Seed biopriming with Ochrobactrum ciceri mediated defense responses in Zea mays (L.) against Fusarium rot

Seed bio-priming is a simple and friendly technique to improve stress resilience against fungal diseases in plants. An integrated approach of maize seeds biopriming with Ochrobactrum ciceri was applied in Zn-amended soil to observe the response against Fusarium rot disease of Zea mays (L.) caused by Fusarium verticillioides. Initially, the pathogen isolated from the infected corn was identified as F. verticillioides based on morphology and sequences of the internally transcribed spacer region of the ribosomal RNA gene. Re-inoculation of maize seed with the isolated pathogen confirmed the pathogenicity of the fungus on the maize seeds. In vitro, the inhibitory potential of O. ciceri assessed on Zn-amended/un-amended growth medium revealed that antifungal potential of O. ciceri significantly improved in the Zn-amended medium, leading to 88% inhibition in fungal growth. Further assays with different concentrations (25, 50, and 75%) of cell pellet and the cultural filtrate of O. ciceri (with/without the Zn-amendment) showed a dose-dependent inhibitory effect on mycelial growth of the pathogen that also led to discoloration, fragmentation, and complete disintegration of the fungus hyphae and spores at 75% dose. In planta, biopriming of maize seeds with O. ciceri significantly managed disease, improved the growth and biochemical attributes (up to two-fold), and accelerated accumulation of lignin, polyphenols, and starch, especially in the presence of basal Zn. The results indicated that bioprimed seeds along with Zn as the most promising treatment for managing disease and improving plant growth traits through the enhanced accumulation of lignin, polyphenols, and starch, respectively.

Dysphagia and obstructive sleep apnoea in post-extubated intensive care unit patients

OBJECTIVE

To determine the relationship between dysphagia and obstructive sleep apnoea and its association with age, gender and Glasgow Coma Scale in post-extubated patients in an intensive care setting.

METHODS

The correlational study was conducted from July 1 to October 31, 2021, at the intensive care unit of Evercare Hospital, Lahore, Pakistan, and comprised post-extubated patients of either ender aged 45-70 years within 72 hours following extubation and having Glasgow comma scale score 11-15. Gugging Swallowing Screen and Obstructive Sleep Apnoea questionnaires were used for data collection. Data was analysed using SPSS 25.

RESULTS

Of the 29 patients with a mean age of 57.45±8.74 years, 18(62.1%) were males. There was a significant correlation between dysphagia and obstructive sleep apnoea (p=0.005). The Obstructive Sleep apnoea score had a significant negative correlation with Glasgow Coma Scale score (p=0.01), while dysphagia revealed a significant positive correlation (p<0.001) with Glasgow Coma Scale score. Age and gender had no significant association with either dysphagia or obstructive sleep apnoea (p>0.05).

CONCLUSIONS

There was a significant correlation between dysphagia and obstructive sleep apnoea in post-extubated patients under intensive care. Both dysphagia and obstructive sleep apnoea had a significant correlation with Glasgow Coma Scale score.

ENSEAL® Hemorrhoidectomy, a Novel Technique, Versus Conventional Open Method for the Management of Grade III and IV Hemorrhoids

Background

Surgical removal of hemorrhoids is the gold-standard treatment for symptomatic grade III and IV hemorrhoid disease. There are numerous ways the hemorrhoidectomy surgical procedure is done but the most effective and least painful way is still to be elucidated.

Objective

To compare the outcomes of ENSEAL® (Ethicon, Inc., Raritan, USA) versus gold standard Milligan-Morgan hemorrhoidectomy in patients presenting with grade-III and IV hemorrhoids

Materials and methods

After ethical approval, the Randomized Controlled Trial was conducted at the Department of Surgery, Unit III, Lahore General Hospital, Lahore, Pakistan, between January 2020 and January 2022. In this study, 140 patients who met the inclusion criteria were recruited after informed consent. Patients were split randomly into two equal groups using a lottery technique. In group A, hemorrhoidectomy was carried out with ENSEAL®, whereas in group B, open hemorrhoidectomy was performed by the Milligan-Morgan method. the surgery duration and blood loss were noted. After the operation, patients were transferred to and discharged from the post-anesthesia recovery room. Patients were further followed up for pain scores after 24 hours. Data was analyzed by using Statistical Package for Social Sciences (SPSS) v25 (IBM Corp., Armonk, USA). Data was categorized for age, gender, body mass index (BMI), degree of hemorrhoids, and duration of hemorrhoids. A p-value <0.05 was considered significant.

Results

140 patients were included in this study. Group A patients underwent ENSEAL® hemorrhoidectomy, and group B was formed from those who underwent the Milligan-Morgan procedure. In group A, there were 41 (58.5%) males and 29 (41.4%) females, while in group B, there were 43 (61.4%) males and 27 (38.5%) females. The mean age of group A patients was 49.97 ± 7.36 years and 43.2 ± 8.01 years in group B. In group A, the mean operative time was 20.87 ± 3.05 min, while 27.10 ± 3.42 min in group B, which is statistically significant with a p-value of <0.001. In group A, mean blood loss was 9.79 ± 2.87 ml, while 13.36 ± 3.73 ml in group B, which is statistically significant with a p-value of <0.001. In group A, the mean pain score was 2.7 ± 1.08, while 3.34 ± 1.16 in group B, which is statistically significant with a p-value of <0.001.

Conclusion

When considering the length of the procedure and blood loss, ENSEAL® hemorrhoidectomy has been determined to be an effective treatment that the patients tolerated well. Therefore, ENSEAL® hemorrhoidectomy can be a safe and efficient alternative to conventional treatment for hemorrhoids that are causing symptoms.

163 Anterior Sacral Meningocystocele Manifesting as Vague Gastrointestinal and Urinary Syndromes – Two Case Reports

Aim

Anterior Sacral Meningocystocele (ASM) carries a unique place in the current literature regarding its rarity. The condition arises in association with a congenital defect of the sacrum and coccyx through which the caudal part of the meninges may herniate to form a cyst-like structure. The disorder derives from a genetic defect of the coccyx and sacrum of which some meningeal segments protrude or herniate, forming a cyst-like entity.

Method

We report two cases of ASM. The first is a 65-year-old male with active complaints of urinary retention and hesitancy for two weeks and chronic constipation associated with lower back pain. The second, a 17-year-old girl, was presenting with abdominal bloating, pain, and backache. Magnetic resonance imaging (MRI) of the pelvis and lumbosacral spine was conducted for both patients, respectively, each scan exhibiting evidence of ASM development. Surgical correction and closure of the ASM's were performed via a posterior midline approach, which successfully alleviated the symptoms presented clinically by both patients.

Conclusions

ASM may develop asymptomatically, often with incidental discovery. Although ASM is well-regarded as a rare anomaly, diagnosis of such a defect must always be kept pertinent when a cystic structure in the pelvis is unveiled on ultrasound or during surgery. Puncture or aspiration of the cyst should be avoided if the diagnosis is in doubt. A posterior midline approach with careful obliteration of the meningocele sac opening may be curative.

Content of Serious Illness Care conversation documentation is associated with goals of care orders-a quantitative evaluation in hospital

Background

The Serious Illness Care Program (SICP) increases quality of documentation about patients’ values and priorities, but it is not known whether patient characteristics and goals of care are associated with the elements documented. The purpose of this study was to explore for associations between the quantity and type of elements documented after SICP conversations with patient characteristics and goals of care order.

Methods

Documentation of SICP conversations by internal medicine physicians with hospitalized patients was evaluated in a retrospective chart review between March 2018 to December 2019. The conversations occurred after SICP implementation in a Tertiary Hospital, Medical teaching unit which uses “Goals of Care Designation” (GCD) medical orders to communicate a patient’s general intent, specific interventions, and preferred locations of care. A validated SICP codebook was used to determine the frequency of conversation elements documented for (1) Goals and Values; (2) Prognosis/illness understanding; (3) End-of-life care planning and (4) GCD/Life-sustaining treatment preferences. Univariate and multivariate generalized linear models were used to analyze associations between quantity of elements documented and patient characteristics (age, gender, frailty, language spoken and GCD).

Results

Of 175 SICP conversations documented, in the univariate analysis more goals and values were documented for patients who understand/speak English (0.89; 95% CI: 0.14 - 1.63) and more content was recorded for patients with a non-resuscitative GCD focus (“Medical”: 2.42; 95% CI: 1.51 – 3.33; “Comfort”: 1.06; 95% CI: 0.24 – 1.88) although not in all domains. In the multivariate analysis, controlling for age, gender, language and frailty, the association between content scores and GCD remained highly significant. Patients with a non-resuscitative GCD had higher total domain scores than those with a resuscitative GCD (“Medical”: 1.27 95% CI: 0.42–2.13; “Comfort”: 2.67, 95% CI:1.71–3.62).

Conclusion

The type of content documented by physicians after a SICP conversation is associated with the patient’s goals of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01006-2.

Frequency and Culture Sensitivity for Bacteremia During Febrile Neutropenia in Children with Acute Lymphoblastic Leukemia. Do Age and Gender Matter?

Objectives: To determine the frequency of bacteremia and its association with age and gender in febrile neutropenic children suffering from acute lymphoblastic leukemia and identify the commonest pathogens and their antibiotic susceptibility identified on blood cultures. Study Design: Cross-sectional analytical study Place and Duration of Study: Pediatrics Inpatient Department, Shifa International Hospital, Islamabad Pakistan, from Sep 2018 to Mar 2019. Methodology: Children with acute lymphoblastic leukemia aged 1-12 years, presenting with temperature >100ºF and absolute neutrophil count of <500 cells/µL were enrolled. An automated blood culture system was used and Clinical and Laboratory Standards Institute Guidelines 2017 were used for susceptibility testing. Antibiotics were started empirically in all cases and changed after susceptibility testing. Results: A total of 62 children were enrolled. The mean age was 8.6 ± 2.4 years. Majority of the children i.e., 32 (51.6%) were females. The frequency of bacteremia was 16 (25.8%) and there was no significant association with age or gender (p=0.475 and p=0.881 respectively). Majority of the isolates were gram-positive. The organism isolated in the highest frequency was Methicillin-Resistant Staphylococcus Epidermidis (MRSE) 5 (31.25%). Susceptibility to Vancomycin was present in 10 isolates while seven isolates were sensitive to penicillins/cephalosporins. Conclusion: Bacteremia, primarily caused by gram-positive bacteria was found in 25.8% of our sample and was uninfluenced by age or gender. MRSE was the most frequent isolate. The bacterial isolates were susceptible primarily to vancomycin and penicillins/cephalosporins.

POS0208 STRESS AT HOME IS COMMON AND HAS SIGNIFICANT ASSOCIATION WITH MARITAL STATUS, HIGHER DISEASE ACTIVITY, COMORBIDITIES, AND WORSE QUALITY OF LIFE AMONG PATIENTS WITH RHEUMATOID ARTHRITIS: SINGLE CENTRE RESULTS FROM THE PRIME REGISTRY COHORT

Background

In chronic inflammatory diseases like rheumatoid arthritis (RA), psychological stress is widely recognised as an important risk factor to negatively affect the disease course. Perceived stress can potentially induce the disease exacerbation, but on the other hand, the disease itself might produce significant stress to patients thus the vicious circle is formed and maintained.

Objectives

We aimed to examine the prevalence of mental/emotional stress at home and its associations among patients with Rheumatoid arthritis. We addressed this question using real-world data from the PRIME registry.

Methods

This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. The PRIME Registry is a large, independent, prospective, observational cohort initiated in October 2019 that comprises patients diagnosed with RA, SLE, PsA or AS by a rheumatologist, and is being actively followed up. IRB approval and informed consent was obtained. We assessed the data for RA patients. The clinical variables studied were gender, age, smoking habits, body mass index, education status, marital status, disease duration, comorbidities (using Charlson Comorbidity Index). Education status was stratified by whether participants completed secondary (high) school education. The SF-12 Physical Component Score (PCS-12) and Mental Component Score (MCS-12) was also measured. Evaluation of disease activity and severity was made as per internationally agreed definitions, such as: swollen joint counts, tender joint counts, deformed joint counts, and DAS-28. All participants were directly inquired at the interview during the time of patient enrolment about the presence or otherwise of mental/emotional stress at home, and to rate it from 1-3 (mild, moderate, severe). For better understanding and ease of statistical analysis, dichotomous variable was made with moderate-to-severe stress patients were categorised into one group and none-to-mild stress patients into second group.

Results

The data from consecutive 1016 RA patients (mean age 40.8±13 years, 78.6% female, disease duration of 65±67 months) was reviewed. Forty-nine percent of patients accepted to have moderate-severe stress at home. Female gender (p=0.003), low education status (p=0.050), being unmarried (p=0.051), and MCS, PCS, CCI (p<0.001) were associated with moderate-severe stress. However, no statistical association of age and disease duration was noted. On univariate analysis, significant association of moderate-severe stress at home was noted with deformed joint counts (p=0.003), higher DAS-28 scores (p<0.001), low education status (p=0.02) and being married (p<0.001). Weak statistical association of age (p=0.30), disease duration (p=0.12), low education status (p=0.14), female gender (p=0.24) was noted. On multiple logistic regression analysis, a significant association of moderate-severe stress at home was observed with higher DAS-28 scores (OR 2.38, CI 2.00-2.84, p<0.001), MCS-12 (OR 0.65, CI 0.61-0.69, p<0.001), comorbidities-CCI (OR 1.41, CI 1.15-1.74, p=0.001) and being unmarried (OR 0.55, CI 0.36-0.83, p=0.005). The final regression model resulted in a statistically significant improved association/prediction of worse moderate-severe stress at home (R square=71%). Following variables were included in multiple stepwise regression analysis: age, disease duration, gender, education status, marital status, comorbidities index, major trauma/stress in last one year, DAS-28, MCS-12 and PCS-12 scores.

Conclusion

Nearly half of the cohort was noted to have moderate-severe level of stress at home, and is associated with important adverse clinical outcomes. These findings demonstrate an important need for integration of rheumatologic, social workers and mental health services

Disclosure of Interests

Muhammad Haroon Speakers bureau: Novartis, Abbvie, Pfizer, Roche, Grant/research support from: Abbvie, Sadia Asif: None declared, Saadat Ullah: None declared, Farzana Hashmi: None declared, Saba Javed: None declared

POS0574 FEMALE GENDER AND STRESS ARE MAIN DETERMINANTS OF NON-ADHERENCE AND NEGATIVE ILLNESS PERCEPTION AMONG PATIENTS WITH RHEUMATOID ARTHRITIS: SINGLE CENTRE RESULTS FROM THE PRIME REGISTRY COHORT

Background

Adherence to medications among patients with RA is traditionally considered to be low. Little is known about the indicators and the outcomes of patients having good adherence to medications among Pakistani RA patients.

Objectives

We aimed to assess the level of non-adherence and its associations with clinical indicators and outcomes using validated measures in a large consecutive Pakistani RA population. Moreover, we measured illness perception using additional validated tools to help us better understand this concept.

Methods

This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. IRB approval and informed consent was obtained. The clinical variables studied were gender, age, smoking habits, body mass index, education status, marital status, disease duration, Charlson Comorbidity Index. Education status was stratified by whether participants completed secondary (high) school education. Evaluation of disease activity and severity was made as per internationally agreed definitions. To measure adherence, the instrument used in the study was the Urdu version of the General Medication Adherence Scale (GMAS), which has been validated for RA patients. Brief Illness Perception Questionnaire (BIPQ) is the simplified version of the Illness Perception Questionnaire (IPQ). BIPQ is a nine-item scale designed to rapidly assess the cognitive and emotional representations of illness. To facilitate interpretation of results in daily clinical practice and to identify patients with the most negative illness perception, we dichotomized the BIPQ scores using the 75th interquartile range score as cutoff, as previously done.

Results

The data of consecutive 320 RA patients enrolled in PRIME registry (mean age 37.4±13.4 years, 74% female, disease duration of 73±68 months, 30% rural residents, 32.5% had low education status of ≤primary school, and 35% of the cohort was employed) was reviewed. Thirty six percent of the cohort (n=116) was noted to have non adherence. On multiple logistic regression analysis, a significant association of moderate-severe stress (OR 1.85, CI 1.04-3.2, p=0.03), DAS-28 scores (OR 1.83, CI 1.52-2.21, p<0.001), HAQ scores (OR 1.77, CI 1.07-2.92, p=0.02), deformed joint counts (OR 1.30, CI 1.15-1.46, p<0.001). We further examined the concept of non-adherence among our cohort across three domains or components of GMAS questionnaire individually. Firstly, on multivariate regression analysis showed that non-adherence due to patient behavior had significant association with male gender (OR 0.48, p=0.01), unemployment (OR 1.82, p=0.02), stress (OR 2.17, p=0.001), DAS-28 (OR 1.15, p=0.050), worse HAQ scores (OR 1.83, p=0.005). Secondly, multivariate regression analysis showed that non-adherence due to comorbidity and pill burden was associated with age of onset of arthritis (OR 1.02, p=0.006), DAS-28 (OR 1.18, p=0.03), and HAQ (OR 1.81, p=0.008). Thirdly, multivariate regression analysis showed that cost-related non-adherence had no significant association with patient related demographics and traits, but was noted to have significant association with worse DAS-28 and HAQ scores. The mean total BIPQ score of the cohort was 62±8.8. Twenty six percent of the cohort (n=86) was noted to have the most negative illness perception (BIPQ score of >68). On multiple logistic regression analysis, a significant protective association of male gender (OR 0.24, CI 0.11-0.53, p<0.001) and age of onset of arthritis (OR 0.96, CI 0.94-0.99, p=0.01), along with significant association of worse HAQ scores (OR 3.7, CI 2.2-6.1, p<0.001) was noted with the most negative illness perception.

Conclusion

Non-adherence is common and its main determinants were female gender and stress, along with associated adverse clinical outcomes. Gender-based discrimination in low socioeconomic states along with associated stress is a plausible explanation.

Disclosure of Interests

Farzana Hashmi: None declared, Muhammad Haroon Speakers bureau: Novartis, Roche, Abbvie, Pfizer, Grant/research support from: Abbvie, Pfizer, Sadia Asif: None declared, Saadat Ullah: None declared, Saba Javed: None declared.

Association Between Low Back Pain and Body Mass Index in Pakistani Population: Analysis of the Software Bank Data

Background: Obesity is a growing public health concern and is one of the leading causes of human suffering and disability worldwide. The number of overweight and obese people is dramatically increasing, and local data showed that low back pain (LBP) is more common in people with obesity, prolonged sitting jobs, psychological disorders, and lack of exercise.

Methods: This study was conducted in a cohort of 300 adult patients of either gender who visited a pain management clinic with LBP. Patient data were retrieved from the hospital software program and recorded in a pre-designed proforma. The data included the patient’s age, gender, weight, height, BMI, comorbidities, site of pain, duration of pain, distribution of pain, severity of pain, history of spinal trauma, previous spinal surgery, and working diagnosis.

Results: Out of 300 patients with LBP, 185 (61.7 %) were female and 115 (38.3%) were male, of these, 224 (74.6%) were overweight or obese. One hundred and three (34.3%) had axial back pain and 197 (65.7%) patients had lumbar radicular pain. Linear regression analysis showed that 17% variability in pain scores in both genders can be explained by the increase in BMI. There is a statistically significant relationship, i.e. P=0.0005, exists between pain score and BMI.

Conclusion: This study showed the strong association between obesity and LBP in the Pakistani population. Approximately, 75% were overweight or obese in our LBP population-based cohort and this association was stronger among women than men.

Associations between serum triglycerides and abdominal aortic calcification in a cross-sectional study from the United States of America

Background

Abdominal aortic calcification (AAC) has recently been recognised as a risk factor for cardiovascular disease, as it shares pathophysiological mechanisms with coronary artery disease.

Purpose

We investigated relationships between AAC and traditional cardiovascular risk factors in a cross-sectional epidemiological cohort from the USA

Methods

We used data from the National Health and Nutrition Evaluation Survey (NHANES) from the years 2103–2014. Dual-energy X-ray absorptiometry (DXA scans) were performed for a subset of 3140 NHANES participants over the age of 40. The images were scored according to ACC-24, a 24-point scale.

We performed binary logistic regression to investigate relationships between demographic variables (age, sex, poverty income ratio, & educational status) CV risk factors (triglycerides (fasting, and non-fasting) LDL-C, HDL-C systolic blood pressure, body mass index, smoking status & diabetes) medicine use (statins, antihypertensives and antiplatelets) and AAC status (patients with a score ≥2 on the 24-point scale were considered AAC positive). Non normally-distributed variables were categorised for the purposes of analysis.

Results

Participants with AAC were older (mean 65.5 years ± SD 11.7) than unaffected individuals (56.1±11.1) AAC was also associated with higher BMI (28.7±5.8 v. 27.6±4.8 kg/m2), and higher systolic blood pressure (131.3±19.5 v 125.8±18.4 mmHg).

We found a strong relationship between plasma triglyceride concentrations and AAC. In univariate analysis, fasting triglycerides above the first quartile were associated with approximately double the risk of AAC, compared to those in the first quartile (see table). This relationship persisted when the analysis was adjusted for demographics, risk factors and medicine use. A similar pattern was seen with non-fasting triglycerides (see table).

Conclusions

We found a strong relationship between triglycerides and AAC. Further work is required to determine whether this observation can be validated in other cohorts, and whether interventions to reduce triglyceides can alter the progression of AAC.

Funding Acknowledgement

Type of funding sources: None. Odds ratios (95% CI) for AAC

191 Improving Consent and Legibility in Orthopaedic Surgery Through Introducing Pre-Populated Stickers

Aim

Incomplete informed consent can lead to patient dissatisfaction and litigation.1 Time constraints, legibility, human error, limit completion of consent forms, putting surgeons and trusts at risk of litigation.2 The aim of this project was to assess legibility and completeness of handwritten consent forms, with the objective to improve legibility to 100% and risks listed to 100% of those endorsed by the British Orthopaedic Association (BOA).3

Method

An initial baseline study in multiple hospitals across the UK identified 113 patients who underwent hemiarthroplasties. The consent forms were assessed for legibility and risks included, compared to those listed by the BOA. Pre-populated risks stickers were introduced in 1 district general hospital (DGH) and 2 cycles repeated again (62 patients identified).

Results

Overall, 35% of consent forms 1 were illegible; 100% of the time in the risks section. Mean number of risks missing was 2.34 and most frequently missed risk was ‘death’ (missing on 35.5% of consent forms). In the DGH that introduced stickers, consent forms were 100% legible and 100% compliant to the standards set by the BOA when the stickers were used. However, sticker use remained low; only used 20% of the time in the second cycle, marginally increased from the previous cycle (18%).

Conclusions

A high proportion of consent forms are not completed to BOA standards and are illegible. Pre-populated stickers could aid in achieving 100% legibility and 100% risk inclusion. The stickers will be implemented in other trusts and methods to increase compliance with sticker use will be trialled.

O44 Gender bias and sexual discrimination in orthopaedics: time for change

Introduction

Gender bias and sexual discrimination (GBSD) have been widely recognized across a range of fields and are now part of the wider social consciousness. Such conduct can occur in the medical workplace, with detrimental effects on recipients. The aim of this review was to identify the prevalence and impact of GBSD in orthopaedic surgery, as well as mitigating strategies.

Method

A systematic review was conducted by searching Medline, EMCARE, CINAHL, PsycINFO, and the Cochrane Library Database. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Original research papers pertaining to the prevalence and impact of GBSD, or mitigating strategies, within orthopaedics were reviewed.

Result

Of 570 papers, 27 were eligible for inclusion. These were published between 1998 and 2020. 13 papers discussed the prevalence of GBSD, 13 related to the impact of these behaviours, and six discussed mitigating strategies. GBSD was found to be common in the orthopaedic workplace, with all sources showing women to be the subjects. Effects include poor workforce representation, lower salaries, and less career success for women in orthopaedics. Mitigating strategies in the literature are focused on providing female role models, mentors, and educational interventions.

Conclusion

GBSD is common in orthopaedic surgery, with a substantial impact on sufferers. A small number of mitigating strategies have been tested but these are limited in their scope. As such, the orthopaedic community is obliged to participate in more thoughtful and proactive strategies that mitigate against GBSD, by improving female recruitment and retention within the specialty.

Take-home Message

Gender bias and sexual discrimination remain common within orthopaedics. The international orthopaedic community is obliged to do more to tackle this problem.

Synthesis and evaluation of coastal and marine biodiversity spatial information in the United Arab Emirates for ecosystem-based management

The United Arab Emirates (UAE) host valuable coastal and marine biodiversity that is subjected to multiple pressures under extreme conditions. To mitigate impacts on marine ecosystems, the UAE protects almost 12% of its Exclusive Economic Zone. This study mapped and validated the distribution of key coastal and marine habitats, species and critical areas for their life cycle in the Gulf area of the UAE. We identified gaps in the current protection of these ecological features and assessed the quality of the data used. The overall dataset showed good data quality, but deficiencies in information for the coastline of the north-western emirates. The existing protected areas are inadequate to safeguard key ecological features such as mangroves and coastal lagoons. This study offers a solid basis to understand the spatial distribution and protection of marine biodiversity in the UAE. This information should be considered for implementing effective conservation planning and ecosystem-based management.

Effect of necrotrophic fungus and PGPR on the comparative histochemistry of Vigna radiata by using multiple microscopic techniques

Rapid advances in the field of pathogen detection have opened new opportunities and better understanding for their management approaches. Aim of this study was to elucidate histopathological observations of different tissues affected by Macrophomina phaseolina and to observe the defense responses of plant growth promoting rhizobacteria (PGPR) in mungbean plants. Sections of the stem and root were prepared and stained with ferric chloride, Lugol's iodine and Wiesner's reagent and were then observed under multiple microscopic techniques. Results revealed that both pathogen and PGPR produce responses on the plant that include colonization of xylem vessels by hyphae and sclerotia, hypertrophy and hyperplasia of the cells, destruction of xylem fibers and amyloplasts in parenchymatous cells; and production of gels by the plant were observed. There was a significant increase in lignin and phenolic compounds deposition in stem and root sections of PGPR treated and non-treated mungbean plants. Whereas the soil amended with PGPR showed very less to no starch production. Moreover, production of gels and gums were also observed in both stem and root sections. Compared to light microscopy, scanning electron microscope provided greater depth of focus and resolution of the pathogen attack on plant tissues, associated bacteria. As a whole, the data demonstrated that inoculation of PGPR can be an effective strategy to stimulate plant growth and they could significantly activate disease resistance against M. phaseolina.

988 The Prevalence and Incidence of Gender Bias and Sexual Discrimination in Orthopaedics, and Mitigating Strategies: A Systematic Review

Background

The aim of this systematic review was to outline the prevalence and impact of Gender bias and sexual discrimination (GBSD) in orthopaedics, and to investigate interventions countering such behaviours.

Method

Original research papers pertaining to the prevalence and impact of gender bias or sexual discrimination, or mitigating strategies in orthopaedics, were suitable for inclusion. PRISMA guidelines were adhered to in this review.

Results

Of 570 papers, 27 were eligible for inclusion. A total of 13 papers discussed the prevalence of GBSD, whilst 13 related to the impact of these behaviours, and 6 discussed mitigating strategies. GBSD were found to be prevalent in the orthopaedic workplace, with all sources showing females to be the victims. The impact of GBSD includes poor workforce representation, lower salaries, barriers to career progression, and reduced academic output for females in orthopaedics. Mitigating strategies in the literature are focussed on encouraging females to apply for orthopaedic training programmes, by providing female role models, mentors, and educational interventions.

Conclusions

GBSD are highly prevalent in orthopaedic surgery, impacting females at all stages of their careers. Mitigating strategies have been tested but are limited in their scope. As such, the orthopaedic community as a whole is obliged to do more to tackle GBSD.

Muslim perspectives on advance care planning: a model for community engagement

Background:

Advance care planning is the process of communicating and documenting a person’s future health care preferences. Despite its importance, knowledge of advance care planning is limited, especially among the Islamic community. In addition, little is known about how the Islamic community views advance care planning in the context of their religious and cultural beliefs.

Objectives:

We aimed to increase knowledge of the importance of advance care planning, to improve health care provider and public knowledge, and to encourage dialogue between the community and health care providers.

Methods:

We organized a community event and assembled a multi-disciplinary panel. Through a moderated discussion, the panel members offered their perspectives of advance care planning within a Muslim context.

Results:

Approximately 100 individuals attended the event including community members, health care providers, medical students, and faith leaders. More than 90% of respondents rated the event as very good or excellent, found the session useful and were encouraged to reflect further on advance care planning.

Conclusion:

This event was successful in raising awareness about advance care planning within the Islamic community as well as educating health care providers on Islamic views. This model of community and health care provider engagement may also be beneficial for other faith groups wishing to discuss advance care planning within their respective religious and cultural contexts.

Rising resistance of urinary tract pathogens in children: a cause for concern

BACKGROUND

Urinary tract infection (UTI) is one of the common infections in childhood. Prompt diagnosis and treatment reduces the risk of complications. The choice of antibiotic to treat UTI varies from region to region. Rational use and appropriately chosen antibiotic reduces the emergence of resistant uropathogens.

OBJECTIVE

We investigated the resistance pattern of uropathogens for commonly used antibiotics to treat UTI locally.

METHODS

Data was collected between 2009 and 2019 on all infants and children under 16 years of age with culture proven UTI. Results were compared with previously published figures between 2002 and 2008.

RESULTS

A total of 1002 samples were analysed (91/year). Male to female ratio was 1:4.6. About 94% of the samples grew E. coli. As before, high resistance rates were recorded to Amoxicillin and Trimethoprim (Z = -0.325: P = 0.7452; not significant). Overall, average resistance has decreased for Nitrofurantoin from 10% between 2002 and 2008 to 5.84% between 2009 and 2019 (Z = 3.002: P = 0.0027). On the other hand, Cefalexin resistance has increased from 7.4 to 14.56% between the two study periods (Z = -4.2: P = < 0.0002).

CONCLUSION

Despite rising resistance rates, we recommend that Cefalexin should cautiously remain the antibiotic of choice for empirically treating uncomplicated urinary tract infections in secondary care pending urine culture. Nitrofurantoin should be reserved for treating non-coliform/atypical UTIs or multi-drug resistant UTIs. There is an ongoing need for clinicians in all geographic regions to continue to monitor antibiotic resistance rates every few years.

Urate Nephropathy from Tumor Lysis Syndrome in an Undiagnosed Case of Prostate Cancer

Prostate cancer can masquerade as just normocytic anemia and thrombocytopenia, thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), or tumor lysis syndrome (TLS). We are reporting an intriguing case of metastatic prostate cancer which remained undiagnosed until the patient showed signs of tumor lysis syndrome (TLS), leading to urate nephropathy requiring urgent hemodialysis. Tumor lysis syndrome is an oncological emergency but an exceedingly rare complication in non-hematological malignancies, including prostate cancer. It is challenging to recognize features of TLS in a case such as this with an unknown diagnosis. In the case of an established diagnosis of malignancy, however, checking baseline renal function, uric acid, lactate dehydrogenase (LDH), potassium, and phosphate to monitor for TLS as well as considering urate lowering therapy can help prevent adverse outcomes.

Diabetic peripheral neuropathy in people with type 2 diabetes: too little too late

Diabetic peripheral neuropathy in people with type 2 diabetes is poorly managed because of its insidious onset, delayed diagnosis and more complex aetiology resulting from the contribution of not only hyperglycaemia, but also ageing, hyperlipidaemia, hypertension and obesity. Because there is no US Food and Drug Adminstration-approved disease-modifying therapy for diabetic peripheral neuropathy, the key to ameliorating it in type 2 diabetes has to be through earlier diagnosis and timely multi-factorial risk factor reduction. The management of painful diabetic peripheral neuropathy also requires a detailed appraisal of the choice of therapy, taking into account efficacy, patient wishes, comorbidities, side effect profile and potential for abuse.

Varying Architecture of Heat Shock Elements Contributes to Distinct Magnitudes of Target Gene Expression and Diverged Biological Pathways in Heat Stress Response of Bread Wheat

The heat shock transcription factor (HSF) binds to cis-regulatory motifs known as heat shock elements (HSEs) to mediate the transcriptional response of HSF target genes. However, the HSF-HSEs interaction is not clearly understood. Using the newly released genome reference sequence of bread wheat, we identified 39,478 HSEs (95.6% of which were non-canonical HSEs) and collapsed them into 30,604 wheat genes, accounting for 27.6% wheat genes. Using the intensively heat-responsive transcriptomes of wheat, we demonstrated that canonical HSEs have a higher propensity to induce a response in the closest downstream genes than non-canonical HSEs. However, the response magnitude induced by non-canonical HSEs was comparable to that induced by canonical HSEs. Significantly, some non-canonical HSEs that contain mismatched nucleotides at specific positions within HSEs had a larger response magnitude than that of canonical HSEs. Consistently, most of the HSEs identified in the promoter regions of heat shock proteins were non-canonical HSEs, suggesting an important role for these non-canonical HSEs. Lastly, distinct diverged biological processes were observed between genes containing different HSE types, suggesting that sequence variation in HSEs plays a key role in the evolution of heat responses and adaptation. Our results provide a new perspective to understand the regulatory network underlying heat responses.

4119Predictors of progression of preclinical left ventricular diastolic dysfunction to clinical heart failure in patients with malignancy

Background

Preclinical diastolic dysfunction PDD is a well-known but poorly understood risk factor for clinical heart failure CHF. Preclinical diastolic dysfunction and predictors of progression of PDD to CHF in patients with malignancy has never been studied.

Purpose

The purpose of our study was to determine the incidence of CHF in cancer patients who have preexisting preclinical diastolic dysfunction, with a particular focus on identifying the risk factors contributing to progression of PDD to CHF.

Study design

We retrospectively sought all the patients who underwent echocardiography from 2003 to 2008 and were found to have preclinical diastolic dysfunction at our institution. PDD was defined as presence of grade I diastolic dysfunction, LVEF ≥50%, and free of clinical diagnosis of heart failure. Of these, only the patients who had a confirmed histopathological diagnosis of malignancy were included in the study. The end point was incidence of clinical heart failure, HFrEF and HFpEF. Multivariable adjusted Cox proportional hazards regression were performed to study the predictors of CHF.

Results

Out of 1086 patients with PDD and a histopathological diagnosis of malignancy, 208 patients were diagnosed with new onset CHF during the 10 years follow-up. Incidence of CHF, HFpEF and HFrEF was found to be 32.1 per 1,000 person-year, 13.9 per 1,000 person-year and 2.93 per 1,000 person-year respectively. Patients who developed clinical heart failure were found to have more hypertension, diabetes, myocardial infarction, peripheral vascular disease, pulmonary disease, renal disease, hematological malignancies and metastatic disease when compared to patients who did not develop heart failure. In multivariable adjusted Cox regression analysis, age at index date (HR 1.02, 95% CI 1.01–1.04, p=0.001), diabetes (HR 1.74, 95% CI 1.28–2.35, p<0.001), myocardial infarction (HR 2.19, 95% CI 1.49–3.20, p<0.001), lung disease (HR 1.53, 95% CI 1.14–2.06, p=0.004) and renal disease (HR 2.03, 95% CI 1.45–2.84, p<0.001) were independent predictors of CHF in patients with PDD and malignancy. Among chemotherapy agents, Vincristine, Ifosfamide, transtuzumab and Bortezomib were found to be associated with CHF.

Conclusion

This is the first study ever to report the incidence of CHF, HFrEF and HFpEF and identify a distinct set of predictors of heart failure in patients with PDD and malignancy. We estimated a much higher incidence of CHF (19%) in our study population, when compared to the general population with malignancy. Our study also depicted a significantly high incidence of HFpEF compared to HFrEF (8.3% vs 1.75%). Our study shows that patients with malignancy are at a significantly higher risk of developing heart failure if they have preexisting diastolic dysfunction. This emphasizes the importance of identifying patients with diastolic dysfunction and a more rigorous cardiovascular surveillance to prevent them from potential heart failure.

Acknowledgement/Funding

None

Retrospective cohort study of 925 OAGB procedures. The UK MGB/OAGB collaborative group

BACKGROUND

Mini-One Anastomosis Gastric Bypass is a new operation that provides comparable outcomes to the common bariatric procedures. Revisional surgery is still needed after a number of MGB-OAGB procedures. The aim of this study is to report the causes and management of these revisions.

METHODS

From 2010 to 2018, 925 MGB-OAGB operations were performed at 7 bariatric units across the United Kingdom and included in this retrospective cohort study. The data was retrospectively collected and analysed. The primary end point was the identification of the causes and management of revisions. Follow up ranged from 6 months to 3 years.

RESULTS

Twenty-two patients [2.3%] required revisional surgery after MGB-OAGB. Five patients [0.5%] developed severe diarrhoea managed by shortening the bilio-pancreatic limb to 150 cm. Four patients [0.4%] developed afferent loop syndrome and bile reflux was reported in another 3 [0.3%] cases; all were managed by either conversion to Roux en Y Gastric Bypass or a Braun anastomosis. Postoperative bleeding was controlled laparoscopically in 3 patients [0.3%]. Liver decompensation that was reported in 2 patients [0.2%] was treated by shortening the BPL in one patient and a reversal to normal anatomy in another. The liver failure resolved in both patients. Other indications for revision included two gastro-jejunal stenosis [0.2%], one perforated ulcer [0.1%], one patient [0.1%] with excessive weight loss and one case [0.1%] of protein malnutrition. None of the 22 patients undergoing revisional surgery after MGB-OAGB died. Lost to follow up rate was 0.2%.

CONCLUSION

Complications requiring revisional surgery after MGB-OAGB are uncommon [2.3%] and the majority can be managed by bilio-pancreatic limb shortening, the addition of a Braun side-to-side anastomosis or conversion to RYGB. Bilio-pancreatic limb length of 200 cm or more resulted in serious complications of liver failure, protein malnutrition, excessive weight loss and diarrhoea.

Subpectoral biceps tenodesis using a novel anterior cortical button technique

BACKGROUND

Various surgical treatments are described in the literature for biceps pathology.

METHOD

The techniques currently described for subpectoral tenodesis involve the use of suture anchors, interference screws, bicortical suture buttons or unicortical suture buttons.

RESULTS

A review of 31 patients with a subpectoral biceps tenodesis using the anterior cortical button technique is presented.

CONCLUSIONS

We describe a novel technique, which provides an opportunity to obtain a robust cortical and intramedullary tenodesis, performed under direct vision without the risk of drilling the far cortex and therefore avoiding any potential for neurological injury. There is no cortical implant, which may lead to a diaphyseal stress riser and subsequent fracture risk.

Should all acromioclavicular joint injections be performed under image guidance?

INTRODUCTION

Steroid and local anaesthetic injection to the acromioclavicular joint (ACJ) is a very common diagnostic and therapeutic procedure, which is often performed in the outpatient department. However, it can be difficult to localize this joint because of its small size, presence of osteophytes and variable morphology in the population. We performed a study to determine whether the use of an image intensifier (X-ray guidance), in theatre, improves the accuracy of this injection.

METHODS

This was a prospective study carried out between March 2014 and March 2015. The injections were performed by two senior orthopaedic surgeons. First, we clinically palpated the ACJ and marked the area over this point as A. Then, with the use of a needle and an image intensifier in a single plane, we identified the actual location of the ACJ and marked this point as B. We measured the distance between A and B in millimetres (mm) and determined the accuracy of the injections. Further analysis taking into account the ACJ capsular attachments was also performed.

RESULTS

In total, 45 patients and 50 injections were included in the study; five patients had repeated injections at different times. We found that only 12 injections (24%) were palpated to be correct with no discrepancies between A and B (95% confidence interval: 14-37%). For the remaining 38 injections (76%), the use of an image intensifier had significantly improved the accuracy of ACJ location ( p < 0.05). Taking the capsular attachments of the ACJ into consideration reduced the number of inaccurate injections to 27 (54%).

CONCLUSION

We recommend the use of an image intensifier (or ultrasound guidance) to accurately determine the location of the ACJ for steroid and local anaesthetic injections. This prevents an injection into the wrong place, which can lead to wrong diagnosis and/or suboptimal treatment.

Application of real-time quantitative polymerase chain reaction assay to detect Legionella pneumophila in patients of community-acquired pneumonia in a tertiary care hospital

Legionella pneumophila is one of the important pathogen responsible for community -acquired pneumonia attributing for 1-5% of cases. Since early and accurate therapy reduces mortality, rapid and reliable diagnostic methods are needed. A total of 134 samples of blood, urine and respiratory tract fluids were collected. Blood was tested for IgG, IgM and IgA antibodies using commercially available kits. A total of 8 (6%) samples were found to be positive for L. pneumophila by quantitative reverse transcription polymerase chain reaction (qRT-PCR), compared to conventional PCR where 6 (4.4%) samples were positive. Serology was positive in a total of 32 (23%) cases though only 3 (2.2%) of the PCR-positive cases were positive by serology as well. These results suggest that real-time PCR can detect Legionella infection early in the course of the disease before serological response develops.

Effect of some phytoconstituents on Fe2+/ascorbate induced lipid peroxidation

Transition metals like iron and copper, present inside the body system play a key role in the production of reactive oxygen radicals. These free radicals, causative agents of lipid peroxidation, not only damage proteins and DNA but also gradually changes the cellular membrane structure and ultimately leads to the loss of function and integrity. Uncontrolled lipid peroxidation results in various age related diseases, malignancy, infective diseases and injuries. Antioxidants and other phytochemical constituents present in the various plants are known to protect cells from such reactive oxygen species (ROS)-mediated damages. Here, we evaluated the effect of certain phytoconstituents present in the well-known medicinal plants on ROS scavenging using rat liver homogenate. The basal lipid peroxidation was found to be 0.1625±0.0095 ngMDA/min/mg protein, which got induced to 0.7938±0.0478 ngMDA/min/mg protein in the presence of Fe2+/ascorbate system. In this context, acteoside, berberine, catechin, 3´5-dihydroxyflavone7-o-ß-D-galacturonide-4-o-ß-D-glucopyranoside (a flavonoid glycoside from cumin), silibin and tetrahydrocurcumin decreased both basal and Fe2+/ascorbate induced lipid peroxidation as determined by thiobarbituric acid reaction. On the other hand, agnuside, andrographolide, picroside-I, negunoside, oleanolic acid, and glycerrihizin, showed enhancement in both basal and induced lipid peroxidation. Phytoconstituents which have decreased both basal and Fe2+/ascorbate induced lipid peroxidation may act as defensive against the deadly effects of ROS, causative agents of lipid peroxidation and other diseases either alone or in combination with diet/nutritional supplements.

Risk factors involved in spread of HCV in patients from sub urban Rawalpindi and their association with existing genotypes

The current epidemiological study was designed to trace the involved risk factors in Hepatitis C Virus (HCV) spread and to identify any association between HCV genotypes and risk factors. Blood samples were taken from 400 participants and viral genotyping was performed in order to find any possible relationship between the risk factors and genotypes. Major genotypes included 3, 1, 4 and several untypeable ones with prevalence rates 65%, 22.5%, 2.75% and 9.75% respectively. Surgery and dental procedure were strongly related to the spread of genotype 3b, while genotype 1b was strongly related to blood transfusion and dental procedures as a single combination risk factor. On the other hand genotypes 1a, 3a, 4 and the untypeable genotypes, were equally affected by all reported risk factors. The probability of occurrence of genotype 3a with reference to dental procedures was 11%. Dental procedures, unsafe injection and surgical procedures are the main risk factors while the blood transfusion in combination with dental procedures has emerged as a potent risk factor in the transmission of HCV.

Reduced length of stay with minimally invasive repair of ruptured achilles tendon

Minimally invasive techniques to repair ruptured achilles tendons have been developed to enhance recovery following tendon repair and decrease wound complications associated with open repair. We investigated outcomes of minimally invasive and open repair of acutely ruptured achilles tendons at our institution. We compared all cases of achilles tendon repair at our department, using open techniques and minimally invasive techniques with the Achillon device, over a two year period. Length of stay and operating time was recorded, as were any complication rates, including tendon re-rupture. Post-operatively functional outcome questionnaires were sent to all patients. In total 39 patients underwent open repair and 26 underwent minimally invasive repair. Length of stay was significantly shorter in the minimally invasive group, with 58% of minimally invasive cases performed as a day case, compared to 31.1% of open cases (p = 0.02). There was no difference in complication rates, including re-rupture, or functional outcome scores. Minimally invasive repair of ruptured achilles tendons results in reduced length of stay, compared to open repair. There is no evidence of weaker tendon repairs with minimally invasive techniques. Overall functional outcomes between both groups appear similar. Level of Evidence : III.

Burning through the pain: treatments for diabetic neuropathy

The rise in the global burden of diabetes is spurring an increase in the prevalence of its complications. Diabetic peripheral neuropathy (DPN) is a common and devastating complication of diabetes, with multiple clinical manifestations. The most common is a symmetrical length-dependent dysfunction and damage of peripheral nerves. The management of DPN rests on three tenets: intensive glycaemic control, even though the evidence of benefit is questionable in people with type 2 diabetes; pathogenetic therapies; and symptomatic treatment. A number of pathogenetic treatments have been evaluated in phase III clinical trials, including α-lipoic acid (stems reactive oxygen species formation), benfotiamine (prevents vascular damage) and aldose-reductase inhibitors (reduce flux through the polyol pathway), protein kinase C inhibitors (prevent hyperglycaemia-induced activation of protein kinase C), nerve growth factors (stimulate nerve regeneration) and Actovegin® (improves tissue glucose and oxygen uptake). However, none have gained US Food and Drug Administration or European Medicines Agency (EMA) approval, questioning the validity of current trial designs and the endpoints deployed to define efficacy. For painful diabetic neuropathy, clinical guidelines recommend: atypical analgesics for pain relief, including duloxetine and amitriptyline; the γ-aminobutyric acid analogues gabapentin and pregabalin; opioids, including Tapentadol; and topical agents such as lidocaine and capsaicin. No single effective treatment exists for painful DPN, highlighting a growing need for studies to evaluate more potent and targeted drugs, as well as combinations. A number of novel potential candidates, including erythropoietin analogues and angiotensin II type 2 receptor anatagonists are currently being evaluated in phase II clinical trials.

Rowena: the trainee’s perspective on simulation

A time-saving and cost-effective way to practise basic neurosurgical techniques.

Endoscopic ultrasound-guided radiation therapy in pancreatic cancer

During the last two decades, endoscopic ultrasound has revolutionized the diagnosis and treatment of gastrointestinal (GI) malignancies. The role of EUS has expanded well beyond its role as a diagnostic modality, and has emerged as a highly sophisticated interventional modality. More recently, EUS has paved its way into radiation oncology by either facilitating highly targeted image guided radiotherapy (IGRT) by insertion of fiducial markers in tumors or by direct instillation of radioactive seeds (brachytherapy). Although the experience regarding these techniques is in a preliminary stage, if developed further, this can potentially provide a highly accurate and minimally invasive approach for implantation of fiducial and radioactive seeds. This review will discuss potential role of EUS in implantation therapy, current literature and also speculate on future prospects for these EUS-guided interventions in pancreatic cancer.

Combined avulsion fracture of the tibial tuberosity and lateral tibial plateau in an adolescent: case report

Avulsion of the tibial tuberosity is uncommon. It is usually an athletic injury, accounting for less than 3% of all epiphyseal injuries. We report the case of an avulsion fracture of the tibial tuberosity with unusual articular involvement of the lateral tibial plateau treated with open reduction and internal fixation using cancellous screws. The result was excellent, with complete union of the fracture site, full range of movement at three months and return to normal athletic activity within six months with no complications.