A systematic review and meta-analysis of spectral CT to differentiate focal liver lesions

AIM

To determine the feasibility of spectral computed tomography (CT) in the differentiation of focal liver lesions from hepatocellular carcinoma (HCC) using a network meta-analysis (NMA).

MATERIALS AND METHODS

The review was completed in accordance with PRISMA guidelines. Searches of three medical databases were performed. A total of nine articles were found for the qualitative synthesis. The meta-analysis was performed on five studies for the normalised iodine concentration (NIC; which is the iodine concentration in the lesion divided by the iodine concentration in the aorta) and the lesion-normal parenchyma iodine ratio (LNR; which is the iodine concentration in the lesion divided by the iodine concentration in the non-tumour hepatic parenchyma) on portal venous and arterial phase images due to sufficient data.

RESULTS

Spectral CT can be used to differentiate HCC from hepatic haemangioma (HH), focal nodular hyperplasia (FNH), regenerative nodules, neuroendocrine tumours (NETs), abscesses, and angiomyolipoma (AML). Hepatic metastases versus abscess and FNH versus HH could also be differentiated. The NMA demonstrated that HCC, NETs, and regenerative nodules could be differentiated due to lower quantitative iodine values. FNH, AML, and HH all had higher values.

CONCLUSION

Spectral CT shows promise in differentiating focal liver lesions. Studies with larger sample sizes are warranted. Future studies should be performed comparing benign lesions using quantitative markers.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

High-purity solid parahydrogen

Alkali atoms trapped in solid hydrogen matrices have demonstrated ultralong electron spin coherence times and are promising as quantum sensors. Their spin coherence is limited by magnetic noise from naturally occurring orthohydrogen molecules in the parahydrogen matrix. In the gas phase, the orthohydrogen component of hydrogen can be converted to parahydrogen by flowing it over a catalyst held at cryogenic temperatures, with lower temperatures giving a lower orthohydrogen fraction. In this work, we use a single cryostat to reduce the orthohydrogen fraction of hydrogen gas and grow a solid matrix from the resulting high-purity parahydrogen. We demonstrate the operation of the catalyst down to a temperature of 8 K, and we spectroscopically verify that orthohydrogen impurities in the resulting solid are at a level <10^-6. We also find that, at sufficiently low temperatures, the cryogenic catalyst provides isotopic purification, reducing the HD fraction.

Role of Magnetic Resonance Cholangiopancreatography in the Evaluation of Obstructive Jaundice

Background Magnetic Resonance Cholangiopancreatography is a reliable and highly sensitive imaging modality in the diagnosis of Obstructive jaundice. Objective To evaluate the diagnostic accuracy of Magnetic Resonance Cholangiopancreatography as compared to Endoscopic Retrograde Cholangiopancreatography. Method A prospective, analytical study was conducted in the Department of Radiodiagnosis and Imaging at Dhulikhel Hospital between October 2018 and December 2020. Altogether 100 patients of all ages with obstructive jaundice undergoing Magnetic Resonance Cholangiopancreatography and Endoscopic Retrograde Cholangiopancreatography were included. The causes of obstructive jaundice as identified by Magnetic Resonance Cholangiopancreatography were compared to that of Endoscopic Retrograde Cholangiopancreatography considering Endoscopic Retrograde Cholangiopancreatography as gold standard for the diagnosis. Result Magnetic Resonance Cholangiopancreatography revealed choledocholithiasis in 60 (60%) patients, benign stricture - 14(14%), malignant stricture-11(11%), periampullary carcinoma in 8(8%) and normal study in 4(4%) patients. Endoscopic Retrograde Cholangiopancreatography showed choledocholithiasis in 59(59%) patients, strictures (benign in 13%, malignant in 10%), ascariasis in 3(3%) and normal findings in 5(5%) patients. The sensitivity, specificity, positive predictive value and negative predictive value of Magnetic Resonance Cholangiopancreatography in detecting choledocholithiasis were 96.6%, 92.3%, 95%, and 95%. The same values for benign strictures were 92.3%, 97.7%, 85.7% and 98.9%, whereas those for malignant strictures were 90.9%, 98.8%, 90.9% and 98.8%. All values were 100% for peri-ampullary carcinoma and ascariasis. Hence, Magnetic Resonance Cholangiopancreatography showed good accuracy for detecting causes of obstructive jaundice (p < 0.05) as compared to Endoscopic Retrograde Cholangiopancreatography. Conclusion Magnetic Resonance Cholangiopancreatography is an accurate, non-invasive technique in evaluation of obstructive jaundice and offers similar diagnostic value compared to Endoscopic Retrograde Cholangiopancreatography.

Central vein sign for multiple sclerosis: A systematic review and meta-analysis

AIMS

To systematically review the diagnostic value of the central vein sign (CVS) in multiple sclerosis (MS) and to meta-analyse the proportion of positive lesions for CVS needed to distinguish MS from non-MS mimics.

MATERIALS AND METHODS

A literature review was performed and a proportion meta-analysis was performed to examine the proportion of the CVS in MS lesions. Studies reporting a threshold of the CVS containing lesions with 100% diagnostic accuracy were included in the meta-analysis. This was compared to MS mimics in order to establish the discriminative value of the CVS.

RESULTS

The CVS was found to be viable at lower field strengths (3 T and 1.5 T) and automated analysis is currently less accurate than manual counting. Five studies were included for the proportional meta-analysis. From the analysis, a proportion of 45% of lesions having the CVS was suggested given that the findings that the weighted proportion was 46.4% (95% confidence interval [CI]: of 40.3%-52.6%) with low heterogeneity (I² = 0.0%; p=0.5).

CONCLUSION

Although the CVS is a clinically relevant and viable sign, further work is needed to integrate this into the existing diagnostic criteria. As manual determination is a time-consuming process, the development of automated methods will be beneficial. With improvements in computational imaging techniques, the CVS will have an important role in the diagnosis and differentiation of MS.

Can teamwork and situational awareness (SA) in ED resuscitations be improved with a technological cognitive aid? Design and a pilot study of a team situation display

Effective teamwork in ED resuscitations, including information sharing and situational awareness, could be degraded. Technological cognitive aids can facilitate effective teamwork.

OBJECTIVE

This study focused on the design of an ED situation display and pilot test its influence on teamwork and situational awareness during simulated resuscitation scenarios.

MATERIAL AND METHODS

The display design consisted of a central area showing the critical dynamic parameters of the interventions with an events time-line below it. Static information was placed at the sides of the display. We pilot tested whether the situation display could lead to higher scores on the Clinical Teamwork Scale (CTS), improved scores on a context-specific Situational Awareness Global Assessment Technique (SAGAT) tool, and team communication patterns that reflect teamwork and situational awareness.

RESULTS

Resuscitation teamwork, as measured by the CTS, was overall better with the presence of the situation display as compared with no situation display. Team members discussed interventions more with the situation display compared with not having the situation display. Situational awareness was better with the situation display only in the trauma scenario.

DISCUSSION

The situation display could be more effective for certain ED team members and in certain cases.

CONCLUSIONS

Overall, this pilot study implies that a situation display could facilitate better teamwork and team communication in the resuscitation event.

Transport of Liposome Encapsulated Drugs in Voxelized Computational Model of Human Brain Tumors

There are many obstacles in the transport of chemotherapeutic drugs to tumor cells that lead to irregular and non-uniform uptake of drugs inside tumors. The study of these transport problems will help with accurate prediction of drug transport and optimizing treatment strategy. To this end, liposome mediated drug delivery has emerged as an excellent anticancer therapy due to its ability to deliver drugs at site of action and reducing the chances of side effects to the healthy tissues. In this paper, a computational fluid dynamics (CFD) model based on realistic vasculature of human brain tumor is presented. This model utilizes dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) data to account for heterogeneity in tumor vasculature. Porosity of the interstitial space inside the tumor and normal tissue is determined voxel-wise by processing the DCE-MRI images by general tracer kinetic model (GTKM). The CFD model is applied to predict transport of two different types of liposomes (stealth and conventional) in tumors. The amount of accumulated liposomes is compared with accumulated free drug (doxorubicin) in the interstitial space. Simulation results indicate that stealth liposomes accumulate more and remain for longer periods of time in tumors as compared with conventional liposomes and free drug. The present model provides us a qualitative and quantitative examination on the transport and deposition of liposomes as well as free drugs in actual human brain tumors.

Perfusion kinetics in human brain tumor with DCE-MRI derived model and CFD analysis

Cancer is one of the leading causes of death all over the world. Among the strategies that are used for cancer treatment, the effectiveness of chemotherapy is often hindered by factors such as irregular and non-uniform uptake of drugs inside tumor. Thus, accurate prediction of drug transport and deposition inside tumor is crucial for increasing the effectiveness of chemotherapeutic treatment. In this study, a computational model of human brain tumor is developed that incorporates dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) data into a voxelized porous media model. The model takes into account realistic transport and perfusion kinetics parameters together with realistic heterogeneous tumor vasculature and accurate arterial input function (AIF), which makes it patient specific. The computational results for interstitial fluid pressure (IFP), interstitial fluid velocity (IFV) and tracer concentration show good agreement with the experimental results. The computational model can be extended further for predicting the deposition of chemotherapeutic drugs in tumor environment as well as selection of the best chemotherapeutic drug for a specific patient.

Clustering of disulfide-rich peptides provides scaffolds for hit discovery by phage display: application to interleukin-23

BACKGROUND

Disulfide-rich peptides (DRPs) are found throughout nature. They are suitable scaffolds for drug development due to their small cores, whose disulfide bonds impart extraordinary chemical and biological stability. A challenge in developing a DRP therapeutic is to engineer binding to a specific target. This challenge can be overcome by (i) sampling the large sequence space of a given scaffold through a phage display library and by (ii) panning multiple libraries encoding structurally distinct scaffolds. Here, we implement a protocol for defining these diverse scaffolds, based on clustering structurally defined DRPs according to their conformational similarity.

RESULTS

We developed and applied a hierarchical clustering protocol based on DRP structural similarity, followed by two post-processing steps, to classify 806 unique DRP structures into 81 clusters. The 20 most populated clusters comprised 85% of all DRPs. Representative scaffolds were selected from each of these clusters; the representatives were structurally distinct from one another, but similar to other DRPs in their respective clusters. To demonstrate the utility of the clusters, phage libraries were constructed for three of the representative scaffolds and panned against interleukin-23. One library produced a peptide that bound to this target with an IC₅₀ of 3.3 μM.

CONCLUSIONS

Most DRP clusters contained members that were diverse in sequence, host organism, and interacting proteins, indicating that cluster members were functionally diverse despite having similar structure. Only 20 peptide scaffolds accounted for most of the natural DRP structural diversity, providing suitable starting points for seeding phage display experiments. Through selection of the scaffold surface to vary in phage display, libraries can be designed that present sequence diversity in architecturally distinct, biologically relevant combinations of secondary structures. We supported this hypothesis with a proof-of-concept experiment in which three phage libraries were constructed and panned against the IL-23 target, resulting in a single-digit μM hit and suggesting that a collection of libraries based on the full set of 20 scaffolds increases the potential to identify efficiently peptide binders to a protein target in a drug discovery program.

Novel, selective EPO receptor ligands lacking erythropoietic activity reduce infarct size in acute myocardial infarction in rats

Erythropoietin (EPO) has been shown to protect the heart against acute myocardial infarction in pre-clinical studies, however, EPO failed to reduce infarct size in clinical trials and showed significant safety problems. Here, we investigated cardioprotective effects of two selective non-erythropoietic EPO receptor ligand dimeric peptides (AF41676 and AF43136) lacking erythropoietic activity, EPO, and the prolonged half-life EPO analogue, darbepoetin in acute myocardial infarction (AMI) in rats. In a pilot study, EPO at 100U/mL significantly decreased cell death compared to vehicle (33.8±2.3% vs. 40.3±1.5%, p<0.05) in rat neonatal cardiomyocytes subjected to simulated ischemia/reperfusion. In further studies (studies 1-4), in vivo AMI was induced by 30min coronary occlusion and 120min reperfusion in male Wistar rats. Test compounds and positive controls for model validation (B-type natriuretic peptide, BNP or cyclosporine A, CsA) were administered iv. before the onset of reperfusion. Infarct size (IS) was measured by standard TTC staining. In study 1, 5000U/kg EPO reduced infarct size significantly compared to vehicle (45.3±4.8% vs. 59.8±4.5%, p<0.05). In study 2, darbepoetin showed a U-shaped dose-response curve with maximal infarct size-reducing effect at 5μg/kg compared to the vehicle (44.4±5.7% vs. 65.9±2.7%, p<0.01). In study 3, AF41676 showed a U-shaped dose-response curve, where 3mg/kg was the most effective dose compared to the vehicle (24.1±3.9% vs. 44.3±2.5%, p<0.001). The positive control BNP significantly decreased infarct size in studies 1-3 by approximately 35%. In study 4, AF43136 at 10mg/kg decreased infarct size, similarly to the positive control CsA compared to the appropriate vehicle (39.4±5.9% vs. 58.1±5.4% and 45.9±2.4% vs. 63.8±4.1%, p<0.05, respectively). This is the first demonstration that selective, non-erythropoietic EPO receptor ligand dimeric peptides AF41676 and AF43136 administered before reperfusion are able to reduce infarct size in a rat model of AMI. Therefore, non-erythropoietic EPO receptor peptide ligands may be promising cardioprotective agents.

Discovery and Characterization of a Potent Interleukin-6 Binding Peptide with Neutralizing Activity In Vivo

Interleukin-6 (IL-6) is an important member of the cytokine superfamily, exerting pleiotropic actions on many physiological processes. Over-production of IL-6 is a hallmark of immune-mediated inflammatory diseases such as Castleman's Disease (CD) and rheumatoid arthritis (RA). Antagonism of the interleukin IL-6/IL-6 receptor (IL-6R)/gp130 signaling complex continues to show promise as a therapeutic target. Monoclonal antibodies (mAbs) directed against components of this complex have been approved as therapeutics for both CD and RA. To potentially provide an additional modality to antagonize IL-6 induced pathophysiology, a peptide-based antagonist approach was undertaken. Using a combination of molecular design, phage-display, and medicinal chemistry, disulfide-rich peptides (DRPs) directed against IL-6 were developed with low nanomolar potency in inhibiting IL-6-induced pSTAT3 in U937 monocytic cells. Targeted PEGylation of IL-6 binding peptides resulted in molecules that retained their potency against IL-6 and had a prolongation of their pharmacokinetic (PK) profiles in rodents and monkeys. One such peptide, PN-2921, contained a 40 kDa polyethylene glycol (PEG) moiety and inhibited IL-6-induced pSTAT3 in U937 cells with sub-nM potency and possessed 23, 36, and 59 h PK half-life values in mice, rats, and cynomolgus monkeys, respectively. Parenteral administration of PN-2921 to mice and cynomolgus monkeys potently inhibited IL-6-induced biomarker responses, with significant reductions in the acute inflammatory phase proteins, serum amyloid A (SAA) and C-reactive protein (CRP). This potent, PEGylated IL-6 binding peptide offers a new approach to antagonize IL-6-induced signaling and associated pathophysiology.

Comparison of social circumstances, substance use and substance-related harm in soon-to-be-released prisoners with and without intellectual disability

BACKGROUND

The transition out of prison is likely to be a challenging time for prisoners with intellectual disability (ID). However, little evidence exists to inform interventions for people with ID making this transition. In this study we aimed to describe social circumstances, patterns of substance use and substance-related harm in soon-to-be-released prisoners with ID. We compare this group with those without ID, to better understand how the health-related needs of this group compare with the 'mainstream' prison population.

METHODS

Data came from face-to-face, confidential interviews with 1325 adult prisoners in seven adult prisons in Queensland, Australia. Prisoners with ID were identified using the Hayes Ability Screening Index (HASI). We used cross-sectional data to examine (i) demographics and criminographics; (ii) social circumstances; and (iii) substance use and substance use related harm. We compared characteristics of those with and without ID using univariable logistic regression.

RESULTS

Prisoners with ID (n = 115) were more likely than their peers without ID to be male, to identify as Indigenous Australian, and to report low educational attainment (<10 years) and pre-incarceration unemployment. Those with ID reported a high prevalence of poly-drug use (28.0%), unsafe tattooing (51.1%), unsafe sex (91.0%) and HCV infection (55.6%), although differences with their peers were non-significant.

CONCLUSIONS

The health and social needs of prisoners with ID transitioning into the community are a significant concern for researchers, policy makers and practitioners. Our findings highlight the need for proactive, appropriate and targeted service responses from disability, health and justice sectors.

Rehabilitation of an edentulous mouth with severe mandibular ridge resorption using neutral zone impression technique: a case report

Alveolar ridge atrophy poses a clinical challenge towards the fabrication of a successful prosthesis. Resorption of denture bearing areas results in an unstable non-retentive dentures associated with pain and discomfort. Prosthetic Rehabilitation of a patient with severely resorbed ridge is the most challenging therapy a prosthodontist can undertake. For a favourable prognosis of the denture therapy, impression technique selected should be based on the present state of the basal tissue support. This article presents rehabilitation of a patient with severely resorbed mandibular ridge with the application of neutral zone concept being incorporated into impression making in an effort to achieve successful complete denture therapy. Finally, patient had more stable, retentive and functionally efficient complete denture. In conclusion, neutral zone impression technique proved to be a quite effective method for prosthetic rehabilitation of patient with severe mandibular ridge resorption. DOI: http://dx.doi.org/10.3329/bjms.v13i4.15605 Bangladesh Journal of Medical Science Vol.13(4) 2014 p.477-480

Stigma related to tuberculosis among patients attending DOTS clinics of Dharan municipality

BACKGROUND

The patients suffering from tuberculosis are receiving shame and unfair treatment from the people living around them within their own society attending DOTS clinic of Dharan municipality.

OBJECTIVE

To assess the stigma experienced by tuberculosis patients and to find out the association between stigma experienced by Tuberculosis patient and the selected variables (socio-demographic characteristics, clinical profile and illness experience).

METHODS

Descriptive Cross Sectional study was done among sixty tuberculosis patients. Stratified random sampling was used to select the main center and sub center of Tuberculosis treatment and population proportionate simple random sampling using lottery method was done. Data was collected using predesigned, pretested performa from Explanatory Model Interview Catalogue developed by World Health Organization.

RESULTS

The study revealed that 63.3% of the subjects were stigmatized. There was association between stigma and variables such as occupation, monthly family income and past history of Tuberculosis. There was also association of stigma with treatment phase, category of the patient and past outcome of illness.

CONCLUSION

Due to lack of knowledge and awareness about Tuberculosis, many patients were stigmatized. Efforts should be made to educate the public about Tuberculosis to reduce stigma experienced by Tuberculosis patients and improve the compliance of the patient.

RP-HPLC Method for Simultaneous Estimation of Nitazoxanide and Ofloxacin in Tablets

A reverse phase high performance liquid chromatography method was developed for simultaneous estimation of nitazoxanide and ofloxacin in tablet formulation. The separation and quantification was achieved by Hiq Sil C₁₈V Size 4.6 mm Ø ^*250 mm column in isocratic mode, with mobile phase consisting of acetonitrile-methanol-0.4 M citric acid, (60:30:10, v/v/v). Citric acid used to stabilize nitazoxanide and ofloxacin in mobile phase. The mobile phase was pumped at a rate of 0.6 ml/min and the detection was carried out at 304 nm. The retention time of ofloxacin and nitazoxanide was found to be 3.122 and 5.902 min, respectively. The method was validated for linearity, accuracy, and precision. Linearity for ofloxacin and nitazoxanide were in the range 2-36 μg/ml and 5-90 μg/ml, respectively. The developed method was found to be accurate, precise and selective for simultaneous estimation of ofloxacin and nitazoxanide in tablets.

Polymers for colon targeted drug delivery

The colon targeted drug delivery has a number of important implications in the field of pharmacotherapy. Oral colon targeted drug delivery systems have recently gained importance for delivering a variety of therapeutic agents for both local and systemic administration. Targeting of drugs to the colon via oral administration protect the drug from degradation or release in the stomach and small intestine. It also ensures abrupt or controlled release of the drug in the proximal colon. Various drug delivery systems have been designed that deliver the drug quantitatively to the colon and then trigger the release of drug. This review will cover different types of polymers which can be used in formulation of colon targeted drug delivery systems.

Sepbox technique in natural products

Natural compounds still play an increasingly important role in many areas of research and development. Their structural diversity is enhanced by the synthetic potential of combinatorial chemistry. Fractionation and separation of samples obtained from nature remain time-consuming, tedious and extremely expensive even though the assays for testing these samples have become faster and more cost-effective thanks to advanced high-throughput screening (HTS) processes. Today, sepbox is the standard technology used for separating compounds from natural resources. Fractionations and separation of samples obtained from nature remain very difficult. Automation of sample preparation therefore has great economic potential. The unique sepbox concept allows processing sample automatically and will make up to 30 times faster than by using a conventional process.

Fitting Community Based Newborn Care Package into the health systems of Nepal

Community-based strategies for delivering effective newborn interventions are an essential step to avert newborn death, in settings where the health facilities are unable to effectively deliver the interventions and reach their population. Effective implementation of community-based interventions as a large scale program and within the existing health system depends on the appropriate design and planning, monitoring and support systems. This article provides an overview of implementation design of Community-Based Newborn Care Package (CB-NCP) program, its setup within the health system, and early results of the implementation from one of the pilot districts. The evaluation of CB-NCP in one of the pilot districts shows significant improvement in antenatal, intrapartum and post natal care. The implementation design of the CB-NCP has six different health system management functions: i) district planning and orientation, ii) training/human resource development, iii) monitoring and evaluation, iv) logistics and supply chain management, v) communication strategy, and vi) pay for performance. The CB-NCP program embraced the existing system of monitoring with some additional components for the pilot phase to test implementation feasibility, and aligns with existing safe motherhood and child health programs. Though CB-NCP interventions are proven independently in different local and global contexts, they are piloted in 10 districts as a "package" within the national health system settings of Nepal.

State of maternal, newborn and child health programmes in Nepal: what may a continuum of care model mean for more effective and efficient service delivery?

The cost-effective interventions exist across the continuum of maternal to child survival at each level of the health system that can contribute to achieve the Millennium Development Goals 4 and 5. However, implementation inefficiency, low coverage and equity gaps along this continuum remain a serious challenge to Nepal's efforts to achieve these goals. This paper proposes a continuum of care model; discusses the readiness of policy and programs to provide high impact interventions across the continuum; identifies existing gaps in MNCHN programs; and recommends policy and program actions to improve coverage, equity, effectiveness and efficiency along the continuum of MNCHN service delivery in Nepal. The literature review includes systematic desk review, followed by discussions and deliberations amongst a group of professionals and MNCH experts in Nepal. Within the government health system in Nepal, a continuum of care approach is feasible, as policies and plans exist to ensure an integrated approach across the maternal to child care continuum. However, health programs largely remain vertically oriented. Achieving integration across the maternal to child continuum of care remains a challenge at each level of health system. An integrated system of program management for maternal, newborn and child health would be a feasible solution to enable an efficient and effective delivery of intervention packages. A collaborative and partnership approach to strengthen health systems, building managerial capacity, improving governance and engaging the private and civil sectors remains vital to achieve effective coverage and improve equity across the continuum of care.

Hordeum vulgare hull in the design of fast disintegrating tablets

In the present study, fast disintegrating tablets were designed with a view to enhance patient compliance. In this method, the hull of Hordeum vulgare, cross carmellose sodium, and sodium starch glycolate were used as superdisintegrants (4 and 6%), along with microcrystalline cellulose and mannitol, to enhance mouth feel. The prepared batches of tablets were evaluated for hardness, friability, drug content uniformity, wetting time, water absorption ratio and in vitro dispersion time. Based on the in vitro dispersion time, the formulations were tested for the in vitro drug release pattern. Tablets having H. vulgare hull showed the release profile comparable to those tablets having sodium starch glycolate and cross carmellose sodium.

Modeling optical properties of human skin using Mie theory for particles with different size distributions and refractive indices

We used size distributions of volume equivalent spherical particles with complex refractive index to model the inherent optical properties (IOPs) in four different layers of human skin at ten different wavelengths in the visible and near-infrared spectral bands. For each layer, we first computed the size-averaged absorption coefficient, scattering coefficient, and asymmetry factor for the collection of particles in a host medium using Mie theory and compared these IOPs in each layer with those obtained from a bio-optical model (BOM). This procedure was repeated, using an optimization scheme, until satisfactory agreement was obtained between the IOPs obtained from the particle size distribution and those given by the BOM. The size distribution as well as the complex refractive index of the particles, obtained from this modeling exercise, can be used to compute the phase matrix, which is an essential input to model polarized light transport in human skin tissue.

Zero order spectrophotometric method for estimation of escitalopram oxalate in tablet formulations

A new, simple, fast and reliable zero order spectrophotometric method has been developed for determination of Escitalopram Oxalate in bulk and tablet dosage forms. The quantitative determination of drug was carried out using the zero order values (absorbance) measured at 238 nm. Calibration graph constructed at 238 nm was linear in concentration range of 2-20 µg/ml with correlation coefficient 0.9999. The method was found to be precise, accurate, specific, and validated as per ICH guidelines and can be used for determination of Escitalopram Oxalate in tablet formulations.

Pneumatoceles in preterm infants-incidence and outcome in the post-surfactant era

OBJECTIVE

Pneumatoceles are gas-filled cysts within the lung parenchyma resulting mostly from ventilator-induced lung injury and air-leak in premature infants with respiratory distress syndrome. The use of surfactant in the treatment of respiratory distress syndrome has resulted in a decrease in the incidence of air-leak disease. Our aim was to study the incidence and clinical course of pneumatoceles in the surfactant era.

STUDY DESIGN

A retrospective study of infants born at < or =30 weeks gestational age was admitted to the University of Connecticut Health Center NICU from 1998 to 2007. Pneumatoceles and other intrathoracic air-leaks were identified and comparisons were made with infants without these conditions.

RESULT

Pneumatoceles were identified in 19 preterm infants, born at gestational age < or =30 weeks, needing positive pressure ventilation for respiratory distress syndrome between the years 1998 to 2007. Pneumatoceles appeared early (median, 7th day of life; range, 1st to 28th day of life) and usually resolved with decrease in mean airway pressure (median, 4 days; range, 3 to 125 days). The majority of pneumatoceles were located in the right parahilar region (18/19). Associated intrathoracic air-leaks were pulmonary interstitial emphysema (5/19), pneumothorax (10/19), and pneumomediastinum (1/19). None of the infants required any invasive procedures to alleviate the pneumatoceles. In infants who survived, most pneumatoceles resolved with a decrease in mean airway pressure or extubation (14/15). One infant had a persistent pneumatocele for 125 days without any cardiopulmonary compromise and five infants died as a result air-leaks along with other complications of prematurity.

CONCLUSION

Pneumatoceles are a manifestation of intrathoracic air-leaks of prematurity. They are markers for ventilator-induced lung injury and are associated with significant mortality similar to other intrathoracic air-leaks. However, conservative management with reduction in mean airway pressure is effective in the resolution of this condition and interventional decompression of the pneumatocele is generally not necessary.

DNA as therapeutics; an update

Human gene therapy is the introduction of new genetic material into the cells of an individual with the intention of producing a therapeutic benefit for the patient. Deoxyribonucleic acid and ribonucleic acid are used in gene therapy. Over time and with proper oversight, human gene therapy might become an effective weapon in modern medicine's arsenal to help fight diseases such as cancer, acquired immunodeficiency syndrome, diabetes, high blood pressure, coronary heart disease, peripheral vascular disease, neurodegenerative diseases, cystic fibrosis, hemophilia and other genetic disorders. Gene therapy trials in humans are of two types, somatic and germ line gene therapy. There are many ethical, social, and commercial issues raised by the prospects of treating patients whose consent is impossible to obtain. This review summarizes deoxyribonucleic acid-based therapeutics and gene transfer technologies for the diseases that are known to be genetic in origin. Deoxyribonucleic acid-based therapeutics includes plasmids, oligonucleotides for antisense and antigene applications, deoxyribonucleic acid aptamers and deoxyribonucleic acidzymes. This review also includes current status of gene therapy and recent developments in gene therapy research.

Effect of Erythromycin on Gastric Emptying Time of Low Birth Weight Babies

BACKGROUND

To study the promotility effects of low dose erythromycin on gastric emptying time in a population of normal low birth weight (LBW) neonates on breast feeds with or without nutritional supplements and human milk fortifier (HMF).

METHOD

A randomised control trial involving 50 neonates was undertaken and they were given 6mg/kg/day of oral erythromycin or placebo in three divided doses for four consecutive days in the first two weeks of life. The gastric emptying time (GET) was assessed ultrasonographically by measuring the decrease in the antral cross sectional area (ACSA). The time taken for the ACSA to become half the prefeed value, was taken as t/2 or half GET. The babies were also assessed for pre and post intervention side effects of the drug. The results were analysed using SPSS ver 11.5.

RESULTS

The test group showed a significant decrease in GET after the intervention. This effect was mainly seen in the preterm babies as compared to term Small for Gestational Age (SGA) babies. The decrease in GET was more in babies born after 34 weeks of gestation as compared to smaller babies. The reduction in GET was seen in babies on breast milk alone and nutritional supplements with breast milk but not when HMF was added. No side effects of the drug were noted.

CONCLUSION

Low dose erythromycin is a safe way of decreasing gastric emptying in preterm babies born after 34 weeks of gestation in the first two weeks of life.

Miglustat has no apparent effect on spermatogenesis in normal men

BACKGROUND

In mice, administration of the glycosphingolipid biosynthesis inhibitor miglustat results in reversible infertility, characterized by impaired sperm motility and markedly abnormal sperm morphology. This observation suggested that miglustat might have utility for fertility control in man. To ascertain the impact of miglustat on human spermatogenesis, we conducted a pilot study of miglustat administration in normal men.

METHODS

After a 2-week baseline period, seven normal men were administered miglustat 100 mg, orally, twice daily for 6 weeks. During treatment, subjects had frequent seminal fluid analyses to assess the impact of treatment on sperm concentration, motility and morphology and the ability to undergo the acrosome reaction by in vitro assays.

RESULTS

Five subjects completed all aspects of the study. In these subjects, there was no apparent effect of miglustat on sperm concentration, motility or sperm morphology after 6 weeks of therapy. In addition, no changes in acrosome structure or function were observed with treatment, despite therapeutic concentrations of miglustat in the serum and seminal plasma. All subjects experienced gastrointestinal upset, diarrhoea and mild weight loss during treatment. No other abnormalities in blood counts, serum chemistries, vision or overall health were observed.

CONCLUSION

In contrast to the observations in mice, the oral administration of miglustat does not appear to affect human spermatogenesis. Further elucidation of the mechanism underlying the species specificity of miglustat may improve our understanding of the role of glycosphingolipids in spermatogenesis and result in alternative approaches to male fertility control.

Discovery and structure–activity relationships of novel sulfonamides as potent PTP1B inhibitors

A series of novel sulfonamides containing a single difluoromethylene-phosphonate group were discovered to be potent inhibitors of protein tyrosine phosphatase 1B. Structure-activity relationships around the scaffold were investigated, leading to the identification of compounds with IC50 or Ki values in the low nanomolar range. These sulfonamide-based inhibitors exhibit 100 and 30 times higher inhibitory activity than the corresponding tertiary amines and carboxamides, respectively.

Alpha,alpha-difluoro-beta-ketophosphonates as potent inhibitors of protein tyrosine phosphatase 1B

A novel series of inhibitors that contain an aryl alpha,alpha-difluoro-beta-ketophosphonate group has been synthesized and evaluated against protein tyrosine phosphatase 1B. These compounds exhibit strong inhibitory activity, the best of which has a K(i) value of 0.17 microM. These results demonstrate that aryl alpha,alpha-difluoro-beta-ketophosphonates are powerful phosphotyrosine mimetics for the development of potent PTP inhibitors.

Effectiveness of Teaching of Neonatal Resuscitation Programme at a Workshop for a Mixed Population of Medical Personnel

We evaluated the effectiveness of teaching at a neonatal resuscitation programme (NRP) workshop held for 35 medical personnel (including postgraduate trainee doctors, general duty medical officers, nursing officers and probationer nurses) using a one-group pretest-posttest design. None of the participants had any formal exposure to the NRP guidelines. A pre-workshop test of 20 multiple-choice questions was administered to all the participants. At the end of the workshop, the same 20 questions were administered and the two scores compared using t-test for paired data on SPSS statistical software. The mean pre-workshop score was 9.03 (SD 2.66) which improved to a mean of 15.53 (SD 1.93) post-workshop. This improvement was highly significant with p < 0.0001 (two-tailed) and the 95% confidence interval being -7.41 to -5.59. Subgroup analysis revealed that nursing officers and probationer nurses showed highly significant improvement in the post-workshop scores while trainee doctors doing Medicine, Pediatrics and the general duty medical officers showed statistically significant improvement in the post-workshop scores. This study shows that a medical workshop is an effective means of imparting knowledge to a mixed group of medical personnel.

The technique of apical dissection of the prostate and urethrovesical anastomosis in robotic radical prostatectomy

OBJECTIVE

To describe the technique of dissecting the apex of the prostate and a modified single running-suture urethrovesical anastomosis in patients undergoing robot-assisted radical prostatectomy for organ-confined prostate cancer.

PATIENTS AND METHODS

Over 550 robot-assisted radical prostatectomies have been undertaken using Vattikuti Institute Prostatectomy (VIP) technique in patients with localized carcinoma of the prostate. We present a critical analysis of the first 120 procedures by one surgeon (M.M.) at our institution using this newly developed technique of urethrovesical anastomosis preceded by dissecting the apex of the prostate.

RESULTS

The mean time for the urethrovesical anastomosis was 13 min. All but 24 patients had their catheter removed 4 days after surgery, as indicated by a cystogram. The catheter was removed successfully at 7 days in the remaining 24 patients who had a mild leak on cystography. Two patients had urinary retention within a week of removing the catheter and had to be re-catheterized. Continence was evaluated using standardized criteria before and after the procedure. The patients also replied to a mailed validated questionnaire survey; 96% were continent at 3 months and the remaining 4% used a thin pad for security.

CONCLUSIONS

We report a technique of dissecting the apex of the prostate and prostatovesical junction for dividing the bladder neck, and a modified single running-suture urethrovesical anastomosis, in patients undergoing robot-assisted radical prostatectomy for organ-confined cancer of the prostate. The same principles can also be applied for the anastomosis during pure laparoscopic procedures and for urethro-neovesical anastomosis in patients undergoing robotic radical cystoprostatectomy for carcinoma of the bladder.

Counting respiratory rate in infants under 2 months: comparison between observation and auscultation

The World Health Organization's global programme for the control of acute respiratory infections relies on counting respiratory rate (RR) by observing abdominal and chest movements in order to diagnose pneumonia. However, few studies on the reliability of the observation method have been published. We counted RR simultaneously by observation and auscultation in 100 healthy infants at 1, 2, 4, 6 and 8 weeks of age for 15, 30 and 60 sec, and compared RRs obtained by the two methods. In all the age groups studied, the co-efficients of variation for the RRs recorded by observation or auscultation were similar. The mean RR by observation was higher by 1-3 breaths/min than mean RR by auscultation (p < 0.001). The 95% confidence interval (+/-2 SD) for the difference between RR by the two methods ranged from +5 to -8 breaths/min for RR counted for 1 full minute. Our data support the assumption that observation is as reliable as auscultation for counting RR.