Treacher Collins Syndrome: A Case Report

Treacher collins syndrome (TCS) or Franceschetti syndrome is an autosomal dominant inherited disorder with variable expressivity. It affects mainly craniofacial structure that derives from 1st and 2nd branchial arches approximately between the 20th day and 12th week of intrauterine life. This syndrome has different clinical types. Most common features are antimongoloid slanting of the palpebral fissures, hypoplasia of zygoma, maxilla & mandible with various eye and ear abnormalities. Here we present a case of an 11 days old female neonate, who was ill looking, dyspnoeic having significant facial profile, multiple congenital anomalies and dolicocephaly; admitted in the department of Neonatology, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh on 7th August 2020. After taking all the diagnostic assistance of the multidisciplinary approach mainly on the basis of clinical features and radiology we diagnosed the case as TCS. We managed the patient by maintaining temperature, giving nutritional support and injectable antibiotic, took consultation from Otolaryngology department then we discharged the baby with proper counseling, advised regarding further follow up and to consult with paediatric surgeon and cardiologist.

Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart

BACKGROUND

Oshikhandass is a rural village in northern Pakistan where a 1989-1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality. Intensive surveillance, active community health education and child health interventions were delivered in 1989-1996; here we assess improvements in under-5 mortality, diarrhea, and pneumonia over this period and 15 years later.

METHODS

Two prospective open-cohort studies in Oshikhandass from 1989 to 1996 (Study 1) and 2011-2014 (Study 2) enrolled all children under age 60 months. Study staff trained using WHO guidelines, conducted weekly household surveillance and promoted knowledge on causes and management of diarrhea and pneumonia. Information about household characteristics and socioeconomic status was collected. Hurdle models were constructed to examine putative risk factors for diarrhea and pneumonia.

RESULTS

Against a backdrop of considerable change in the socioeconomic status of the community, under-5 mortality, which declined over the course of Study 1 (from 114.3 to 79.5 deaths/1000 live births (LB) between 1989 and 1996), exceeded Sustainable Development Goal 3 by Study 2 (19.8 deaths/ 1000 LB). Reductions in diarrhea prevalence (20.3 to 2.2 days/ Child Year [CY]), incidence (2.1 to 0.5 episodes/ CY), and number of bloody diarrhea episodes (18.6 to 5.2%) seen during Study 1, were sustained in Study 2. Pneumonia incidence was 0.5 episodes /CY in Study 1 and 0.2/CY in Study 2; only 5% of episodes were categorized as severe or very severe in both studies. While no individual factors predicted a statistically significant difference in diarrhea or pneumonia episodes, the combined effect of water, toilet and housing materials was associated with a significant decrease in diarrhea; higher household income was the most protective factor for pneumonia in Study 1.

CONCLUSIONS

We report a 4-fold decrease in overall childhood mortality, and a 2-fold decrease in childhood morbidity from diarrhea and pneumonia in a remote rural village in Pakistan between 1989 and 2014. We conclude that significant, sustainable improvements in child health may be achieved through improved socioeconomic status and promoting interactions between locally engaged health workers and the community, but that continued efforts are needed to improve health worker training, supervision, and the rational use of medications.

TRIAL REGISTRATION

Not Applicable.

Abstract P2-12-01: Dose- and exposure-response relationship and biomarker correlation analysis in breast tumors from patients treated with capivasertib, an AKT inhibitor, in the STAKT randomized, placebo controlled pre-surgical study

Background: Capivasertib (AZD5363), an AKT1,2,3 inhibitor, significantly improved progression-free and overall survival when added to paclitaxel in triple negative breast cancer (BC) patients (Schmid et al. ASCO 2018). We have previously reported in STAKT, robust target inhibition at 480mg BD versus placebo, including significant decreases in the primary biomarkers (PBs) - Ki67, pPRAS40 & pGSK3β - in primary BCs (Robertson et al. SABCS 2017). We now report the dose- and exposure-response relationship of capivasertib and the correlation between primary and secondary (pAKT, pS6, nuclear FOXO3a) tumor biomarkers.

Design: STAKT was a two-stage, double blind, randomized, placebo controlled 'window-of-opportunity' trial in newly diagnosed ER+ BC patients. Stage 1 assessed capivasertib at a dose of 480mg BD p.o. versus placebo. Stage 2 assessed capivasertib at two lower doses 360mg and 240mg BD. Tumor biopsies were taken prior to 1st dose and after 4.5 days of dosing. Evaluable patients (who required pre-defined minimum baseline PD values for PBs) included placebo (n=11), capivasertib at 480mg (n=17), 360mg (n=5) and 240mg (n=6). Blood samples for pharmacokinetic (PK) studies were scheduled at pre-dose; 2, 4, optional 6 & 8 hrs post first dose on Day 1; ˜2-4 h post last dose on Day 5 (before biopsy). The % change from baseline for PBs were evaluated against the following exposure variables (placebo=0): i) Dose, ii) Observed Cmax Day 1 (˜2h post-dose), iii) Observed plasma concentration on Day 5, iv) Model-predicted plasma concentration Day 5 at time of biopsy, and v) Model-predicted AUC on Day 5. Spearman correlation coefficient measured the strength and direction of association between biomarkers.

Results:

· Significant mean reductions in % change from baseline were observed for the PBs pGSK3β (-39%; p<0.006), pPRAS40 (-50%; p<0.0001) and Ki67 (-23%; p=0.052) at 480mg versus placebo. At 360mg and 240mg, mean % changes from baseline in pGSK3β were -27% and -9%, respectively; in pPRAS40 -45% and -28%, respectively; and in Ki67 0% and +22%, respectively.

· Dose-response relationships for individual % change from baseline could be described by an Emax model for all PBs. Overall, the correlation to PK exposure (observed or predicted) was similar to the correlation to dose.

· Correlation coefficient analyses between biomarkers at capivasertib 480mg BD identified- i) Positive correlations for pGSK3β with Ki67 (ρ = 0.52, p-value < 0.05) & with pS6 (ρ = 0.54, p-value<0.05); ii) Negative correlations between FOXO3a and Ki67 (ρ = -0.75, p-value<0.001) pGSK3β (ρ = -0.71, p-value<0.001) & also pS6 (ρ = -0.61, p-value<0.001).Correlation coefficients for lower doses are not robust due to small sample size in these groups.

Conclusions

· Capivasertib caused dose- and concentration- dependent effects on biomarkers after only 4.5 days.

· Significant changes in the PBs were demonstrated at 480 mg BD. Biomarker changes was observed at 360mg and 240mg BD, but statistical analysis was limited by the small sample size at lower doses.

· Correlation between a number of tumor biomarkers (relative changes) were identified for capivasertib 480mg BD.

Citation Format: Gee J, Coleman RE, Cheung KL, Evans A, Holcombe C, Skene A, Rea D, Ahmed S, Jahan A, Horgan K, Rauchhaus P, Littleford R, Finlay P, Cheung A, Cullberg M, de Bruin E, Foxley A, Koulai L, Pass M, Schiavon G, Rugman P, Deb R, Robertson JFR. Dose- and exposure-response relationship and biomarker correlation analysis in breast tumors from patients treated with capivasertib, an AKT inhibitor, in the STAKT randomized, placebo controlled pre-surgical study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-12-01.

Abstract P4-04-06: AZD5363, an AKT inhibitor, significantly inhibits key biomarkers of the AKT pathway and Ki67, in a randomized, placebo, controlled study (STAKT) in human breast cancers

Background: AKT is an important intracellular control point through which Type 1 growth factors and IGFR signal. Mutations in PIK3CA, AKT and PTEN are prevalent in estrogen receptor positive (ER+) breast cancer (BC) and have been implicated in resistance to endocrine therapies. AZD5363 is an inhibitor of AKT 1, 2 and 3 currently in Phase 2 trials for BC and other solid cancers.

Design: The study examined whether AZD5363 impacts on key biomarkers within the AKT pathway and their subsequent effects on Ki67, a marker of tumor proliferation. STAKT is a multi-center, two-stage, double blind, randomized, placebo controlled, biomarker 'window-of-opportunity' trial in women with newly diagnosed, previously untreated ER+ BC who were deemed would require chemotherapy as part of their primary treatment regimen. Stage 1 assessed AZD5363 at a dose of 480mg bd p.o. versus matching placebo. Up to 30 patients per arm were permitted, to allow 12 subjects per arm with evaluable paired biopsies - obtained at baseline, and after 4.5 days of AZD5363 / placebo. Primary endpoint markers were pPRAS40, pGSK3β and Ki67 assessed by immunohistochemistry. pPRAS40 and pGSK3β were assessed by H-scores and measured separately for cytoplasmic (cyto), nuclear (nuc) and total (cyto+nuc) staining. Ki67 was assessed as % positive staining of 500 tumor nuclei. Laboratory staff were blinded to treatment arm and whether the biopsies were taken before or after AZD5363/placebo. Changes in marker expression (both absolute and %) between biopsies were calculated, and compared between the two groups. An ANOVA test was applied for normally distributed data and Wilcoxon Mann-Whitney used if not normally distributed.

Results: 28/36 patients were evaluable with patient & tumor characteristics as follows: 17 received AZD5363 and 11 placebo; the median ages were 48 & 49 years respectively. 27 patients were Caucasian and 1 African-American. Tumors were all ER+. For HER2 status 8 were positive & 9 negative in the AZD5363 treated group compared to 2 & 9 respectively in the placebo group.

For pPRAS40 and pGSK3β cyto was the predominant staining while for Ki67 staining was nuclear. Changes in each marker with associated p-values are shown in the table.

MarkerType of change vs baselineDegree of change in AZD5363 arm (n=17)p-value versus placebo arm (n=11)pPRAS40 (H-score)TotalAbsolute-83.8<0.0001Total%-50.2<0.0001CytoAbsolute-90.0<0.0001Cyto%-55.8<0.0001NucAbsolute+6.90.42Nuc%+8.90.94pGSK3β (H-score)TotalAbsolute-55.30.006Total%-39.00.006CytoAbsolute-53.60.006Cyto%-39.20.006NucAbsolute-2.80.065Nuc%-36.50.058Ki67 (% cells+)Absolute-9.60.031%-29.40.052

Conclusions• AZD5363 for 4.5 days caused highly significant falls in pGSK3β and pPRAS40, key markers of AKT pathway activation

• AZD53643 also caused a significant decline in Ki67 even after only 4.5 days of drug. This is one of the shortest 'window'-studies to report such an early effect on proliferation.

• Placebo controlled 'window' studies of this short duration can provide important evidence of the therapeutic potential early in a drug's development.

Citation Format: Robertson JFR, Coleman RE, Cheung KL, Evans A, Holcombe C, Skene A, Rea D, Ahmed S, Jahan A, Kelly S, Horgan K, Rauchhaus P, Littleford R, Foxley A, Lindemann JPO, Pass M, Rugman P, Deb R, Finlay P, Gee JMW. AZD5363, an AKT inhibitor, significantly inhibits key biomarkers of the AKT pathway and Ki67, in a randomized, placebo, controlled study (STAKT) in human breast cancers [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-04-06.

Abstract P3-06-03: The short term effects of an AKT inhibitor (AZD5363) on biomarkers of the AKT pathway and anti-tumour activity in a breast cancer paired biopsy study (STAKT trial)

This abstract was withdrawn by the authors.

Application of TOPSIS and VIKOR improved versions in a multi criteria decision analysis to develop an optimized municipal solid waste management model

Selecting a suitable Multi Criteria Decision Making (MCDM) method is a crucial stage to establish a Solid Waste Management (SWM) system. Main objective of the current study is to demonstrate and evaluate a proposed method using Multiple Criteria Decision Making methods (MCDM). An improved version of Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) applied to obtain the best municipal solid waste management method by comparing and ranking the scenarios. Applying this method in order to rank treatment methods is introduced as one contribution of the study. Besides, Viekriterijumsko Kompromisno Rangiranje (VIKOR) compromise solution method applied for sensitivity analyses. The proposed method can assist urban decision makers in prioritizing and selecting an optimized Municipal Solid Waste (MSW) treatment system. Besides, a logical and systematic scientific method was proposed to guide an appropriate decision-making. A modified TOPSIS methodology as a superior to existing methods for first time was applied for MSW problems. Applying this method in order to rank treatment methods is introduced as one contribution of the study. Next, 11 scenarios of MSW treatment methods are defined and compared environmentally and economically based on the waste management conditions. Results show that integrating a sanitary landfill (18.1%), RDF (3.1%), composting (2%), anaerobic digestion (40.4%), and recycling (36.4%) was an optimized model of integrated waste management. An applied decision-making structure provides the opportunity for optimum decision-making. Therefore, the mix of recycling and anaerobic digestion and a sanitary landfill with Electricity Production (EP) are the preferred options for MSW management.

Familial, Social and Environmental Risk Factors in Autism: A Case-Control Study

This case-control study was done to identify the correlation between the familial, social and environmental risk factors and autism. This hospital and specialized centre based study done from January 2002 to November, 2004. Thirty two children from the autism group and 14 children from the control group were enrolled. Mean age were 3.75 yrs. and 2.83 yrs. respectively. Significant proportion of children were in the highest birth orders, 68.8% in autism and 78.6% in the control group. Full term children were 96.9% and 92.9% respectively. 53.1% children in the autism and 57.1% in the normal speech delay group were born by cesarean sections. Higher education of parents in autism group was statistically significant (p<0.05). Too much watching TV, inadequate opportunity to mix with peers and inadequate interactive relationship with the family members in the early childhood were significantly (p= 0.001) related to the development of autism.Bangladesh Med Res Counc Bull 2014; 40 (3): 113-117

Endothelial function, arterial wall mechanics and intima media thickness in juvenile idiopathic arthritis

OBJECTIVES

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease of children which might persist into adulthood. Systemic inflammation seen in adult RA patients has been shown to be associated with alteration in endothelial function, arterial wall mechanics and intima media thickness. Our study was planned to assess similar changes in JIA patients.

METHODS

Thirty-one newly diagnosed JIA patients and a similar number of age- and sex-matched controls were enrolled in the study. Endothelial function was assessed by measuring flow mediated dilation and glyceryl trinitrate (GTN)-mediated dilation of the brachial artery. To assess arterial stiffness, various arterial wall mechanic parameters such as cross-sectional compliance, cross-sectional distensibility, shear stress and elastic modulus were derived. Intima media thickness of the common carotid artery was measured as a marker of subclinical atherosclerosis.

RESULTS

The brachial artery diameter at rest was found to be slightly lower in the patients than controls (0.258 ± 0.042 vs. 0.264 ± 0.039; p=0.54). No significant difference was found in flow mediated dilation (17.71 ± 9.26 vs. 16.31 ± 8.23; p=0.53), GTN mediated dilation (25.25 ± 10.02 vs. 23.66 ± 9.79; p=0.53) or FMD: GTN mediated dilation ratio (0.730 ± 0.432 vs. 0.717 ± 0.280; p=0.89) between the cases and controls. There was also no significant difference in carotid artery intima media thickness (0.065 ± 0.0068 vs. 0.068 ± 0.007; p=0.084) between cases and controls. Cases in different subsets of JIA were also analysed separately with regards to FMD, GTN mediated dilation and cIMT but no difference was found between cases in each subset and their controls. Cross-sectional compliance was significantly lower in cases than controls (0.0016 ± 0.0005 vs. 0.002 ± 0.001; p=0.034). Cross-sectional distensibility (0.009 ± 0.003 vs. 0.011 ± 0.006; p=0.14) was also found to be lower whereas diastolic wall shear stress (299.9 ± 47.08 vs. 294.9 ± 59.5; p=0.72) and elastic modulus (1138.5 ± 1085.8 vs. 911 ± 453; p=0.19) were found to be higher in cases as compared to controls. But these differences were not statistically significant. When the subsets were analysed separately for vessel wall indices, cross-sectional compliance was found to be significantly lower in systemic arthritis patients as compared to controls. A high level of intra- and inter-observer agreement was found for all the ultrasonographically evaluated parameters.

CONCLUSIONS

Arterial wall indices were found altered in JIA patients indicating increased arterial stiffness. Larger studies are required to assess endothelial dysfunction, intima media thickness and arterial stiffness in each subset of JIA patients.

Detection of tropical bovine theileriosis by polymerase chain reaction in cattle

Tropical bovine theileriosis, a tick borne disease, caused by, Theileria annulata with marked clinical signs of pyrexia (102-105 °F), enlargement of lymphnodes etc., causes heavy economic losses in terms of high mortality and morbidity rates. Diagnosis of theileriosis is mainly based on clinical symptoms and microscopic examination of stained blood smears and lymph node biopsy smears but limitations of these methods against Theileria sp. limits the specificity. Hence, to overcome the limitations, the present study reports the detection of T. annulata in blood samples of cattle by polymerase chain reaction. The study was conducted on 155 cattle having typical clinical symptoms and blood smear after staining with Giemsa stain was examined for the presence of T. annulata in RBC. The Primer sequences were used as per d'Oliveira et al. The assay employs primers specific for the gene encoding the 30-kDa major merozoite surface antigen of T. annulata and the amplification of 721 bp was done. Out of the total 155 animals, 34 were positive for T. annulata by blood smear method whereas 134 samples were positive by PCR. So diagnosis of blood samples by PCR is found to be the most sensitive and specific methodology as compared to cytological blood smear examination. The sensitivity was 23.88 % and specificity was 90.47 % of blood smear method considering PCR as gold standard and it was found that PCR is more sensitive than the conventional method of examination.

An introduction to digital cameras

BACKGROUND AND OBJECTIVES

People in all walks of life are using digital cameras instead of the traditional film cameras. Reasons include simplicity of use, ease of development, ability to incorporate the pictures into documents, potential to edit the pictures easily, and capability to send them by e-mail. This article will briefly discuss digital cameras, how they work, what they can do, and what you should look for in one. Editor's Note: This is the fourth in a series of articles demonstrating and describing information technology. The articles include nontechnical information and are geared toward the computer novice with interest in regional anesthesia and pain medicine.