A retrospective audit of the timescales involved in the diagnosis and management of suspected Achilles tendon ruptures at a single National Health Service trust: A quality service improvement and redesign project

Introduction

The Achilles tendon is the most frequently ruptured tendon. Prompt diagnosis of this injury ensures optimal management decisions are instituted early ensuring the best outcome and patient experience, at minimal cost to the United Kingdom National Health Service. Despite this, regional and national variations to diagnosis and management exist, with anecdotal evidence of inefficiencies in the local patient pathway. To explore this further, a retrospective departmental audit of timescales from presentation to ultrasound diagnosis and definitive treatment decision was undertaken.

Methods

All suspected Achilles tendon ruptures in 2018 were identified through electronic and written patient records, and information on timescales involved in the diagnosis and management of each compiled. Descriptive statistics were used to map each step of the pathway and timescales involved, with performance assessed against local departmental standards and the Swansea Morriston Achilles Rupture Treatment (SMART) protocol.

Results

In total, 119 patients were identified, of which 113 received an ultrasound examination. Local departmental standards were met in the majority of cases, with 78% (n = 88) diagnosed by ultrasound within one week of the request and 83% (n = 91) given a treatment decision within two weeks of presentation. However, this was suboptimal when compared with timeframes utilised for developing the SMART protocol, with only 7% (n = 8) scanned within 48 hours of presentation.

Conclusions

Key areas of the patient pathway were identified for quality service improvement and redesign, with multidisciplinary discussion resulting in the development of a revised patient pathway which expedites diagnosis and treatment for these injuries.

GPUPeP: Parallel Enzymatic Numerical P System simulator with a Python-based interface

Membrane computing is a computational paradigm inspired by the structure and behavior of a living cell. P Systems are the computing devices that are used to realize membrane computing models. Numerous theoretical studies on many variants of P Systems have shown them to be computationally universal. There is a wide range of applications of P Systems from modeling of biological processes to image processing. Among many variants of P Systems, one of the most important is Enzymatic Numerical P System (ENPS). ENPS is a class of P System in which membranes operate on numerical values. To realize the power of ENPS there are a few simulators developed. Each and every simulator has some advantages as well as some disadvantages. Here, a GPU based simulator using Python as a user interaction language is developed. This tool is a completely parallel variant, compatible with a Python based sequential simulator (PeP) which was the first Python based work for ENPS. The developed simulator uses CUDA to interact with GPU and gives the desired speed up, while processing the membranes. There are two important case studies which show the performance of the developed tool to be far better than the other serial simulators.

Multi-ENPS simulator support tool with automatic file inter-conversion and multi-membrane execution

P System or Membrane Computing is an unconventional and natural computing model inspired by the functioning of a living cell. This model has an inherently parallel structure. There are several variants of P System developed, each of which has a different application. One of the variants, Enzymatic Numerical P System (ENPS), has primarily been developed to be used with numerical values (as in economics) and thus has vast applications. For realizing ENPS there are several tools available, primarily based on Java and Python, each of which has a different input format. Currently, there is no tool which allows the user to execute ENPS using both the simulators on the same platform, the issue being inter-conversion between input formats, namely, XML and PeP (specific format designed for Python based ENPS). Another major issue with existing simulators is their inability to allow multiple membrane systems to be executed and there is no facility for interconnection between two membrane systems. A tool developed here solves both problems namely, file inter-conversion and multiple membrane support by transferring dependent variable values automatically according to users' choice. The tool is developed using Python 3.0 and has only a few dependencies. The tool is tested under different scenarios and the results confirm the correctness of the tool.

Exploring the support for high performance applications in the container runtime environment

Cloud computing is the driving power behind the current technological era. Virtualization is rightly referred to as the backbone of cloud computing. Impacts of virtualization employed in high performance computing (HPC) has been much reviewed by researchers. The overhead in the virtualization layer was one of the reasons which hindered its application in the HPC environment. Recent developments in virtualization, especially the OS container based virtualization provides a solution that employs a lightweight virtualization layer and promises lesser overhead. Containers are advantageous over virtual machines in terms of performance overhead which is a major concern in the case of both data intensive applications and compute intensive applications. Currently, several industries have adopted container technologies such as Docker. While Docker is widely used, it has certain pitfalls such as security issues. The recently introduced CoreOS Rkt container technology overcomes these shortcomings of Docker. There has not been much research on how the Rkt environment is suited for high performance applications. The differences in the stack of the Rkt containers suggest better support for high performance applications. High performance applications consist of CPU-intensive and data-intensive applications. The High Performance Linpack Library and the Graph500 are the commonly used computation intensive and data-intensive benchmark applications respectively. In this work, we explore the feasibility of this inter-operable Rkt container in high performance applications by running the HPL and Graph500 applications and compare its performance with the commonly used container technologies such as LXC and Docker containers.

Structural, spectral, thermodynamical, NLO, HOMO, LUMO and NBO analysis of fluconazole

Fluconazole is an efficient antifungal drug used in the treatment and prevention of superficial and systemic fungal infections. The molecular structure, fundamental vibrational wavenumber and intensity of the vibrational bands are interpreted, aided by density functional theory method. The results of the calculations were applied to simulated spectra of the title compound, which show excellent agreement with observed spectra. The vibrational analysis of the title compound has been carried out using FT-IR and FT-Raman spectra. Stability of the molecule arising from hyperconjugative interactions and charge delocalization has been analyzed using natural bond orbital analysis. The present investigation is extended to calculate the HOMO-LUMO energy gap, polarizability, Mulliken charges and thermodynamical properties of fluconazole at different temperature. The calculated HOMO-LUMO energy gap shows that the charge transfer occurs within the molecule. The frontier orbital and molecular electrostatic potential surface studies have been employed to understand the active sites of fluconazole. Nonlinear optical properties related to polarizability and hyperpolarizability are also discussed. The absorption characteristics and solvent analysis of fluconazole have been made using UV-Vis spectroscopic method.

Growth response of Casuarina equisetifolia Forst. rooted stem cuttings to Frankia in nursery and field conditions

Casuarina equisetifolia Forst. is a tree crop that provides fuel wood, land reclamation, dune stabilization, and scaffolding for construction, shelter belts, and pulp and paper production. C. equisetifolia fixes atmospheric nitrogen through a symbiotic relationship with Frankia, a soil bacterium of the actinobacteria group. The roots of C. equisetifolia produce root nodules where the bacteria fix atmospheric nitrogen, which is an essential nutrient for all plant metabolic activities. However, rooted stem cuttings of elite clones of C. equisetifolia by vegetative propagation is being planted by the farmers of Pondicherry as costeffective method. As the vegetative propagation method uses inert material (vermiculite) for rooting there is no chance for Frankia association. Therefore after planting of these stocks the farmers are applying 150 kg of di-ammonium phosphate (DAP)/acre/year. To overcome this fertilizer usage, the Frankia-inoculated rooted stem cuttings were propagated under nursery conditions and transplanted in the nutrient-deficient soils of Karaikal, Pondicherry (India), in this study. Under nursery experiments the growth and biomass of C. equisetifolia rooted stem cuttings inoculated with Frankia showed 3 times higher growth and biomass than uninoculated control. These stocks were transplanted and monitored for their growth and survival for 1 year in the nutrient-deficient farm land. The results showed that the rooted stem cuttings of C. equisetifolia significantly improved growth in height (8.8 m), stem girth (9.6 cm) and tissue nitrogen content (3.3 mg g-1) than uninoculated controls. The soil nutrient status was also improved due to inoculation of Frankia.

A retrospective audit of 200 cases of CNS tumours and their surgical management in a tertiary care centre

AIMS

To study the nature of the tumours managed in the Irish population.

METHODS

This audit research was completed via a retrospective medical review on 200 patients with CNS tumours managed in a tertiary care centre between 2008 and 2009.

RESULTS

The mean age was 53 years. The male:female ratio was 2:1. The majority were glioblastomas and astrocytomas. Grade IV tumours were predominant (65.5 %). Headaches (37 %), motor weakness (32 %) and seizures (25.5 %) were the highest presentations. The commonest sites affected were the left parietal and left temporal lobes. There were 17.5 % operative morbidities with motor weakness (22.9 %), seizure (14.3 %) and thrombo-embolism (14.3 %) dominating and significant association to surgical radicality (p = 0.041). 3.5 % operative mortalities were reported. 52.5 and 62.5 % of patients received adjuvant chemotherapy and radiotherapy, respectively.

CONCLUSIONS

Patients with CNS tumours typically had multiple presentations. More extensive surgical resection was associated with higher postoperative morbidities (p = 0.041). The 30-day postoperative morbidity (17.5 %) and mortality (3.5 %) were concordant with the currently available literature.

Combinatorial stresses kill pathogenic Candida species

Pathogenic microbes exist in dynamic niches and have evolved robust adaptive responses to promote survival in their hosts. The major fungal pathogens of humans, Candida albicans and Candida glabrata, are exposed to a range of environmental stresses in their hosts including osmotic, oxidative and nitrosative stresses. Significant efforts have been devoted to the characterization of the adaptive responses to each of these stresses. In the wild, cells are frequently exposed simultaneously to combinations of these stresses and yet the effects of such combinatorial stresses have not been explored. We have developed a common experimental platform to facilitate the comparison of combinatorial stress responses in C. glabrata and C. albicans. This platform is based on the growth of cells in buffered rich medium at 30°C, and was used to define relatively low, medium and high doses of osmotic (NaCl), oxidative (H ₂O₂) and nitrosative stresses (e.g., dipropylenetriamine (DPTA)-NONOate). The effects of combinatorial stresses were compared with the corresponding individual stresses under these growth conditions. We show for the first time that certain combinations of combinatorial stress are especially potent in terms of their ability to kill C. albicans and C. glabrata and/or inhibit their growth. This was the case for combinations of osmotic plus oxidative stress and for oxidative plus nitrosative stress. We predict that combinatorial stresses may be highly signif cant in host defences against these pathogenic yeasts.

Persistence of stunting after highly active antiretroviral therapy in HIV-infected children in South India

After one year of antiretroviral treatment in 49 HIV infected children compared to 53 children without, weight for age improved significantly and was highly correlated with baseline immune status and CD4% increase but height for age did not change. Stunting is a common feature of pediatric HIV, both on and off HAART.

Cardiac allograft remodeling after heart transplantation is associated with increased graft vasculopathy and mortality

The aim of this study was to assess the patterns, predictors and outcomes of left ventricular remodeling after heart transplantation (HTX). Routine echocardiographic studies were performed and analyzed at 1 week, 1 year and 3-5 years after HTX in 134 recipients. At each study point the total cohort was divided into three subgroups based on determination of left ventricle mass and relative wall thickness: (1) NG-normal geometry (2) CR-concentric remodeling and (3) CH-concentric hypertrophy. Abnormal left ventricular geometry was found as early as 1 week after HTX in 85% of patients. Explosive mode of donor brain death was the most significant determinant of CH (OR 2.9, p = 0.01) at 1 week. CH at 1 week (OR 2.72, p = 0.01), increased body mass index (OR 1.1, p = 0.01) and cytomegalovirus viremia (OR - 4.06, p = 0.02) were predictors of CH at 1 year. CH of the cardiac allograft at 1 year was associated with increased mortality as compared to NG (RR 1.87, p = 0.03). CR (RR 1.73, p = 0.027) and CH (RR 2.04, p = 0.008) of the cardiac allograft at 1 year is associated with increased subsequent graft arteriosclerosis as compared to NG.

Disease mapping using mixture distribution

BACKGROUND & OBJECTIVES

Data on infectious diseases like tuberculosis (TB) have been analyzed in the past without giving adequate attention to spatial variations. Earlier studies also attempted to display disease status of sub regions, usually census tracts, by categorizing them into quartiles, that helps the authorities to identify high- or low-risk areas. This approach is based mainly on binomial and Poisson models for disease data, and the recent attempts focus on using mixture models of Poisson distribution. We carried out this study to find wards of Madurai Corporation having high risks for TB disease, to develop a model of mixture of Poisson distributions for the number of cases and to classify each ward to one of many risk groups for TB disease, and to represent spatial distribution of TB incidence in Madurai city.

METHODS

produced the observed counts of TB patients in 72 wards of Madurai Corporation. The number of risk groups and the Poisson parameters of each group were found by maximum likelihood approach using the computer package C.A.MAN (Computer Assisted Mixture ANalysis). Bayesian methods were used to associate each ward to a particular risk group. The results were geographically presented in maps by using ArcView mapping software.

RESULTS

Using binomial model, 26 wards were categorized as high risk wards, and with mixture model approach 15 wards showed standardized morbility ratio (SMR) >1. The wards along river Vaigai and densely populated wards had high risk.

INTERPRETATION & CONCLUSION

Our findings demonstrate the usefulness of the mixture models for disease data with geographical variations.

Clinical presentation, investigation, and management of pulmonary vein stenosis complicating ablation for atrial fibrillation

BACKGROUND

Although segmental or circumferential ablation is effective in eliminating pulmonary vein (PV)-mediated atrial fibrillation (AF), this procedure may be complicated by the occurrence of PV stenosis.

METHODS AND RESULTS

To establish the clinical presentation, diagnostic manifestations, and interventional management of PV stenosis, 23 patients with stenosis of 34 veins complicating ablation of AF were evaluated. Each patient became symptomatic 103+/-100 days after undergoing ablation. In 8 veins, the ablation producing the PV stenosis was a repeated procedure for continued AF. Nineteen patients presented with dyspnea on exertion, 7 with dyspnea at rest, 9 with cough, and 6 with chest pain. On multirow spiral computed tomography examination, the narrowest lumen of the affected PVs measured 3+/-2 mm compared with 13+/-3 mm at baseline (P< or =0.001). The relative perfusion of affected lung segments on isotope scans was reduced to 4+/-3% of total perfusion compared with 22+/-10% in unaffected segments. At percutaneous intervention, these veins showed 80+/-13% stenosis, with a mean gradient of 12+/-5 mm Hg. This was significantly reduced to a residual stenosis of 9+/-8% (P< or =0.001) and a residual gradient of 3+/-4 mm Hg (P< or =0.001). Twenty veins were treated with balloon dilatation alone, whereas 14 veins were stented with standard 10-mm-diameter bare-metal stents. Although the symptomatic response was nearly immediate and impressive, 14 patients developed in-stent or in-segment restenosis, requiring repeated interventions in 13.

CONCLUSIONS

Percutaneous intervention produces rapid and dramatic symptom relief in patients with highly symptomatic PV stenosis after radiofrequency ablation for AF. Nevertheless, alternative treatment methods will be required to decrease recurrent in-stent or in-segment restenosis.

Chronic exposure of neural cells to elevated intracellular sodium decreases mitochondrial mRNA expression

Regulation of expression of mitochondrial DNA- (mtDNA-) encoded genes of oxidative phosphorylation can occur rapidly in neural cells subjected to a variety of physiological and pathological conditions. However, the intracellular signal(s) involved in regulating these processes remain unknown. Using mtDNA-encoded cytochrome oxidase subunit III (COX III), we show that its mRNA expression in a differentiated rat pheochromocytoma cell line PC12S is decreased by chronic exposure to agents that increase intracellular sodium. Treatment of differentiated PC12S cells either with ouabain, an inhibitor of Na/K-ATPase, or with monensin, a sodium ionophore, decreased the steady-state levels of COX III mRNA by 50%, 3-4 h after addition of the drugs. No significant reduction in mtDNA-encoded 12S rRNA or nuclear DNA-encoded beta-actin mRNA were observed. Removal of the drugs restored the normal levels of COX III mRNA. Determination of half-lives of COX III mRNA, 12S rRNA, and beta-actin mRNA revealed a selective decrease in the half-life of COX III mRNA from 3.3 h in control cells to 1.6 h in ouabain-treated cells, and to 1 h in monensin-treated cells. These results suggest the existence of a mechanism of posttranscriptional regulation of mitochondrial gene expression that is independent of the energetic status of the cell and may operate under pathological conditions.

In situ matrix evaporation by isothermal distillation of high-purity reagents for the determination of trace impurities by ion chromatography

In situ matrix evaporation of high-purity acids based on isothermal distillation was achieved in a high-density polyethylene (HDPE) container on a water bath, to avoid contamination from the laboratory environment. The solubility of water and acid vapours in glycerol due to co-association was utilized to achieve complete evaporation. All major sources which contribute to the process blank were taken care of in a simple and effective way. A 50-fold preconcentration with >99.9% matrix removal was achieved for the analysis of low-boiling acids, HCl, HF, HNO3 and H2O2. The non-volatile ions NH4+, Li+, Na+, K+, Mg2+, Ca2+, SO4(2-) and PO4(3-) were determined by ion chromatograph with conductivity detection. The detection limits were 6-130 ng/l with recoveries of 85-110% for all ions studied.

Ion chromatographic determination of trace level phosphorus in purified quartz

Trace levels of phosphorus in purified quartz are determined by ion chromatography. In situ reagent purification, matrix digestion and oxidation of phosphorus to orthophosphate ion are carried out simultaneously in a vapour phase digestion (VPD) assembly using a mixture of HF, HNO3 and H2O2. A drastic reduction (475 times) in phosphate blank from reagents (HF/H2O2) was achieved in the VPD through in situ purification of the reagent. The residues remaining after volatilisation (solvent/matrix), mostly consisting of insoluble phosphate/fluoride salts of divalent and trivalent cations, were solubilised by ion-exchange dissolution. Phosphate was analysed on the IonPac AS17 column with suppressed conductivity detection. The results of the ion chromatography (IC) method were compared with a spectrophotometric method. Accuracy was evaluated by analysing a certified reference material (silicon, NIST 57a). The method detection limit was 0.05 microg g(-1).

Determination of trace metallic impurities in high-purity quartz by ion chromatography

A method has been developed for the determination of relevant trace impurities (alkali, alkaline and transition metals) in high purity quartz by ion-chromatography. In situ reagent (HF) purification and simultaneous sample dissolution was achieved in a multichannel vapour phase digestion assembly. Twenty-one samples can be digested at a time in this vapour phase system. Significant decrease in the process blank levels for all the analytes was observed. Drastic reduction (250 times) of NH4+ blank was achieved in the described vapour phase digestion, which enables the determination of trace concentration of sodium in high purity quartz. After volatilisation of the matrix and unreacted HF, the clear water leached solutions were injected into an ion-chromatograph equipped with conductivity detector for the determination of alkali and alkaline earth metals. In the case of transition metals, the trace residues were leached with 10 mM HCl and after separation on a mixed bed analytical column (IonPac CS5) were detected by spectrophotometry after post column derivatisation using 4-(2-pyridylazo)resorcinol (PAR). The accuracy of the result was checked by their comparison with those obtained by independent methods like inductively coupled plasma (ICP) MS and ICP atomic emission spectrometry. The achievable detection limits are between 0.4 ng/g (Li) and 22 ng/g (Mn). The application of the method to the determination of the above trace metals in two high-purity-grade quartz samples is demonstrated.

Preliminary phytochemical studies on bark of commiphora berryi (arn) engllor

Commiphora berryi (Arn)Englor (Burseraceae) is a well known plant in Tamil nadu, India. It is used in several parts of the state for various medicinal properties. The present work summarizes preliminary phyto chemical study of bark of this plant.

Anatomical basis for acquired intracardiac shunt postaortic valve replacement: Doppler echocardiographic diagnosis

We report a case of postoperative intracardiac shunts across the membranous septum detected by Doppler echocardiography and discuss the anatomical basis for the development of such a complication.

Predictors of left ventricular dysfunction in patients with Takayasu's or giant cell aortitis

OBJECTIVES

The aim of this study was to determine the clinical and angiographic predictors of left ventricular systolic dysfunction (LVSD) from a relatively large and angiographically characterized Takayasu's or Giant Cell aortitis (TA/GCA) population.

BACKGROUND

LVSD in patients with TA/GCA has been described in case reports and attributed variously to hemodynamic and immunologic factors. The predictors of LVSD in patients with angiographically confirmed TA/GCA are not known.

METHODS

We identified 78 patients with angiographically confirmed TA/ GCA that underwent transthoracic echocardiography (TTE) at Mayo Clinic. Echocardiograms were then reviewed independently by reviewers blinded to clinical and angiographic data. LVSD was defined as an ejection fraction (LVEF) less than 50%.

RESULTS

The study population was 84% Caucasian (54/78), 91% female (58/78), and had a mean age of disease onset of 30 years (+/- 15 years). LVSD was present in 14 of 78 patients (18%) with TA/GCA. The mean LVEF in the LVSD group (n = 14) was 37% +/- 7%, compared to an LVEF of 62% +/- 6% (p < 0.0001) in those without LVSD (n = 64). LVSD was not associated with hypertension or aortic regurgitation (p > 0.5). However, LVSD was found in 43% (9/21) of patients with aortic arch involvement, versus only 9% (5/57) of patients without aortic arch involvement (p = 0.0013). Patients with LVSD had a median of 2 (range 1-4) involved aortic segments compared to a median of 1 (range 1-4) among those without LVSD (p = 0.013).

CONCLUSIONS

In TA/GCA aortitis, LVSD is associated with involvement of the aortic arch and with the greater extent of aortic involvement. The hemodynamic variables, aortic regurgitation and systemic hypertension, were not associated with LVSD, consistent with reports that cardiac inflammation is responsible for LVSD in a majority of cases. Ours is the first study to estimate an incidence of LVSD in patients with TA/GCA aortitis, which was 18%.

Characterization of the N-acetylaspartate biosynthetic enzyme from rat brain

Aspartate N-acetyltransferase (Asp-NAT; EC 2.3.1.17) activity was found in highly purified intact mitochondria prepared by Percoll gradient centrifugation as well as in the three subfractions obtained after the sucrose density gradient centrifugation of Percoll purified mitochondria; citrate synthase was used as a marker enzyme for mitochondria. The proportion of recoverable activities of Asp-NAT and citrate synthase were comparable in mitochondrial and synaptosomal fractions but not in the fraction containing myelin. Asp-NAT was solubilized from the pellet of the rat brain homogenate (26 000 g for 1 h) for the recovery of maximum activity and partially purified using three protein separation methods: DEAE anion exchange chromatography, continuous elution native gel electrophoresis and size-exclusion high performance liquid chromatography. Asp-NAT activity and the optical density pattern of the eluted protein from size-exclusion column indicated a single large protein (approximately 670 kDa), which on sodium dodecyl sulfate-polyacrylamide gel electrophoresis showed at least 10 bands indicative of an enzyme complex. This seemingly multi-subunit complex Asp-NAT was stable towards ionic perturbations but vulnerable to hydrophobic perturbation; almost 95% of activity was lost after 10 mm 3-[(3-cholamidopropyl)dimethylammonia]-1-propanesulfonate (CHAPS) treatment followed by size-exclusion chromatography. Asp-NAT showed an order of magnitude difference in Km between l-aspartate (l-Asp, approximately 0.5 mm) and acetyl CoA (approximately 0.05 mm). Asp-NAT showed high specificity towards l-Asp with 3% or less activity towards l-Glu, l-Asn, l-Gln and Asp-Glu. A model on the integral involvement of NAA synthesis in the energetics of neuronal mitochondria is proposed.

Neuroprotective effects of bilobalide, a component of Ginkgo biloba extract (EGb 761) in global brain ischemia and in excitotoxicity-induced neuronal death

In this study, we compared the protective effect of bilobalide, a purified terpene lactone component of ginkgo biloba extract EGb 761, (definition see editorial) and EGb 761 against ischemic injury and against glutamate-induced excitotoxic neuronal death. In ischemic injury, we measured neuronal loss and the levels of mitochondrial DNA (mtDNA)-encoded cytochrome oxidase (COX) subunit III mRNA in vulnerable hippocampal regions of gerbils. At 7 days of reperfusion after 5 min of transient global ischemia, a significant increase in neuronal death and a significant decrease in COX III mRNA were observed in the hippocampal CA1 neurons. Oral administration of EGb 761 at 25, 50 and 100 mg/kg/day and bilobalide at 3 and 6 mg/kg/day for 7 days before ischemia progressively protected CA1 neurons from death and from ischemia-induced reductions in COX III mRNA. In rat cerebellar neuronal cultures, addition of bilobalide or EGb 761 protected in a dose-dependent manner against glutamate-induced excitotoxic neuronal death (effective concentration [EC (50)] = 5 microg/ml (12 microM) for bilobalide and 100 microg/ml for EGb 761. These results suggest that both EGb 761 and bilobalide are protective against ischemia-induced neuronal death in vivo and glutamate-induced neuronal death in vitro by synergistic mechanisms involving anti-excitotoxicity, inhibition of free radical generation, scavenging of reactive oxygen species, and regulation of mitochondrial gene expression.