Expert Opinions on the Management of Hemophilia A in India: The Role of Emicizumab

Hemophilia A (HA) is a genetic disorder of hemostasis associated with a deficiency or reduced activity of clotting factor VIII (FVIII). This disorder remains unacceptably underdiagnosed in India. Early diagnosis and appropriate management of HA can substantially prevent morbidity and mortality. Currently, HA is managed with regular replacement therapy using standard or extended half-life FVIII concentrates or non-factor drug products. The challenges associated with FVIII concentrates include plateauing of drug effect, issues with its administration and adherence to treatment, breakthrough bleeds, and the development of inhibiting antibodies against administered clotting factors. Emicizumab is a bispecific antibody, launched in India in April 2019, for managing patients with HA. To investigate the role of emicizumab in Indian patients with HA, opinions were sought from 13 eminent hematologists and experts from India on the effectiveness of emicizumab in preventing all bleeds, spontaneous bleeds, perioperative bleeds, and intracranial hemorrhage; resolving target joints; and reducing the rate of hospitalizations and fatality associated with HA in children and adults, with or without inhibitors. The benefits of emicizumab over traditional FVIII concentrates include the subcutaneous route of delivery, less frequent dosing, and a lack of inhibitor development, in addition to providing sustained hemostasis without in-depth monitoring. It is a safe and effective management option for all HA patients, especially for patients with certain archetypes, such as those with inhibitors, those with high annualized bleed rates, those living far away from hemophilia care centers, pediatric patients and infants with intravenous access challenges, and those with a history of life-threatening bleeding events.

Peripancreatic tuberculosis

Peripancreatic tuberculosis (PTB) is a very rare variant of tuberculosis and its clinical and radiological findings are similar to those of pancreatic malignancy. Diagnosis of PTB is usually incidental and is made after surgical resection. We are presenting a male patient who had complaints of prolonged fever, significant weight loss and yellowish discolouration of eyes and dark-coloured urine. Investigations revealed that there was a pancreatic mass causing obstructive jaundice. However, the aetiology of the mass, whether tubercular or malignant, was not clear. Hence, the patient was planned for endoscopic ultrasound-guided fine needle aspiration cytology. Cytology and aspirate were sent for a cartridge-based nucleic acid amplification test which revealed the presence of Mycobacterium tuberculosis, sensitive to rifampicin. The patient improved completely after treatment with antitubercular therapy.

Assessing Menstrual Changes Among Young Indian Females Post-SARS-CoV-2 Vaccination

Background The rollout of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines has significantly enhanced immunity against coronavirus disease 2019 (COVID-19), leading to a reduction in the severity of illness, hospitalizations, and deaths. While various side effects of the vaccine have been reported, its impact on the menstrual cycle remains unclear. Methods We conducted a cross-sectional study involving university students who had received either partial or full vaccination against SARS-CoV-2. Data was gathered through a questionnaire designed to assess the relationship between menstrual changes and the SARS-CoV-2 vaccination. Results A total of 773 participants, with a mean age of 20.6 ± 1.7 years, were included in this study. The participants reported a significant increase in the irregularity of the menstrual cycle. We observed a slight increase in the length of the menstrual cycle, from 30.0 ± 4.0 days (pre-vaccination) to 30.5 ± 5.6 days (post-vaccination), which was statistically significant (p<0.001). The duration of menstruation also increased, from 4.9 ± 1.7 days (pre-vaccination) to 5.0 ± 1.7 days (post-vaccination). However, this increase in menstrual length due to vaccination was not statistically significant (p = 0.898). Notably, there was a significant increase in pain reported by the participants after receiving the SARS-CoV-2 vaccine (p = 0.004). Conclusion The SARS-CoV-2 vaccination significantly impacted the regularity of the menstrual cycle, length of the menstrual cycle, and pain during menstruation, though temporarily. Our study found no significant differences in menstrual changes or the type of vaccine administered (Covishield and Covaxin).

Primary hepatoid adenocarcinoma of lung: A rare malignancy mimicking tuberculosis

Hepatoid adenocarcinoma of lung (HAL) is a rare aggressive malignant tumour which histologically resembles hepatocellular carcinoma (HCC). Hepatoid adenocarcinoma (HAC) mostly produces high levels of alphafetoprotein (AFP) and is frequently found in extrahepatic organs including stomach, testes, ovaries, lungs and pancreas. Our patient was a male in his 40s with a chronic smoking history, presented with complaints of fever, weight loss, cough and anorexia for one month. On the basis of history, examination and initial investigation patient were started on empirical antitubercular therapy. However, within a span of 10 days, patient's condition worsened, and he developed a pulmonary embolism, which despite adequate treatment did not improve and the patient succumbed to his illness. Postmortem biopsy revealed a rare primary lung tumour, HAL.

Evaluation of visual evoked potential in chronic myeloid leukemias

BACKGROUND

Visual complaint is not very uncommon in chronic myeloid leukemia (CML) patients. Our study aims to evaluate the visual pathway using visual evoked potential (VEP) in cases of CML at the time of diagnosis and 6 weeks after tyrosine kinase therapy, to find out treatment impact in asymptomatic as well as symptomatic individuals and compare it with the general population.

MATERIALS AND METHODS

This is an analytical cross-sectional study. The study group comprised 20 newly diagnosed cases of CML and 20 age- and sex-matched healthy control population. A thorough history and clinical examination with detailed ophthalmological studies, including VEP, were done. Cases who had VEP abnormalities were then followed-up after 6 weeks post-Imatinib therapy and underwent repeat investigations, including VEP.

RESULTS

VEP in cases was significantly deranged (P < 0.001), where 15 patients (75%) had abnormalities in VEP compared to 3 (15%) in control. Post 6 weeks chemotherapy, Out of 10 cases that were followed up, 7 patients had achieved hematological remission with normal VEP finding (P = 0.02). Simultaneously, an increase in hemoglobin (P = 0.002) and reduction in total leukocyte count (TLC) (P = 0.004) were observed.

CONCLUSION

Considerable evidence appear to support the notion that CML patients have a higher prevalence of ophthalmic manifestations as compared to the general population, which can be screened earlier with objective tests like VEP. Concurrently, hematological parameters and VEP showed derangement at the time of diagnosis. After 6 weeks of Imatinib treatment, the improvement in VEP can then be attributed to a reduction in TLC. Hence it can be deduced that VEP has paramount importance in the early identification of ophthalmic manifestations, which are reversible with timely treatment.

Disseminated tuberculosis presenting as cutaneous leucocytoclastic vasculitis

Cutaneous leucocytoclastic vasculitis (CLV) is a type of small vessel vasculitis, predominantly presenting with palpable purpuras and sometimes with systemic manifestations. The following report describes the case of a woman, who presented with fever, anorexia and maculopapular lesions over both lower limbs. Skin biopsy revealed CLV. CT scan demonstrated bilateral pulmonary nodules, ileocecal wall thickening and generalised lymphadenopathy. Colonoscopy guided biopsy obtained from ileocecal valve ulcer showed epitheloid cell granuloma with Langhans-type giant cells and caseous necrosis. Rapid clinical improvement was seen with anti-tubercular therapy. Among infectious causes, although rare and an uncommon presentation, Mycobacterium tuberculosis should be considered as an important cause of CLV.

Antiepileptic drug-induced severe granulomatous interstitial nephritis

Granulomatous interstitial nephritis (GIN) is a type of tubulointerstitial nephritis characterised by tubulointerstitial infiltration of mononuclear cells and eosinophils. It accounts for about 6% of all tubulointerstitial nephritis and is detected in ∼0.5%-0.9% of all renal biopsies. GIN has been linked to several antibiotics, non steroidal anti-inflammatory drugs (NSAIDs), and granulomatous disorders like tuberculosis and sarcoidosis but is rarely reported with anti-epileptic medications like phenytoin and levetiracetam. We present a case report of a man in his early 20's with previously normal renal function who developed GIN following levetiracetam and phenytoin consumption for 7 years. After withdrawal of the causative drug and starting steroid therapy, his kidney function gradually improved. In cases of GIN, medication history is important in the evaluation of aetiology.

Comparison of Serum Holotranscobalamin with Serum Vitamin B12 in Population Prone to Megaloblastic Anemia and their Correlation with Nerve Conduction Study

Early detection of megaloblastic anemia and associated neurological complications is crucial for management. This study was conducted to compare serum holotranscobalamin level with serum vitamin B12 level as early biomarker in people prone to megaloblastic anemia and to evaluate co-relation between these biomarkers and nerve conduction study in study patients. 83 adult patients (Hb > 12 gm/dl) prone to megaloblastic anemia were studied for basic haematological investigations, random blood sugar, thyroid function test, liver function test, kidney function test, serum vitamin B12, serum holotranscobalamin and serum folic acid levels. 45 patients among them underwent nerve conduction studies. All study patients were classified in 6 groups on the basis of risk factors for megaloblastic anemia. 29 patients (34.9%) were on antiepileptic drugs, 26 (31.3%) were chronic alcoholic, 10 patients (12%) each, had malabsorption and ileal tuberculosis, 6 (7.22%) had chronic pancreatitis and 2 (2.4%) had ileal resection. 30 patients (36.14%) had low serum holotranscobalamin, including 7 patients (8.43%) with low serum vitamin B12 level also, unmasking vitamin B12 deficiency in 23 patients (27.7%). 7 patients (8.43%) had mean corpuscular volume (MCV) > 100fL and 8 patients (9.63%) had vitamin B12 deficiency related changes on peripheral smear. Serum vitamin B12 and holotranscobalamin levels were significantly low in patients with peripheral smear changes, with p value 0.039 and 0.041 respectively, while no such association seen with MCV. Subclinical peripheral neuropathy was detected in 18 (40%) out of 45 patients on nerve conduction study. Serum holotranscobalamin levels were significantly lower (p = 0.031) than serum vitamin B12 levels (p = 0.2) in patients with neuropathic changes. Rest investigations and serum folic acid levels were normal in all patients. Holotranscobalamin levels can be considered early and reliable marker for vitamin B12 deficiency and deficiency associated peripheral neuropathy, even in patients who are prone to megaloblastic anemia, and not yet anemic or symptomatic for neuropathy.

Transformation of diffuse large B-cell lymphoma to lymphoblastic lymphoma

Transformations in diffuse large B-cell lymphoma (DLBCL) are extremely rare. Here, we are presenting a very rare case of DLBCL transforming into lymphoblastic lymphoma (LBL) diagnosed by fine-needle aspiration cytology (FNAC) and flow cytometry. A 31-year old male on antiretroviral therapy and a known case of diffuse large B-cell lymphoma diagnosed 1 year back on cervical lymphadenopathy, presented with left axillary swelling for 3 months. FNAC and Flow cytometry were performed from the left axillary swelling which confirmed the diagnosis of LBL.

Postbiotics: From emerging concept to application

The microbiome innovation has resulted in an umbrella term, postbiotics, which refers to non-viable microbial cells, metabolic byproducts and their microbial components released after lysis. Postbiotics, modulate immune response, gene expression, inhibit pathogen binding, maintain intestinal barriers, help in controlling carcinogenesis and pathogen infections. Postbiotics have antimicrobial, antioxidant, and immunomodulatory properties with favorable physiological, immunological, neuro-hormonal, regulatory and metabolic reactions. Consumption of postbiotics relieves symptoms of various diseases and viral infections such as SARS-CoV-2. Postbiotics can act as alternatives for pre-probiotic specially in immunosuppressed patients, children and premature neonates. Postbiotics are used to preserve and enhance nutritional properties of food, elimination of biofilms and skin conditioning in cosmetics. Postbiotics have numerous advantages over live bacteria with no risk of bacterial translocation from the gut to blood, acquisition of antibiotic resistance genes. The process of extraction, standardization, transport, and storage of postbiotic is more natural. Bioengineering techniques such as fermentation technology, high pressure etc., may be used for the synthesis of different postbiotics. Safety assessment and quality assurance of postbiotic is important as they may induce stomach discomfort, sepsis and/or toxic shock. Postbiotics are still in their infancy compared to pre- and pro- biotics but future research in this field may contribute to improved physiological functions and host health. The current review comprehensively summarizes new frontiers of research in postbiotics.

P-070 Comparison of Microfluidic Sperm Sorting (MFSS) versus Physiological Intracytoplasmic Sperm Injection (PICSI) versus Density Gradient versus Swim Up in high DNA fragmentation index sperm samples

Study question

To evaluate the effectiveness of using Microfluidic Sperm Sorting (MFSS) over other technique in patient with high DNA fragmentation index (DFI) sperm samples?

Summary answer

Microfluidic is not only correlated with better DNA integrity but also with the better reproductive outcome.

What is known already

DNA damage is unrecognisable in living sperm prior to insemination and an increased sperm DNA fragmentation index has been associated with lower fertilization rates, impaired embryo development and reduced pregnancy rates. Standard semen processing techniques are associated with centrifugation, which may induce reactive oxygen species and DNA damage.

In strategies to minimize sperm DNA fragmentation, Physiological ICSI can relatively reduce sperm DNA fragmentation by 67.9% (Parmegiani et al., 2010) while new technique Microfluidic sperm sorter technique also demonstrate sperm selection with significantly reduced DNA damage

Study design, size, duration

A prospective randomised study was conducted from 1st January 2019 to 1st December 2021. Four hundred patients were randomised by computer generated list and divided into 4 groups. Group A (n = 100) , in which sperm were processed by microfluidic sperm sorter (MFSS) while in group B (n = 100), sperm were selected by Physiological Intracytoplasmic Sperm Injection (PICSI), Group C (n = 100), sperm were processed by density gradient and Group D (n = 100), sperm were processed by swim-up technique.

Participants/materials, setting, methods

The study period included all normozoospermic patients with high DNA fragmentation index (&gt;25%) while oligospermic, asthenozoospermic samples, patients with poor ovarian reserve and advanced age were excluded from the study. All A grade embryos were vitrified and transferred in frozen embryo replacement cycle. All the 3 groups were compared on the basis of fertilisation rate, day 3 grade A embryo development rate, clinical pregnancy rate and miscarriage rate.

Main results and the role of chance

Cycle characteristics (female age, length of stimulation, gonadotrophin dose, number of oocytes and number of transferred embryos) were similar among all 4 groups.

Among 4 groups, There was a statistically significant increase observed in Group A (Microfluidic Sperm Sorting), day 3 grade A embryo development rate (60% vs. 42% vs. 38% vs. 40%, p-0.016) and clinical pregnancy rate (62% vs. 46% vs. 41% vs 43%, p-0.049), while no statistical significant difference observed in fertilisation rate (82% vs. 78% vs. 76% vs. 78%, p-0.80) comparing group B, group C and group D. But significantly higher miscarriage rate (12% vs. 11% vs. 25%, 12%) observed in density gradient (Group C) technique.

Limitations, reasons for caution

Larger randomised control studies are needed to strengthen these results.

Wider implications of the findings

We have demonstrated that sperm sorted by microfluidic helps in selection of sperm with better DNA integrity over Physiological ICSI, Density Gradient and Swim-up techniues. Using it in routine practice can help in reducing the negative effect of reactive oxygen species and thus improve pregnancy rate and live birth rate.

Trial registration number

MCDH/2019/35

Diagnostic utility of flow cytometry in identifying histiocytic sarcoma-A case report

Histiocytic sarcoma (HS) is a malignant neoplasm of hematopoietic origin. It is an exceedingly rare and aggressive malignancy commonly seen in adults. Diagnosis is difficult owing to lack of specific clinical manifestations with the absence of precursor lesions or causative agents. Hence, it primarily relies on histopathological morphology combined with immunohistochemistry, which is time-consuming, hence resulting in delayed treatment. However, diagnostic utility of flow cytometry is not well established in this. We report a case of a 45-year-old man who presented with right axillary lymphadenopathy for 1 month. FNAC was performed on the axillary lymph node, which showed large, atypical lymphoid/histiocyte-like cells. On flow cytometry, these cells were CD64+, CD11c+, and CD45+ suggesting histiocytic sarcoma. Similar morphology was seen on incisional biopsy. On immunohistochemistry, the cells were negative for B and T cell markers, PAX5, EMA, CK, ALK, and CD1a and expressed CD68, S100, and CD11c. A diagnosis of histiocytic sarcoma was made. Hence, flow cytometry can be a highly effective and powerful tool for the early detection of HS and can help in prompt treatment, given its aggressive clinical course and low survival interval.

Correlation between NEWS, CT Severity Score and RT-PCR Cycle Threshold Value among Mild and Moderate COVID-19 Patients

Introduction: The clinical diagnosis of COVID-19 is supplemented by clinical severity indices. These indices are the National Early Warning Score (NEWS, which aids in risk stratification), CT severity score (radiological severity score), and Reverse TranscriptionPolymerase Chain Reaction (RT-PCR) cycle threshold (Ct value, which provides a semi-quantitative measure of viral load). Aim: To assess the correlation between NEWS at admission, RT-PCR Ct value and CT severity score in mild and moderate COVID-19 patients. Methods and Materials: This prospective cohort study was conducted in Maulana Azad Medical College and Lok Nayak hospital, New Delhi, from January to June 2021. The study included 50 subjects (25 with mild COVID-19 and 25 with moderate COVID-19). NEWS was calculated at admission and Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Ct value was estimated using real-time RT-PCR. CT severity score was calculated based on High Resolution Computed Tomography (HRCT) chest findings. The correlation among the parameters was determined using Pearson correlation formula. Results: The mean age of subjects in the mild and moderate COVID-19 groups were 49.52 years and 51.84 years, respectively. The mean RT-PCR Ct value of E gene was 24.48 and Rdrp gene was 24.56 in the mild COVID-19 group; while in the moderate group it was 23.72 for both E gene and Rdrp genes. The correlation between NEWS and Ct value of E gene (r-value=-0.06, p-value=0.68), Ct value of Rdrp gene (r-value=- 0.03, p-value=0.79) and the correlation between CT severity score and Ct value of E gene (r-value=-0.05, p-value=0.73), Ct value of Rdrp gene (r-value=-0.06, p-value=0.68) was negative and insignificant. The mean CT severity score in mild COVID-19 group was 3.92, and in moderate COVID-19 group was 9.88. A significant positive correlation was found between the CT severity score and NEWS at admission. Conclusion: The clinical severity of COVID-19 as estimated by NEWS corroborates with CT severity score while the relationship between RT-PCR Ct value and clinicoradiological severity needs to be ascertained by further research.

Evaluation of Use of RPMI Medium to Preserve Cell Morphology for Pleural/Peritoneal Fluid Cytology

INTRODUCTION

Cytologic evaluation is the best way to detect the presence of malignancy in body cavity fluids. Roswell Park Memorial Institute (RPMI) medium or RPMI 1640 is used in cell culture, tissue culture, and also to improve the cellularity and morphology of CSF cytology specimens.

OBJECTIVES

To determine whether RPMI medium can be used to preserve cell morphology in pleural/peritoneal effusion samples.

METHOD AND MATERIAL

The study was conducted on 30 pleural/peritoneal fluid samples received routinely during 2 months for diagnostic purposes in our department. The samples were divided into four parts. One-fourth of the sample was directly refrigerated and the other fourth was at room temperature. In the other two parts, an equal volume of RPMI media was added, and one was kept at room temperature and the other refrigerated. These cytospin-prepared Giemsa-stained smears were examined for cell morphology, cellularity, and occurrence of bacterial colonies at 24 h, 48 h, 72 h, and 1 week, respectively.

RESULT

Refrigerated RPMI medium is the best preservative for pleural/peritoneal samples; however, samples with RPMI at room temperature were equivalent/even worse than the simple refrigerated sample.

Tuberculoma - a great mimicker: can diffusion tensor imaging and tractography help?

BACKGROUND

Central nervous system (CNS) tuberculomas often mimic tumors on conventional imaging, differentiation of which may not be possible without invasive tissue sampling. Diffusion tensor imaging (DTI), owing to its unrivalled property of characterizing molecular diffusion, may help in better lesion characterization and tractography may help understand the pattern of white matter involvement by tuberculomas.

PURPOSE

To estimate qualitative and quantitative diffusion tensor changes in brain tuberculomas and to evaluate patterns of white matter involvement using 3D tractography.

MATERIAL AND METHODS

Thirty patients with brain tuberculomas were evaluated on a 3-T magnetic resonance scanner. Diffusion tensor images were acquired along 20 non-colinear encoding directions with two b-values (b = 0, b = 1000). Regions of interest (ROIs) were drawn on quantitative fractional anisotropy (FA) and apparent diffusion coefficient (ADC) maps in the center of the tuberculoma and perilesional area. Similar ROIs were placed in contralateral hemispheres for comparison. Tractography maps were also generated.

RESULTS

Mean FA in the center and perilesional area of tuberculomas were 0.098 ± 0.041 and 0.311 ± 0.135, respectively. ADC values in corresponding regions were 0.920 ± 0.272 ×10^-3 mm²/s and 1.157 ± 0.277 ×10^-3 mm²/s. These values were significantly different compared to contralateral similar brain parenchyma. Tractography revealed interruption of white fibers in the center with deviation of fibers at the periphery in the majority of tuberculomas with none showing infiltration of white matter described in tumors.

CONCLUSION

Significant qualitative as well as quantitative DTI changes were seen in tuberculoma and perilesional areas compared to contralateral hemisphere with tractography showing a pattern different from that described in tumors. These findings may help to differentiate tuberculomas from infiltrating tumors.

Sex-based differences in program completion and clinical outcomes in patients following outpatient cardiac rehabilitation

Funding Acknowledgements

Type of funding sources: None.

Background

Females have greater reduction in mortality compared to males, following completion of a cardiac rehabilitation (CR) program, yet they continue to have lower referral rates and program completion. Since 1996, a local rehabilitation program has been the main provider of CR in our health zone. A standardized rapid referral program was implemented in 2008 to improve referral rates of hospitalized patients. Since then, the relationship between sex and CR completion is unknown.

Purpose

To evaluate the relationship between sex and CR completion and to evaluate the association between CR completion and clinical outcomes, stratified by sex.

Methods: We included consecutive patients who were referred to CR and who

1) were hospitalized for an acute coronary syndrome (ACS) or stable angina between 2008 and 2016; 2) had angiographic evidence of at least one-vessel coronary disease; and 3) had revascularization with percutaneous intervention, coronary artery bypass or medical management. The outcomes of interest were CR completion, anxiety and depression categories, exercise capacity, death, and need for revascularization. Logistics regression models were used to determine the association between sex and CR completion. The association between sex, CR completion, and the outcomes of interest were assessed using multivariable cox proportional hazards models.

Results

A total of 726 females and 2645 males were included in this study. The rate of CR completion was lower in females compared to males (64.6% vs 69.98%, p = 0.006). Following adjustment for baseline characteristics, female sex independently predicted lower rates of CR completion, OR 0.81 (95%CI 0.67-0.97).

Both sexes displayed improvements in peak metabolic equivalents (METs) achieved during exercise testing (W: initial 5.99 ± 1.93; 12-week 7.22 ± 1.92; M: initial 7.62 ± 2.04; 12-week 8.81 ± 1.93, p = 0.001). Amongst CR completers, one-year mortality was similar between sex (W: 1.84% vs M: 3.27%, p = 0.118), as was revascularization (W: 14.29% vs M: 11.97%, p = 0.193), however both sexes had higher one-year mortality in CR non-completers.

Conclusion

Despite a standardized CR referral protocol, a sex-difference in CR completion remains. In CR completers, one-year mortality and revascularization was similar in both sexes, however mortality was higher in CR non-completers. Our study suggests that addressing the causes of female CR non-completion following ACS or stable angina may improve outcomes.

Outcomes by CR Completion and Sex All NC (n = 1051) W-NC (n = 257) M-NC (n = 794) p-value All C (n = 2320) W-C (n = 469) M-C (n = 1851) p-value Revascularization-1 year (%) 146 (14.94) 28 (11.72) 118 (15.59) 0.107 267 (12.44) 62 (14.29) 205 (11.97) 0.193 Death-1 year (%) 67 (6.86) 19 (7.95) 48 (6.50) 0.442 64 (2.98) 8 (1.84) 56 (3.27) 0.118 W = Women;M = Men;NC = Non-Completers;C = Completers

Supercritical carbon dioxide drying of municipal sewage sludge - Novel waste-to-energy valorization pathway

Eighty percent of the world's wastewater is discharged back into nature without reuse and further treatment and solid byproduct of wastewater is either spread on land or landfilled. The valorization of municipal sewage sludge for energy use is a major opportunity for sustainable energy applications. This includes effective dewatering and drying of the sludge in addition to producing biogas during the anaerobic digestion. Supercritical CO 2 extraction process was investigated for the purpose of drying municipal sewage sludge. Remarkably our results showed that after sCO2 processing the higher heating value (HHV) of sludge at wet basis moisture content of 52% was 14 MJ/kg and thus higher than the HHV of brown coal with similar moisture level (12 MJ/kg). Our research also shows that under specific conditions sCO2 extraction reduces the moisture content of the municipal sludge from 89% to 53% in 15 min. Although, more research is needed this dewatering process could be considerably less energy intensive than conventional thermal and other drying processes. Another benefit is extraction of micro pollutants by sCO₂ treatment and thus making the dried sludge more useable in energy applications as per regulations. Our results show an alternative and novel pathway for highly effective dewatering and drying of municipal and other types of sludge.

Effect of one-day training on Knowledge related to Biosafety and waste management among life-science Students

Context: Laboratory workers are at increased risk of occupational hazards especially microbial infections. These occupational hazards can be reduced by merely creating awareness related to Biosafety. Thus biosafety and waste management training is important and needs to be inculcated at novice stage. Aims: The present study aimed to assess the effect of one-day training program on knowledge related to biosafety and biohazard among life-science students. Settings and Design: The study was conducted through online medium, organized by Department of Microbiology, Institute of Home Economics, University of Delhi using a Quasi Experimental design. Methods and Material: A one-day training on Biosafety and Waste Management was organized by Department of Microbiology for life-science students. A pre-test with 15 questions was administered to the participants before commencement of the training. One mark was allotted for each correct response and zero marks for incorrect marks. At the end of training, post knowledge was assessed using the same questions as pre-test. Statistical analysis used: The data on pre-post knowledge assessment was analyzed using SPSS Version 21. Paired t-test was used to assess the mean difference in pre and post knowledge assessment amongst the participants. The level of significance was taken as <0.05. Results: A total of 81 participants was analyzed for pre-post analysis. The mean age was 19.98 ± 1.06 years with 59(72.8%) being females. The mean pre-knowledge and post-knowledge score was found to be 10.20 ± 2.09 and 14.02 ± 1.63 respectively. The mean difference of 3.83 ± 2.23 in pre and post knowledge was found to be significant (p<0.001). Conclusions: Life-science students have poor-to-moderate knowledge about biosafety and waste management. Training on biosafety helps in improving knowledge.

Practical consensus recommendations on Her2 +ve breast cancer with solitary brain mets

Breast cancer is a common cause of brain metastases, with metastases occurring in at least 10-16% of patients. Longer survival of patients with metastatic breast cancer and the use of better imaging techniques are associated with an increased incidence of brain metastases. Current therapies include surgery, whole-brain radiation therapy, stereotactic radiosurgery, chemotherapy and targeted therapies. However, the timing and appropriate use of these therapies is controversial and careful patient selection by using available prognostic tools is extremely important. Expert oncologist discussed on the mode of treatment to extend the OS and improve the quality of life ofHER2-positivebreast cancer patients with Solitary brain metastases. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations for tumor margins and breast conservative surgery

My suggestion: There is no difference in survival of breast cancer patients treated with either mastectomy or with breast conservation therapy combined with external beam radiotherapy. A positive margin (s) is an important factor contributing to the increased risk of local recurrence. However, in published literature, there is a lack of consensus on the definition of acceptable margin (s). As a result decision process about need for re-excision after positive margins remains uncrear.

Practical consensus recommendations regarding the management of HER2 neu positive metastatic breast cancer

Metastatic breast cancer (MBC) is cancer that has spread from the breast to another part of the body or has come back in another distant location. Treatment options for MBC depend on several factors, including where the cancer has spread, the patient's overall health, and the levels of hormone receptors and HER2 in the tumour. Over-expression of HER2 is generally considered to be a negative prognostic feature because it accompanies an increase in breast cancer mortality. However, the development of agents that specifically target HER2 has improved the management of patients with these tumours.^{[7],[8],[9],[10]} This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of these agents and the management of HER2 positive MBC for the benefit of community oncologists.

Practical consensus recommendations on fertility preservation in patients with breast cancer

Young women diagnosed with cancer today have a greater chance of long-term survival than ever before. Successful survivorship for this group of patients includes maintaining a high quality of life after a cancer diagnosis and treatment; however, lifesaving treatments such as chemotherapy, radiation, and surgery can impact survivors by impairing reproductive and endocrine health. Expert oncologists along with reproductive medicine specialists discuss fertility preservation options in this chapter since fertility preservation is becoming a priority for young women with breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations regarding the management of sentinel lymph node issues in early breast cancer

Axillary lymph node involvement is a very important poor prognostic factor in the clinical staging and management of breast cancer patients. Traditionally, axillary lymph node dissection (ALND) has been used for determining the status of the axillary lymph nodes. More recently the sentinel lymph node biopsy (SLNB) procedure has gained wider acceptance as the standard of care, having the advantage of being less invasivewhile providing good accuracy. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of the two different procedures and other issues in patients with early breast cancer for the benefit of community oncologists.

Practical consensus recommendations regarding role of mastectomy in metastatic breast cancer

Whether to recommend mastectomy in metastatic disease or not has been a matter of debate. Is local therapy, such as mastectomy, of any benefit in advanced breast cancer is the main question. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations regarding role of postmastectomy radiation therapy

The use of radiation therapy after mastectomy (PMRT) has been limited to those patients who are at significant risk of cancer recurring in the chest wall or in the nodal basins. The use of PMRT has been widely accepted for patients with four or more positive lymph nodes,^[1],[2] but there is still controversy regarding the value of PMRT for those with one to three positive nodes. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations for neo-adjuvant chemotherapy in triple negative breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to use neoadjuvant chemotherapy in triple negative breast cancer patients.

Practical consensus recommendations for gestational breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to manage gestational breast cancer.

Practical consensus recommendaton for adjuvant bone-modifying agents in breast cancer

Bone-modifying therapy is a primary research interest in breast cancer. Several features contribute to the importance of the bone environment in the management of breast cancer. Firstly, bone metastases represent the most common site of breast cancer metastases and secondly, the emergence of cancer treatment-induced bone loss (CTIBL) among breast cancer survivors and patients is of increasing concern. In the adjuvant setting, bisphosphonates can be given to prevent and treat tumor therapy-induced bone loss in premenopausal and postmenopausal women and, owing to their beneficial effect on bone turnover, have also been evaluated for prevention of bone metastases occurrence. Expert oncologists discusses on the update on the approaches of Bone-modifying Agents and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations on ovarian suppression in early breast cancer (adjuvant)

Substantial survival benefits exist for patients with early-stage breast cancer who undergo treatment with single-modality ovarian suppression, but its value is uncertain. Expert oncologist discussed to determine whether additional benefits exist with ovarian suppression plus multiple adjuvant therapy which provides a new treatment option that reduces the risk of recurrence in early breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations on management of HR + ve early breast cancer with specific reference to genomic profiling

Breast cancer is a heterogeneous disease and patients are managed clinically based on ER, PR, HER2 expression, and key risk factors. The use of gene expression assays for early stage disease is already common practice. These tests have found a place in risk stratifying the heterogeneous group of stage I–II breast cancers for recurrence, for predicting chemotherapy response, and for predicting breast cancer-related mortality. Most guidelines for hormone receptor (HR)–positive early breast cancer recommend addition of adjuvant chemotherapy for most women, leading to overtreatment, which causes considerable morbidity and cost. Expert oncologist discussed about strategies of gene expression assays and aid in chemotherapy recommendations for treatment of HR + ve EBC and the expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations regarding the management of hormone receptor positive early breast cancer in elderly women

Breast cancer is a leading cause of death among women, and its incidence increases with age. Currently the treatment of breast cancer in older patients is almost identical to their younger counterparts. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists regarding the management of early breast cancer specifically in elderly women.

Practical consensus recommendations regarding the use of hormonal therapy in metastatic breast cancer

Metastatic breast cancer (MBC) is cancer that has spread from the breast to another part of the body or has come back in another distant location. Treatment options for MBC depend on several factors. One of these factors is the levels of hormone receptors (HRs) in the tumor. Cancers with high levels of HRs, called HR-positive, use the hormones estrogen and progesterone to grow and spread. Hormonal therapy is a type of treatment specifically for HR-positive breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of hormonal therapy and the management of HR-positive MBC for the benefit of community oncologists.

Practical consensus recommendations on duration of adjuvant hormonal therapy in breast cancer

Optimization of adjuvant systemic therapy in women with early-stage hormone receptor-positive breast cancer includes the consideration of chemotherapy and duration of hormone therapy. Adjuvant hormonal therapy significantly improves long-term survival of breast cancer patients with hormone receptor-positive disease. Despite the proven clinical efficacy of tamoxifen and aromatase inhibitors, many breast cancer survivors either fail to take the correct dosage at the prescribed frequency (adherence) or discontinue therapy (persistence). Expert oncologist discussed on the duration of adjuvant hormonal therapy for improvement of OS and quality of life of breast cancer patients by providing reduction in recurrence and mortality. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Predictors of major bleeding following an acute coronary event: insights from a national study of 5,116 consecutive patients in clinical practice

Background

Major bleeding after acute coronary syndrome (ACS) predicts a poor outcome. Although predictors of major bleeding following ACS have been validated, these have been mostly in clinical trial populations and few contemporary analyses have been undertaken in clinical practise

Methods

Major bleeding was assessed in a national study of ACS and antiplatelet choice. A total of 5116 consecutive patients [Clopidogrel (n 2,491, 2011–13) and Ticagrelor (n 2,625, 2013–16)] were enrolled in 5 UK hospitals. Clinical outcomes were identified from a national coding database (n=59.5 million) with bleeding events tracked to 11 health care facilities. Bleed severity was independently adjudicated by 2 consultant cardiologists, blinded to antiplatelet, sequence and year. Bleeding events were categorised using BARC 3–5 and PLATO criteria. A logistic regression analysis was used to define independent predictors of bleeding.

Results

The median age was 68 (IQR57–78, 30.5%&gt;75), 34% were female. 39% underwent PCI and 13% coronary artery bypass surgery. Clinical outcome data was 100% complete. 1-year mortality was 12.9%. Of 1193 icd10 codes for bleeding or anaemia 165 (3.2%) and 193 (3.8%) patients were adjudicated to have suffered a BARC 3–5 and PLATO major bleeding respectively. Independent predictors common between PLATO major and BARC 3–5 bleeding, in the year following ACS, were CRUSADE score &gt;40 (OR 1.63, CI 1.1–2.4, p=0.008) moderate left ventricular systolic dysfunction (OR, 1.65, CI: 1.2–2.4, p=0.006), age (OR per year increase in age 1.03, CI 1.02–1.05, p&lt;0.001) and subsequent coronary artery bypass surgery (OR 2.6, CI 1.8–3.8, p&lt;0.001)

Conclusion

In a broad real-world population of ACS, CRUSADE score &gt;40, incorporating simple clinical and laboratory criteria, remained an independent predictor of major bleeding using 2 internationally recognised bleed criteria

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Liverpool university hospitals; North-West Educational Cardiac Group

Medical education focus in published articles related to COVID-19

OBJECTIVE

The ongoing pandemic of Coronavirus Disease 2019 (COVID-19) has affected >2 million patients with approximately 900,000 cases in the United States alone. Medical education has possibly suffered during this time, due to disease mitigation strategies and stress on both students and teachers. We aimed to quantify the publications describing the impact of COVID-19 on medical education in the early stage of the pandemic.

MATERIALS AND METHODS

Abstract and titles related to COVID-19 listed in PubMed were reviewed for an educational focus. Articles with an educational focus were further evaluated for characteristics of content.

RESULTS

Out of a total of 3641 articles related to COVID-19, only 26 (0.7%) articles had an educational theme. Thirteen articles were pertaining to residency and fellowship education and twelve articles were focused on medical student education. Only one article referred to nursing education.

CONCLUSIONS

Publications pertaining to medical education during the ongoing COVID-19 pandemic are few. There is an urgent need for scholarship to understand the best processes and develop innovative methods that can help improve the educational experience of students and trainees during this extraordinary time.