Measuring the visual angle of polarization-related entoptic phenomena using structured light

The ability to perceive polarization-related entoptic phenomena arises from the dichroism of macular pigments held in Henle's fiber layer of the retina and can be inhibited by retinal diseases, such as age-related macular degeneration, which alters the structure of the macula. Structured light tools enable the direct probing of macular pigment density and retinal structure through the perception of polarization-dependent entoptic patterns. Here, we directly measure the visual angle of an entoptic pattern created through the illumination of the retina with a structured state of light and a perception task that is insensitive to corneal birefringence. The central region of the structured light stimuli was obstructed, with the size of the obstruction varying according to a psychophysical staircase. Two stimuli, one producing 11 azimuthal fringes and the other three azimuthal fringes, were presented to 24 healthy participants. The pattern with 11 azimuthal fringes produced an average visual angle threshold of 10° ± 1° and a 95% confidence interval (C.I.) of [6°, 14°]. For the pattern with three azimuthal fringes, a threshold extent of 3.6° ± 0.3° C.I. = [1.3°, 5.8°] was measured, a value similar to the published extent of Haidinger's brush (4°). The increase in apparent size and clarity of entoptic phenomena produced by the presented structured light stimuli offers the potential to detect the early signs of macular disease over perception tasks using uniform polarization stimuli.

Temozolomide and flavonoids against glioma: from absorption and metabolism to exosomal delivery

Patients with glioblastoma multiforme and anaplastic astrocytoma are treated with temozolomide. Although it has been demonstrated that temozolomide increases GBM patient survival, it has also been connected to negative immune-related adverse effects. Numerous research investigations have shown that flavonoids have strong antioxidant and chemo-preventive effects. Consequently, it might lessen chemotherapeutic medicines' side effects while also increasing therapeutic effectiveness. The need for creating innovative, secure, and efficient drug carriers for cancer therapy has increased over time. Recent research indicates that exosomes have enormous potential to serve as carriers and cutting-edge drug delivery systems to the target cell. In recent years, researchers have been paying considerable attention to exosomes because of their favorable biodistribution, biocompatibility, and low immunogenicity. In the present review, the mechanistic information of the anti-glioblastoma effects of temozolomide and flavonoids coupled with their exosomal delivery to the targeted cell has been discussed. In addition, we discuss the safety aspects of temozolomide and flavonoids against glioma. The in-depth information of temozolomide and flavonoids action via exosomal delivery can unravel novel strategies to target Glioma.

Solvent-free synthesis and in-silico molecular docking study of (E)-3-(β-C-glycosylmethylidene)-N-aryl/alkyl succinimides

Globally, human papillomavirus (HPV) infection is the leading cause of mortality associated with cervical cancer, oral cancer (oropharyngeal), and head and neck squamous cell carcinoma (HNSCC). It is essential to explore anti-cancer drugs against life-threatening HPV infections. Aiming to search for potentially better anticancer agents, a small library of β-C-glycosylated methylidene succinimides have been synthesized under bulk and mechanical grinding conditions using the Wittig olefination reaction. Thus, the reaction of different 2,3,4,6-tetra-O-benzyl-C-glycosyl aldehydes with N-aryl/alkyl maleimides in the presence of PPh3 at 25 °C under bulk and mechanical grinding conditions results in the formation of stereochemically defined (E)-3-(2,3,4,6-tetra-O-benzyl-C-glycosylmethylidene)-N-alkyl/phenyl succinimides, which upon debenzylation with 1 M BCl3 in DCM at -78 °C lead to the synthesis of (E)-3-(C-glycosylmethylidene)-N-alkyl/phenyl succinimides in good to excellent yields. The developed methodology is efficient and environmentally benign because there is no use of organic solvents, and the products are obtained in a stereochemically defined form and in high yields. The aqueous solubility of all synthesized β-C-glycosylated methylidene succinimides makes them potential candidates for the evaluation of their different biological activities. In the present work, the synthesized glycosylated alkylidine succinimides were subjected to an in-silico molecular docking study against the E6 oncoprotein of high-risk type HPV16, which is responsible for the inactivation of the tumor suppressor p53 protein. Analysis of the molecular docking data revealed that the synthesized compounds are effective inhibitors of HPV infection, which is the cause of oral, head and neck, and cervical cancer. In comparison with the positive control 5-FU, an anti-cancer drug used in chemotherapy, more than fifteen compounds were found to be better E6 protein inhibitors.

Nanoformulations of quercetin for controlled delivery: a review of preclinical anticancer studies

One of the well-studied older molecules, quercetin, is found in large quantities in many fruits and vegetables. Natural anti-oxidant quercetin has demonstrated numerous pharmacological properties in preclinical and clinical research, including anti-inflammatory and anti-cancer effects. Due to its ability to control cell signaling pathways, including NF-κB, p53, activated protein-1 (AP-1), STAT3, and epidermal growth response-1 (Egr-1), which is essential in the initiation and proliferation of cancer, it has gained a lot of fame as an anticancer molecule. Recent research suggests that using nanoformulations can help quercetin to overcome its hydrophobicity while also enhancing its stability and cellular bioavailability both in vitro and in vivo. The main aim of this review is to focus on the comprehensive insights of several nanoformulations, including liposomes, nano gels, micelles, solid lipid nanoparticles (SLN), polymer nanoparticles, gold nanoparticles, and cyclodextrin complexes, to transport quercetin for application in cancer.

Anti-angiogenic Potential of Trans-chalcone in an In Vivo Chick Chorioallantoic Membrane Model: An ATP Antagonist to VEGFR with Predicted Blood-brain Barrier Permeability

BACKGROUND

Glioblastoma multiforme (GBM) is characterized by massive tumorinduced angiogenesis aiding tumorigenesis. Vascular endothelial growth factor A (VEGF-A) via VEGF receptor 2 (VEGFR-2) constitutes majorly to drive this process. Putting a halt to tumordriven angiogenesis is a major clinical challenge, and the blood-brain barrier (BBB) is the prime bottleneck in GBM treatment. Several phytochemicals show promising antiangiogenic activity across different models, but their ability to cross BBB remains unexplored.

METHODS

We screened over 99 phytochemicals having anti-angiogenic properties reported in the literature and evaluated them for their BBB permeability, molecular interaction with VEGFR-2 domains, ECD2-3 (extracellular domains 2-3) and TKD (tyrosine kinase domain) at VEGF-A and ATP binding site, cell membrane permeability, and hepatotoxicity using in silico tools. Furthermore, the anti-angiogenic activity of predicted lead Trans-Chalcone (TC) was evaluated in the chick chorioallantoic membrane.

RESULTS

Out of 99 phytochemicals, 35 showed an efficient ability to cross BBB with a probability score of >0.8. Docking studies revealed 30 phytochemicals crossing benchmark binding affinity <-6.4 kcal/mol of TKD with the native ligand ATP alone. Out of 30 phytochemicals, 12 showed moderate to low hepatotoxicity, and 5 showed a violation of Lipinski's rule of five. Our in silico analysis predicted TC as a BBB permeable anti-angiogenic compound for use in GBM therapy. TC reduced vascularization in the CAM model, which was associated with the downregulation of VEGFR-2 transcript expression.

CONCLUSION

The present study showed TC to possess anti-angiogenic potential via the inhibition of VEGFR-2. In addition, the study predicted TC to cross BBB as well as a safe alternative for GBM therapy, which needs further investigation.

Evaluation of Therapeutic Potential of Selected Plant-Derived Homeopathic Medicines for their Action against Cervical Cancer

BACKGROUND

Plant-derived homeopathic medicines (HMs) are cheap and commercially available but are mechanistically less explored entities than conventional medicines.

PURPOSE

The aim of our study was to evaluate the impact of selected plant-derived HMs derived from Berberis aquifolium (BA), Berberis vulgaris (BV), Mentha piperita (MP), Curcuma longa (CL), Cinchona officinalis (CO), Thuja occidentalis (TO) and Hydrastis canadensis (HC) on cervical cancer (CaCx) cells in vitro.

METHODS

We screened the mother tincture (MT) and 30C potencies of the above-mentioned HMs for anti-proliferative and cytotoxic activity on human papillomavirus (HPV)-negative (C33a) and HPV-positive CaCx cells (SiHa and HeLa) by MTT assay. Total phenolic content (TPC) and the free-radical scavenging activity of each HM was also determined using standard assays. Phytochemicals reportedly available in these HMs were examined for their potential inhibitory action on HPV16 E6 by in silico molecular docking.

RESULTS

All tested MTs induced a differential dose-dependent cytotoxic response that varied with cell line. For C33a cells, the order of response was TO > CL > BA > BV > HC > MP > CO, whereas for SiHa and HeLa cells the order was HC > MP > TO > CO > BA > BV > CL and CL > BA > CO, respectively. 30C potencies of all HMs showed an inconsistent response. Further, anti-CaCx responses displayed by MTs did not follow the order of an HM's phenolic content or free radical scavenging activity. Analysis revealed anti-oxidant content of BA, BV and HC had the lowest contribution to their anti-CaCx activity. Using in silico modeling of molecular docking between the HPV16 E6 protein crystallographic structures (6SJA and 4XR8) and main phytochemical components of BV, BA, HC, CL and TO, their potential to inhibit the HPV16 E6 protein carcinogenic interactions was identified.

CONCLUSION

The study has shown a comparative evaluation of the potential of several plant-derived MTs and HMs to affect CaCx cell line survival in vitro (through cytotoxicity and free radical scavenging) and their theoretical molecular targets in silico for the first time. Data demonstrated that MTs of BA and BV are likely to be the most potent HMs that strongly inhibited CaCx growth and have a strong anti-HPV phytochemical constitution.

Cardiovascular complications following medical termination of pregnancy: An updated review

BACKGROUND

Around 1 million cases of medical termination of pregnancy (MTP) take place yearly in the United States of America with around 2 percent of this population developing complications. The cardiovascular (CVD) complications occurring post MTP or after stillbirth is not very well described.

AIM

To help the reader better understand, prepare, and manage these complications by reviewing various cardiac comorbidities seen after MTP.

METHODS

We performed a literature search in PubMed, Medline, RCA, and google scholar, using the search terms "abortions" or "medical/legal termination of pregnancy" and "cardiac complications" or "cardiovascular complications".

RESULTS

The most common complications described in the literature following MTP were infective endocarditis (IE) (n = 16), takotsubo cardiomyopathy (TTC) (n = 7), arrhythmias (n = 5), and sudden coronary artery dissection (SCAD) (n = 4). The most common valve involved in IE was the tricuspid valve in 69% (n = 10). The most observed causative organism was group B Streptococcus in 81% (n = 12). The most common type of TTC was apical type in 57% (n = 4). Out of five patients developing arrhythmia, bradycardia was the most common and was seen in 60% (3/5) of the patients. All four cases of SCAD-P type presented as acute coronary syndrome 10-14 d post termination of pregnancy with predominant involvement of the right coronary artery. Mortality was only reported following IE in 6.25%. Clinical recovery was reported consistently after optimal medical management following all these complications.

CONCLUSION

In conclusion, the occurrence of CVD complications following pregnancy termination is infrequently documented in the existing literature. In this review, the most common CVD complication following MTP was noted to be IE and TTC.

Twenty-four years lucerne (Medicago sativa L.) breeder seed production in India: a retrospective study

Lucerne (Medicago sativa L.) is the second most significant winter leguminous fodder crop after berseem in India. Breeder seed (BS) is the first stage of the seed production chain, as it is the base material for producing foundation and certified seeds. In India, lucerne BS demand has been reduced by 85.58% during the last 24 years (1998-1999 to 2021-2022), declining from 2150 kg to 310 kg. Out of 14 varieties released and notified so far, only nine varieties entered the seed chain since 1998-1999. It shows narrow varietal diversification and, hence, needs robust breeding programs towards enriching genetic variability and varietal development. The present study also highlights the disparity in BS demand and production over the years and puts forth the possible reasons behind the reduction in BS demand and production in the country. Out of the nine varieties, the BS demand of Anand-2 (53.11%) was highest, followed by Type-9 (19.44%) and RL-88 (13.60%). Varietal replacement rate (VRR) was found to be moderate, i.e., 23.67% for the varieties having <5 years old age in the last 3 years (2019-2020 to 2021-2022). It has also been estimated that BS produced (233 kg) during 2021-2022 can cover the approximate area of 6,300 ha at farmers' fields in 2024-2025 if the seed chain functions 100%, effectively. The present study provides a holistic overview of lucerne BS demand and production, challenges in BS production, and the way forward to develop more varieties and surplus BS production in the country.

Early Bone Mineral Density Changes and Endocrinal Dysfunction in Childhood Brain Tumor Patients: A Prospective Study

PURPOSE/OBJECTIVE(S)

Reduced bone mineral density (BMD) and hormonal dysfunction are considered as a late effect of cranial radiation (RT). Only few studies have reported the occurrence of these problems soon after the diagnosis of brain tumor or RT initiation, emphasizing that these are not necessarily the late effects of RT. Thus, we conducted the study to analyze the incidence of low BMD and hormonal dysfunction prior to or within 6 months of RT (early change) in children with brain tumors.

MATERIALS/METHODS

The study was conducted as a part of intramural funding program at a tertiary care center in India. Childhood and adolescent brain tumor patients were advised for dual energy X-ray absorptiometry scan (DXA) and hormonal evaluation prior to RT. In some patients, first DXA was done within 6 months of RT due to logistics. To see the effect of radiation, we have planned to repeat hormonal evaluation after 6 and 12 months and DXA after 12 months of RT.

RESULTS

Twenty-five patients were analyzed. Median age at diagnosis was 11 years with a male to female ratio of 5.2:1. Medulloblastoma was the commonest diagnosis (n = 12), followed by glioma (n = 8), pineal tumors (n = 3) and ependymoma (n = 2). Nineteen and six patients underwent DXA before RT and within 6 months of RT respectively. For BMD assessment, Z score was calculated at hip and lumbar spine. BMD was defined as low (Z score = -1 to-1.99), very low (Z score = -2 to -2.5) and secondary osteoporosis (Z score ≤ -2.5). Median Z score at femur neck and spine was -2 and -1.9 respectively. Overall; 6, 3 and 9 patients had normal, low and very low BMD respectively. Seven patients had secondary osteoporosis (Table 1). Two patients with secondary osteoporosis had low vitamin D levels. None of the patient had compression fracture. On statistical analysis, no correlation was found between BMD changes and age, sex and site of the tumor. Pre RT endocrinal assessment (N = 25) was done by tanner staging and serum hormonal levels (GH, T3/T4/TSH, ACTH, cortisol and prolactin). Gonadal hormonal assessment was done in children with early or delayed puberty. Three patients were found to have endocrinal abnormality before RT (precautious puberty, central hypothyroidism and low sex hormones in 1 patient each). Follow up DXA and hormonal evaluation are awaited to see the effect of RT.

CONCLUSION

The index study is one of the very few studies evaluating the early changes in BMD and hormonal dysfunction soon after brain tumor diagnosis or within 6 months of RT. We observed that a significant proportion of children had reduced BMD and hormonal dysfunction before RT, highlighting the importance of early assessment and referral to the specialist for better quality of life. Table 1: BMD and endocrinal dysfunction before or within 6 months of RT.

Sexual Function and Dosimetric Relationships to Erectile Structures among Patients Treated Definitively with Pd-103 LDR Prostate Brachytherapy

PURPOSE/OBJECTIVE(S)

Sexual potency and erectile function are important quality of life metrics for many men and is a significant consideration when planning and treating prostate cancer. There are limited long-term data correlating post-implant dosimetry with patient-reported sexual toxicity outcomes following LDR prostate brachytherapy using Pd-103, specifically as it pertains to genital substructures. Our aim was to correlate dosimetric patterns with quality-of-life outcomes to determine if dose to the pudendal arteries and neurovascular bundles is a significant consideration when planning prostate LDR brachytherapy.

MATERIALS/METHODS

We analyzed a prospectively collected IRB-approved database of men receiving LDR prostate brachytherapy between 11/2014-04/2019 at our institution. Patients received either LDR brachytherapy only, or combined with intensity-modulated radiation therapy (IMRT) to the prostate with or without pelvic lymph node coverage. Patients were given quality of life questionnaires at consultation and at subsequent follow up visits. Outcomes data related to sexual toxicity were evaluated based on the Sexual Health Inventory (SHIM) Questionnaire. The right/left pudendal arteries, and right/left neurovascular bundles (NVB) were contoured retrospectively on CT-MRI fusion sequences. Dosimetric data for each of the erectile substructures was analyzed. Statistical analyses included generalized linear mixed effects models with random intercept for patient to explore the association between dose and SHIM confidence.

RESULTS

A total of 50 patients met criteria for inclusion in the analysis. 5 patients received combined IMRT to 45 Gy with Pd-103 (90-100 Gy) and 45 patients received Pd-103 monotherapy (125 Gy). Median follow-up was 18 months for 50 patients; 40 (80%) patients had follow-up greater than 2 years, and 15 (30%) greater than 5 years. There were 344 individual questionnaires completed. 28% of records reported low or very low confidence level (Question #1 of SHIM questionnaire). Likelihood of moderate-very high confidence increased up to 2 years after beginning of treatment (p = 0.052) and then subsequently decreased between 2- and 5 years post treatment (p = 0.042). NVB doses were not associated with SHIM confidence level. D100 greater than 150 cGy to either pudendal artery was associated with worse SHIM confidence score after treatment (p = 0.003).

CONCLUSION

Sexual function is variable in the post treatment setting following definitive prostate radiation with Pd-103 LDR-brachytherapy. Avoiding pudendal artery dose may improve sexual outcomes and should be considered when planning prostate brachytherapy. Further investigation with a larger prospective, cohort may be warranted.

Association Between Psychosocial Risk Factors and Readmissions After Acute Myocardial Infarction: Role of COVID-19 Pandemic

Psychosocial risk factors (PSRFs) are known to be associated with worse cardiovascular (CV) outcomes. However, there are limited data on the impact of PSRFs on readmissions after acute myocardial infarction (AMI) before and during the COVID-19 (Coronavirus Disease 2019) pandemic. Therefore, we aimed to examine this association and whether the effects of PSRFs were amplified during the COVID-19 pandemic. We queried the 2019 and 2020 Nationwide Readmissions Database for adult (age ≥18 years) index admissions with AMI as the primary diagnosis. They were then divided into 2 cohorts based on the presence or absence of ≥1 PSRF and compared across non-COVID-19 (2019) and COVID-19 (2020) time periods. The primary outcome was 30-day all-cause readmissions. Secondary outcomes included cause-specific readmissions (cardiac, noncardiac, AMI, heart failure). Multivariable hierarchical logistic regression was conducted to evaluate differences in outcomes. The study included 380,820 patients with index AMI, of which 214,384 (56%) had ≥1 PSRFs. Patients with PSRFs were younger, more likely to be female, and had a higher prevalence of CV risk factors. Of 30-day all-cause readmissions were higher in patients with PSRFs in both eras. Moreover, noncardiac and heart failure readmissions were also higher in patients with PSRFs admitted with AMI in 2019 and 2020. This study of a nationally representative population magnifies the association of PSRF with more unplanned readmissions after AMI in both pre-COVID-19 and COVID-19 times.

Anastrozole-mediated modulation of mitochondrial activity by inhibition of mitochondrial permeability transition pore opening: an initial perspective

The mitochondrial permeability transition pore (mtPTP) plays a vital role in altering the structure and function of mitochondria. Cyclophilin D (CypD) is a mitochondrial protein that regulates mtPTP function and a known drug target for therapeutic studies involving mitochondria. While the effect of aromatase inhibition on the mtPTP has been studied previously, the effect of anastrozole on the mtPTP has not been completely elucidated. The role of anastrozole in modulating the mtPTP was evaluated by docking, molecular dynamics and network-guided studies using human CypD data. The peripheral blood mononuclear cells (PBMCs) of patients with mitochondrial disorders and healthy controls were treated with anastrozole and evaluated for mitochondrial permeability transition pore (mtPTP) function and apoptosis using a flow cytometer. Spectrophotometry was employed for estimating total ATP levels. The anastrozole-CypD complex is more stable than cyclosporin A (CsA)-CypD. Anastrozole performed better than cyclosporine in inhibiting mtPTP. Additional effects included inducing mitochondrial membrane depolarization and a reduction in mitochondrial swelling and superoxide generation, intrinsic caspase-3 activity and cellular apoptosis, along with an increase in ATP levels. Anastrozole may serve as a potential therapeutic agent for mitochondrial disorders and ameliorate the clinical phenotype by regulating the activity of mtPTP. However, further studies are required to substantiate our preliminary findings.Communicated by Ramaswamy H. Sarma.

Effect of thermal treatments on the matrix components, inherent glycemic potential, and bioaccessibility of phenolics and micronutrients in pearl millet rotis

Pearl millet (PM) is a nutri-cereal rich in various macro and micronutrients required for a balanced diet. Its grains have a unique phenolic and micronutrient composition; however, the lower bioaccessibility of nutrients and rancidity of flour during storage are the major constraints in its consumption and wide popularity. Here, to explore the effect of different thermal processing methods, i.e., hydrothermal (HT), microwave (MW), and infrared (IR) treatments, on the digestion of starch, phenolics, and microelements (Fe and Zn), an in vitro digestion model consisting of oral, gastric and intestinal digestion was applied to PM rotis. The hydrothermally treated PM roti was promising as it showed lower inherent glycemic potential (60.4%) than the untreated sample (72.4%) and less enzymatic activities associated with rancidity in PM flour. FTIR revealed an increased ratio of 1047/1022 cm^-1 in the hydrothermally treated sample, reflecting the enhancement of the structurally ordered degree and compactness of starch compared to other thermal treatments. A tighter and more compact microstructure with an agglomeration of starch in the hydrothermally treated PM flour was observed by SEM. These structural changes could provide a better understanding of the lower starch digestion rate in the hydrothermally treated flour. However, HT treatment significantly (P < 0.05) reduced the bioaccessibility of phenolics (10.6%) compared to native PM rotis and slightly reduced the Fe (2%) and Zn (3.2%) bioaccessibility present in PM rotis.

Serratia endocarditis, uncommon organism, with significant complications

Serratia marcescens is an aerobic, Gram-negative bacillus predominantly seen in patients with intravenous drug use, immunosuppression, previous antibiotic exposure, and indwelling catheterization. Gram-negative organism causing infective endocarditis (IE) is rare. Serratia marcescens IE is uncommon and is reported to be seen in 0.14% of all cases. In this report, we discuss in detail about a 38-year-old man with a history of intravenous drug abuse presenting with S. marcescens related prosthetic valve IE.

Evaluation of global Cenchrus germplasm for key nutritional and silage quality traits

Cenchrus is important genera of grasses inhabiting tropical pastures and the Indian grasslands system. Its forage value is well established to sustain nomadic livestock and wildlife. This study deals with the evaluation of the representative set of global Cenchrus germplasm collection with 79 accessions belonging to six species (C. ciliaris, C. setigerus, C. echinatus, C. myosuroides, C. pennisetiformis, and C. biflorus) at flowering stage. Crude protein (CP), neutral detergent fiber (NDF), acid detergent fiber (ADF), cellulose, and lignin values were in the range of 61.1-136, 640-749, 373-490, 277-375, and 35.6-75.50 g kg-1DM, respectively, while sugar contents varied from 11.6 to 101 mg g-1 DM. From the evaluated germplasm, 14 accessions of C. ciliaris having >70 mg g-1 DM sugar contents were selected and further evaluated for protein, fiber, carbohydrate and protein fractions, palatability indices, in vitro CH4 production, and ensiling traits. Protein contents were lower in EC397323 (61.8) and higher in IG96-96 (91.5), while the NDF, ADF, cellulose, and lignin contents varied between 678-783, 446-528, 331-405, and 39.6-62.0 g kg-1DM, respectively. The carbohydrate and protein fractions of selected accessions differed (p < 0.05), and the sugar contents varied (p < 0.05) between 74.6 and 89.6 mg-1g DM. Dry matter intake (DMI) and relative feed value (RFV) of accessions varied (p < 0.05) and were in the range of 1.53-1.77% and 58.2-73.8 g kg-1 DM, respectively. The total digestible nutrients (TDNs), digestible energy (DE), and metabolizable energy (ME) of selected accessions varied between 362-487 g kg-1 DM, 6.62-8.90, and 5.42-7.29 Mj kg-1 DM, respectively. In vitro gas and CH4 production (24 h) varied (p < 0.05) between 73.1 to 146 and 7.72 to 21.5 ml/g, respectively, while the degraded dry matter (g kg-1 DM) and CH4 (ml/g DDM) ranged between 399-579 and 17.4-47.2, respectively. The DM contents at ensiling, silage pH, and lactic acid contents of accessions differed (p < 0.05) and ranged between 185-345 g kg-1 DM, 5.10-6.05, and 1.39-23.3 g kg-1 DM, respectively. Wide genetic diversity existed in germplasm and selected C. ciliaris accessions for protein fiber, energy, sugar, and other nutritional traits. Silage prepared from EC397366, IG96-96, IG96-50, and EC397323 had pH and lactic acid contents acceptable for moderate to good quality silage of tropical range grasses.

Anticancer potential of oroxylin A: from mechanistic insight to synergistic perspectives

Oroxylin A (OA), a well-known constituent of the root of Scutellariae plants, has been used in ethnomedicine already for centuries in treating various neoplastic disorders. However, only recent molecular studies have revealed the different mechanisms behind its action, demonstrating antiproliferative, anti-inflammatory, and proapoptotic effects, restricting also the spread of cancer cells to distant organs. A variety of cellular targets and modulated signal transduction pathways regulated by OA have been determined in diverse cells derived from different malignant tissues. In this review article, these anticancer activities are thoroughly described, representing OA as a potential lead structure for the design of novel more potent anticancer medicines. In addition, co-effects of this natural compound with conventional anticancer agents are analyzed and the advantages provided by nanotechnological methods for more efficient application of OA are discussed. In this way, OA might represent an excellent example of using ethnopharmacological knowledge for designing modern medicines.

Exosomal miRNAs as novel avenues for breast cancer treatment

Breast cancer is the most commonly diagnosed cancer and a leading cause of death in women worldwide. It is a heterogeneous disease, as shown by the gene expression profiles of breast cancer samples. It begins in milk-producing ducts, with a high degree of diversity between and within tumors, as well as among cancer-bearing individuals. The enhanced prevalence of breast cancer is influenced by various hormonal, lifestyle, and environmental factors, and very early onset of the disease correlates strongly with the risk of local and distant recurrence. Many subtypes are difficult to treat with conventional therapeutic modalities, and therefore, optimal management and early diagnosis are the first steps to minimizing the mortality linked with breast cancer. The use of newer methods of nanotechnology extends beyond the concept of synthesizing drug delivery mechanisms into the creation of new therapeutics, such as delivering chemotherapeutics with nanomaterial properties. Exosomes, a class of nanovesicles, are emerging as novel tools for deciphering the patient-specific proteins and biomarkers across different disease models, including breast cancer. In this review, we address the role of exosomal miRNA in breast cancer diagnosis and treatment.

Competency-based medical education and the McNamara fallacy: Assessing the important or making the assessed important?

The McNamara fallacy refers to the tendency to focus on numbers, metrics, and quantifiable data while disregarding the meaningful qualitative aspects. The existence of such a fallacy in medical education is reviewed in this paper. Competency-based medical education (CBME) has been introduced in India with the goal of having Indian Medical Graduates competent in five different roles - Clinician, Communicator, Leader and member of the health care team, Professional, and Lifelong learner. If we only focus on numbers and structure to assess the competencies pertaining to these roles, we would be falling prey to the McNamara fallacy. To assess these roles in the real sense, we need to embrace the qualitative assessment methods and appreciate their value in competency-based education. This can be done by using various workplace-based assessments, choosing tools based on educational impact rather than psychometric properties, using narratives and descriptive evaluation, giving grades instead of marks, and improving the quality of the questions asked in various exams. There are challenges in adopting qualitative assessment starting with being able to move past the objective-subjective debate, to developing expertise in conducting and documenting such assessment, and adding the rigor of qualitative research methods to enhance its credibility. The perspective on assessment thus needs a paradigm shift - we need to assess the important rather than just making the assessed important; and this would be crucial for the success of the CBME curriculum.

Molecular mechanisms behind ROS regulation in cancer: A balancing act between augmented tumorigenesis and cell apoptosis

ROS include hydroxyl radicals (HO^.), superoxide (O₂^..), and hydrogen peroxide (H₂O₂). ROS are typically produced under physiological conditions and play crucial roles in living organisms. It is known that ROS, which are created spontaneously by cells through aerobic metabolism in mitochondria, can have either a beneficial or detrimental influence on biological systems. Moderate levels of ROS can cause oxidative damage to proteins, DNA and lipids, which can aid in the pathogenesis of many disorders, including cancer. However, excessive concentrations of ROS can initiate programmed cell death in cancer. Presently, a variety of chemotherapeutic drugs and herbal agents are being investigated to induce ROS-mediated cell death in cancer. Therefore, preserving ROS homeostasis is essential for ensuring normal cell development and survival. On account of a significant association of ROS levels at various concentrations with carcinogenesis in a number of malignancies, further studies are needed to determine the underlying molecular mechanisms and develop the possibilities for intervening in these processes.

Quantitative assessment of antioxidant potential of selected homeopathic preparations in clinical practice

OBJECTIVES

Antioxidant property like radical scavenging is a primary target to elucidate the efficacy mechanism of a drug against diseases linked to oxidative stress such as cancer, metabolic disorders, rheumatoid arthritis, etc. In alternative therapies, homeopathy is one of the preferred choices by patients and clinicians due to its potential to cure chronic and complex illnesses. However, the efficacy of homeopathic preparations at high diluted potencies attracts rational criticism due to insufficient scientific knowledge supporting the mechanism of action. Therefore, an attempt was made to estimate the total phenolic content (TPC) and radical scavenging activity of clinically prescribed homeopathic drugs.

METHODS

With gallic acid as a reference control, mother tinctures (MTs) and different potencies of Eucalyptus globulus (EG), Syzygium jambolanum (SJ), Ruta graveolens (RG), and Thuja occidentalis (TO) were used to perform Folin-Ciocalteu test, 2,2'-azino-bis(3-ethylbenzothiazoline-6-sulphonic acid) (ABTS), and 2,2-diphenyl-1-picrylhydrazyl (DPPH) assays.

RESULTS

The results showed TPC of MTs equivalent to µg/mL of gallic acid viz; EG (4,872.5 ± 133.2), SJ (8,840.5 ± 14.8), RG (985.6 ± 39.1), and TO (341.5 ± 19.5) with significant ABTS and DPPH radical scavenging potential. Whereas 30C and 200C potencies of each homeopathic drug showed undetectable phenolic content and insignificant radical scavenging potential compared to vehicle control, i.e., alcohol 90% (2.0 ± 1.5).

CONCLUSIONS

The reported efficacy of 30C and 200C potencies of homeopathic medicines against oxidative stress-related illnesses might be due to mechanisms other than radical scavenging. Furthermore, the assays studied can be helpful in drug standardization and quality control of MTs that are used as starting material in homeopathic preparations.

Unravelling a novel, promising and convenient tool for differential diagnosis of delayed puberty: GnRHa-stimulated inhibin B (GnRH-iB)

BACKGROUND

Etiological diagnosis of delayed puberty is difficult. Despite availability of various basal and stimulation tests differentiation between constitutional delay in puberty and hypogonadotropic hypogonadism is still challenging.

OBJECTIVE

To elucidate the role of GnRH agonist-stimulated inhibin B (GnRH-iB) for the differential diagnosis of delayed puberty.

STUDY DESIGN

Participants were recruited into "exploratory cohort" (n = 39) and "validation cohort" (n = 16). "Exploratory cohort" included children with spontaneous puberty and patients with hypogonadotropic hypogonadism. "Validation cohort" constituted children who presented with delayed puberty.

INTERVENTION AND OUTCOME

GnRHa (Triptorelin) stimulation test along with measurement of inhibin B level at 24 h after GnRHa injection was performed in all the study participants. Cut-offs for GnRH-iB were derived from the "exploratory cohort". These cut-offs were applied to the "validation cohort". Basal LH, basal inhibin B(INH-B), GnRHa-stimulated LH at 4 h (GnRH-LH) and GnRH-iB were evaluated for the prediction of onset of puberty on prospective follow-up.

RESULTS

GnRH-iB at a cut-off value of 113.5 pg/ml in boys and 72.6 pg/ml in girls had 100% sensitivity and specificity for the documentation of puberty. In the "validation cohort" basal LH, basal INH-B, GnRH-LH, and GnRH-iB had a diagnostic accuracy of 68.75%, 81.25%, 68.75% and 93.75% respectively, for the prediction of onset of puberty. Basal LH, basal INH-B and GnRH-LH used alone or in combination were inferior to GnRH-iB used alone.

CONCLUSION

GnRHa-stimulated inhibin B (GnRH-iB) is a convenient and easily employable test for the differentiation of constitutional delay in puberty from hypogonadotropic hypogonadism.

CTRI REGISTRATION NO

CTRI/2019/10/021570.

Luteolin, a Potent Anticancer Compound: From Chemistry to Cellular Interactions and Synergetic Perspectives

Increasing rates of cancer incidence and the toxicity concerns of existing chemotherapeutic agents have intensified the research to explore more alternative routes to combat tumor. Luteolin, a flavone found in numerous fruits, vegetables, and herbs, has exhibited a number of biological activities, such as anticancer and anti-inflammatory. Luteolin inhibits tumor growth by targeting cellular processes such as apoptosis, cell-cycle progression, angiogenesis and migration. Mechanistically, luteolin causes cell death by downregulating Akt, PLK-1, cyclin-B1, cyclin-A, CDC-2, CDK-2, Bcl-2, and Bcl-xL, while upregulating BAX, caspase-3, and p21. It has also been reported to inhibit STAT3 signaling by the suppression of STAT3 activation and enhanced STAT3 protein degradation in various cancer cells. Therefore, extensive studies on the anticancer properties of luteolin reveal its promising role in chemoprevention. The present review describes all the possible cellular interactions of luteolin in cancer, along with its synergistic mode of action and nanodelivery insight.

Manganese enhanced magnetic resonance imaging in type 1 and type 2 diabetes mellitus

Background

The pathophysiology of diabetic cardiomyopathy has yet to be established although pre-clinical studies suggest a role for altered myocardial calcium handling. Manganese-enhanced magnetic resonance imaging (MEMRI) is a novel non-invasive method of assessing in vivo myocardial calcium handling.

Purpose

To investigate whether myocardial calcium handling is impaired in patients with either type 1 or type 2 diabetes mellitus in the absence of underlying heart disease.

Methods

In a prospective case-control study, patients with type 1 (n=19) or type 2 (n=10) diabetes mellitus and healthy volunteers (n=15) underwent MEMRI. Participants with prior coronary artery disease, cardiomyopathy or an abnormal electrocardiogram were excluded. Manganese dipyridoxyl diphosphate (0.1 mL/kg) was administered over 10 min and myocardial T1 mapping was performed prior to and every 2.5 min for 30 min after contrast infusion (Figure 1). Quantitative manganese uptake analysis was performed by measuring T1 relaxation times in a region of interest within the interventricular septum and compared to the left ventricular blood pool. The rate of myocardial manganese uptake was determined by Patlak modelling [1].

Results

Participants with type 1 and type 2 diabetes mellitus were older (50±13 and 55±15.3 years) than the healthy volunteers (32±10 years). All participants had preserved left ventricular ejection fraction (type 1 diabetes mellitus, 67.7±6.1%; type 2 diabetes mellitus, 66.8±3.2%; healthy volunteers, 65±3.5%). Mean myocardial manganese uptake was reduced in participants with both type 1 (6.4±0.6 mL/100 g of tissue/min) and type 2 (6.4±0.5 mL/100 g of tissue/min) diabetes mellitus compared with healthy volunteers (8.3±0.5 mL/100 g of tissue/min; p&lt;0.0001 for both, Figure 2). There were no differences in myocardial manganese uptake between those with type 1 or type 2 diabetes mellitus (p=0.22). There was no statistically significant correlation between myocardial manganese uptake and age in the study population (r=−0.28, p=0.07).

Conclusion

Using MEMRI, we have demonstrated that myocardial calcium handling is impaired in patients with either type 1 or type 2 diabetes mellitus even in the absence of left ventricular systolic dysfunction. This suggests altered myocardial calcium handling may underlie, or contribute to, diabetic cardiomyopathy which has implications developing novel therapeutic targets for the prevention and treatment of diabetic cardiomyopathy.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart Foundation - Clinical Research Training Fellowship (FS/CRTF/20/24087)AstraZeneca - Investigator initiated award (ESR-19-20118)

Manganese-enhanced magnetic resonance imaging in Takotsubo syndrome

Background

Takotsubo syndrome is an increasingly common acute cardiac emergency characterised by profound transient left ventricular systolic dysfunction following a stressful event. Its pathophysiology remains poorly understood and a third of patients will have a major adverse cardiac or cerebrovascular event by 5 years [1]. Defective myocardial calcium homeostasis is central to contractile dysfunction and may be implicated in its pathophysiology. Manganese-enhanced magnetic resonance imaging is a novel non-invasive imaging technique that assesses myocardial manganese uptake as a measure of myocardial calcium handling [2]. Our aim was to investigate myocardial calcium handling using manganese-enhanced magnetic resonance imaging during the acute and recovery phase of takotsubo syndrome.

Methods

This single centre case-controlled observational longitudinal cohort study was conducted in accordance with the Declaration of Helsinki and ethical committee approval with written informed consent. Twenty patients with takotsubo syndrome and 20 age, sex and cardiovascular risk factor matched volunteers were recruited between March 2020 and September 2021. Patients underwent gadolinium and manganese-enhanced magnetic resonance imaging during the index event with repeat manganese-enhanced magnetic resonance imaging after 3 months. Myocardial manganese uptake was characterised by Patlak modelling.

Results

During the acute presentation, most patients had an “apical” pattern of takotsubo syndrome with reduced left ventricular ejection fraction (51±11 versus 67±8%, P&lt;0.001, Figure 1), elevated left ventricular mass (89±11 versus 57±14 g/m2, P&lt;0.01) and native T1 (1358±49 versus 1211±28 ms, P&lt;0.001) and T2 (60±7 versus 38±3 ms, P&lt;0.001) values compared to matched volunteers. Patlak modelling demonstrated reduced myocardial manganese uptake (5.1±0.5 versus 8.0±1.0 mL/100g of tissue/min, P&lt;0.0001) consistent with a major abnormality of myocardial calcium handling. Reduced myocardial manganese uptake attributable to apical takotsubo syndrome could be seen in one patient, scanned 18 days after symptom onset despite apparent resolution of cardiac function. Beyond 3 months of convalescence, left ventricular mass, ejection fraction, native T1 and T2 values were comparable to matched volunteers. Despite this, myocardial calcium handling remained abnormal compared to matched volunteers (6.7±0.7 versus 8.0±1.0 mL/100 g of tissue/min, P&lt;0.001, Figure 2).

Conclusions

In patients with takotsubo syndrome, there is a profound perturbation of myocardial calcium handling which is most marked acutely but persists after apparent recovery of left ventricular ejection fraction and resolution of myocardial oedema. Abnormal myocardial calcium handling is implicated in the pathophysiology of takotsubo syndrome and manganese-enhanced magnetic resonance imaging could play a major role in the diagnosis and risk stratification of patients with takotsubo syndrome.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Medical Research CouncilBritish Heart Foundation

Impaired myocardial calcium handling in people with type 2 diabetes: an in vivo manganese-enhanced magnetic resonance imaging study

Background

There is a high prevalence of subclinical cardiac dysfunction in people with type 2 diabetes (T2D) which is associated with subsequent development of heart failure. Dysregulated myocardial calcium handling has been demonstrated in animal models of T2D and may be a key mechanism driving the development of heart failure. Manganese-enhanced cardiac magnetic resonance imaging (MEMRI) provides a unique method to assess in vivo myocardial calcium handling.

Purpose

To determine whether myocardial calcium handling is perturbed in people with T2D with no history of cardiovascular disease. We hypothesised that myocardial manganese uptake would be reduced in people with T2D compared with healthy volunteers.

Methods

Cross-sectional case-control study, adults with (n=20) and without (n=9) T2D underwent both gadolinium-enhanced MRI and MEMRI. Standard gadolinium-enhanced MRI was used to assess cardiac structure, function and tissue characteristics. MEMRI scans were performed within two weeks of the initial scan. Native T1 maps were obtained in the mid-short axis slice position using a Modified Look-Locker Inversion recovery sequence. An intravenous infusion of manganese dipyridoxyl diphosphate (5 μmol/kg (0.1 mL/kg) at 1 mL/min) was administered and T1 maps at the same location were repetitively acquired every 2.5 min for 30 min. Regions of interest were drawn in the inferoseptal segment and blood pool for all T1 maps from 0 to 30 min by a single observer. The primary outcome was the rate of manganese uptake which was assessed by Patlak modelling as a measure of myocardial calcium handling. Manganese uptake constants were compared using analysis of co-variance, with age, sex and body mass index as co-variates.

Results

Subjects with T2D were older (62±7 vs. 57±5 years, p=0.046) but body mass index (29.0±4.5 vs. 26.2±3.4 kg/m2, p=0.106), systolic (135±16 vs. 134±17 mmHg, p=0.809) and diastolic (81±10 vs. 83±9 mmHg, p=0.736) blood pressures were similar. Compared to control subjects, participants with T2D had normal systolic function but more concentric left ventricular remodelling (mass/volume ratio 0.90±0.14 vs. 0.71±0.06 g/mL, p&lt;0.001) and reduced peak early diastolic strain rate (0.64±0.17 vs. 0.91±0.26 s–1, p=0.002). Myocardial manganese uptake was substantially reduced in people with T2D compared with controls (6.51±1.46 vs. 8.45±2.52 ml/100 g of tissue/min, p=0.003) (Figure 1).

Conclusions

For the first time, we have demonstrated in vivo that despite no history of cardiovascular disease and normal systolic function, patients with T2D have marked impairment of myocardial calcium handling. This has potential major implications for the pathogenesis, diagnosis and treatment of diabetic cardiomyopathy.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation and National Institute for Health Research

Synthesis of benzothiazole-appended bis-triazole-based structural isomers with promising antifungal activity against Rhizoctonia solani

In order to explore new antifungal agrochemicals, we reported the synthesis of two series 5a-f, 6 and 7a-f, 8 of benzothiazole-appended bis-triazole derivative-based structural isomers using a molecular hybridization approach. The synthesized compounds were tested for fungal growth inhibition against the plant pathogen Rhizoctonia solani. All the synthesized compounds showed excellent antifungal activity in their minimum concentrations (10-0.62 μM). Among all the synthetics, compounds 5b (ED50: 2.33 μM), 5f (ED50: 0.96 μM), and 7f (ED50: 1.48 μM) exerted a superior inhibitory effect in comparison to the commercially available fungicide, hexaconazole (ED50: 2.44 μM). The binding interactions of the active compounds 5f, 7f, 6, and 8 within the active site of the sterol 14α-demethylase enzyme were studied with the help of molecular docking studies. The studies revealed that these hybrid pharmacophores could be used as an important intermediate to demonstrate new structural isomer-based fungicides.

Ampelopsin targets in cellular processes of cancer: Recent trends and advances

Cancer is being considered as a serious threat to human health globally due to limited availability and efficacy of therapeutics. In addition, existing chemotherapeutic drugs possess a diverse range of toxic side effects. Therefore, more research is welcomed to investigate the chemo-preventive action of plant-based metabolites. Ampelopsin (dihydromyricetin) is one among the biologically active plant-based chemicals with promising anti-cancer actions. It modulates the expression of various cellular molecules that are involved in cancer progressions. For instance, ampelopsin enhances the expression of apoptosis inducing proteins. It regulates the expression of angiogenic and metastatic proteins to inhibit tumor growth. Expression of inflammatory markers has also been found to be suppressed by ampelopsin in cancer cells. The present review article describes various anti-tumor cellular targets of ampelopsin at a single podium which will help the researchers to understand mechanistic insight of this phytochemical.

38 Virtual Trauma Meeting-the Game Changer During COVID 19 Era. A Quantitative Comparative Analysis

Introduction

In an orthopaedic department, majority of plans and decision-making cases occur at the daily trauma meeting. With the advent of COVID-19 pandemic, it was challenging to deliver the standard care maintaining social distancing guidelines. Therefore, virtual trauma handover replaced the traditional face-to-face handover as a standalone solution. This study has tried to report on effectivity of the new virtual trauma handover process.

Method

This single centre observational study compared retrospectively collected data during pre-COVID-19 period (2019) and prospectively followed data from virtual trauma meetings during COVID 19 pandemic. The study analysed comparison of meeting start and finish time, attendance of key members, punctuality of attendees and interruptions during the handover process.

Results

Changing from face-to-face to virtual trauma meetings, average participation doubled from 9 to 18 with increased consultant attendance (Mean: 7.5 vs 2) -statistically significant (p &lt; 0.05). Enhanced senior clinician participation helped in multidisciplinary decision making promptly. Punctuality of attendance noted as declining late arrivals in 28/34 face-to-face to 4/34 virtual meetings. Although meetings start-time remained similar overall, there was less interruptions during virtual handover and mean meeting span reduced by 13 minutes.

Conclusions

As part of adaptive changes during COVID-19 pandemic, virtual trauma handover meetings have introduced changes in delivery of existing acute trauma services. Within very few limitations, it could be an aid to improve clinician participation, easiness of having multidisciplinary opinion and decision making. Moreover, it helped to practice social distancing guidelines. Educational activities are also effectively managed through virtual meetings.

Use of vegetables for enhancing oxidative stability of omega-3 oils in the powdered state

The preliminary study examined the effectiveness of various vegetables for the stabilisation of omega-3 oil powders against oxidative deterioration. Purees made from different vegetables (mushroom, brussels sprouts, broccoli, cauliflower, snow peas, tomato, and garlic) were employed for preparation of vegetable-tuna oil emulsions, which were subsequently freeze-dried into powders. Oxipres® data showed that vegetable-tuna oil powders had longer induction periods than neat tuna oil. During accelerated oxidation storage (40 °C/4weeks), eicosapentaenoic and docosahexaenoic acids in the vegetable-tuna oil powders were protected against oxidation, and there were lower levels of headspace secondary and tertiary oxidation products. Whole vegetable purees were suitable protective matrices for omega-3 oils. Of the various vegetable purees examined for protective effects against omega-3 oxidation, mushroom, brussels sprouts, broccoli, and cauliflower were superior to snow peas, garlic and tomato. The antioxidant properties of phytonutrients inherent in various vegetables are likely contributors to protection of omega-3 oil powders against oxidation.

Transcriptome analysis of cervical cancer exosomes and detection of HPVE6*I transcripts in exosomal RNA

Background

Exosomes play a key role in cell-to-cell communication and are integral component of the tumor microenvironment. Recent observations suggest transfer of RNA through tumor-derived exosomes that can potentially translate into regulatory proteins in the recipient cells. Role of cervical cancer-derived exosomes and their transcript cargo is poorly understood.

Materials and methods

The total RNA of exosomes from HPV-positive (SiHa and HeLa) and HPV-negative (C33a) cervical cancer cell lines were extracted and the transcripts were estimated using Illumina HiSeq X. Further, validation of HPV transcripts were performed using RT-PCR.

Results

3099 transcripts were found to be differentially-exported in HPV-positive vs. HPV-negative exosomes (p value <0.05). Analysis of top 10 GO terms and KEGG pathways showed enrichment of transcripts belonging to axon guidance and tumor innervation in HPV-positive exosomes. Among top 20 overexpressed transcripts, EVC2, LUZP1 and ANKS1B were the most notable due to their involvement in Hh signaling, cellular migration and invasion, respectively. Further, low levels of HPV-specific reads were detected. RT-PCR validation revealed presence of E6*I splice variant of HPV18 in exosomal RNA of HeLa cells. The E6*I transcripts were consistently retained in exosomes obtained from HeLa cells undergoing 5-FU and cisplatin-induced oxidative stress.

Conclusion

Our data suggests the enrichment of poly-A RNA transcripts in the exosomal cargo of cervical cancer cells, which includes pro-tumorigenic cellular RNA and viral transcripts such as HPV E6, which may have clinical utility as potential exosomal biomarkers of cervical cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09262-4.

Developing a competency-based undergraduate logbook for pediatrics: Process and lessons

With the first MBBS batch admitted under the new National Medical Commission (NMC) undergraduate curriculum entering pediatric clinical posting soon, creation of a Pediatric logbook in consonance with this competency-based curriculum was felt to be a need of the hour. No such document is yet available in the public domain. The logbook template, created after enormous brainstorming amongst authors, includes 176 Shows (S), Shows How (SH) and Perform (P) level competencies. These were further segregated into certifiable (23), affective domain (25) and clinic/field visits (9) leaving 51 as documentable competencies. The institutions may use this template to build their own institute-specific logbook based on the infrastructure, faculty strength, clinical patient load, student intake and preferred assessment method(s). It would also be worthwhile to integrate this with the internship logbook (and later the postgraduate one for students opting for post-graduation in pediatrics) to provide a longitudinal record of each student's trajectory of learning.

The RAIS Device for Global Surgery: Using a Participatory Design Approach to Navigate the Translational Pathway to Clinical Use

Background: Over 5 billion people worldwide have no access to surgery worldwide, typically in low-resource settings, despite it being a primary life-saving treatment. Gas Insufflation-Less Laparoscopic Surgery (GILLS) can address this inequity, by improving current GILLS instrumentation to modern surgical standards. Objective: to develop and translate a new Retractor for Abdominal Insufflation-less Surgery (RAIS) into clinical use and thus provide a context-appropriate system to advance GILLS surgery. Methods: A collaborative multidisciplinary team from the UK and India was formed, embedding local clinical stakeholders and an industry partner in defining user and contextual needs. System development was based on a phased roadmap for ‘surgical device design in low resource settings’ and embedded participatory and frugal design principles in an iterative process supported by traditional medical device design methodologies. Each phase of development was evaluated by the stakeholder team through interactive workshops using cadaveric surgical simulations. A Commercialisation phase undertook Design to Manufacture and regulatory approval activities. Clinical validation was then conducted with rural surgeons performing GILLS procedures using the RAIS system. Semi-structured questionnaires and interviews were used to evaluate device performance. Results: A set of user needs and contextual requirements were defined and formalised. System development occurred across five iterations. Stakeholder participation was instrumental in converging on a design which met user requirements. A commercial RAIS system was then produced by an industry partner under Indian regulatory approval. This was successfully used in clinical validation to conduct 12 surgical procedures at two locations in rural India. Surgical feedback showed that the RAIS system provided a valuable and usable surgical instrument which was appropriate for use in low-resource contexts. Conclusions: Using a context-specific development approach with close engagement of stakeholders was crucial to develop the RAIS system for low-resource regions. The outcome is translation from global health need into a fully realized commercial instrument which can be used by surgeons in low-resource regions across India.

A comparison of effective dose and risk for different collimation options used in AP shoulder radiography

INTRODUCTION

Radiography forms the cornerstone of the evaluation of shoulder disorders. While the benefits of radiography exceed the risks, there continues to be a compelling case for reduction of radiation exposure from diagnostic radiography. The aim of this project was to evaluate the radiation dose and risk for a variety of collimation settings used during anteroposterior (AP) shoulder radiography.

METHODS

This was a phantom based study where an ATOM adult dosimetry phantom was loaded with 272 thermoluminescent dosimeters (TLDs). Following loading, the phantom was setup for an AP shoulder X-ray projection with standard 25 × 30 cm rectangular collimation. The phantom was exposed three times and then the TLDs were removed and read. The experiment was repeated using a diamond shaped collimation and rectangular collimation with a minimum field of view to portray only relevant anatomy. Using the TLD dose measurements the effective doses and radiation risks were determined and compared.

RESULTS

As expected, organs neighbouring the shoulder experienced the highest absorbed doses (greater than 0.01 mGy); these organs included breast, lung and thyroid gland. The effective doses for standard rectangular, small rectangular and diamond collimation were 0.011, 0.008 and 0.016 mSv, respectively. When compared to standard collimation, a small field of view reduced effective dose by 27.3% and when moving to a diamond shape there was a 45.5% increase. The differences are likely driven by differences in the coverage of the radiosensitive lung and breast tissue.

CONCLUSION

By utilising a variety of different collimation settings, effective dose can be reduced. Reducing the radiation dose is both financially beneficial and results in a lower stochastic risk for patients. Image quality must also be considered when choosing different collimation settings. It stands to reason that by reducing the field size, dose will be reduced, and our study has served to quantify the effects in a practical situation.

IMPLICATIONS FOR PRACTICE

The utilisation of smaller/tight collimation is recommended as it offers the lowest dose when compared with other types of collimations. Although well-known this study serves to remind practitioners of the practical importance of collimation and is associated effect on effective dose and risk.

Detection of human papillomavirus infection in oral cancers reported at dental facility: assessing the utility of FFPE tissues

Incidence of human papillomavirus (HPV)-associated oral cancers is on the rise. However, epidemiological data of this subset of cancers are limited. Dental hospital poses a unique advantage in detection of HPV-positive oral malignancies. We assessed the utility of formalin-fixed paraffin-embedded (FFPE) tissues, which are readily available, for evaluation of high-risk HPV infection in oral cancer. For protocol standardization, we used 20 prospectively collected paired FFPE and fresh tissues of histopathologically confirmed oral cancer cases reported in Oral Medicine department of a dental hospital for comparative study. Only short PCRs (~ 200 bp) of DNA isolated using a modified xylene-free method displayed a concordant HPV result. For HPV analysis, we used additional 30 retrospectively collected FFPE tissues. DNA isolated from these specimens showed an overall 23.4% (11/47) HPV positivity with detection of HPV18. Comparison of HPV positivity from dental hospital FFPE specimens with overall HPV positivity of freshly collected oral cancer specimens (n = 55) from three cancer care hospitals of the same region showed notable difference (12.7%; 7/55). Further, cancer hospital specimens showed HPV16 positivity and displayed a characteristic difference in reported sub-sites and patient spectrum. Overall, using a xylene-free FFPE DNA isolation method clubbed with short amplicon PCR, we showed detection of HPV-positive oral cancer in dental hospitals.

Targeting Aberrant Expression of STAT3 and AP-1 Oncogenic Transcription Factors and HPV Oncoproteins in Cervical Cancer by Berberis aquifolium

Background: Present study examines phytochemical preparation that uses berberine's plant source B. aquifolium root for availability of similar anti-cervical cancer (CaCx) and anti-HPV activities to facilitate repurposing of the B. aquifolium based drug in the treatment of CaCx. Purpose: To evaluate therapeutic potential of different concentrations of ethanolic extract of B. aquifolium root mother tincture (BAMT) against HPV-positive (HPV16: SiHa, HPV18: HeLa) and HPV-negative (C33a) CaCx cell lines at molecular oncogenic level. Materials and Methods: BAMT was screened for anti-proliferative activity by MTT assay. Cell cycle progression was analyzed by flowcytometry. Then, the expression level of STAT3, AP-1, HPV E6 and E7 was detected by immunoblotting, whereas nuclear localization was observed by fluorescence microscopy. Phytochemicals reportedly available in BAMT were examined for their inhibitory action on HPV16 E6 by in silico molecular docking. Results: BAMT induced a dose-dependent decline in CaCx cell viability in all cell types tested. Flowcytometric evaluation of BAMT-treated cells showed a small but specific cell growth arrest in G1-phase. BAMT-treatment resulted in reduced protein expression of key transcription factors, STAT3 with a decline of its active form pSTAT3 (Y705); and components of AP-1 complex, JunB and c-Jun. Immunocytochemistry revealed that BAMT did not prevent the entry of remnant active transcription factor to the nucleus, but loss of overall transcription factor activity resulted in reduced availability of transcription factors in the cancer cells. These changes were accompanied by gradual loss of HPV E6 and E7 protein in BAMT-treated HPV-positive cells. Molecular docking of reported active phytochemicals in B. aquifolium root was performed, which indicated a potential interference of HPV16 E6's interaction with pivotal cellular targets p53, E6AP or both by constituent phytochemicals. Among these, berberine, palmatine and magnoflorine showed highest E6 inhibitory potential. Conclusion: Overall, BAMT showed multi-pronged therapeutic potential against HPV infection and cervical cancer and the study described the underlying molecular mechanism of its action.

Mechanisms of myocardial injury and clinical outcomes in patients hospitalised with suspected COVID-19

Background

Myocardial injury is associated with adverse outcomes in patients with COVID-19. However, the prognostic role of myocardial injury in COVID-19 compared to other acute illnesses and the underlying mechanisms of injury are poorly understood.

Methods

In a prospective, multi-centre, cohort study conducted in secondary and tertiary care hospitals in Scotland, all consecutive patients with suspected COVID-19 underwent cardiac troponin (ARCHITECTSTAT high-sensitive troponin I (hs-cTnI) assay; Abbott Laboratories) testing in plasma that was surplus to clinical requirements. The results were not reported unless required by the attending clinician. We evaluated the prevalence of myocardial injury, mechanisms and outcomes in all patients. In those with any hs-cTnI concentration above the sex-specific 99th centile the diagnosis was adjudicated according to the 4th Universal Definition of Myocardial Infarction. The primary outcome of all-cause mortality was compared in those with and without myocardial injury and COVID-19 by cox regression adjusted for age, sex, renal function and co-morbidities.

Results

A total of 2,916 (median age 69 [interquartile range, IQR 54–79] years, 53% women) consecutive patients with suspected COVID-19 were followed up for 228 [IQR 203–249] days. Myocardial injury occurred in 26% (750/2,916) with a median troponin concentration of 66 [35–178] ng/L; the prevalence was 41% (46/112) and 25% (704/2,804) in those with and without COVID-19, respectively. The most common mechanism was acute non-ischaemic myocardial injury occurring in 80% (37/46) and 71% (502/704) of patients with and without COVID-19, respectively. Type 1 myocardial infarction (2% and 4%), type 2 myocardial infarction (7% and 14%) and chronic myocardial injury (11% and 11%) were less common and only one patient had confirmed myocarditis. In patients with myocardial injury mortality was increased compared to those without (P&lt;0.001 log rank), whether they had COVID-19 (54% [25/46] versus 26% [17/66]) or not (35% [248/704] versus 14% [294/2100]). Myocardial injury was an independent predictor of death in all patients (adjusted hazard ratio [aHR] 2.04, 95% confidence interval [CI] 1.71 to 2.43), but this excess risk was not higher in patients with COVID-19 (aHR 1.58, 95% CI 0.75 to 3.15) compared to those without the condition (aHR 2.01, 95% CI 1.81 to 2.49).

Conclusion

Myocardial injury is common in hospitalised patients with suspected COVID-19 whether or not COVID-19 was the cause of their presentation. The majority of patients had acute non-ischaemic myocardial injury rather than a defined cardiac condition. Despite this the presence of myocardial injury was an independent predictor of death in all hospitalised patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation Kaplan-Meier curve for all-cause death