloadable presentations, and micro-lectures. They also identified challenges related to technology, institutional support, and internet connectivity. In the subsequently customized MOOC course, 66% of PGs (n = 6) attempted the pre-test, achieving a mean score of 43.8%. Following the VLE module, all PGs (n = 9) successfully passed the end-of-module test, averaging a score of 96%, highlighting its impact on learning. The majority (n = 8, 88.9%) agreed that the course content could be applied in clinical practice, and 66.7% (n = 6) expressed extreme satisfaction with the learning objectives and content. Participants favoured end-of-module assessments and the use of best-choice questions for evaluation.

CONCLUSION

This study highlights the importance of virtual learning, particularly MOOCs, in addressing the educational challenges faced by developing nations. It emphasizes the need for tailored online courses that cater to the preferences and requirements of PGs. The findings suggest that MOOCs can foster collaboration, networking, and opportunities for professional development, and interdisciplinary collaboration among faculty members can be a key strength in course development. This research provides valuable insights for educators, institutions, and e-learning developers seeking to enhance their teaching methodologies and establish accessible educational environments in the digital age.

Reporting Practices of Serum Protein Electrophoresis in Pakistan - a Multicenter Survey

BACKGROUND

Serum Protein Electrophoresis (SPE) is crucial for the diagnosis and follow-up of monoclonal gammopathy (MG), as it helps to separate and identify these paraproteins. Currently, Pakistan lacks standardized guidelines for SPE reporting and analytical performance. This survey aims to analyze reporting variations from Consultant Chemical Pathologists in Pakistani laboratories.

METHODS

This cross-sectional survey was conducted by the section of Chemical Pathology, Department of Pathology and Laboratory Medicine, at Aga Khan University Hospital, Karachi. A previously validated and published tool was used with some modifications to assess analytical techniques, reporting patterns, and interpretations provided with SPE by different laboratories. Frequency and percentages were calculated for each response and descriptive results were also evaluated. Differences between laboratories were also assessed qualitatively.

RESULTS

Out of the eight laboratories contacted, seven participated in the survey, yielding a response rate of 87.5%. Immunofixation Electrophoresis (IFE) was used by all labs for serum immunotyping. All labs reported a new small abnormal band in patients with no known monoclonal gammopathy or with a known M-protein. Variations were found in terminologies used to label paraprotein, terminologies used to report normal and pathological SPE patterns, electrophoretic technique, methods for quantifying paraprotein in the gamma region on SPE and for albumin quantification. Similarly, the number of decimal places reported, reporting of multiple monoclonal proteins and small paraprotein in the beta region or monoclonal proteins less than 1 g/L, approach for screening, number of fractions reported in gamma region and reporting of interferences were also not standardized and var-iations were noticed.

CONCLUSIONS

Our survey highlighted variations in practices of SPE reporting. These differences in laboratory practices could result in inconsistent test results, which could adversely affect patient care.

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.

Sequence variants in the BTD underlying biotinidase deficiency in families of Pakistani origin

BACKGROUND

Biotinidase deficiency (BTD) is a rare autosomal recessive metabolic disease, which develops neurological symptoms because of the impaired biotin recycling. Pathogenic mutations on BTD gene cause BTD deficiency. The clinical features and mutation analysis of Pakistani children with BTD deficiency have rarely been described. Herein, for the first time, we report the clinical features, BTD gene mutations and biochemical analysis of seven symptomatic children with BTD deficiency from Pakistan.

METHODS

Seven suspected BTD-deficient patients who presented abnormal organic acid profiles and clinical features were subjected to Sanger sequencing to identify pathogenic mutations in the BTD gene. The results were analyzed by Mutation Surveyor Software.

RESULTS

All seven patients exhibited common biotinidase deficiency symptoms including hypotonia, developmental delay and seizures. Biochemical analysis shows marked excretion of 3-hydroxy isovalerate in all cases, followed by 3-hydroxy propionate and methyl citrate. Sanger sequencing revealed one frame-shift mutation, c.98_104delinsTCC (p.Cys33Phefs), and two missense mutations, c.1612C>A (p.Arg538Ser) and c.1330G>C (p.Asp444His). All mutations were in the homozygous state and classified as pathogenic in published studies and mutation databases.

CONCLUSIONS

This study has validated the BTD variants as the underlying cause of biotinidase deficiency in which molecular testing of BTD is supported by urinary organic acid analysis and clinical diagnosis. Secondly, the strength of the local availability of this test in Pakistan will paved the way for the neonatal screening of biotinidase deficiency.

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

Exploring the Potential of Plant Bioactive Compounds against Male Infertility: An In Silico and In Vivo Study

Infertility is a well-recognized multifactorial problem affecting the majority of people who struggle with infertility issues. In recent times, among infertility cases, the male factor has acquired importance, and now it contributes to approximately half of the infertility cases because of different abnormalities. In the current study, we used natural phytochemicals as potential drug-lead compounds to target different receptor proteins that are involved in the onset of male infertility. A set of 210 plant phytochemicals were docked counter to active site residues of sex hormone-binding globulin, a disintegrin and metalloproteinase 17, and DNase I as receptor proteins. On the basis of binding scores and molecular dynamics simulation, the phytochemicals tricin, quercetin, malvidin, rhamnetin, isorhamnetin, gallic acid, kaempferol, esculin, robinetin, and okanin were found to be the potential drug candidates to treat male infertility. Molecular dynamics simulation showed tricin as a strong inhibitor of all selected receptor proteins because the ligand-protein complexes remained stabilized during the entire simulation time of 100 ns. Further, an in vivo study was designed to evaluate the effect of tricin in male rats with nicotine-induced infertility. It was explored that a high dose of tricin significantly reduced the levels of alanine transaminase, aspartate transaminase, urea, creatinine, cholesterol, triglyceride, and low-density lipoprotein and raised the level of high-density lipoprotein in intoxicated male rats. A high dose of tricin also increased the reproductive hormones (i.e., testosterone, luteinizing hormone, follicle-stimulating hormone, and prolactin) and reduced the level of DHEA-SO4. The phytochemical (tricin, 10 mg/kg body weight) also showed significant improvement in the histo-architecture after nicotine intoxication in rats. From the current study, it is concluded that the phytochemical tricin could serve as a potential drug candidate to cure male infertility.

Assessing the knowledge, attitude and practice of osteoporosis among Pakistani women: A national social-media based survey

BACKGROUND

There are numerous risk factors for osteoporosis and understanding and recognizing these risk factors is critical when deciding whether to take preventive measures. It is critical to reduce the healthcare expenditure burden of the Pakistani population by raising awareness and implementing osteoporosis-preventable measures. This survey aims to assess the knowledge, attitudes, and practices (KAP) of Pakistani women as well as their misconceptions about osteoporosis.

METHODS

A cross-sectional survey was conducted from August 2021 to January 2022 by the Bone & Mineral Disease research group at Section of Chemical Pathology, Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, with exemption from the ethical review committee. Using snowball sampling, a validated Osteoporosis Prevention and Awareness Tool (OPAAT) was disseminated online via social media. With informed consent, 400 Pakistani women aged ≥ 18 years were included in the study. SPSS Statistics version 25.0 was used for data analysis. Chi-square test for association and Fisher-exact test were applied, and significance level was α<0.05.

RESULTS

Based on the OPAAT scores of all (n = 400) participants, 22% (n = 88) had low knowledge, 44% (n = 176) had average knowledge, while 34% (n = 136) had good knowledge of osteoporosis. The most common misconceptions were about age-related risk, presentation of symptoms, radiation risk, associated risk factors like tooth loss, osteoarthritis, and knowledge about predictors of bone health.

CONCLUSION

Adult Pakistani women have a fair understanding of osteoporosis, but the OPAAT tool clarifies some common misconceptions. There is a need to develop educational strategies to increase the knowledge of osteoporosis among Pakistani adults and to promote a bone-healthy lifestyle.

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.

Indirect Reference Intervals of Serum Calcium in Pakistani Children Using KOSMIC, Bhattacharya, and Hoffman Approach

BACKGROUND

Reference intervals (RIs) of serum calcium vary based on age, population demographics, and methods of assessment. However, conventional approaches to establish serum calcium (Ca)RIs pose ethical and practical challenges, especially in the pediatric population. Hence, the use of indirect approaches is beneficial. This study was carried out to estimate the RIs of serum Ca using three indirect approaches in the pediatric and adolescent population of Pakistan.

METHODS

Data mining laboratory information systems, for serum Ca results from 2013 - 2021 was done on a target population ranging from birth to 18 years of age. The population was grouped into three categories based on age (birth - 1 year, 2 - 4 years, and 5 - 18 years), as defined previously by Tahmasebi et al. in the CALIPER cohort. Pre-validated indirect algorithms, 'KOSMIC', Bhattacharya, and Hoffman, were used for analyzing the RIs.

RESULTS

A total of non-duplicate 40,914 serum Ca tests were retrieved over a period of 6 years, including 38.7% (n = 15,830) from birth - 1 year, 16.3% (n = 6,641) from > 1 - 4 years, and 45.2% (n = 18443) from > 4 - 18 years respectively. The three methods revealed comparable performance with the direct RIs reported by Tahmasebi et al. in the CALIPER cohort. Keeping a stringent total allowable error of 1 mg/dl for Serum Ca as given by Clinical Laboratory Improvement Amendments (CLIA) the KOSMIC method outperformed the other two when compared to Tahmasebi, Houman, et al. Conclusions: The study advocates the use of the indirect approach for calculating RIs for serum calcium in the pediatric population, especially to aid clinical decision making in a low resource setting, due to its ability to reproduce results in line with the direct approach in a more economical, practical, and feasible way.

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.

Factors Associated With Awareness Of Literate Mothers About Newborn Screening: A Cross-Sectional Study From A Low-Middle-Income Country

Objectives

To explore the awarenesslevel of literate mothersregarding newborn screening programmes, and to evaluate the associated factors.

METHODS

The descriptive, cross-sectional study was conducted at the Section of Chemical Pathology, Department of Pathology andLaboratoryMedicine,AgaKhanUniversity,Karachi,fromJanuary toSeptember 2021, andcomprisedmothers aged 18 years or more. Data was collected using a structured questionnaire about newborn screening, and the subjects were compared in terms of age, residential background, education and parity. Data was analysed using SPSS 23.

RESULTS

Of the 1016 responses, 896(88.2%) were analysed. The mean age of the sample was 37.7±10.87 years. There were 470(52.4%) mothers aged 31-45 years, 859(95.87%) were from urban areas, 751(84%) had a graduate degree, 652(72.7%) weremultiparous andhad824(91.9%)hadhealthy children.Overall, 386 (43%)mothershadawarenessofnewbornscreening programmes. The main factors associated with awareness were age, education, primiparity, having healthy children, and province ofresidencebeing Sindh andPunjab(p<0.05),while the urban-ruraldividedwas not a significantfactor(p=0.737). Cost of healthcare 417(46.5%) and lack of awareness among physicians 356(39.7%) were identified asthe main challenges in establishing newborn screening servicesin the country.

CONCLUSIONS

The awareness among mothers about new born screening programmes was generally low among the subjects studied.

Underlying Mechanisms of Bergenia spp. to Treat Hepatocellular Carcinoma Using an Integrated Network Pharmacology and Molecular Docking Approach

Hepatocellular carcinoma (HCC) is the fifth most common and fatal cancer reported, representing 72.5% of malignancies around the world. The majority of HCC incidents have been associated with infections caused by hepatitis B and C viruses. Many first- and second-line conventional drugs, e.g., sorafenib, cabozantinib, or ramucirumab, have been used for the management of HCC. Despite different combinational therapies, there are still no defined biomarkers for an early stage diagnosis of HCC. The current study evaluated the potential of Bergenia stracheyi, Bergenia ciliata, Bergenia pacumbis, and Bergenia purpurascens, which belong to the family Saxifragaceae, to treat HCC using an integrated network pharmacology and molecular docking approach. Four active phytochemicals were selected based on oral bioavailability (OB) and drug likeness (DL) parameters. The criteria of phytochemical selection were set to OB > 30% and DL > 0.18. Similarly, the gene targets related to Bergenia spp. and the genes related to HCC were retrieved from different databases. The integration of these genes revealed 98 most common overlapping genes, which were mainly interrelated with HCC pathogenesis. Ultimately, the 98 Bergenia-HCC associated genes were used for protein-protein interaction (PPI), Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway, and Gene Ontology (GO) enrichment analyses. Finally, the topological analysis revealed the top ten hub genes with maximum degree rank. From the top ten genes, STAT3, MAPK3, and SRC were selected due to their involvement in GO annotation and KEGG pathway. To confirm the network pharmacology results, molecular docking analysis was performed to target STAT3, MAPK3, and SRC receptor proteins. The phytochemical (+)-catechin 3-gallate exhibited a maximum binding score and strong residue interactions with the active amino acids of MAPK3-binding pockets (S-score: -10.2 kcal/mol), SRC (S-score: -8.9 kcal/mol), and STAT3 (S-score: -8.9 kcal/mol) as receptor proteins. (+)-Catechin 3-gallate and β-sitosterol induced a significant reduction in cell viability in HepG2 after 24 h of treatment in a dose-dependent manner. The results of this study explore the potential of (+)-catechin 3-gallate and β-sitosterol, which can be used in the future as potential drug candidates to suppress HCC.

Evaluation of the clinical, biochemical, and genetic presentation of neonatal and adult-onset 5,10-methylene tetrahydrofolate reductase (MTHFR) deficiency in patients from Pakistan

OBJECTIVES

To study the biochemical, clinical and molecular characteristics of 5,10- methylenetetrahydrofolate reductase (MTHFR) deficiency in Pakistani patients from a single center.

METHODS

Medical charts, urine organic acid chromatograms, plasma methionine and Hcys levels, and molecular testing results of MTHFR gene of patients presenting at the Biochemical Genetics Clinic, AKUH from 2016 to 2022 were reviewed.

RESULTS

Neonatal MTHFR deficiency was found in five patients. The median (IQR) age of symptom onset and diagnosis were 18 (8.5-22) and 26 (16.5-31) days. The median lag between symptom onset and diagnosis was 8 (4.5-12.5) days. The median age of treatment initiation and duration of treatment were 26 (16.5-49) and 32 (25.5-54) days. The most common clinical features were lethargy, poor feeding, and seizures. The MTHFR gene sequencing revealed homozygous variants p.K510K, p.R567*, and p.R157W. Renal insufficiency manifesting as elevated serum creatinine and responding to betaine therapy was noted in one patient. This has not been previously reported in neonatal MTHFR deficiency and may reflect engagement of alternate pathways of remethylation. Adult onset MTHFR deficiency was found in six patients, with a heterogeneous neurological presentation. The median lag between symptoms onset and diagnosis was 7 (3-11) years. MTHFR gene sequencing revealed homozygous variant p.A195V in five patients from one family and p.G261V in the other. Two of the five reported variants are novel that include p.R157W and p.G261V.

CONCLUSIONS

Eleven patients of this rare disorder from a single center indicate the need for clinical awareness and appropriate biochemical evaluation to ensure optimal outcomes.

An Evaluation of the new 2021 Creatinine-Based Equation for Estimating Glomerular Filtration Rate (eGFR) in Pakistanis

BACKGROUND

The new eGFR equation without race coefficients was recently developed and published by the CKD-EPI Collaboration. The new equation termed CKD-EPI 2021 has been endorsed by the National Kidney Foundation and the American Society of Nephrology. It is important to understand the impact this new equation might have on clinical decision making in practice; hence, this study is planned to evaluate the CKD-EPI 2021 equation in Pakistani population. To evaluate the performance of CKD-EPI 2021, CKD-EPI 2009, CKD-EPI Pak, and MDRD equations taking CrCl as gold standard.

METHODS

This retrospective cross-sectional study was conducted at the section of Chemical Pathology, Department of Pathology and Laboratory Medicine, in collaboration with section of Nephrology, Department of Medicine, Aga Khan University, Karachi. Consecutive laboratory results of subjects above 18 years; tested for CrCl or three months December 2021 to February 2022 was retrieved from the integrated laboratory management system (iLMS). Demographic details including gender and age alongside biochemical results of CrCl and serum Cr were recorded on a prestructured questionnaire. Statistical analysis of the data will be performed using Statistical Package of Social Sciences (SPSS) version 22.

RESULTS

After excluding those below 18 years of age, 2,609 cases were included in the final data analysis, with 1,419 (54.4%) males and 1,190 (45.6%) females. Mean age of the group was 52.8 ± 14.9 years. Among the 4 formulae tested against CrCl, CKD-EPI Pak showed the strongest correlation (r2 = 0.83), highest sensitivity 93.2% and negative predictive value of 93.0% with an overall agreement of 88%.

CONCLUSIONS

The CKD-EPI Pak equation is more accurate and precise in estimating GFR in Pakistani population. Based on the successful five years of experience of reporting eGFR using this equation by a large tertiary care hospital in Pakistan, this is high time to propagate its incorporation reflexly with SCr laboratory reports with no additional cost constraints.

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.

Phenolics Extracted from Jasminum sambac Mitigates Diabetic Cardiomyopathy by Modulating Oxidative Stress, Apoptotic Mediators and the Nfr-2/HO-1 Pathway in Alloxan-Induced Diabetic Rats

Diabetes mellitus is a chronic metabolic disorder defined as hyperglycemia and pancreatic β-cell deterioration, leading to other complications such as cardiomyopathy. The current study assessed the therapeutic effects of phenolic acids extracted from Jasminum sambac phenols of leaves (JSP) against diabetes-induced cardiomyopathy in rats. The rats were divided into four groups, with each group consisting of 20 rats. The rats were given intraperitoneal injections of alloxan monohydrate (150 mg/kg) to induce diabetes. The diabetes-induced groups (III and IV) received treatment for six weeks that included 250 and 500 mg/kg of JSP extract, respectively. In the treated rats, the results demonstrated that JSP extract restored fasting glucose, serum glucose, and hyperlipidemia. Alloxan induced cardiomyopathy, promoted oxidative stress, and altered cardiac function biomarkers, including cardiac troponin I, proBNP, CK-MB, LDH, and IMA. The JSP extract-treated rats showed improved cardiac function indicators, apoptosis, and oxidative stress. In diabetic rats, the mRNA expression of caspase-3, BAX, and Bcl-2 was significantly higher, while Bcl-2, Nrf-2, and HO-,1 was significantly lower. In the treated groups, the expression levels of the BAX, Nrf-2, HO-1, Caspase-3, and Bcl-2 genes were dramatically returned to normal level. According to our findings, the JSP extract prevented cardiomyopathy and heart failure in the hyperglycemic rats by improving cardiac biomarkers and lowering the levels of hyperlipidemia, oxidative stress, apoptosis, hyperglycemia, and hyperlipidemia.

In Silico Analysis of Honey Bee Peptides as Potential Inhibitors of Capripoxvirus DNA-Directed RNA Polymerase

The genus Capripoxvirus belongs to the Poxviridae family. The sheeppox, goatpox, and lumpy skin disease viruses are three species of this genus with 96% identity in their genomes. These are financially devastating viral infections among cattle, which cause a reduction in animal products and lead to a loss in livestock industries. In the current study, the phylogenetic analysis was carried out to reveal the evolutionary relationships of Capripoxvirus species (i.e., sheeppox virus (SPPV), goatpox virus (GTPV), and lumpy skin disease virus (LSDV)) with other viruses from the Poxviridae family with >96% query coverage to find the similarity index among all members. The three viruses (i.e., SPPV, GTPV, and LSDV) joined the clade of Capripoxvirus of the Poxviridae family in the phylogenetic tree and exhibited close evolutionary relationships. The multiple sequence alignment using ClustalOmega revealed significant variations in the protein sequences of the DNA-dependent RNA polymerase of SPPV, GTPV, and LSDV. The three-dimensional structures of five selected bee peptides and DNA-directed RNA polymerase of SPPV, GTPV, and LSDV were predicted using trRosetta and I-TASSER and used for molecular docking and simulation studies. The protein-protein docking was carried out using HADDOCK server to explore the antiviral activity of peptides as honey bee proteins against SPPV, GTPV, and LSDV. In total, five peptides were docked to DNA-directed RNA polymerase of these viruses. The peptides mellitin and secapin-1 displayed the lowest binding scores (-106.9 +/- 7.2 kcal/mol and -101.4 +/- 11.3 kcal/mol, respectively) and the best patterns with stable complexes. The molecular dynamics simulation indicated that the complex of protein DNA-dependent RNA polymerase and the peptide melittin stayed firmly connected and the peptide binding to the receptor protein was stable. The findings of this study provide the evidence of bee peptides as potent antimicrobial agents against sheeppox, goatpox, and lumpy skin disease viruses with no complexity.

A framework for implementing best laboratory practices for non-integrated point of care tests in low resource settings

The method we respond to pandemics is still inadequate for dealing with the point of care testing (POCT) requirements of the next large epidemic. The proposed framework highlights the importance of having defined policies and procedures in place for non-integrated POCT to protect patient safety. In the absence of a pathology laboratory, this paradigm may help in the supply of diagnostic services to low-resource centers. A review of the literature was used to construct this POCT framework for non-integrated and/or unconnected devices. It also sought professional advice from the Chemical Pathology faculty, quality assurance laboratory experts and international POCT experts from the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). Our concept presents a comprehensive integrated and networked approach to POCT with direct and indirect clinical laboratory supervision, particularly for outpatient and inpatient care in low-resource health care settings.

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.

Valorization of Using Agro-Wastes for Levan through Submerged Fermentation and Statistical Optimization of the Process Variables Applying Response Surface Methodology (RSM) Design

Levan is a homopolysaccharide of fructose units that repeat as its structural core. As an exopolysaccharide (EPS), it is produced by a great variety of microorganisms and a small number of plant species. The principal substrate used for levan production in industries, i.e., sucrose, is expensive and, hence, the manufacturing process requires an inexpensive substrate. As a result, the current research was designed to evaluate the potential of sucrose-rich fruit peels, i.e., mango peels, banana peels, apple peels, and sugarcane bagasse, to produce levan using Bacillus subtilis via submerged fermentation. After screening, the highest levan-producing substrate, mango peel, was used to optimize several process parameters (temperature, incubation time, pH, inoculum volume, and agitation speed) employing the central composite design (CCD) of response surface methodology (RSM), and their impact on levan production was assessed. After incubation for 64 h at 35 °C and pH 7.5, the addition of 2 mL of inoculum, and agitation at 180 rpm, the highest production of levan was 0.717 g/L of mango peel hydrolysate (obtained from 50 g of mango peels/liter of distilled water). The F-value of 50.53 and p-value 0.001 were calculated using the RSM statistical tool to verify that the planned model was highly significant. The selected model's accuracy was proven by a high value (98.92%) of the coefficient of determination (R²). The results obtained from ANOVA made it clear that the influence of agitation speed alone on levan biosynthesis was statistically significant (p-value = 0.0001). The functional groups of levan produced were identified using FTIR (Fourier-transform ionization radiation). The sugars present in the levan were measured using HPLC and the levan was found to contain only fructose. The average molecular weight of the levan was 7.6 × 10⁶ KDa. The findings revealed that levan can be efficiently produced by submerged fermentation using inexpensive substrate, i.e., fruit peels. Furthermore, these optimized cultural conditions can be applied on a commercial scale for industrial production and commercialization of levan.

Interleukin-6 (IL-6) as a Predictor of Clinical Outcomes in Patients with COVID-19

BACKGROUND

Interleukin-6 (IL-6) has been known to be involved in immune regulation, inflammatory response, and metabolism. It is also recognized as the major cause to underscore the pathology of severe COVID-19 patients. However, it remains to be seen if IL-6 is superior to other inflammatory biomarkers in ascertaining clinical severity and mortality rate for COVID-19. This study aimed to determine the value of IL-6 as a predictor of severity and mortality in COVID-19 patients and compare it with other pro-inflammatory biomarkers in the South Asian region.

METHODS

An observational study was conducted, including all adult SARS-CoV-2 patients who had undergone IL-6 testing from December 2020 to June 2021. The patients' medical records were reviewed to collect demographic, clinical, and biochemical data. Other pro-inflammatory biomarkers apart from IL-6 included Neutrophils to Lymphocyte Ratio (NLR), D-dimer, C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procal-citonin for analysis. SPSS version 22.0 was utilized.

RESULTS

Out of the 393 patients who underwent IL-6 testing, 203 were included in the final analysis with a mean (SD) age of 61.9 years (12.9) and 70.9% (n = 144) were male. Fifty-six percent (n = 115) subjects had critical disease. IL-6 levels were elevated (> 7 pg/mL) in 160 (78.8%) patients. Levels of IL-6 significantly correlated with age, NLR, D-dimer, CRP, ferritin, LDH, length of stay, clinical severity, and mortality. All the inflammatory markers were significantly increased in critically ill and expired patients (p < 0.05). The receiver operator curve showed that IL-6 had the best area under the curve (0.898) compared to other pro-inflammatory biomarkers for mortality with comparable results for clinical severity.

CONCLUSIONS

Study findings show that though IL-6 is an effective marker of inflammation and can be helpful for clinicians in recognizing patients with severe COVID-19. However, we still need further studies with larger sample size.

GRADE-ADOLOPMENT of clinical practice guideline for postmenopausal osteoporosis management-a Pakistani context

Due to its high prevalence, we aimed to create postmenopausal osteoporosis clinical practice guideline via GRADE-ADOLOPMENT for Pakistan. We recommend a higher dose (2000-4000 IU) of vitamin D for osteoporotic patients who are old, have malabsorption, or are obese. The guideline will help standardize care provision and improve health care outcomes for osteoporosis.

PURPOSE

Postmenopausal osteoporosis affects one in every five postmenopausal women in Pakistan. An evidence-based clinical practice guideline (CPG) is needed to standardize care provision to optimize health outcomes. Hence, we aimed to develop CPG for the management of postmenopausal osteoporosis in Pakistan.

METHODS

The GRADE-ADOLOPMENT process was used to adopt (as is or with minor changes), exclude (omit), or adapt (modify based on local context) recommendations to the source guideline (SG)-clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update from American Association of Clinical Endocrinology (AACE).

RESULTS

The SG was "adoloped" to cater to the local context. The SG consisted of 51 recommendations. Forty-five recommendations were adopted as is. Due to unavailability of drugs, 4 recommendations were adopted with minor changes, and one was excluded, while one recommendation was adopted with the inclusion of use of a surrogate FRAX tool specific for Pakistan. One recommendation regarding vitamin D dosage was adapted to recommend a dose of 2000-4000 IU of vitamin D in patients with obesity, malabsorption, and old age.

CONCLUSION

The developed Pakistani postmenopausal osteoporosis guideline consists of 50 recommendations. The guideline created recommends a higher dose (2000-4000 IU) of vitamin D for patients who are old, have malabsorption, or are obese, which is an adaptation from the SG by the AACE. This higher dose is justified as lower doses prove to be suboptimal in these groups and should be complemented with baseline vitamin D and calcium levels.

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.

L-2 hydroxyglutaric aciduria- review of literature & case series

L-2-hydroxyglutaric aciduria (L2HGA) is an autosomal recessive, slowly progressive neurodegenerative disease characterized by psychomotor delay and cerebellar dysfunction. The biochemical hallmark is increased concentrations of L2HG in body fluids. Brain MRI exhibits characteristic centripetal extension of the white matter involvement that differentiates it from other leukodystrophies. The authors report two sisters from Pakistan with L2HGA with 4 years of follow-up. The authors have also compared the clinical outcome of our patients with 45 previously reported patients with L2HGA for whom treatment and clinical outcome was reported.

Case presentation

The authors report two sisters with L2HGA from Pakistan born to consanguineous parents. The 15- and 17-year-old girls presented with psychomotor delay, seizures, ataxia, intentional tremors, and dysarthria. Both had normal anthropometric measurements for age. Exaggerated tendon reflexes and bilateral sustained ankle clonus were observed in addition to cerebellar signs. Urine organic acids analysis showed marked excretion of 2-hydroxyglutaric acid, chiral differentiation of 2-hydroxyglutaric acid showed it to be L2HGA. Brain MRI of the 15-year-old showed diffuse subcortical white matter changes evident by T2/FLAIR hyperintense signals bilaterally, particularly in the frontal region in the centripetal distribution with some diffusion restriction along involvement of globus pallidus. The characteristic MRI pattern raised the suspicion of L2HGA. Targeted L2HGDH sequencing identified a homozygous pathogenic variant, c.829C>T (p.Arg227*) in L2HGDH gene in both girls. Both parents were heterozygous carriers of the familial variant.

Conclusion

Neuroradiological features of centripetal subcortical leukoencephalopathy with basal ganglia and dentate nuclei involvement are rather specific to L2HGA and should lead to further biochemical investigations to look for L2HGA and L2HGDH gene sequencing.

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.