Mouth Dissolving Film of Domperidone: An approach towards Formulation and its Evaluation

The objective of the current work is to formulate and evaluate the mouth dissolving film of domperidone. It is ideally suitable for the treatment of emesis. The mouth dissolving film of domperidone is useful in the vomiting through the journey. Mouth dissolving films were formulated by the solvent casting technique and its in-vitro as well as the in-vivo evaluation was done by the usual pharmacopoeial and unofficial tests and by using human volunteers. The main benefit of the preparation technique includes fewer operation units, better content consistency. The mouth dissolving film formed was found to be disintegrated in 1 minute. The ratio of components in the aqueous phase affected the thickness, drug content, tensile strength, percentage elongation, folding endurance, and release profile of mouth dissolving film and the best results were obtained for the HPMC E15 and polyethyleneglycol. The compatibility between domperidone and excipients was confirmed by FTIR and DSC studies. The developed mouth dissolving film of domperidone demonstrated usefulness for fast release of drug in mouth, for better drug utilization, and improved patient compliance. The optimized formulation, due to low HPMC E15 content, has optimum tensile strength and thickness. Formulation F8 containing HPMC E15 and PG showed a cumulative % drug release of 95.10 at the end of 12 minutes. HPMC E15 films showed higher cumulative % drug release than films of other HPMC E grades at different concentrations. It was found to be stable during the accelerated stability study. The effect of different concentrations of polymers and plasticizers on in-vitro evaluation parameters was evaluated. Hence, data showed that formulation F8 was the most suitable for the development of fast dissolving oral films of domperidone.

Well-differentiated gastroenteropancreatic G3 NET: findings from a large single centre cohort

Neuroendocrine neoplasms are known to have heterogeneous biological behavior. G3 neuroendocrine tumours (NET G3) are characterized by well-differentiated morphology and Ki67 > 20%. The prognosis of this disease is understood to be intermediate between NET G2 and neuroendocrine carcinoma (NEC). Clinical management of NET G3 is challenging due to limited data to inform treatment strategies. We describe clinical characteristics, treatment, and outcomes in a large single centre cohort of patients with gastroenteropancreatic NET G3. Data was reviewed from 26 cases managed at Queen Elizabeth Hospital, Birmingham, UK, from 2012 to 2019. Most commonly the site of the primary tumour was unknown and majority of cases with identifiable primaries originated in the GI tract. Majority of cases demonstrated somatostatin receptor avidity. Median Ki67 was 30%, and most cases had stage IV disease at diagnosis. Treatment options included surgery, somatostatin analogs (SSA), and chemotherapy with either platinum-based or temozolomide-based regimens. Estimated progression free survival was 4 months following initiation of SSA and 3 months following initiation of chemotherapy. Disease control was observed following treatment in 5/11 patients treated with chemotherapy. Estimated median survival was 19 months; estimated 1 year survival was 60% and estimated 2 year survival was 13%. NET G3 is a heterogeneous group of tumours and patients which commonly have advanced disease at presentation. Prognosis is typically poor, though select cases may respond to treatment with SSA and/or chemotherapy. Further study is needed to compare efficacy of different treatment strategies for this disease.

TMJOAI: An Artificial Web-Based Intelligence Tool for Early Diagnosis of the Temporomandibular Joint Osteoarthritis

Osteoarthritis is a chronic disease that affects the temporomandibular joint (TMJ), causing chronic pain and disability. To diagnose patients suffering from this disease before advanced degradation of the bone, we developed a diagnostic tool called TMJOAI. This machine learning based algorithm is capable of classifying the health status TMJ in of patients using 52 clinical, biological and jaw condyle radiomic markers. The TMJOAI includes three parts. the feature preparation, selection and model evaluation. Feature generation includes the choice of radiomic features (condylar trabecular bone or mandibular fossa), the histogram matching of the images prior to the extraction of the radiomic markers, the generation of feature pairwise interaction, etc.; the feature selection are based on the p-values or AUCs of single features using the training data; the model evaluation compares multiple machine learning algorithms (e.g. regression-based, tree-based and boosting algorithms) from 10 times 5-fold cross validation. The best performance was achieved with averaging the predictions of XGBoost and LightGBM models; and the inclusion of 32 additional markers from the mandibular fossa of the joint improved the AUC prediction performance from 0.83 to 0.88. After cross-validation and testing, the tools presented here have been deployed on an open-source, web-based system, making it accessible to clinicians. TMJOAI allows users to add data and automatically train and update the machine learning models, and therefore improve their performance.

Structural brain lesions in schizophrenia -magnetic resonance imaging on a mid field magnet

Objectives : The brain damage associated with schizophrenia has been established beyond doubt; however, what remains unexplored is the biological nature of transcultural variations. An important reason for this was the lack of mid and high field scanners in developing countries like India. Material and Methods : We undertook a pilot study using a 0.5 Tesla MRI scanner (General Electric Signa Contour) to explore identifiable structural brain lesions in ten randomly selected individuals with schizophrenia. Results: Nine of the ten participants in the series had structural brain changes. The most common findings were ventricular dilatation and prominent cerebral cortical sulci and cerebellar folia. Additionally non-focal white matter lesions were observed in three patients and small right hippocampus was noted in one participant. Conclusions : The study discusses that establishing structural brain lesions with mid field scanners is indeed feasible. The small study sample and heterogeneity of schizophrenia however made it difficult to establish any definite associations

75 Treatment Escalation Plan (TEP) Completion Rates in General Surgery

Background

TEPs ensure every patient has a ceiling of care formally documented, including a DNACPR decision. This pre-empts complications and provides guidance on how to appropriately manage acutely unwell patients. There is no national standard for TEPs. Our aim: to formally document the incidence of TEP completion in general surgery at a local District General Hospital.

Method

A multi-phase, cross-sectional study of 1. Inpatients on three general surgical wards, 2. TEP completion at post-take after a typical on-call cycle.

Results

15.4% of TEPs were completed, of which 75% had a DNARCPR form. For the two post-take ward rounds, 5% and 7.7% of admitted patients had a TEP. Elective surgical/Enhanced recovery patients (ERP) did not have a TEP. Findings were presented locally, and posters placed in the surgical offices. Cycle 2: 19.6% and 10% completion rate for ward and post-take patients, respectively.

Conclusions

TEPs are rarely completed. Minimal improvement in completion rate was noted at cycle 2. TEPs are more commonly completed for patients not for resuscitation. Future aims include editing the surgical clerking proforma and the elective surgery/ERP paperwork to encourage completion, improving patient care. Currently we are arranging similar audits across other NHS trusts to determine if this is a national problem.

Comparison of pulmonary vein sizing by transesophageal echocardiogram and by direct angiogram

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein (PV) anatomy and sizing is important to know before performing PV isolation. This information is conventionally obtained by angiography or by CT scan.

Aim

We undertook this study to identify and measure the PVs during TEE studies and validate these against angiography.

Method

17 consecutive patients due to undergo PV isolation for paroxysmal atrial fibrillation were analysed. Using TEE, the PVs were visualised (Upper panel) as follows:  i) From the mid-esophageal four chamber view, the chamber probe was turned to the right at 110-130º for the bicaval view, where the RSPV was seen entering the left atrium adjacent to the SVC. ii) At 0º the SVC was imaged in its short axis, and the probe advanced till the interatrial septum was seen. The angle was changed to 30º to visualise the right inferior PV (RIPV). iii) From the two chamber view (70-90º), the probe was turned to the left and withdrawn to display the left superior PV (LSPV) entering the left atrium parallel to the appendage.iv) Keeping the LSPV in focus, the angle was changed to 135º and the probe advanced till the AV groove, where the left inferior PV (LIPV) was visualised. After transseptal puncture, each PV was cannulated. The PV angiograms were performed in several projections to obtain the best PV profile (lower panel). Using electronic callipers, each PV was measured within 1 cm of its entry into the left atrium, after having received all tributaries. Those PVs were considered for analysis which were measured by both TEE and angiography. The paired ‘T’ test was used to compare the PV diameters by TEE and angiography and the Bland Altman analysis was done to see the level of agreement.

Results

Of a total of 68 PVs, 62 could be adequately visualised by TEE and 50 by angiography. These 50 PVs were measured using both methods. The diameters of the PVs measured by TEE and angiography were not statistically different by the paired t test; LSPV14 ± 1.8 mm v/s 14.4 ± 2.1 mm; RSPV 13 ± 1.8 mm v/s 14.6 ± 3.5 mm; LIPV 11.9 ± 2.1 vs 13.2 ± 2.8 mm and RIPV 10.5 ± 2.7 vs 12.1 ± 2.9 mm. Bland Altman analysis showed most PV sizes estimated by TEE and angiography lay within limits of agreement.

Conclusions

A majority of PVs can be visualised by TEE using a defined protocol. TEE is a good technique to visualise and assess the size of PVs, avoiding the need for contrast medium and radiation.

Abstract Figure. TEE and angiographic images of PVs

An automated framework for image classification and segmentation of fetal ultrasound images for gestational age estimation

Accurate assessment of fetal gestational age (GA) is critical to the clinical management of pregnancy. Industrialized countries rely upon obstetric ultrasound (US) to make this estimate. In low- and middle- income countries, automatic measurement of fetal structures using a low-cost obstetric US may assist in establishing GA without the need for skilled sonographers. In this report, we leverage a large database of obstetric US images acquired, stored and annotated by expert sonographers to train algorithms to classify, segment, and measure several fetal structures: biparietal diameter (BPD), head circumference (HC), crown rump length (CRL), abdominal circumference (AC), and femur length (FL). We present a technique for generating raw images suitable for model training by removing caliper and text annotation and describe a fully automated pipeline for image classification, segmentation, and structure measurement to estimate the GA. The resulting framework achieves an average accuracy of 93% in classification tasks, a mean Intersection over Union accuracy of 0.91 during segmentation tasks, and a mean measurement error of 1.89 centimeters, finally leading to a 1.4 day mean average error in the predicted GA compared to expert sonographer GA estimate using the Hadlock equation.

Social network analysis of COVID-19 transmission in Karnataka, India

We used social network analysis (SNA) to study the novel coronavirus (COVID-19) outbreak in Karnataka, India, and to assess the potential of SNA as a tool for outbreak monitoring and control. We analysed contact tracing data of 1147 COVID-19 positive cases (mean age 34.91 years, 61.99% aged 11-40, 742 males), anonymised and made public by the Karnataka government. Software tools, Cytoscape and Gephi, were used to create SNA graphics and determine network attributes of nodes (cases) and edges (directed links from source to target patients). Outdegree was 1-47 for 199 (17.35%) nodes, and betweenness, 0.5-87 for 89 (7.76%) nodes. Men had higher mean outdegree and women, higher mean betweenness. Delhi was the exogenous source of 17.44% cases. Bangalore city had the highest caseload in the state (229, 20%), but comparatively low cluster formation. Thirty-four (2.96%) 'super-spreaders' (outdegree ⩾ 5) caused 60% of the transmissions. Real-time social network visualisation can allow healthcare administrators to flag evolving hotspots and pinpoint key actors in transmission. Prioritising these areas and individuals for rigorous containment could help minimise resource outlay and potentially achieve a significant reduction in COVID-19 transmission.

Comparison of 68Ga-DOTA-NaI3-Octreotide/tyr3-octreotate positron emission tomography/computed tomography and contrast-enhanced computed tomography in localization of tumors in multiple endocrine neoplasia 1 syndrome

The optimum imaging modality for the screening of multiple endocrine neoplasia type 1 (MEN1)-associated tumors is not well established. Here, we compare the performance of contrast-enhanced CT (CECT) versus ⁶⁸Ga DOTA-NOC/TATE PET/CT in MEN1 patients. The retrospective case record study is conducted at a tertiary health-care center. Thirty-four patients, who have undergone both CECT and ⁶⁸Ga DOTA-NOC/ TATE PET, were included in the analysis. CECT had higher per-lesion sensitivity than ⁶⁸Ga DOTA-NOC/TATE PET/CT for the detection of parathyroid lesions, (82.6% vs. 24.6%, P < 0.001). ⁶⁸Ga DOTA-NOC/TATE PET/CT had higher per-lesion sensitivity than CECT for the detection of metastases (85% vs. 47.5%, P < 0.001) and gastrinomas (90% vs. 10%, P = 0.003). When combined use of the two imaging modalities is compared to CECT alone (63.7% vs. 93.1%, P = 0.00012) and ⁶⁸Ga-DOTA-NOC/TATE PET/CT alone (74.1% vs. 93.1%, P = 0.0057), it provided significantly higher per-lesion sensitivity for the detection of gastroenteropancreatic neuroendocrine tumors (GEP-NETs). ⁶⁸Ga-DOTA-NOC/ TATE PET was more sensitive for the detection of gastrinomas and metastases than CECT, whereas it was less sensitive for the detection of parathyroid lesions than CECT. The combined use of both the imaging modalities significantly increases the sensitivity for detection of GEP-NETs.

P636 A unique case of purulent pericarditis resulting in cardiac tamponade

Introduction and case report description

A 54-year-old male with no past cardiac disease was experiencing a productive cough, fevers, chills, and shortness of breath for 3 days in the community. His dyspnea worsened significantly, and he then presented to the emergency room. He admitted to using intravenous recreational drugs. His initial vital signs included a temperature of 38.2 degrees Celsius, a heart rate of 116 beats per minute, and a blood pressure of 88/42 mmHg. He had a positive pulses paradoxus with a decrease in systolic blood pressure of 14 mmHg on inspiration.

Description of the problem and procedures

This presentation was consistent with cardiac tamponade. He had an emergent echocardiogram showing a large pericardial effusion in the apical-four-chamber view (Image 1, A), including collapse of the right ventricle during diastole (Image 1, B, Green Arrow). There were also fibrin strands seen in a modified parasternal long axis view (Image 1, C, Blue Arrow). He had an emergency pericardiocentesis using real-time ultrasound guidance, which drained 400 mL of thick brown purulent fluid. A pigtail catheter was inserted to allow for continued drainage. Immediately afterwards, the patient’s blood pressure normalized, and his shortness of breath improved significantly.

Using the ultrasound, the physician also saw bilateral pleural effusions. The larger left pleural effusion was drained, and a pigtail catheter was inserted into the left pleural space. After confirming that there was no post-procedure left pneumothorax, the right pleural effusion was also drained.

An echocardiogram after the pericardiocentesis showed a significant decrease in the size of the pericardial effusion (Image 1, D).

The patient was started on broad-spectrum antibiotics, which was then narrowed after cultures from both the pericardial fluid and pleural fluid grew methicillin-susceptible Staphylococcus aureus.

Discussion

Cardiac tamponade results in increased compression of the cardiac chambers due to raised pericardial pressures. As it progresses, it can result in significant impairment in venous return, cardiac output, and blood pressure. This is a life-threatening condition if it is not promptly treated. In this case, the patient had a methicillin-susceptible Staphylococcus aureus empyema which spread contiguously into the pericardium and resulted in cardiac tamponade.

Conclusions and implications for clinical practice

This case highlights the clinical benefits of being proficient in performing a point-of-care ultrasound because a bedside echocardiogram by the physician immediately confirmed the diagnosis and allowed for safer drainage of the pericardial effusion using ultrasound guidance to decrease the chance of causing a perforation of the ventricle. Using ultrasound, the clinician was also able to promptly diagnose the pleural effusions and urgently drain them, which was necessary for achieving source control in order to fully treat the infection.

Abstract P636 Figure. Image 1. Cardiac Tamponade

A review of skeletal dysplasia research in India

We aimed to review the contributions by Indian researchers to the subspecialty of skeletal dysplasias (SDs). Literature search using specific keywords in PubMed was performed to retrieve all the published literature on SDs as on July 6, 2017. All published literature on SDs wherein at least one author was from an Indian institute was included. Publications were grouped into different categories based on the major emphasis of the research paper. Five hundred and forty publications in English language were retrieved and categorized into five different groups. The publications were categorized as reports based on: (i) phenotypes (n = 437), (ii) mutations (n = 51), (iii) novel genes (n = 9), (iv) therapeutic interventions (n = 31), and (v) reviews (n = 12). Most of the publications were single-patient case reports describing the clinical and radiological features of the patients affected with SDs (n = 352). We enlisted all the significant Indian contributions. We have also highlighted the reports in which Indians have contributed to discovery of new genes and phenotypes. This review highlights the substantial Indian contributions to SD research, which is poised to reach even greater heights given the size and structure of our population, technological advances, and expanding national and international collaborations.

SlicerSALT: Shape AnaLysis Toolbox

SlicerSALT is an open-source platform for disseminating state-of-the-art methods for performing statistical shape analysis. These methods are developed as 3D Slicer extensions to take advantage of its powerful underlying libraries. SlicerSALT itself is a heavily customized 3D Slicer package that is designed to be easy to use for shape analysis researchers. The packaged methods include powerful techniques for creating and visualizing shape representations as well as performing various types of analysis.