Noninvasive imaging tools in dermatology

The diagnosis of skin disease relies on visual inspection, often followed by biopsy and histopathologic examination, which remains the gold standard in diagnosis. New imaging tools, including dermoscopy, reflectance confocal microscopy (RCM), and optical coherence tomography (OCT), can provide noninvasive diagnoses while sparing unnecessary biopsies. We discuss dermoscopy, RCM, and OCT, and compare cost, clinical integration, reimbursement, and accuracy of these imaging modalities.

Back to the future: integrating technology to improve patient-provider interactions

The adoption of electronic medical records (EMRs) resulted in both improvement and deterioration of different aspects of patient-provider interactions. We envision further integration of current and future technology to optimize patient-provider interactions, which we present using a hypothetical patient encounter.

"Deep" vertical Mohs and closure with a tumor-free flap for dermatofibrosarcoma protuberans: A case report

Dermatofibrosarcoma protuberans is an uncommon low-grade malignant tumor that can invade locally and rarely metastasize. Dermatofibrosarcoma protuberans has a high rate of local recurrence due to incomplete excision, especially in deep tissues. Morbidity is often related to multiple local recurrences and removal of excessive tissue with large, complex repairs. We present a case of incompletely excised dermatofibrosarcoma protuberans after initial wide local excision. We subsequently employed a "deep" vertical Mohs micrographic surgical technique to remove the remaining tumor while creating a flap with the tumor-free superficial portion to preserve tissue and avoid a complicated repair. The patient is tumor-free for 7 years.

Life of a Wound: Serial Documentation of Wound Healing After Shave Removal Using Reflectance Confocal Microscopy

Reflectance Confocal Microscopy (RCM) is a new noninvasive skin imaging modality that is comparable to traditional histopathology. We present serial in vivo RCM imaging of an atypical nevus after shave excision over a 1-month period. Findings on RCM images are consistent with the inflammatory, proliferative, and remodeling phases of wound healing, and RCM may serve as a new tool to study wound healing in vivo over time. J Drugs Dermatol. 2019;18(5):472-474.

Abstract P3-16-01: Responding at patient's time of need: Scaling rapid access to evidence-based treatment plans

Background: Cancer patients worldwide feel intense anxiety, often racing to start treatments at non expert centers. Further, imbalanced oncologist to patient ratios (˜1600: 1.8 M in India, ˜23,000: 15M in USA), impedes access to expertise. We study the impact of rapid evidence based expert treatment plans in relieving patient anxiety. Navya, a health services technology, generates personalized treatment plans that maps within NCCN Resource Stratified Guidelines [SABCS 2017]. This is vetted on mobile by oncologists at tertiary centers like TMC NCG to provide expert opinion reports to patients. Since 2015, ˜19,457 patients from 57 countries have reached out for an online opinion. On the ground, 78% of patients received evidence based treatments recommended by Navya [ASCO 2017].

Methods: To assess impact of timeliness, a prospective series of patients (from Sep '17 to April '18) were asked: “Were you relieved to receive expert opinion report in [x] days?” “Does it matter to you to receive expert opinion report in 1 day?” To assess time savings, preliminary reports with treatment options from NCCN and TMC NCG guidelines were shared with patients who matched all guidelines criteria. Subsequently, expert opinion reports were shared as usual.

Results: 543/701 patients responded to phone follow-up. 97% [± 3.2] were relieved to receive expert opinion reports in 1-2 days (103/106) vs 83% [± 3.8 ] for 3+ days (365/437). Of those not relieved by 3+ day turnaround, 83% stated that it would matter to receive expert opinion reports in 1 day (60/72). The first 300 preliminary reports shared in median time of 3.37 hours, resulted in 90% time savings vs expert opinion reports. On 10% of the preliminary reports, experts added information such as de-/escalating therapy (18/31), and additional diagnostic tests (6/31).

Conclusions: Navya relieves patient anxieties by responding at the time of need with evidence based treatment plans. Scaling such health services technologies to patients worldwide is feasible.

Citation Format: Ramarajan N, Srivastava R, Begum F, Gupta S, Pramesh C, Badwe R. Responding at patient's time of need: Scaling rapid access to evidence-based treatment plans [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-16-01.

AFOMP policy number 6: code of ethics for medical physicists in AFOMP Countries

This policy statement, which is the sixth of a series of documents prepared by the Asia-Oceania Federation of Organizations for Medical Physics (AFOMP) Professional Development Committee, gives guidance on how medical physicists in AFOMP countries should conduct themselves in an ethical manner in their professional practice (Ng et al. in Australas Phys Eng Sci Med 32:175-179, 2009; Round et al. in Australas Phys Eng Sci Med 33:7-10, 2010; Round et al. in Australas Phys Eng Sci Med 34:303-307, 2011; Round et al. in Australas Phys Eng Sci Med 35:393-398, 2012; Round et al. in Australas Phys Eng Sci Med 38:217-221, 2015). It was developed after the ethics policies and codes of conducts of several medical physics societies and other professional organisations were studied. The policy was adopted at the Annual General Meeting of AFOMP held in Jaipur, India, in November 2017.

Lipopolysaccharide-induced priming enhances NO-mediated activation of defense responses in pearl millet challenged with Sclerospora graminicola

Lipopolysaccharide (LPS) elicitors isolated from Pseudomonas fluorescens UOM SAR 14 effectively induced systemic and durable resistance against pearl millet downy mildew disease caused by the oomycete Sclerospora graminicola. Rapid and increased callose deposition and H2O2 accumulation were evidenced in downy mildew susceptible seeds pre-treated with LPS (SLPS) in comparison with the control seedlings, which also correlated with expression of various other defense responses. Biochemical analysis of enzymes and quantitative real-time polymerase chain reaction data suggested that LPS protects pearl millet against downy mildew through the activation of plant defense mechanisms such as generation of nitric oxide (NO), increased expression, and activities of defense enzymes and proteins. Elevation of NO concentrations was shown to be essential for LPS-mediated defense manifestation in pearl millet and had an impact on the other downstream defense responses like enhanced activation of enzymes and pathogen-related (PR) proteins. Temporal expression analysis of defense enzymes and PR-proteins in SLPS seedlings challenged with the downy mildew pathogen revealed that the activity and expression of peroxidase, phenylalanine ammonia lyase, and the PR-proteins (PR-1 and PR-5) were significantly enhanced compared to untreated control. Higher gene expression and protein activities of hydroxyproline-rich glycoproteins (HRGPs) were observed in SLPS seedlings which were similar to that of the resistant check. Collectively, our results suggest that, in pearl millet-downy mildew interaction, LPS pre-treatment affects defense signaling through the central regulator NO which triggers the activities of PAL, POX, PR-1, PR-5, and HRGPs.

Risk of cardiovascular diseases and gastrointestinal tract disorders in relation to the impact of shift work among male workers of textile mills in Pali district of Rajasthan, India

he present study was conducted in textile mill of Pali city with the objective to study the risk of cardiac and gastric problems in relation to shift work among male workers. The results showed significant difference between Body Mass Index (χ2=14.2, p=0.0008) and waist hip ratio (χ2=5.2, p=0.0226) of shift and non shift workers. Results on food intake showed comparatively more deficient daily intake of nutrients like fiber (7.21 g), β carotene (1842.89 μg), and folic acid (99.03 μg) in shift workers with respect to recommended dietary allowances and an overconsumption of fats (37.72 g). Alcoholism (χ2=17.3, p=0.0001) and smoking habit (χ2=14, p=0.0029) was found to be significantly higher among shift workers. Comparatively higher segment of shift workers suffered from hypertension (56.0%), disturbed appetite (87.50%), stomach upsets (90.0%), nausea (88.50%), heartburn (85.0%) and breathlessness (34.0%). Shift workers also had higher mean levels of lipid profile fractions and relatively more subjects fell into the category of high risk (20.50%) of CVD. Longer duration of involvement in shift work also influenced the occurrence of gastric and cardiac problems like disturbed appetite (χ2=9.96, p=0.0411), stomach upsets (χ2=9.73, p=0.0452), stomach ache (χ2=10.1, p=0.0389), constipation (χ2=9.88, p=0.0424), dizziness (47.37%), breathlessness (50.0%) and swollen feet (44.74%). The study concludes that shift work affects food intake, BMI, WHR, BP, alcohol intake, smoking habits and lipid profile of the subjects, thus increasing the risk of health problems like cardiovascular and gastric diseases.

Kinetic study of furan and furfural generation during baking of cake models

This study describes the kinetics of furan and furfural generation in a cake model, for the first time. These process-induced compounds impact safety and sensory aspects of baked products. Understanding their generation with regards to process dynamics will serve food quality design. However, the complexity of real products makes this task challenging. This work provides a novel approach to understand and model chemical reactivity by implementing an inert cake model (starch, water and cellulose), specifically designed for mimicking a sponge cake structure. The addition of reaction precursors (glucose and leucine) to follow Maillard and caramelization reactions, resulted in browning and generated considerable levels of furanic compounds (up to 17.61ng/g for furan and 38.99μg/g for furfural, dry basis). Multiresponse data modeling resulted in a kinetic model which adequately describes experimental concentrations and makes it possible to estimate the degradation of precursors and the behavior of two hypothetic intermediates.

Airway epithelial cells enhance the immunogenicity of human myeloid dendritic cells under steady state

Dendritic cells (DCs) and airway epithelial cells (AECs) are in close proximity, and AECs secrete factors such as retinoic acid which induce tolerance in DCs at homeostasis. However, the question remains as to how DCs in the lung are able to respond to pathogens in the immunosuppressive environment. Using an in vitro human myeloid DC (mDC)-AEC co-culture system, we demonstrate that AECs induced several gene changes in the mDCs cultured with AECs compared to the mDCs not cultured with AECs. Analysis revealed that several chemokine genes were altered. These chemokine genes could serve to attract neutrophils, natural killer (NK) T as well as T helper type 1 (Th1)/Th2 cells to the airways. Genes priming lipid and major histocompatibility complex (MHC) class II antigen presentation were also up-regulated, along with certain anti-microbial protein genes. In addition, the expression and function of pathogen-sensing Toll-like receptors (TLRs) as well as Nod-like receptors (NLRs) and their downstream signalling molecules were up-regulated in mDCs cultured with AECs. Moreover, murine mucosal DCs from the lung expressed significantly higher levels of TLRs and NLRs compared to peripheral DCs from the spleen. These results indicate that AECs prime mDCs to enhance their immunogenicity, which could be one of the mechanisms that compensates for the immunosuppressive mucosal environment.

Dual responsive magnetic composite nanogels for thermo-chemotherapy

With the onset of hyperthermia and their advantage in increasing vascular perfusion and permeability in the cancer milieu, thermo-responsive polymers have become an attractive candidate for designing therapeutic nano-vehicles for targeted on-demand delivery of bioactive agents. For this purpose, we developed a dual (thermo- and pH-) responsive nanotherapeutic composite system rendering a combinational therapy of hyperthermia mediated drug delivery. This composite system comprises of magnetic chitosan-g-PNVCL (MCP) polymeric nanogels loaded with anticancer drug, Doxorubicin (DOX). The size distribution and the stability of the MCP nanogels have been characterized using DLS and Zeta-potential studies. XRD and TG-DTA confirms the presence of magnetic nanoparticles loaded onto MCP nanogel. ICP-AES analysis was done to determine the amount of iron content in the MCP nanogels. The magnetic property of the MCP nanogels was estimated to be ∼37 emu/g using Vibrating Sample Magnetometer (VSM). The heating ability of MCP nanogels was calculated to be ∼204W/g for the concentration of 2mg/mL using time-dependent Specific Absorption Rate (SAR) method. Magnetic field induced thermo-responsive and pH responsive drug release studies were carried out and it was found that MCP nanogels have a good on-demand drug release properties. The DOX-MCP nanogels were evaluated for its in vitro killing efficacy of breast cancer cells MCF 7 and MDAMB 231 cells with synergistic effects of both hyperthermia and chemotherapy in presence of magnetic field at the concentration of 2mg/mL. Thus, MCP nanogels can be a potential dual modal on-demand hyperthermia mediated drug delivery platform for the breast cancer treatment.

Inpatient care of small and sick newborns in healthcare facilities

Neonatal units in teaching and non-teaching hospitals both in public and private hospitals have been increasing in number in the country since the sixties. In 1994, a District Newborn Care Programme was introduced as a part of the Child Survival and Safe Motherhood Programme (CSSM) in 26 districts. Inpatient care of small and sick newborns in the public health system got a boost under National Rural Health Mission with the launch of the national programme on facility-based newborn care (FBNC). This has led to a nationwide creation of Newborn Care Corners (NBCC) at every point of child birth, newborn stabilization units (NBSUs) at First Referral Units (FRUs) and special newborn care units (SNCUs) at district hospitals. Guidelines and toolkits for standardized infrastructure, human resources and services at each level have been developed and a system of reporting data on FBNC created. Till March 2015, there were 565 SNCUs, 1904 NBSUs and 14 163 NBCCs operating in the country. There has been considerable progress in operationalizing SNCUs at the district hospitals; however establishing a network of SNCUs, NBSUs and NBCCs as a composite functional unit of newborn care continuum at the district level has lagged behind. NBSUs, the first point of referral for the sick newborn, have not received the desired attention and have remained a weak link in most districts. Other challenges include shortage of physicians, and hospital beds and absence of mechanisms for timely repair of equipment. With admission protocols not being adequately followed and a weak NBSU system, SNCUs are faced with the problem of admission overload and poor quality of care. Applying best practices of care at SNCUs, creating more NBSU linkages and strengthening NBCCs are important steps toward improving quality of FBNC. This can be further improved with regular monitoring and mentoring from experienced pediatricians, and nurses drawn from medical colleges and the private sector. In addition there is a need to further increase such units to address the unmet need of facility-based care.

State of newborn health in India

About 0.75 million neonates die every year in India, the highest for any country in the world. The neonatal mortality rate (NMR) declined from 52 per 1000 live births in 1990 to 28 per 1000 live births in 2013, but the rate of decline has been slow and lags behind that of infant and under-five child mortality rates. The slower decline has led to increasing contribution of neonatal mortality to infant and under-five mortality. Among neonatal deaths, the rate of decline in early neonatal mortality rate (ENMR) is much lower than that of late NMR. The high level and slow decline in early NMR are also reflected in a high and stagnant perinatal mortality rate. The rate of decline in NMR, and to an extent ENMR, has accelerated with the introduction of National Rural Health Mission in mid-2005. Almost all states have witnessed this phenomenon, but there is still a huge disparity in NMR between and even within the states. The disparity is further compounded by rural-urban, poor-rich and gender differentials. There is an interplay of different demographic, educational, socioeconomic, biological and care-seeking factors, which are responsible for the differentials and the high burden of neonatal mortality. Addressing inequity in India is an important cross-cutting action that will reduce newborn mortality.