The association in diabetic retinopathy and stroke finding from NHANES evidence

PURPOSE

Diabetic retinopathy and stroke are both vascular pathologies, and this study intends to investigate the relationship between diabetic retinopathy and stroke.

METHODS

The NHANES database was used to find the relationship between diabetic retinopathy and stroke with 1948 individuals aged 40 years or older. The sensitivity of the data was verified by multiple interpolation, further analysis was done by subgroup analyses, and possible links were investigated with mediation studies.

RESULTS

Diabetes retinopathy was found to be closely associated with stroke, with the PDR group having a higher stroke incidence than the NPDR group. After controlling for covariates, there were still substantial differences in the risk of stroke among patients with NPDR and PDR. Overall, subgroup analysis revealed DR group showed an important distinction, compared to the non-DR (OR = 1.76, 95% CI 1.15-2.64). The results of the mediation research indicated that the connection between DR and stroke was mediated by the frailty index and hypertension.

CONCLUSION

This study demonstrated a statistically significant correlation between DR and stroke, which persisted even after DR staging and was more prevalent in PDR patients than in NPDR patients. Stroke prevention may benefit from DR health management.

Surveillance of Antimicrobial Resistance and Multidrug Resistance Prevalence of Clinical Isolates in a Regional Hospital in Northern Greece

Antimicrobial resistance is a global health threat resulting in increased morbidity and mortality. This retrospective study aimed to estimate antimicrobial susceptibility and multidrug resistance prevalence of clinical isolates in a regional hospital in Northern Greece during the last 6 years by analyzing the annual reports of the Laboratory of Microbiology. A total of 12,274 strains of certain bacteria were isolated from both hospitalized and ambulatory patients from biological products, mainly urine (range 63-78% during the study period). E. coli was the most frequent pathogen found (37.4%). A significant increase in the number of the main pathogens causing hospital-acquired infections (Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterococcus faecium) was found in the time period of 2021-2023 compared to 2018-2020 (p < 0.0001). In total, 1767 multidrug-resistant bacterial strains were isolated, most of them belonging to Acinetobacter baumannii (36.4%) and Klebsiella pneumoniae (39.6%), and were located in the intensive care unit (ICU) (59.8%). Extensively drug resistance (XDR) and pan drug resistance (PDR) were significantly higher in 2021-2023 than in 2018-2020 (XDR: 641/1087 in 2021-2023 vs. 374/680 in 2018-2020 and PDR: 134/1087 in 2021-2023 vs. 25/680 in 2018-2020, p < 0.0001), resulting in an urgent need to establish certain strategies in order to eliminate this threatening condition.

The relationship of diabetic retinopathy severity scales with frequency and surface area of diabetic retinopathy lesions

PURPOSE

To assess the relationship between qualitative diabetic retinopathy (DR) scales with the precise numbers and surface area of DR lesions within the Early Treatment Diabetic Retinopathy Study (ETDRS) standard seven field (S7F) region on ultrawide-field (UWF) color fundus images.

METHODS

In this study, we collected UWF images from adult patients with diabetes. Poor-quality images and eyes with any pathology precluding assessment of DR severity were excluded. The DR lesions were manually segmented. DR severity was graded according to the International Clinical Diabetic Retinopathy (ICDR) and AA protocol by two masked graders within the ETDRS S7F. These lesions' numbers and surface area were computed and correlated against the DR scores using the Kruskal-Wallis H test. Cohen's Kappa was performed to determine the agreement between two graders.

RESULTS

One thousand five hundred and twenty eyes of 869 patients (294 females, 756 right eyes) with a mean age of 58.7 years were included. 47.4% were graded as no DR, 2.2% as mild non-proliferative DR (NPDR), 24.0% as moderate NPDR, 6.3% as severe NPDR, and 20.1% as proliferative DR (PDR). The area and number of DR lesions generally increased as the ICDR level increased up to severe NPDR, but decreased from severe NPDR to PDR. There was perfect intergrader agreement on the DR severity.

CONCLUSION

A quantitative approach reveals that DR lesions' number and area generally correlate with ICDR-based categorical DR severity levels with an increasing trend in the number and area of DR lesions from mild to severe NPDR and a decrease from severe NPDR to PDR.

On Indoor Localization Using WiFi, BLE, UWB, and IMU Technologies

Indoor localization is a key research area and has been stated as a major goal for Sixth Generation (6G) communications. Indoor localization faces many challenges, such as harsh wireless propagation channels, cluttered and dynamic environments, non-line-of-sight conditions, etc. There are various technologies that can be applied to address these issues. In this paper, four major technologies for implementing an indoor localization system are reviewed: Wireless Fidelity (Wi-Fi), Ultra-Wide Bandwidth Radio (UWB), Bluetooth Low Energy (BLE), and Inertial Measurement Units (IMU). Sections on Data Fusion (DF) and Machine Learning (ML) have been included as well due to their key role in Indoor Positioning Systems (IPS). These technologies have been categorized based on the techniques that they employ and the associated errors in localization. A brief comparison between these technologies is made based on specific performance metrics. Finally, the limitations of these techniques are identified to aid future research.

Case report: Azithromycin-meropenem combination therapy as a low-cost approach to combat PDR gram-negative infections of war wounds in Ukraine

Antimicrobial resistance recognised as a major global health problem and it poses a significant challenge in conflict zones, such as the Russia-Ukraine war. This case study focuses on a 32-year-old soldier who sustained combat-related injuries, including extensive wound infections caused by multidrug-resistant and pan-resistant bacteria and was successfully treated with azithromycin-meropenem combination therapy. The emergence of pan-resistant bacteria, particularly a pandrug-resistant strain of Pseudomonas aeruginosa, highlights the severity of the problem and the limited treatment options available. Additionally, the financial burden posed by reserve antibiotics further complicates the management of these infections. The case study demonstrates the effectiveness of including azithromycin-meropenem combination therapy in the treatment regimen, which resulted in improvements in the patient's condition and the eradication of the resistant strains. The findings underscore the need for effective antimicrobial stewardship, infection control measures, and alternative treatment strategies to combat antimicrobial resistance in conflict zones.

A Fusion Positioning Method for Indoor Geomagnetic/Light Intensity/Pedestrian Dead Reckoning Based on Dual-Layer Tent-Atom Search Optimization-Back Propagation

Indoor positioning using smartphones has garnered significant research attention. Geomagnetic and sensor data offer convenient methods for achieving this goal. However, conventional geomagnetic indoor positioning encounters several limitations, including low spatial resolution, poor accuracy, and stability issues. To address these challenges, we propose a fusion positioning approach. This approach integrates geomagnetic data, light intensity measurements, and inertial navigation data, utilizing a hierarchical optimization strategy. We employ a Tent-ASO-BP model that enhances the traditional Back Propagation (BP) algorithm through the integration of chaos mapping and Atom Search Optimization (ASO). In the offline phase, we construct a dual-resolution fingerprint database using Radial Basis Function (RBF) interpolation. This database amalgamates geomagnetic and light intensity data. The fused positioning results are obtained via the first layer of the Tent-ASO-BP model. We add a second Tent-ASO-BP layer and use an improved Pedestrian Dead Reckoning (PDR) method to derive the walking trajectory from smartphone sensors. In PDR, we apply the Biased Kalman Filter-Wavelet Transform (BKF-WT) for optimal heading estimation and set a time threshold to mitigate the effects of false peaks and valleys. The second-layer model combines geomagnetic and light intensity fusion coordinates with PDR coordinates. The experimental results demonstrate that our proposed positioning method not only effectively reduces positioning errors but also improves robustness across different application scenarios.

Antibiotic-Resistant ESKAPE Pathogens and COVID-19: The Pandemic beyond the Pandemic

Antibacterial resistance is a renewed public health plague in modern times, and the COVID-19 pandemic has rekindled this problem. Changes in antibiotic prescribing behavior, misinformation, financial hardship, environmental impact, and governance gaps have generally enhanced the misuse and improper access to antibiotics during the COVID-19 pandemic. These determinants, intersected with antibacterial resistance in the current pandemic, may amplify the potential for a future antibacterial resistance pandemic. The occurrence of infections with multidrug-resistant (MDR), extensively drug-resistant (XDR), difficult-to-treat drug-resistant (DTR), carbapenem-resistant (CR), and pan-drug-resistant (PDR) bacteria is still increasing. The aim of this review is to highlight the state of the art of antibacterial resistance worldwide, focusing on the most important pathogens, namely Enterobacterales, Acinetobacter baumannii, and Klebsiella pneumoniae, and their resistance to the most common antibiotics.

Advanced non-melanoma skin cancer in elderly patients: When surgery says NO, interventional radiotherapy (brachytherapy) says YES

Purpose

The prevalence of non-melanoma skin cancer (NMSC) increases, especially in older adults with comorbidities, narrowing radical treatment options. About 5% of skin cancer patients are diagnosed with an advanced stage, which impairs daily functioning. The study was to present a retrospective summary of elderly patients unfit for surgery and treated with various brachytherapy (BT) techniques tailored individually for locally advanced NMSCs in a reference BT department. Clinical case presentations supported the findings.

Material and methods

Inoperable patients older than 75 years presenting with advanced pathologically confirmed NMSCs were retrospectively identified. All cases were individually assessed, and the best suiting radical treatment option was chosen, including contact, interstitial, or hybrid high-dose-rate (HDR) or pulsed-dose-rate (PDR) BT. Doses ranging from 45 to 60 Gy were administered to clinical target volume (CTV) in different time schedules. All patients were closely followed-up until complete remission.

Results

Ten elderly patients (mean age, 84 years) with differently located locally advanced NMSCs (all staged T3) were treated between 2007 and 2022. Six basal and four squamous cell carcinoma cases showed most painful symptoms as well as bleeding and exudation. Six patients underwent HDR-BT and four PDR-BT. Six patients had superficial, and four interstitial or hybrid applications. All patients completed the intended protocols. Median follow-up was 8.5 months (range, 3-35 months). Six out of ten patients died from other reasons before analysis. All case data were presented in the text and respective figures.

Conclusions

Advanced NMSCs in elderly patients are challenging in terms of cure. Inoperable cases may be referred for feasible and locally effective interventional radiotherapy (BT). Individually tailored BT leads to an excellent disease control, function sparing, symptoms release, and quality of life improvement. Large treated volumes are related to prolonged healing. BT should be discussed in a multidisciplinary tumor board regarding older patients with symptomatic functions affecting advanced NMSCs.

Acinetobacter baumannii Global Clone-Specific Resistomes Explored in Clinical Isolates Recovered from Egypt

Acinetobacter baumannii (A. baumannii) is a highly problematic pathogen with an enormous capacity to acquire or upregulate antibiotic drug resistance determinants. The genomic epidemiology and resistome structure of 46 A. baumannii clinical isolates were studied using whole-genome sequencing. The isolates were chosen based on reduced susceptibility to at least three classes of antimicrobial compounds and were initially identified using MALDI-TOF/MS, followed by polymerase chain reaction amplification of bla_OXA-51-like genes. The susceptibility profiles were determined using a broth microdilution assay. Multi-, extensive-, and pan-drug resistance was shown by 34.8%, 63.0%, and 2.2% of the isolates, respectively. These were most susceptible to colistin (95.7%), amikacin, and trimethoprim/sulfamethoxazole (32.6% each), while only 26.1% of isolates were susceptible to tigecycline. In silico multi-locus sequence typing revealed 8 Pasteur and 22 Oxford sequence types (STs) including four novel STs (ST^Oxf 2805, 2806, 2807, and 2808). The majority of the isolates belonged to Global Clone (GC) 2 (76.4%), GC5 (19.6%), GC4 (6.5%), GC9 (4.3%), and GC7 (2.2%) lineages. An extensive resistome potentially conferring resistance to the majority of the tested antimicrobials was identified in silico. Of all known carbapenem resistance genes, bla_OXA-23 was carried by most of the isolates (69.6%), followed by ISAba1-amplified bla_ADC (56.5%), bla_NDM-1 and bla_GES-11 (21.7% each), and bla_GES-35 (2.2%) genes. A significant correlation was found between carbapenem resistance and carO mutations, which were evident in 35 (76.0%) isolates. A lower proportion of carbapenem resistance was noted for strains possessing both bla_OXA-23- and bla_GES-11. Amikacin resistance was most probably mediated by armA, aac(6')-Ib9, and aph(3')-VI, most commonly coexisting in GC2 isolates. No mutations were found in pmrABC or lpxACD operons in the colistin-resistant isolates. Tigecycline resistance was associated with adeS (N268Y) and baeS (A436T) mutations. While the lineage-specific distribution of some genes (e.g., bla_ADC and bla_OXA-51-like alleles) was evident, some resistance genes, such as bla_OXA-23 and sul1, were found in all GCs. The data generated here highlight the contribution of five GCs in A. baumannii infections in Egypt and enable the comprehensive analysis of GC-specific resistomes, thus revealing the dissemination of the carbapenem resistance gene bla_OXA-23 in isolates encompassing all GCs.

Burden of severe infections due to carbapenem-resistant pathogens in intensive care unit

Intensive care units (ICU) for various reasons, including the increasing age of admitted patients, comorbidities, and increasingly complex surgical procedures (e.g., transplants), have become "the epicenter" of nosocomial infections, these are characterized by the presence of multidrug-resistant organisms (MDROs) as the cause of infection. Therefore, the perfect match of fragile patients and MDROs, as the cause of infection, makes ICU mortality very high. Furthermore, carbapenems were considered for years as last-resort antibiotics for the treatment of infections caused by MDROs; unfortunately, nowadays carbapenem resistance, mainly among Gram-negative pathogens, is a matter of the highest concern for worldwide public health. This comprehensive review aims to outline the problem from the intensivist's perspective, focusing on the new definition and epidemiology of the most common carbapenem-resistant MDROs (Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacterales) to emphasize the importance of the problem that must be permeating clinicians dealing with these diseases.

Isolation and Identification of Multidrug-Resistant Klebsiella pneumoniae Clones from the Hospital Environment

Global dispersion, hospital outbreaks, and lineage relationships between emerging antibiotic-resistant strains such as Klebsiella pneumoniae are of public health interest. This study aimed to isolate and identify K. pneumoniae clones from third-level healthcare hospitals in Mexico to establish their multidrug-resistant phenotype, phylogeny, and prevalence. Biological and abiotic surface samples were used to isolate K. pneumoniae strains and to test their antibiotic susceptibility to classify them. The housekeeping genes: gapA, InfB, mdh, pgi, phoE, ropB, and tonB were used for multilocus sequence typing (MLST). Phylogenetic networks were constructed with 48 strains. Isolated strains (93) were mainly from urine and blood, 96% were resistant to ampicillin as expected, 60% were extended-spectrum β-lactamases (ESBL), 98% were susceptible to ertapenem and meropenem and 99% were susceptible to imipenem, 46% were multi-drug resistant (MDR), 17% were extensively-drug resistant (XDR), 1% were pan-drug resistant (PDR), and 36% were not classified. The tonB, mdh, and phoE genes were the most variable, and the InfB gene showed positive selection. The most prevalent sequence types (STs) were ST551 (six clones), ST405 (six clones), ST1088 (four clones), ST25 (four clones), ST392 (three clones), and ST36 (two clones). ST706 was PDR, and ST1088 clones were MDR; neither of these STs has been reported in Mexico. The strains analyzed were from different hospitals and locations; thus, it is important to maintain antibiotic surveillance and avoid clone dissemination to prevent outbreaks, adaptation to antibiotics, and the transmission of antibiotic resistance.

Multi-Phase Fusion for Pedestrian Localization Using Mass-Market GNSS and MEMS Sensors

Precise pedestrian positioning based on smartphone-grade sensors has been a research hotspot for several years. Due to the poor performance of the mass-market Micro-Electro-Mechanical Systems (MEMS) Magnetic, Angular Rate, and Gravity (MARG) sensors, the standalone pedestrian dead reckoning (PDR) module cannot avoid long-time heading drift, which leads to the failure of the entire positioning system. In outdoor scenes, the Global Navigation Satellite System (GNSS) is one of the most popular positioning systems, and smartphone users can use it to acquire absolute coordinates. However, the smartphone's ultra-low-cost GNSS module is limited by some components such as the antenna, and so it is susceptible to serious interference from the multipath effect, which is a main error source of smartphone-based GNSS positioning. In this paper, we propose a multi-phase GNSS/PDR fusion framework to overcome the limitations of standalone modules. The first phase is to build a pseudorange double-difference based on smartphone and reference stations, the second phase proposes a novel multipath mitigation method based on multipath partial parameters estimation (MPPE) and a Double-Difference Code-Minus-Carrier (DDCMC) filter, and the third phase is to propose the joint stride lengths and heading estimations of the two standalone modules, to reduce the long-time drift and noise. The experimental results demonstrate that the proposed multipath error estimation can effectively suppress the double-difference multipath error exceeding 4 m, and compared to other methods, our fusion method achieves a minimum error RMSE of 1.63 m in positioning accuracy, and a minimum error RMSE of 4.71 m in long-time robustness for 20 min of continuous walking.

A two-year retrospective study of multidrug-resistant Acinetobacter baumannii respiratory infections in critically Ill patients: Clinical and microbiological findings

BACKGROUND

Acinetobacter baumannii infection is a serious public health problem because it is highly resistant to antimicrobial therapy and causes a high fatality rate in critically ill patients. The aim of the study is to examine the demographics, microbiological findings, clinical presentation, and outcomes of multi-drug-resistant Acinetobacter baumannii respiratory infections in adult ICU intubated patients during COVID-19 pandemic.

METHODS

This study included 115 mechanically ventilated adult ICU patients who had multi-drug-resistant Acinetobacter baumannii retrieved from respiratory samples during the COVID-19 pandemic in Albaha, Saudi Arabia. The information was obtained from medical and laboratory files. Univariate analysis was used to compare gender, COVID-19 infection, and outcomes.

RESULTS

The rate of Acinetobacter baumanni respiratory infections among adult ICU patients was 6.2 %. Almost 93 % developed ventilator-associated pneumonia, and five of them developed bacteremia. The isolates had significant antibiotic resistance patterns, of which 3 % were pandrug-resistant bacteria. The death rate was 74 %, with major risk factors including sepsis, septic shock, VAP, liver diseases, and the use of inappropriate antibiotic therapy that lacked both colistin and tigecycline. Patients with COVID-19 coinfection had worse outcomes compared to non-COVID-19 patients.

CONCLUSIONS

The identification of MDR-AB as a threat highlights the importance of surveillance studies in this region.

The Epidemiological Pattern, Resistance Characteristics and Clinical Outcome of Enterobacter cloacae: Recent Updates and Impact of COVID-19 Pandemic

OBJECTIVES

E. cloacae is an opportunistic organism that causes serious infections, particularly in immuno-compromised and hospitalized patients, along with the emergence of resistance traits. The COVID-19 pandemic has impacted the epidemiological pattern and resistance traits of E. cloacae infections as well as those of other bacteria. The study aims to assess the epidemiological patterns, resistance characteristics and clinical outcomes of E. cloacae in Saudi Arabia and the impact of the COVID-19 pandemic.

METHODS

King Fahad Medical City in Riyadh provided the data between January 2019 and December 2021 for the retrospective study of 638 isolates of E. cloacae. The clinical outcome of an E. cloacae infection was also determined by collecting and statistically analyzing the clinical records of 153 ICU patients.

RESULTS

The total percentage of resistant E. cloacae isolates decreased from 48.36% in 2019 to 38% in 2020 and 37.6% in 2021. The overall mortality rate among ICU patients was 40.5%, with an adult age group having a substantial relative risk value of 1.37.

CONCLUSION

E. cloacae is a prevalent nosocomial infection in which adult age is a significant risk factor for mortality. Moreover, this study emphasizes the importance of comparing E. cloacae resistance trends before and throughout the pandemic period in order to better understand the bacteria's behaviour.

Exosomal miRNA Profiling in Vitreous Humor in Proliferative Diabetic Retinopathy

MicroRNAs (miRNAs) are small noncoding RNAs which mediate some of the pathological mechanisms of diabetic retinopathy. The aim of this study was to identify differentially expressed miRNAs in the vitreal exosomes of proliferative diabetic retinopathy (PDR) patients and non-diabetic controls. Exosomes were extracted from the vitreous samples of 10 PDR patients and 10 controls. The expression of 372 miRNAs was determined using a quantitative polymerase chain reaction (qPCR) panel. We have demonstrated a significant dysregulation in 26 miRNAs. The most remarkable findings include a profound attenuation of the miR-125 family, as well as enhanced miR-21-5p expression in the diabetic samples. We also showed the downregulation of miR-204-5p and the upregulation of let-7g in PDR compared to the controls. This study identified miR-125 and miR-21 as potential targets for further functional analysis regarding their putative role in the pathogenesis of PDR.

Stenotrophomonas maltophilia Epidemiology, Resistance Characteristics, and Clinical Outcomes: Understanding of the Recent Three Years' Trends

BACKGROUND

Stenotrophomonas maltophilia is an emerging pathogen classified as a public health concern, that infects critically ill patients and has expressed resistance against antimicrobial therapy. The aim of this study was to examine the epidemiological pattern, resistance characteristics and clinical outcomes of S. maltophilia infections in hospitalized patients.

METHODS

The study included 393 S. maltophilia isolates from different clinical specimens as well as the clinical data of 209 Intensive Care Unit (ICU) patients. The patients' data were obtained from medical and laboratory files. Descriptive statistics and a univariate analysis were used to report and compare the demographics, clinical data, and outcomes.

RESULTS

The S. maltophilia was mostly isolated from the respiratory specimens of ICU patients. The adult patients were more likely to develop serious infections and worse outcomes than were pediatric patients. The most common co-infecting pathogens were SARS-CoV2 and Pseudomonas aeruginosa. The death rate was 44.5% and increased to 47.1% in the case of a respiratory infection. Septic shock was the most significant predictor of mortality. Older age and mechanical ventilation were independent and significant risk factors that worsened the outcomes in patients with respiratory infections.

CONCLUSIONS

The identification of S. maltophilia as a threat highlights the importance of surveillance studies in this region.

A Context-Aware Smartphone-Based 3D Indoor Positioning Using Pedestrian Dead Reckoning

The rise in location-based service (LBS) applications has increased the need for indoor positioning. Various methods are available for indoor positioning, among which pedestrian dead reckoning (PDR) requires no infrastructure. However, with this method, cumulative error increases over time. Moreover, the robustness of the PDR positioning depends on different pedestrian activities, walking speeds and pedestrian characteristics. This paper proposes the adaptive PDR method to overcome these problems by recognizing various phone-carrying modes, including texting, calling and swinging, as well as different pedestrian activities, including ascending and descending stairs and walking. Different walking speeds are also distinguished. By detecting changes in speed during walking, PDR positioning remains accurate and robust despite speed variations. Each motion state is also studied separately based on gender. Using the proposed classification approach consisting of SVM and DTree algorithms, different motion states and walking speeds are identified with an overall accuracy of 97.03% for women and 97.67% for men. The step detection and step length estimation model parameters are also adjusted based on each walking speed, gender and motion state. The relative error values of distance estimation of the proposed method for texting, calling and swinging are 0.87%, 0.66% and 0.92% for women and 1.14%, 0.92% and 0.76% for men, respectively. Accelerometer, gyroscope and magnetometer data are integrated with a GDA filter for heading estimation. Furthermore, pressure sensor measurements are used to detect surface transmission between different floors of a building. Finally, for three phone-carrying modes, including texting, calling and swinging, the mean absolute positioning errors of the proposed method on a trajectory of 159.2 m in a multi-story building are, respectively, 1.28 m, 0.98 m and 1.29 m for women and 1.26 m, 1.17 m and 1.25 m for men.

VEGF-targeting drugs for the treatment of retinal neovascularization in diabetic retinopathy

Diabetic retinopathy (DR) is the most common microangiopathic complication of diabetes mellitus, representing a major cause of visual impairment in developed countries. Proliferative DR (PDR) represents the last stage of this extremely complex retinal disease, characterized by the development of neovascularization induced by the abnormal production and release of vascular endothelial growth factor (VEGF). The term VEGF includes different isoforms; VEGF-A represents one of the most important pathogenic factors of DR. Anti-VEGF intravitreal therapies radically changed the outcome of DR, due to combined anti-angiogenic and anti-edematous activities. Nowadays, several anti-VEGF molecules exist, characterized by different pharmacological features and duration. With respect to PDR, although anti-VEGF treatments represented a fundamental step forward in the management of this dramatic complication, a big debate is present in the literature regarding the role of anti-VEGF as substitute of panretinal photocoagulation or if these two approaches may be used in combination. In the present review, we provided an update on VEGF isoforms and their role in DR pathogenesis, on current anti-VEGF molecules and emerging new drugs, and on the current management strategies of PDR. There is an overall agreement regarding the relative advantage provided by anti-VEGF, especially looking at the management of PDR patients requiring vitrectomy, with respect to laser. Based on the current data, laser approaches might be avoided when a perfectly planned anti-VEGF therapeutic strategy can be adopted. Conversely, laser treatment may have a role for those patients unable to guarantee enough compliance to anti-VEGF injections.Key messagesVEGF increased production, stimulated by retinal hypoperfusion and ischaemia, is a major pathogenic factor of neovascular complication onset in diabetic retinopathy and of DR stages progression.Nowadays, several anti-VEGF molecules are available in clinical practice and other molecules are currently under investigation. Each anti-VEGF molecule is characterized by different targets and may interact with multiple biochemical pathways within the eye.All the data agreed in considering anti-VEGF molecules as a first line choice for the management of diabetic retinopathy. Laser treatments may have a role in selected advanced cases and for those patients unable to guarantee enough compliance to intravitreal treatments schemes.

An Algorithm with Iteration Uncertainty Eliminate Based on Geomagnetic Fingerprint under Mobile Edge Computing for Indoor Localization

Indoor localization problems are difficult due to that the information, such as WLAN and GPS, cannot achieve enough precision for indoor issues. This paper presents a novel indoor localization algorithm, GeoLoc, with uncertainty eliminate based on fusion of acceleration, angular rate, and magnetic field sensor data. The algorithm can be deployed in edge devices to overcome the problems of insufficient computing resources and long delay caused by high complexity of location calculation. Firstly, the magnetic map is built and magnetic values are matched. Secondly, orientation updating and position selection are iteratively executed using the fusion data, which gradually reduce uncertainty of orientation. Then, we filter the trajectory from a path set. By gradually reducing uncertainty, GeoLoc can bring a high positioning precision and a smooth trajectory. In addition, this method has an advantage in that it does not rely on any infrastructure such as base stations and beacons. It solves the common problems regarding the non-uniqueness of the geomagnetic fingerprint and the deviation of the sensor measurement. The experimental results show that our algorithm achieves an accuracy of less than 2.5 m in indoor environment, and the positioning results are relatively stable. It meets the basic requirements of indoor location-based services (LBSs).

A Low-Cost Foot-Placed UWB and IMU Fusion-Based Indoor Pedestrian Tracking System for IoT Applications

Among existing wireless and wearable indoor pedestrian tracking solutions, the ultra-wideband (UWB) and inertial measurement unit (IMU) sensors are the popular options due to their accurate and globally referenced positioning, and low-cost and compact size, respectively. However, the UWB position accuracy is compromised by the indoor non-line of sight (NLOS) and the IMU estimation suffers from orientation drift as well as requiring position initialization. To overcome these limitations, this paper proposes a low-cost foot-placed UWB and IMU fusion-based indoor pedestrian tracking system. Our data fusion model is an improved loosely coupled Kalman filter with the inclusion of valid UWB observation detection. In this manner, the proposed system not only adjusts the consumer-grade IMU's accumulated drift but also filters out any NLOS instances in the UWB observation. We validated the performance of the proposed system with two experimental scenarios in a complex indoor environment. The root mean square (RMS) positioning accuracy of our data fusion model is enhanced by 60%, 53%, and 27% compared to that of the IMU-based pedestrian dead reckoning, raw UWB position, and conventional fusion model, respectively, in the single-lap NLOS scenario, and by 70%, 34%, and 12%, respectively, in the multi-lap LOS+NLOS scenario.

Prevalence of Pretreatment HIV-1 Drug Resistance in Armenia in 2017-2018 and 2020-2021 following a WHO Survey

The increased antiretroviral therapy (ART) coverage of patients in the absence of routine genotyping tests and in the context of active labor migration highlight the importance of HIV-1 drug resistance (DR) surveillance in Armenia. We conducted a two-phase pretreatment DR (PDR) study in 2017-2018 (phase I; 120 patients) and 2020-2021 (phase II; 133 patients) according to the WHO-approved protocol. The analysis of HIV-1 genetic variants showed high degrees of viral diversity, with the predominance of A6. The prevalence of any PDR was 9.2% in phase I and 7.5% in phase II. PDR to protease inhibitors was found only in 0.8% in phase II. PDR to efavirenz and nevirapine was found among 5.0% and 6.7% of patients in phase I, and 6.0% and 6.8% of patients in phase II, respectively. The prevalence of PDR to nucleoside reverse-transcriptase inhibitors decreased from 5.0% in phase I to 0.8% in phase II. In addition, we identified risk factors associated with the emergence of DR-male, MSM, subtype B, and residence in or around the capital of Armenia-and showed the active spread of HIV-1 among MSM in transmission clusters, i.e., harboring DR, which requires the immediate attention of public health policymakers for the prevention of HIV-1 DR spread in the country.

Cooperative Energy-Efficient Routing Protocol for Underwater Wireless Sensor Networks

Underwater wireless sensor networks (UWSNs) contain sensor nodes that sense the data and then transfer them to the sink node or base station. Sensor nodes are operationalized through limited-power batteries. Therefore, improvement in energy consumption becomes critical in UWSNs. Data forwarding through the nearest sensor node to the sink or base station reduces the network's reliability and stability because it creates a hotspot and drains the energy early. In this paper, we propose the cooperative energy-efficient routing (CEER) protocol to increase the network lifetime and acquire a reliable network. We use the sink mobility scheme to reduce energy consumption by eliminating the hotspot issue. We have divided the area into multiple sections for better deployment and deployed the sink nodes in each area. Sensor nodes generate the data and send it to the sink nodes to reduce energy consumption. We have also used the cooperative technique to achieve reliability in the network. Based on simulation results, the proposed scheme performed better than existing routing protocols in terms of packet delivery ratio (PDR), energy consumption, transmission loss, and end-to-end delay.

Association study of HIF-1α rs11549465 and VEGF rs3025039 genetic variants with diabetic retinopathy in Egyptian patients: crosslinks with angiogenic, inflammatory, and anti-inflammatory markers

Background

Genetic factors are implicated in the progression of DR—a global cause of blindness. Hence, the current work investigated the association of HIF-1α rs11549465 and VEGF rs3025039 genetic variants with the different stages of retinopathy among T2DM Egyptian patients. The crosslinks of these variants were explored with angiogenesis (VEGF), inflammation (AGEP and VCAM-1), and anti-inflammation (CTRP3) markers. Two hundred eighty-eight subjects were recruited in this study: 72 served as controls and 216 were having T2DM and were divided into diabetics without retinopathy (DWR), diabetics with non-proliferative retinopathy (NPDR), and diabetics with proliferative retinopathy (PDR). The genetic variants were analyzed using PCR-RFLP and their associations with NPDR and PDR were statistically tested. The circulating levels of AGEP, VCAM-1, HIF-1α, VEGF, and CTRP3 were assayed followed by analyzing their associations statistically with the studied variants.

Results

Only HIF-1α rs11549465 genetic variant (recessive model) was significantly associated with the development of NPDR among T2DM patients (p < 0.025) with a significant correlation with the circulating HIF-1α level (p < 0.0001). However, this variant was not associated with PDR progression. Neither HIF-1α rs11549465 nor VEGF rs3025039 genetic variants were associated with the PDR progression. The circulating AGEP, VCAM-1, HIF-1α, and VEGF were significantly elevated (p < 0.0001) while the CTRP3 was significantly decreased (p < 0.0001) in NPDR and PDR groups. The HIF-1α rs11549465 CT and/or TT genotype carriers were significantly associated with AGEP and VCAM-1 levels in the NPDR group, while it showed a significant association with the CTRP3 level in the PDR group. The VEGF rs3025039 TT genotype carriers showed only a significant association with the CTRP3 level in the PDR group.

Conclusion

The significant association of HIF-1α rs11549465 other than VEGF rs3025039 with the initiation of NPDR in T2DM Egyptian patients might protect them from progression to the proliferative stage via elevating circulating HIF-1α. However, this protective role was not enough to prevent the development of NPDR because of enhancing angiogenesis and inflammation together with suppressing anti-inflammation. The non-significant association of HIF-1α rs11549465 with PDR among T2DM patients could not make this variant a risk factor for PDR progression.

Advances in cell therapies using stem cells/progenitors as a novel approach for neurovascular repair of the diabetic retina

BACKGROUND

Diabetic retinopathy, a major complication of diabetes mellitus, is a leading cause of sigh-loss in working age adults. Progressive loss of integrity of the retinal neurovascular unit is a central element in the disease pathogenesis. Retinal ischemia and inflammatory processes drive interrelated pathologies such as blood retinal barrier disruption, fluid accumulation, gliosis, neuronal loss and/or aberrant neovascularisation. Current treatment options are somewhat limited to late-stages of the disease where there is already significant damage to the retinal architecture arising from degenerative, edematous and proliferative pathology. New preventive and interventional treatments to target early vasodegenerative and neurodegenerative stages of the disease are needed to ensure avoidance of sight-loss.

MAIN BODY

Historically, diabetic retinopathy has been considered a primarily microvascular disease of the retina and clinically it is classified based on the presence and severity of vascular lesions. It is now known that neurodegeneration plays a significant role during the pathogenesis. Loss of neurons has been documented at early stages in pre-clinical models as well as in individuals with diabetes and, in some, even prior to the onset of clinically overt diabetic retinopathy. Recent studies suggest that some patients have a primarily neurodegenerative phenotype. Retinal pigment epithelial cells and the choroid are also affected during the disease pathogenesis and these tissues may also need to be addressed by new regenerative treatments. Most stem cell research for diabetic retinopathy to date has focused on addressing vasculopathy. Pre-clinical and clinical studies aiming to restore damaged vasculature using vasoactive progenitors including mesenchymal stromal/stem cells, adipose stem cells, CD34+ cells, endothelial colony forming cells and induced pluripotent stem cell derived endothelial cells are discussed in this review. Stem cells that could replace dying neurons such as retinal progenitor cells, pluripotent stem cell derived photoreceptors and ganglion cells as well as Müller stem cells are also discussed. Finally, challenges of stem cell therapies relevant to diabetic retinopathy are considered.

CONCLUSION

Stem cell therapies hold great potential to replace dying cells during early and even late stages of diabetic retinopathy. However, due to the presence of different phenotypes, selecting the most suitable stem cell product for individual patients will be crucial for successful treatment.

High levels of FBS and HbA1c and their association with diabetic retinopathy: a study in the north of Iran

Background

Diabetic retinopathy, which is a common complication of diabetes, is one of the most common reasons of blindness in adults. There are several potential risk factors for diabetic retinopathy such as hypertension (HTN), hyperlipidemia (HLP), high fasting blood sugar (FBS), and high Hemoglobin A1c (HbA1c). Yet, ethnicity is another factor which may contribute to diabetic retinopathy regardless of the potential risk factors mentioned. The aim of this study, therefore, is to find the risk factors associated with diabetic retinopathy in the north of Iran.

Methods

This was a retrospective cohort study including a total of 1,125 patients divided into three groups as follows: (i) patients with no diabetic retinopathy (NDR group; n = 398); (ii) patients with non-proliferative diabetic retinopathy (non-PDR group; n = 408); (iii) patients with proliferative diabetic retinopathy (PDR group; n = 319). The laboratory data were collected from patients for analysis.

Results

Diabetic patients with retinopathy had significantly higher levels of FBS compared with those without retinopathy (p = 0.001). Patients with PDR or non-PDR had higher levels of HbA1c compared with patients without retinopathy (p = 0.001). In contrast, no association was observed between HTN or HLP and diabetic retinopathy. On the other hand, duration of diabetes was another important factor affecting diabetic retinopathy.

Conclusions

Higher levels of FBS and HbA1c were observed in patients with diabetic retinopathy. Monitoring and controlling of FBS and HbA1c of diabetic patients could prevent the occurrence of diabetic retinopathy.

Transmission Power Influence on WSN-Based Indoor Localization Efficiency

Performing a good-quality indoor localization of a mobile target is a challenging task, which can be affected by many factors such as radio wave behavior, the nature of the experimental environment, and available infrastructure. (1) Background: An indoor localization experiment using an Internet of Things (IoT) wireless sensor network (WSN) testbed is performed, in order to study the influence of transmission power level on the quality of received signals, and consequently, the estimated target positional coordinates. (2) Methods: A received signal strength indicator (RSSI) range-based localization system using a geometrical constrained weighted least squares (WLS) estimator multilateration technique is selected to validate the influence of the transmission power level on the performance of the localization algorithm. (3) Results: Fair localization quality was obtained at the highest transmission power level instead of the proposed transmission power level. (4) Conclusion: Additional factors are discussed to fully represent the required operational transmission power for a better localization quality, along with suggested improvements of the infrastructure configuration as a future work.

Intravitreal administration of recombinant human opticin protects against hyperoxia-induced pre-retinal neovascularization

Opticin is an extracellular glycoprotein present in the vitreous. Its antiangiogenic properties offer the potential for therapeutic intervention in conditions such as proliferative diabetic retinopathy and retinopathy of prematurity. Here, we investigated the hypothesis that intravitreal administration of recombinant human opticin can safely protect against the development of pathological angiogenesis and promote its regression. We generated and purified recombinant human opticin and investigated its impact on the development and regression of pathological retinal neovascularization following intravitreal administration in murine oxygen-induced retinopathy. We also investigated its effect on normal retinal vascular development and function, following intravitreal injection in neonatal mice, by histological examination and electroretinography. In oxygen-induced retinopathy, intravitreal administration of human recombinant opticin protected against the development of retinal neovascularization to similar extent as aflibercept, which targets VEGF. Opticin also accelerated regression of established retinal neovascularization, though the effect at 18 h was less than that of aflibercept. Intravitreal administration of human recombinant opticin in neonatal mice caused no detectable perturbation of subsequent retinal vascular development or function. In summary we found that intraocular administration of recombinant human opticin protects against the development of pathological angiogenesis in mice and promotes its regression.

Opportunistic Colonoscopy Cancer Screening Pays off in Romania-A Single-Centre Study

Colorectal cancer (CRC) is the third most diagnosed cancer in men (after prostate and lung cancers) and in women (after breast and lung cancer). It is the second cause of cancer death in men (after lung cancer) and the third one in women (after breast and lung cancers). It is estimated that, in EU-27 countries in 2020, colorectal cancer accounted for 12.7% of all new cancer diagnoses and 12.4% of all deaths due to cancer. Our study aims to assess the opportunistic colorectal cancer screening by colonoscopy in a private hospital. A secondary objective of this study is to analyse the adenoma detection rate (ADR), polyp detection rate (PDR), and colorectal cancer (CRC) detection rate. We designed a retrospective single-centre study in the Gastroenterology Department of Saint Mary Hospital. The study population includes all individuals who performed colonoscopies in 2 years, January 2019–December 2020, addressed to our department by their family physician or came by themselves for a colonoscopy. One thousand seven hundred seventy-eight asymptomatic subjects underwent a colonoscopy for the first time. The mean age was 59.0 ± 10.9, 59.5% female. Eight hundred seventy-three polyps were found in 525 patients. Five hundred and twenty-five had at least one polyp, 185 patients had two polyps, 87 had three polyps, and 40 patients had more than three polyps. The PDR was 49.1%, ADR 39.0%, advanced adenomas in 7.9%, and carcinomas were found in 5.4% of patients. In a country without any colorectal cancer screening policy, polyps were found in almost half of the 1778 asymptomatic patients evaluated in a single private center, 39% of cases adenomas, and 5.4% colorectal cancer. Our study suggests starting screening colonoscopy at the age of 45. A poor bowel preparation significantly impacted the adenoma detection rate.

Molecular Detection of Fluoroquinolone Resistance among Multidrug-, Extensively Drug-, and Pan-Drug-Resistant Campylobacter Species in Egypt

In recent times, resistant foodborne pathogens, especially of the Campylobacter species, have created several global crises. These crises have been compounded due to the evolution of multidrug-resistant (MDR) bacterial pathogens and the emergence of extensively drug-resistant (XDR) and pan-drug-resistant (PDR) strains. Therefore, this study aimed to investigate the development of resistance and the existence of both XDR and PDR among Campylobacter isolates. Moreover, we explored the use of the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique for the detection of fluoroquinolone (FQ)-resistant Campylobacter isolates. A total of 120 Campylobacter isolates were identified depending on both phenotypic and genotypic methods. Of note, cefoxitin and imipenem were the most effective drugs against the investigated Campylobacter isolates. Interestingly, the majority of our isolates (75%) were MDR. Unfortunately, both XDR and PDR isolates were detected in our study with prevalence rates of 20.8% and 4.2%, respectively. All FQ-resistant isolates with ciprofloxacin minimum inhibitory concentrations ≥4 µg/mL were confirmed by the genetic detection of gyrA chromosomal mutation via substitution of threonine at position 86 to isoleucine (Thr-86-to-Ile) using the PCR-RFLP technique. Herein, PCR-RFLP was a more practical and less expensive method used for the detection of FQ resistant isolates. In conclusion, we introduced a fast genetic method for the identification of FQ-resistant isolates to avoid treatment failure through the proper description of antimicrobials.

Trabeculectomy for neovascular glaucoma in proliferative diabetic retinopathy, central retinal vein occlusion, and ocular ischemic syndrome: Surgical outcomes and prognostic factors for failure

PURPOSE

To evaluate the outcomes of trabeculectomy in the eyes with neovascular glaucoma (NVG), caused by proliferative diabetic retinopathy (PDR), central retinal vein occlusion (CRVO), and ocular ischemic syndrome (OIS).

METHODS

A retrospective review of NVG eyes that underwent trabeculectomy between 1991 and 2019. Complete success was defined as intraocular pressure (IOP) between 6 and 21 mmHg without antiglaucoma medications (AGM). The risk factors were analyzed by Cox's proportional hazard model.

RESULTS

The study included 100 eyes of 100 subjects with a mean age of 58 ± 9.8 years and a median follow-up of 1.27 years (interquartile range: 0.63, 2.27). The cause of NVG was PDR in 59 eyes (59%), CRVO in 25 eyes (25%), and OIS in 16 eyes (16%). Trabeculectomy with mitomycin-C was performed in 88 eyes and trabeculectomy in 12 eyes. The cumulative complete success probability of trabeculectomy in PDR was 50% (95% confidence interval [CI]: 38, 65) at 1 year, 8% (1, 46) at 3-5 years. In OIS, it was 64% (43, 96) from 1 to 5 years. In CRVO, it was 75% (59, 94) at 1 year, 45% (23, 86) from 2 to 5 years. The PDR was associated with a higher risk of surgical failure compared to OIS (P = 0.04) and CRVO (P = 0.004). Other significant risk factors were increasing age (P = 0.02), persistent neovascularization of iris (NVI) (P = 0.03), higher number of anti-vascular endothelial growth factor (VEGF) injections prior to trabeculectomy (P = 0.02), and delay in performing trabeculectomy (P = 0.02).

CONCLUSION

Compared to CRVO and OIS, the eyes with NVG secondary to PDR had poor success with trabeculectomy. Older age, persistent NVI, need for a higher number of anti-VEGF injections, and delayed surgery were associated with a higher risk for trabeculectomy failure.

Screening for obstructive sleep apnea in a diabetic retinopathy clinic in a tertiary care center

Purpose:

To screen for obstructive sleep apnea (OSA) in patients presenting to diabetic retinopathy (DR) clinic and to correlate its presence with the severity of DR.

Methods:

A prospective, cross-sectional study of diabetes mellitus patients in retina clinic of a tertiary care referral center, North India (January 2019–March 2020). All were subjected to STOP-Bang Questionnaire and Epworth Sleepiness Scale (ESS) score. Patients at high OSA risk (STOP-Bang score ≥5 and ESS score ≥10) were referred to Department of Otorhinolaryngology (sleep clinic) for polysomnography. Based on Apnea Hypopnea Index (AHI), OSA was graded as mild (AHI = 5–14/h), moderate (AHI = 15–30/h), and severe (AHI >30/h). Statistical analysis was done using three models of outcome measures: (1) “No DR” versus “any DR,” (2) “Less severe DR” versus “More severe DR,” and (3) “No diabetic macular edema (DME)” versus “DME.”

Results:

Of 362 patients screened, 18 (4.97%) had OSA (11 mild, 5 moderate, and 2 severe). Though OSA did not show a significant association with various outcome measures, patients with moderate–severe OSA had higher odds in developing “any DR” (OR = 7.408; 95% CI = 0.533–102.898), “more severe DR” (OR = 1.961; 95% CI = 0.153–25.215), and “DME” (OR = 2.263; 95% CI = 0.357–14.355), on multiple logistic regression.

Conclusion:

Ours is the first screening study of OSA in DR patients in India, the diabetes capital of the world. We detected OSA in 4.97% of patients in a DR clinic, with an increased risk of “any DR,” “more severe DR,” and “DME” in the presence of moderate–severe OSA.

Immune responses to injury and their links to eye disease

The eye is regarded as an immune privileged site. Since the presence of a vasculature would impair vision, the vasculature of the eye is located outside of the central light path. As a result, many regions of the eye evolved mechanisms to deliver immune cells to sites of dysgenesis, injury, or in response to the many age-related pathologies. While the purpose of these immune responses is reparative or protective, cytokines released by immune cells compromise visual acuity by inducing inflammation and fibrosis. The response to traumatic or pathological injury is distinct in different regions of the eye. Age-related diseases impact both the anterior and posterior segment and lead to reduced quality of life and blindness. Here we focus attention on the role that inflammation and fibrosis play in the progression of age-related pathologies of the cornea and the lens as well as in glaucoma, the formation of epiretinal membranes, and in proliferative vitreoretinopathy.

Largazole Inhibits Ocular Angiogenesis by Modulating the Expression of VEGFR2 and p21

Ocular angiogenic diseases, characterized by abnormal blood vessel formation in the eye, are the leading cause of blindness. Although Anti-VEGF therapy is the first-line treatment in the market, a substantial number of patients are refractory to it or may develop resistance over time. As uncontrolled proliferation of vascular endothelial cells is one of the characteristic features of pathological neovascularization, we aimed to investigate the role of the class I histone deacetylase (HDAC) inhibitor Largazole, a cyclodepsipeptide from a marine cyanobacterium, in ocular angiogenesis. Our study showed that Largazole strongly inhibits retinal vascular endothelial cell viability, proliferation, and the ability to form tube-like structures. Largazole strongly inhibits the vessel outgrowth from choroidal explants in choroid sprouting assay while it does not affect the quiescent choroidal vasculature. Largazole also inhibits vessel outgrowth from metatarsal bones in metatarsal sprouting assay without affecting pericytes coverage. We further demonstrated a cooperative effect between Largazole and an approved anti-VEGF drug, Alflibercept. Mechanistically, Largazole strongly inhibits the expression of VEGFR2 and leads to an increased expression of cell cycle inhibitor, p21. Taken together, our study provides compelling evidence on the anti-angiogenic role of Largazole that exerts its function through mediating different signaling pathways.

Source strength determination in iridium-192 and cobalt-60 brachytherapy: A European survey on the level of agreement between clinical measurements and manufacturer certificates

Background and purpose

Brachytherapy treatment outcomes depend on the accuracy of the delivered dose distribution, which is proportional to the reference air-kerma rate (RAKR). Current societal recommendations require the medical physicist to compare the measured RAKR values to the manufacturer source calibration certificate. The purpose of this work was to report agreement observed in current clinical practice in the European Union.

Materials and methods

A European survey was performed for high- and pulsed-dose-rate (HDR and PDR) high-energy sources (¹⁹²Ir and ⁶⁰Co), to quantify observed RAKR differences. Medical physicists at eighteen hospitals from eight European countries were contacted, providing 1,032 data points from 2001 to 2020.

Results

Over the survey period, 77% of the ¹⁹²Ir measurements used a well chamber instead of the older Krieger phantom method. Mean differences with the manufacturer calibration certificate were 0.01% ± 1.15% for ¹⁹²Ir and –0.1% ± 1.3% for ⁶⁰Co. Over 95% of RAKR measurements in the clinic were within 3% of the manufacturer calibration certificate.

Conclusions

This study showed that the agreement level was generally better than that reflected in prior societal recommendations positing 5%. Future recommendations on high-energy HDR and PDR source calibrations in the clinic may consider tightened agreements levels.

Morbidity following image-guided brachytherapy for cervical cancer: Patient and treatment related factors

PURPOSE

This retrospective study aims to assess factors associated with the occurrence of toxicity after brachytherapy (BT), as boost after external beam radiotherapy (EBRT) for treatment of invasive cervix carcinoma.

METHODS AND MATERIALS

All consecutive patients diagnosed with cervical carcinoma, and treated with concurrent radiochemotherapy from August 2017 to January 2020 were retrospectively included. An isodose conformation index (ICI) was developed to assess the percentage of the prescription isodose contained within the intermediate risk clinical target volume (IR-CTV).

RESULTS

Eighty-one patients with invasive cervix carcinoma from stage IB to stage IVa were included. Thirty-two (40%) and 49 (60%) patients were treated with Pulsed Dose Rate (PDR) and High Dose Rate (HDR) BT, respectively. Median follow-up was 19.6 months (5.6-41.2). The main factors associated with development of gastrointestinal toxicity were: the median volume of the prescription isodose (67.9cm[3] [37.6-92.9] vs. 49.1cm[3] [34.5-53.5], p = 0.05), the value of ICI (59% [51%-83%] vs. 86% [65%-96%], p = 0.01), the median equivalent dose delivered to the sigmoid (D2cc= 58.4 GyEQD2 [53.9-61.1] vs. 55.2 GyEQD2 [52.8-57.5], p = 0.06) and the median equivalent dose delivered to the IR-CTV (D90= 63.9 GyEQD2 [60.6-66.4] vs. 61.2 GyEQD2 [59.4-64.5], p = 0.03). The proportion of patients who received EBRT lymph node boost was higher in patients who developed urinary toxicity than in patients who did not (57.1% vs. 28.6%, p = 0.08). Anticoagulant (p = 0.02) and antiaggregant therapy (p = 0.01) were associated with occurrence of both urinary and gastrointestinal toxicity.

CONCLUSIONS

Our study confirms the predictive value of irradiated volume in the occurrence of gastrointestinal toxicity, as well as the need for a better conformation to the target volume. Precautions should be considered in patients with vascular comorbidities.

An unequivocal superbug: PDR Klebsiella pneumoniae with an arsenal of resistance and virulence factor genes

INTRODUCTION

Infections caused by extensively-drug resistant (XDR) and pan-drug resistant (PDR) Klebsiella pneumoniae represent an emerging threat due to the high associated mortality. This study aimed to characterize two carbapenem resistant K. pneumoniae strains from the same patient, the first being PDR (referred to as IMP 1078b) and the second being XDR (referred to IMP 1078s) isolated from the same patient.

METHODOLOGY

Antimicrobial susceptibility testing was done for the 2 K. pneumoniae isolates, followed by carbapenem/β-lactamase inhibitor combination assay, and fitness cost against cefepime and meropenem. Then, whole-genome sequence analysis was performed to decipher the molecular mechanisms behind the high level of resistance recorded in both isolates. Finally, qRT-PCR was done for β-lactam resistant genes.

RESULTS

This is the first report about a K. pneumoniae isolate harboring 47 antimicrobial resistance genes and having type IV pilli (Yersinia) and the fimbrial adherence determinant Stb (Salmonella) as virulence factors. Further analysis on both isolates are discussed within the article.

CONCLUSION

The co-existence of a high number of antimicrobial resistant (AMR) genes and virulence factor genes may lead to a life threatening invasive and untreatable infection.

Dysregulation of circulating follicular helper T cells in type 2 diabetic patients with diabetic retinopathy

Inflammation is known to be involved in the progression of diabetic retinopathy. Follicular helper T cells (Tfh) play critical roles in the differentiation of long-live plasma cells and production of antibodies, whereas circulating CD4⁺CXCR5⁺ T cells may act as a counterpart to measure Tfh cell disorders. In this study, we investigated whether Tfh could be involved in the development of diabetic retinopathy (DR) by assessing circulating Tfh cells in peripheral blood. Data showed that serum levels of total IgG and IgA were both significantly increased in type 2 diabetes mellitus (T2DM) patients with proliferative diabetic retinopathy (PDR) than with non-PDR. Also, B cell activation and differentiation were both enhanced in T2DM patients with PDR. Little changes were detected in levels of Th1, Th2, and Th17 cells. As indicated by elevated serum levels and supernatant from cultured PBMC of IL-21, we found increased circulating Tfh cells in PDR patients with dysregulated subsets. This study suggests the involvement of circulating Tfh cells in DR and, in particular, the pathogenesis of PDR.

Smartphone Application to Reinforce Education Increases High-Quality Preparation for Colorectal Cancer Screening Colonoscopies in a Randomized Trial

BACKGROUND & AIMS

Sufficient bowel preparation is crucial for successful screening and surveillance colonoscopy. However, rates of inadequate preparation are still high. We investigated the effects of reinforced patient education using a smartphone application software (APP) for colonoscopy preparation in participants in a CRC screening program.

METHODS

We performed a prospective, endoscopist-blinded study of 500 patients undergoing split-dose bowel preparation for CRC screening or surveillance colonoscopies at multiple centers in Germany, from November 2017 through January 2019. Participants (n = 500) were given oral and written instructions during their initial appointment and then randomly assigned (1:1) to groups that received reinforced education starting 3 days before the colonoscopy (APP group) or no further education (controls). The primary outcome was quality of bowel preparation according to the Boston bowel preparation scale. Secondary outcomes included polyp and adenoma detection rates, compliance with low-fiber diet, split-dose laxative intake, perceived discomfort from the preparation procedure.

RESULTS

The mean Boston bowel preparation scale score was significantly higher in the APP-group (7.6 ± 0.1) than in the control group (6.7 ± 0.1) (P < .0001). The percentage of patients with insufficient bowel preparation was significantly lower in the APP group (8%) than in the control group (17%) (P = .0023). The adenoma detection rate was significantly higher in the APP group (35% vs 27% in controls) (P = .0324). Use of the APP was accompanied by a lower level of non-compliance with correct laxative intake (P =.0080) and diet instructions (P = .0089). The APP group reported a lower level of discomfort during preparation (P < .0001).

CONCLUSIONS

In a randomized trial, reinforcing patient education with a smartphone application optimized bowel preparation in the 3 days before colonoscopy, increasing bowel cleanliness, adenoma detection, and compliance in patients undergoing CRC screening or surveillance. ClinicalTrials.gov no: NCT03290157.

Characteristics of Carbapenemase-Producing Klebsiella pneumoniae Isolated in the Intensive Care Unit of the Largest Tertiary Hospital in Bangladesh

For addressing the issue of antimicrobial drug resistance in developing countries, it is important to investigate the characteristics of carbapenemase-producing organisms. We aimed to genetically characterize a carbapenemase-producing Klebsiella pneumoniae (CPKP) isolated in the intensive care unit of a tertiary hospital in Bangladesh. The number of CPKP isolates were 43/145 (30%), of which pandrug-resistant (PDR) strains were 14%. These carbapenemases were New Delhi metallo-beta-lactamase (NDM)-1 (53%), NDM-5 (14%), oxacillinase (OXA)-181 (12%), OXA-232 (10%), NDM-5 + OXA-181 (5%), and NDM-5 + OXA-232 (2%). Many CPKP isolates harbored a variety of resistance genes, and the prevalence of 16S rRNA methyltransferase was particularly high (91%). The 43 CPKP isolates were classified into 14 different sequence types (STs), and the common STs were ST34 (26%), ST147 (16%), ST11 (9%), ST14 (9%), ST25 (7%), and ST231 (7%). In this study, PDR strains were of three types, ST147, ST231, and ST14, and their PDR rates were 57, 33, and 25%, respectively. The spread of the antimicrobial drug resistance of CPKP in Bangladesh was identified. In particular, the emergence of PDR is problem, and there may be its spread as a superbug of antimicrobial treatment.

Evaluation of a New Model of Care for People with Complications of Diabetic Retinopathy: The EMERALD Study

Purpose

The increasing diabetes prevalence and advent of new treatments for its major visual-threatening complications (diabetic macular edema [DME] and proliferative diabetic retinopathy [PDR]), which require frequent life-long follow-up, have increased hospital demands markedly. Subsequent delays in patient's evaluation and treatment are causing sight loss. Strategies to increase capacity are needed urgently. The retinopathy (EMERALD) study tested diagnostic accuracy, acceptability, and costs of a new health care pathway for people with previously treated DME or PDR.

Design

Prospective, multicenter, case-referent, cross-sectional, diagnostic accuracy study undertaken in 13 hospitals in the United Kingdom.

Participants

Adults with type 1 or 2 diabetes previously successfully treated DME or PDR who, at the time of enrollment, had active or inactive disease.

Methods

A new health care pathway entailing multimodal imaging (spectral-domain OCT for DME, and 7-field Early Treatment Diabetic Retinopathy Study [ETDRS] and ultra-widefield [UWF] fundus images for PDR) interpreted by trained nonmedical staff (ophthalmic graders) to detect reactivation of disease was compared with the current standard care (face-to-face examination by ophthalmologists).

Main Outcome Measures

Primary outcome: sensitivity of the new pathway. Secondary outcomes: specificity; agreement between pathways; costs; acceptability; proportions requiring subsequent ophthalmologist assessment, unable to undergo imaging, and with inadequate images or indeterminate findings.

Results

The new pathway showed sensitivity of 97% (95% confidence interval [CI], 92%–99%) and specificity of 31% (95% CI, 23%–40%) to detect DME. For PDR, sensitivity and specificity using 7-field ETDRS images (85% [95% CI, 77%–91%] and 48% [95% CI, 41%–56%], respectively) or UWF images (83% [95% CI, 75%–89%] and 54% [95% CI, 46%–61%], respectively) were comparable. For detection of high-risk PDR, sensitivity and specificity were higher when using UWF images (87% [95% CI, 78%–93%] and 49% [95% CI, 42%–56%], respectively, for UWF versus 80% [95% CI, 69–88%] and 40% [95% CI, 34%–47%], respectively, for 7-field ETDRS images). Participants preferred ophthalmologists’ assessments; in their absence, they preferred immediate feedback by graders, maintaining periodic ophthalmologist evaluations. When compared with the current standard of care, the new pathway could save £1390 per 100 DME visits and between £461 and £1189 per 100 PDR visits.

Conclusions

The new pathway has acceptable sensitivity and would release resources. Users’ suggestions should guide implementation.

Is pandrug-resistance in A. baumannii a transient phenotype? Epidemiological clues from a 4-year cohort study at a tertiary referral hospital in Greece

Pandrug-resistant A. baumannii (PDRAB) is increasingly being reported but remains rare. Several case studies show that A. baumannii can acquire resistance to last resort antibiotics during treatment by single-step chromosomal mutations. However, re-emergence of the ancestral susceptible strain after withdrawal of antibiotics has been described, possibly due to fitness cost associated with acquired resistance. Therefore, PDRAB may be a transient phenotype. Epidemiological data to show this process in larger cohorts are currently lacking. In this study of 91 hospitalized patients with PDRAB we showed the frequent (60%) isolation of non-PDRAB, often susceptible only to colistin, aminoglycosides and/or tigecycline, preceding and/or following PDRAB isolation. However, the isolation of PDRAB in two outpatients, 25 and 36 days after their discharge from the hospital, suggests the potential of some PDRAB strains to persist even in the absence of antimicrobial pressure.

Grid-Based Bayesian Filtering Methods for Pedestrian Dead Reckoning Indoor Positioning Using Smartphones

Indoor positioning systems for smartphones are often based on Pedestrian Dead Reckoning, which computes the current position from the previously estimated location. Noisy sensor measurements, inaccurate step length estimations, faulty direction detections, and a demand on the real-time calculation introduce the error which is suppressed using a map model and a Bayesian filtering. The main focus of this paper is on grid-based implementations of Bayes filters as an alternative to commonly used Kalman and particle filters. Our previous work regarding grid-based filters is elaborated and enriched with convolution mask calculations. More advanced implementations, the centroid grid filter, and the advanced point-mass filter are introduced. These implementations are analyzed and compared using different configurations on the same raw sensor recordings. The evaluation is performed on three sets of experiments: a custom simple path in faculty building in Slovakia, and on datasets from IPIN competitions from a shopping mall in France, 2018 and a research institute in Italy, 2019. Evaluation results suggests that proposed methods are qualified alternatives to the particle filter. Advantages, drawbacks and proper configurations of these filters are discussed in this paper.

Normal vitreous promotes angiogenesi via the epidermal growth factor receptor

Vitreous, a transparent tissue in our body, contains anti-angiogenesis factors. Our previous work reported that vitreous activates the signaling pathway of epidermal growth factor receptor (EGFR), which plays a critical role in angiogenesis. The aim of this study was to determine the role of EGFR in vitreous-induced angiogenesis-related cellular responses in vitro. Using a pharmacologic and molecular approach, we found that vitreous increased proliferation and migration via EGFR in human umbilical vein endothelial cells (HUVECs). Furthermore, we demonstrated that vitreous promoted tube formation via EGFR in HUVECs. Subsequently, depletion of EGFR using CRISPR/Cas9 and blockage with EGFR inhibitor AG1478 suppressed vitreous-induced Akt activation and cell proliferation, migration, and tube formation in HUVECs. The significance of the angiogenic effect derived from vitreous demonstrates the importance of vitreous in the ocular physiology and the pathobiology of angiogenesis-related ophthalmic diseases, such as proliferative diabetic retinopathy.

Citrus Psorosis Virus: Current Insights on a Still Poorly Understood Ophiovirus

Citrus psorosis was reported for the first time in Florida in 1896 and was confirmed as a graft-transmissible disease in 1934. Citrus psorosis virus (CPsV) is the presumed causal agent of this disease. It is considered as a type species of the genus Ophiovirus, within the family Aspiviridae. CPsV genome is a negative single-stranded RNA (-ssRNA) with three segments. It has a coat protein (CP) of 48 kDa and its particles are non-enveloped with naked filamentous nucleocapsids existing as either circular open structures or collapsed pseudo-linear forms. Numerous rapid and sensitive immuno-enzymatic and molecular-based detection methods specific to CPsV are available. CPsV occurrence in key citrus growing regions across the world has been spurred the establishment of the earliest eradication and virus-free budwood programs. Despite these efforts, CPsV remains a common and serious challenge in several countries and causes a range of symptoms depending on the isolate, the cultivar, and the environment. CPsV can be transmitted mechanically to some herbaceous hosts and back to citrus. Although CPsV was confirmed to be seedborne, the seed transmission is not efficient. CPsV natural spread has been increasing based on both CPsV surveys detection and specific CPsV symptoms monitoring. However, trials to ensure its transmission by a soil-inhabiting fungus and one aphid species have been unsuccessful. Psorosis disease control is achieved using CPsV-free buds for new plantations, launching budwood certification and indexing programs, and establishing a quarantine system for the introduction of new varieties. The use of natural resistance to control CPsV is very challenging. Transgenic resistance to at least some CPsV isolates is now possible in at least some sweet orange varieties and constitutes a promising biotechnological alternative to control CPsV. This paper provides an overview of the most remarkable achievements in CPsV research that could improve the understanding of the disease and lead the development of better control strategies.

Morphological changes in intraretinal microvascular abnormalities after anti-VEGF therapy visualized on optical coherence tomography angiography

Background

To examine the baseline morphological characteristics and alterations in intraretinal microvascular abnormalities (IRMAs) in response to anti-vascular endothelial growth factor (anti-VEGF) treatment, documented by optical coherence tomography angiography (OCTA) in diabetic eyes.

Methods

In this retrospective study, IRMAs were evaluated with multimodal imaging (fundus photography, fluorescein angiography, OCTA) in treatment-naïve diabetic eyes before and after anti-VEGF treatment for diabetic macular edema (DME) and/or proliferative diabetic retinopathy (PDR) and compared to diabetic control eyes with similar diabetic retinopathy (DR) severity that did not receive anti-VEGF therapy. The morphological characteristics of IRMAs on enface OCTA imaging were graded by masked readers at baseline, then after anti-VEGF therapy in treated eyes or after observation in control eyes. Characterization of interval changes in an IRMA were based on the following parameters: branching, vessel caliber and area of adjacent capillary non-perfusion.

Results

The treated group included 45 IRMA foci from 15 eyes of 11 patients, while the control group included 27 IRMA foci from 15 eyes of 14 patients. Following anti-VEGF treatment, enface OCTA demonstrated that 14 foci of IRMA (31%) demonstrated regression with normalization of appearance of the capillary bed, 20 IRMAs (44%) remained unchanged, six IRMAs (13%) progressed with enlargement or development of new IRMAs and five IRMAs (11%) demonstrated complete obliteration defined as IRMA disappearance with advancing capillary drop-out. In the control group, 17 IRMA (63%) remained stable, 8 IRMAs (29.6%) progressed and 2 experienced total obliteration (7.4%). The difference in rank order between the two groups was statistically significant (p = 0.022).

Conclusions

In eyes with DR status post anti-VEGF therapy, foci of IRMAs have a variable course demonstrating one of four possible outcomes: regression, stability, progression or complete obliteration. In contrast, none of the untreated control diabetic eyes demonstrated regression of IRMAs, consistent with known progression of DR severity in high risk eyes. Morphologic evaluation of IRMAs with OCTA may help to monitor changes in retinal blood flow as well as the response to anti-VEGF treatment.

Pan drug-resistant Acinetobacter baumannii causing nosocomial infections among burnt children

Background: Nosocomial infection caused by Acinetobacter baumannii has emerged as a world-wide serious problem in the emergence of multidrug-resistant (MDR). Infections caused by antibiotic-resistant strains of A. baumannii cannot be completely eliminated among the infected patients. This study aimed to monitor antibiotic resistance among A. baumannii strains isolated from burnt children.

Methods: After performing biochemical identification tests on 115 isolates, 62 were detected as A. baumannii . Minimum inhibitory concentration (MIC) was used to test susceptibility to colistin, and disk agar diffusion was used for the susceptibility of the isolates to the antibiotics Ciprofloxacin, Amikacin, Gentamicin, Cefepime, Meropenem, Imipenem, Ceftazidime, Levofloxacin and Piperacillin/Tazobactam. Bacterial species were isolated and identified as multidrug-resistant (MDR), extensively drug-resistant (XDR) and pan drug-resistant (PDR), based on the susceptibility patterns to elected antibiotics, deputing different classes of antimicrobial.

Results: The antibiotic susceptibility pattern out of a total of 62 bacterial strains used in this study. Thirty-six (58%) strains were categorized as MDR, 17 (27.5%) as XDR, and nine (14.5%) as PDR.

Conclusion: To reduce the threat of antimicrobial resistance, MDR, XDR and PDR A. baumannii strains must be evaluated by all clinical microbiology laboratories.

Improvement of reporter gene assay for highly sensitive dioxin detection using protoplastic yeast with inactivation of CWP and PDR genes

A yeast reporter gene assay system with improved performance for dioxin detection was established. Since yeast reporter gene assays are relatively simple, easy to handle, and inexpensive, they have been used for various assessments of environmental contaminants. We previously constructed a yeast assay strain expressing the aryl hydrocarbon receptor (AhR) and AhR nuclear translocator (Arnt) carrying the lacZ reporter gene, for detection of dioxins. In the present study, genes encoding cell wall mannoproteins and ATP-binding cassette transporters in the yeast assay strains were deleted in order to increase the substance influx and prevent its efflux. We also established an assay procedure for protoplasts of these yeasts. These modifications improved the detection limit 40-fold and reduced the duration of the assay by 40%. By combining the yeast protoplast and a rapid sample preparation technique using disposal multilayer solid-phase extraction columns to remove unintended aryl hydrocarbons, this yeast reporter gene assay system detected the ligand activities of dioxins and related compounds in 1 g of forest soil containing dioxins at a concentration 10 times lower than the Japanese environmental standard for dioxins in soil.

Characterization of Resistance in Gram-Negative Urinary Isolates Using Existing and Novel Indicators of Clinical Relevance: A 10-Year Data Analysis

Classical resistance classifications (multidrug resistance [MDR], extensive drug resistance [XDR], pan-drug resistance [PDR]) are very useful for epidemiological purposes, however, they may not correlate well with clinical outcomes, therefore, several novel classification criteria (e.g., usual drug resistance [UDR], difficult-to-treat resistance [DTR]) were introduced for Gram-negative bacteria in recent years. Microbiological and resistance data was collected for urinary tract infections (UTIs) retrospectively, corresponding to the 2008.01.01–2017.12.31. period. Isolates were classified into various resistance categories (wild type/susceptible, UDR, MDR, XDR, DTR and PDR), in addition, two new indicators (modified DTR; mDTR and mcDTR) and a predictive composite score (pMAR) were introduced. Results: n = 16,240 (76.8%) outpatient and n = 13,386 (69.3%) inpatient UTI isolates were relevant to our analysis. Citrobacter-Enterobacter-Serratia had the highest level of UDR isolates (88.9%), the Proteus-Providencia-Morganella group had the highest mDTR levels. MDR levels were highest in Acinetobacter spp. (9.7%) and Proteus-Providencia-Morganella (9.1%). XDR- and DTR-levels were higher in non-fermenters (XDR: 1.7%–4.7%. DTR: 7.3%–7.9%) than in Enterobacterales isolates (XDR: 0%–0.1%. DTR: 0.02%–1.5%). Conclusions: The introduction of DTR (and its’ modifications detailed in this study) to the bedside and in clinical practice will definitely lead to substantial benefits in the assessment of the significance of bacterial resistance in human therapeutics.

How Phages Overcome the Challenges of Drug Resistant Bacteria in Clinical Infections

Nowadays the most important problem in the treatment of bacterial infections is the appearance of MDR (multidrug-resistant), XDR (extensively drug-resistant) and PDR (pan drug-resistant) bacteria and the scarce prospects of producing new antibiotics. There is renewed interest in revisiting the use of bacteriophage to treat bacterial infections. The practice of phage therapy, the application of phages to treat bacterial infections, has been around for approximately a century. Phage therapy relies on using lytic bacteriophages and purified phage lytic proteins for treatment and lysis of bacteria at the site of infection. Current research indicates that phage therapy has the potential to be used as an alternative to antibiotic treatments. It is noteworthy that, whether phages are used on their own or combined with antibiotics, phages are still a promising agent to replace antibiotics. So, this review focuses on an understanding of challenges of MDR, XDR, and PDR bacteria and phages mechanism for treating bacterial infections and the most recent studies on potential phages, cocktails of phages, and enzymes of lytic phages in fighting these resistant bacteria.

High precision radiotherapy including intensity-modulated radiation therapy and pulsed-dose-rate brachytherapy for cervical cancer: a retrospective monoinstitutional study

Purpose

To analyse the survival outcomes and toxicity profile of patients treated with pulsed-dose-rate (PDR) brachytherapy (BT) after intensity-modulated radiation therapy (IMRT) for uterine cervical cancer in a single institution.

Material and methods

Between March 2011 and December 2014, 50 patients with histologically proven stages IB1-IVB cervical cancer were treated with IMRT followed by PDR-BT boost. Radiation treatment consisted of IMRT to pelvic with or without paraaortic lymph nodes to a total dose of 45-50.4 Gy. Weekly concomitant chemotherapy was administered to 45 patients. PDR-BT boost was delivered with a median dose of 30 Gy to the high-risk clinical target volume (HR-CTV) after a median time of 14 days since IMRT. Acute and late toxicity were evaluated by Radiation Therapy Oncology Group (RTOG) - European Organization for Research and Treatment of Cancer (EORTC) scoring criteria and Subjective Objective Management Analytic-Late Effects of Normal Tissues (SOMA-LENT) criteria.

Results

Two patients had tumour persistence at 6 months after the end of BT. After a median follow-up of 33 months, 6 distant metastases with or without regional relapse were observed. The 1- and 5-year progression-free survival was 83% (95% CI: 69-91%) and 76% (95% CI: 61-86%), whereas the 3- and 5-year overall survival was 91% (95% CI: 78-97%) and 76% (95% CI: 56-88%), respectively. Urinary and rectal toxicity higher than grade 2 was observed in 6.3% and 17% of patients, respectively. Five patients (10.6%) had grade 4 gastrointestinal toxicity requiring colostomy.

Conclusions

Our study confirms that the combination of IMRT and PDR-BT can be considered an effective treatment for cervical cancer, ensuring high local control, despite the high percentage of locally advanced disease.