Efficacy and Safety of Percutaneous Microwave Ablation and Cementoplasty in the Treatment of Painful Spinal Metastases and Myeloma

BACKGROUND AND PURPOSE

Painful spinal metastases are a common cause of cancer-related morbidity. Percutaneous ablation presents an attractive minimally invasive alternative to conventional therapies. We performed a retrospective review of 69 patients with 102 painful spinal metastases undergoing microwave ablation and cementoplasty to determine the efficacy and safety of this treatment.

MATERIALS AND METHODS

Procedures were performed between January 2015 and October 2016 with the patient under general anesthesia using image guidance for 102 spinal metastases in 69 patients in the following areas: cervical (n = 2), thoracic (n = 50), lumbar (n = 34), and sacral (n = 16) spine. Tumor pathologies included the following: multiple myeloma (n = 10), breast (n = 27), lung (n = 12), thyroid (n = 6), prostate (n = 5), colon (n = 4), renal cell (n = 3), oral squamous cell (n = 1), and adenocarcinoma of unknown origin (n = 1). Procedural efficacy was determined using the visual analog scale measured preprocedurally and at 2-4 weeks and 20-24 weeks postprocedure. Tumor locoregional control was assessed on follow-up cross-sectional imaging. Procedural complications were recorded to establish the safety profile.

RESULTS

The median ablation time was 4 minutes 30 seconds ± 7 seconds, and energy dose, 4.1 ± 1.6 kJ. Median visual analog scale scores were the following: 7.0 ± 1.8 preprocedurally, 2 ± 1.6 at 2-4 weeks, and 2 ± 2.1 at 20-24 weeks. Eight patients died within 6 months following the procedure. Follow-up imaging in the surviving patients at 20-24 weeks demonstrated no locoregional progression in 59/61 patients. Two complications were documented (S1 nerve thermal injury and skin burn).

CONCLUSIONS

Microwave ablation is an effective and safe treatment technique for painful spinal metastases. Further studies may be helpful in determining the role of microwave ablation in locoregional control of metastases.

Association of CD14 and macrophage migration inhibitory factor gene polymorphisms with inflammatory microRNAs expression levels in ankylosing spondylitis and polyarthralgia

This study aimed to investigate the genetic basis of ankylosing spondylitis (AS) and polyarthralgia (PA) conditions among Indian subjects through genotyping two immune regulatory genes CD14 (-159C>T) and MIF (-173G>C) and find their association with the expression levels of three circulating inflammatory miRNAs. This investigation may provide early genetic cause of these two forms of arthritis and more optimal biological targets to predict early therapeutic outcomes. A total of 140 patients (AS: 70 and PA: 70) and 156 controls were recruited from Indian population. CD14 and MIF genotyping was performed using ARMS-PCR. Expression level of three inflammatory miRNAs (miRNA-146a, miRNA-155 and miRNA-181) was quantified using RT-qPCR. C/T genotype of CD14 gene was found to cause 2.06-fold risk of developing AS (CI 1.06-5.98, p = .04) as compared to others and G/C genotype in MIF also shown significant variation between AS and control subjects. In PA subjects, CD14 genotypes (C/T) was found to be associated with disease susceptibility and G/C genotype of MIF gene polymorphism showed 4.71-fold risk of developing PA (CI 2.58-8.62, p = .0001). The study also revealed significant upregulation of miRNA-155 expression in AS subjects (p = .0001) with more than 1.3-fold difference between AS and PA as compared to the control subjects. miRNA-155 had strong association with AS patients with CD14 genotypes (p < .05) than PA and control subjects. This study provides better understanding of the mechanisms and disease susceptibility for MIF and CD14 genetic variants and inflammatory miRNAs networks involved in AS and PA.

A phytobeneficial strain Planomicrobium sp. MSSA-10 triggered oxidative stress responsive mechanisms and regulated the growth of pea plants under induced saline environment

AIMS

The study was planned to characterize Planomicrobium sp. MSSA-10 for plant-beneficial traits and to evaluate its inoculation impact on physiology of pea plants under different salinity levels.

METHODS AND RESULTS

Strain MSSA-10 was isolated from pea rhizosphere and identified by the analysis of 16S rRNA gene sequence. The strain demonstrated phosphate solubilization and auxin production up to 2 mol l-1 NaCl and exhibited 1-aminocyclopropane-1-carboxylic acid deaminase activity up to 1·5 mol l-1 salt. In an inoculation experiment under different salinity regimes, a significant increase in growth was observed associated with decreased levels of reactive oxygen species and enhanced antioxidative enzyme activities. The strain also promoted the translocation of nutrients in plants with subsequent increase in chlorophyll and protein contents as compared to noninoculated plants. It has been observed that rifampicin-resistant derivatives of MSSA-10 were able to survive for 30 days at optimum cell density with pea rhizosphere.

CONCLUSION

Growth-stimulating effect of MSSA-10 on pea plants may be attributed to its rhizosphere competence, nutrient mobilization and modulation of plant oxidative damage repair mechanisms under saline environment.

SIGNIFICANCE AND IMPACT OF THE STUDY

Planomicrobium sp. MSSA-10 might be used as potent bioinoculant to relieve pea plants from deleterious effects of salinity.

Room-temperature superparamagnetism due to giant magnetic anisotropy in Mo S defected single-layer MoS2

Room-temperature superparamagnetism due to a large magnetic anisotropy energy (MAE) of a single atom magnet has always been a prerequisite for nanoscale magnetic devices. Realization of two dimensional (2D) materials such as single-layer (SL) MoS₂, has provided new platforms for exploring magnetic effects, which is important for both fundamental research and for industrial applications. Here, we use density functional theory (DFT) to show that the antisite defect (Mo _S ) in SL MoS₂ is magnetic in nature with a magnetic moment μ of  ∼2 [Formula: see text] and, remarkably, exhibits an exceptionally large atomic scale MAE [Formula: see text] of  ∼500 meV. Our calculations reveal that this giant anisotropy is the joint effect of strong crystal field and significant spin-orbit coupling (SOC). In addition, the magnetic moment μ can be tuned between 1 [Formula: see text] and 3 [Formula: see text] by varying the Fermi energy [Formula: see text], which can be achieved either by changing the gate voltage or by chemical doping. We also show that MAE can be raised to  ∼1 eV with n-type doping of the MoS₂:Mo _S sample. Our systematic investigations deepen our understanding of spin-related phenomena in SL MoS₂ and could provide a route to nanoscale spintronic devices.

[The promising directions for the further development of halotherapy in pediatric medicine]

This article is focused on the modern possibilities for the application of halotherapy with a view to prevention, treatment and rehabilitation of the children with special reference to the main bio-physical properties of the principal active factors of halotherapy including dry finely-dispersed sodium chloride aerosols and specific features of the mechanism of their therapeutic action. The extensive studies have been underway in the recent years for the purpose of development of the new effective methods for the reconstitution of the aerodispersive environment. Halotherapy can be provided either on an individual (haloinhalation) or a group (exposition in the halochambers and halorooms basis. Halotherapy has been shown to produce well apparent anti-inflammatory, draining, mucolytic, immunomodulatory, and sanogenetic action. The high effectiveness of halotherapy for the prophylactic application in the frequently ill children is emphasized together with the possibility of its extensive use for the treatment of acute respiratory diseases and combined medical rehabilitation of the children presenting with chronic ENT disorders, respiratory and skin diseases. The optimal technologies for the clinical application of various types of halotherapy are discussed.

Glaucoma awareness Indian military personnel: a tri-service study

INTRODUCTION

In India, glaucoma is the third most common cause of blindness, reflecting both its asymptomatic presentation and a lack of knowledge in the general population. No previous published data of glaucoma awareness among the Indian Armed forces personnel exists, who constitute a unique group consisting of people drawn from all parts of the country and society.

METHODS

Bilingual questionnaires were distributed to 496 serving Army, Navy and Air Force personnel serving in units local to the Zonal military hospital in North India. Having heard of the term glaucoma resulted in the subject being 'glaucoma aware', while 'knowledge of glaucoma' required at least three out of six questions to be answered correctly.

RESULTS

110/496 (22%) participants were found to be glaucoma aware, while knowledge of glaucoma was found in 60/496 (12%) participants.

CONCLUSIONS

This study demonstrates that glaucoma awareness and knowledge is high compared with rural or urban Indian populations. This is likely reflects the frequent health camps conducted by the armed forces and periodic medical examinations. However, these figures are still low compared with developed countries and likely reflects differences in education standards, socioeconomic status and differing influences of the media.

Pseudopotential calculations of AlSb under pressure

The dependence on hydrostatic pressure of the electronic and optical properties of zinc-blende AlSb semiconducting material in the pressure range of 0-20kbar has been reported using a pseudopotential approach. At zero pressure, our findings showed that the electron and heavy hole effective masses are 0.11 and 0.38m₀, respectively. Moreover, our results yielded values of 3.3289 and 11.08 for refractive index and high frequency dielectric constant, respectively. These results are found to be in good accord with experiment. Upon compression, all physical parameters of interest showed a monotonic behavior. The pressure-induced energy shifts for the optical transition related to band-gaps indicated that AlSb remains an indirect (Г-X) band-gap semiconductor at pressures from 0 to 20kbar. The trend in all features of interest versus pressure has been presented and discussed. It is found that the lattice parameter is reduced from 0.61355 to 0.60705nm when pressure is raised from 0 to 20kbar. The present investigation may be useful for mid-infrared lasers applications, detectors and communication devices.

Long-term impact of manuring and fertilization on enrichment, stability and quality of organic carbon in Inceptisol under two potato-based cropping systems

Soil organic matter (SOM) stability is a prerequisite for long-term C sequestration. The long-term effect of manuring and fertilization on stability of SOM in rice-potato-wheat (R-P-W) and maize-potato-onion (M-P-O) cropping systems was studied in an Inceptisol of semi-arid subtropical India. Soil samples were collected (0-15 and 15-30cm soil depths) from the following treatments: control, 100% NPK-Fertilizer, 100% N-Vermicompost (VC), 50% NPK-Fertilizer+50%N-Vermicompost (VC), 100%NPK-Fertilizer+crop residue (CR), 100% N-VC+CR. The stability of SOM was studied by correlating the ammonium oxalate extractable Fe, Al and Si with stable soil organic C (SOC). Application of 100% N-VC and 100% N-VC+CR increased the SOC stock by 66% and 32%, respectively over 100% NPK in R-P-W cropping system, while in M-P-O system, the above treatments increased the SOC stock by 28% and 12%. As compared to 100%NPK, the integrated use of 50%NPK+50%N-VC increased the SOC stock by 58% and 35% in R-P-W and M-P-O system, respectively. The extractable Fe, Al and Si significantly correlated with stable OC and the multiple regression model developed between these parameters could well predict the stable OC in soil. Complete or partial substitution of chemical fertilizer N with VC could be a promising nutrient management strategy for enhancing the SOC stock in Inceptisol under potato-based cropping systems of semi-arid sub-tropical India. However, the integrated use of 50%NPK+50%N-VC could be promising due to lowest yield reductions and moderate SOC sequestration potential. The enrichment (47%), as well as quality (81%) of SOC was higher in R-P-W system than in M-P-O system. The organic treatments like 100%NPK+CR and 100%N-VC+CR showed higher stability of SOC in R-P-W (31% and 26%) than in M-P-O cropping system. The stability of SOC could well be predicted by extractable amorphous and poorly crystalline Fe, Al and Si and SOC in both the cropping systems.

[The application of the modern phototherapeutic technologies for the medical rehabilitation of the children]

This literature review is focused on the application of polychromatic and monochromatic polarized light for the treatment of various diseases of the childhood including those in the newborns and the premature babies. The analysis of the data of scientific research gives evidence of the beneficial effect of polychromatic polarized light on the clinical course of various skin diseases in the newborn children. Moreover, the improved immunological and reparative processes were revealed after the surgical interventions for congenital heart defects in the newborns. The light-induced changes in the skin contribute to the realization of therapeutic effects of polarized polychromatic light in such children's diseases as atopic dermatitis, bronchitis, bronchial asthma, neurogenic urinary bladder dysfunction, and the traumatic injuries of the limbs. The biologically positive physiological effects of monochromatic polarized light are known to contribute to the improvement of the clinical and functional status in the children presenting with bronchial asthma and in the patients frequently suffering from acute respiratory diseases. The versatility of the biological effects of polarized light taken together with the possibility of its application from the first days of the child's life, the short duration of the procedure, the absence of unpleasant sensations and contact between the damaged surface and the device as well as the simplicity of using the equipment determine the promising prospects for the use of the proposed method in the clinical pediatric practice.

[The application of the physical factors for the medical rehabilitation of the children presenting with neurogenic dysfunction of the bladder]

This article describes the modern technologies for the medical rehabilitation of the children presenting with neurogenic dysfunction of the bladder aimed at improving the act of urination at all levels of innervation. The most frequent variant of neurogenic dysfunction of the bladder in the children is the hyper-reflexive one; it is this variant in which the most pronounced disorders of urodynamics due to intravesical hypertension and detrusor hypoxia are observed. The urodynamic disorders are known to contribute to the formation of the characteristic clinical picture associated with the hyper-reflexive urinary bladder dysfunction in the children characterized by the mandatory urination syndrome, pollakiuria, imperative urges, and mandatory urinary incontinence in the combination with enuresis. The treatment of urinary bladder dysfunction includes both behavioural and medication therapeutic modalities. The "golden standard" for the pharmacotherapy of neurogenic bladder dysfunction of the hyper-reflexive type in the childhood is the use of M-cholinoblockers, such as oxybutynin. The popularity of the physiotherapeutic methods is attributable to their influence on the main links of pathogenesis, the absence of side effects, and the possibility of application in the children of the early age. The combined treatment of neurogenic bladder dysfunction includes the use of a wide range of physiotherapeutic methods the action of which is aimed at regulating the act of urination at all levels of innervation of the bladder, normalizing the tone of the muscles of the bladder, eliminating sphincter insufficiency, improving circulation and accelerating the maturation of the neuromuscular apparatus of the pelvic organs. At present, the natural and preformed methods of physiotherapy are finding the wide application for the management of neurogenic dysfunction of the bladder in the children in the conjunction with therapeutic physical exercises, massage, and the biological feedback (BFB) technique.

Modified supine percutaneous nephrolithotomy with combined fluoroscopy and ultrasound-guided renal puncture: Initial single-surgeon experience at a UK teaching hospital

Objective:

The purpose of this article is to report the outcomes of our initial experience of performing percutaneous nephrolithotomy in the supine position using ultrasound guidance in addition to fluoroscopy for renal access.

Patients and methods:

The first 34 consecutive modified supine percutaneous nephrolithotomy cases performed by a single consultant urologist inserting their own percutaneous tracts using ultrasound-guidance and fluoroscopy were evaluated. Operative data was collected prospectively over a 10-month period including any complications. The stone-free rate was evaluated three months post-operatively with a plain film or non-contrast computed tomography of the kidneys, ureters and bladder.

Results:

Renal access was achieved in all 34 cases. Mean age was 57 years (19–82) with 14 males and 20 females. Mean stone size 37.2 mm (20–72 mm). Overall stone-free rate was 85.3% at a mean follow up of 11.2 months. There was one Clavien Grade I, and three Clavien Grade II complications of post-operative fever requiring treatment with intravenous antibiotics. No patients developed urosepsis, required blood transfusion or sustained any visceral injury. Median in-patient stay was one night (1–4).

Conclusion:

Modified supine percutaneous nephrolithotomy with combined fluoroscopy and ultrasound-guided renal access has a low incidence of complications allowing for short hospital stay.

A clinical correlation of conjunctival microangiopathy with grades of retinopathy in type 2 diabetes mellitus

BACKGROUND

Conjunctival microangiopathy has been described among diabetics similar to retinal vessel angiopathy. Correlation of these conjunctival microangiopathy changes with retinopathy may form the basis of screening by external examination without expert fundus evaluation.

METHODS

Conjunctival vessels widths and tortuous segment length of conjunctival vessels of 96 patients with type 2 diabetes mellitus were photographed and measured by the Zeiss Fundus camera Visupac software. The measurements were correlated with retinopathy grade in those eyes.

RESULTS

The mean conjunctival vessel width was 40.61 μ (SD 17.25) with a uniform increase from 34.4 μ (SD 8.70) in mild NPDR to 53.50 μ (SD 33.45) in the PDR group which was statistically significant (p < 0.01). The tortuous conjunctival vessel segment length increased from 711.51 μ (SD 83.90) in the mild NPDR group to 921.94 μ (SD 129.26) in those with PDR (p < 0.01). Vessel width greater than 80 μ was seen only in PDR and tortuosity values greater than 900 μ were seen in severe grades (severe NPDR and PDR). Both conjunctival vessel width and tortuosity showed a positive statistical correlation with increasing severity of retinopathy (r = 0.386, r² = 0.149 and r = 0.645, r² = 0.415).

CONCLUSION

A positive correlation was seen between conjunctival vessel width and tortuosity with severity of retinopathy. Widths over 80 μ and tortuous segment length over 900 μ are suggestive of severe grades of retinopathy.

Inter- and intra-observer variability of ultrasonographic arm muscle thickness measurement by critical care physicians

PURPOSE

The aim of this study was to assess inter- and intra-observer variability of arm muscle thickness measured by critical care physicians using bedside ultrasonography (USG).

METHODOLOGY

This prospective study included twenty patients admitted with sepsis. Three measurements of thickness of right arm muscles of each patient using B-mode USG were taken by two critical care fellows, independently. Intra- and inter-observer reliability was tested using intraclass correlation coefficient (ICC).

RESULTS

The mean 1st, 2nd, and 3rd measurements of muscle thickness recorded by observer 1 and 2 were 23.620 (±4.171) versus 23.840 (±3.849) mm, 23.235 (±3.620) versus 23.625 (±4.062) mm, and 24.125 (±4.098) versus 23.965 (±3.651) mm, respectively. The average muscle thickness measured by first and second observer was 23.660 (±3.834) mm and 23.810 (±3.674) mm, respectively. ICC for intra-observer variability for observer 1 and 2 was 0.964 (95% confidence interval [CI] 0.924-0.985) and 0.949 (95% CI 0.892-0.978), respectively. ICC for inter-observer variability was 0.995 (95% CI 0.988-0.998).

CONCLUSIONS

USG is a reliable tool for assessment of arm muscle thickness by critical care physicians.

Mathematical modeling and stability analysis of Pine Wilt Disease with optimal control

This paper presents and examine a mathematical system of equations which describes the dynamics of pine wilt disease (PWD). Firstly, we examine the model with constant controls. Here, we investigate the disease equilibria and calculate the basic reproduction number of the disease. Secondly, we incorporate time dependent controls into the model and then analyze the conditions that are necessary for the disease to be controlled optimally. Finally, the numerical results for the model are presented.

Medical professionalism frameworks across non-Western cultures: A narrative overview

BACKGROUND

Medical professionalism is context-specific, but most literature on professionalism stems from Western countries. This study is about benchmarking of different frameworks on professionalism and interpreting the commonalities and discrepancies of understanding professionalism across different cultures. We need to study the cultural underpinning of medical professionalism to graduate future "global" practitioners who are culturally sensitive enough to recognize differences (and also similarities) of expectations of patients in various contexts.

AIM

This study aims at describing culture specific elements of three identified non-Western frameworks of professionalism, as well as their commonalities and differences.

METHOD

A narrative overview was carried out of studies that address professionalism in non-Western cultures in the period 2002-2014.

RESULTS

Out of 143 articles on medical professionalism, only four studies provided three structured professionalism frameworks in non-Western contexts. Medical professionalism attributes in non-Western cultures were influenced by cultural values. Out of the 24 identified attributes of professionalism, 3 attributes were shared by the three cultures. Twelve attributes were shared by at least two cultures, and the rest of the attributes were unique to each culture.

CONCLUSIONS

The three frameworks provided culture-specific elements in a unique conceptual framework of medical professionalism according to the region they originated from. There is no single framework on professionalism that can be globally acknowledged. A culture-oriented concept of professionalism is necessary to understand what the profession is dedicated to and to incorporate the concept into the medical students' and physicians' professional identity formation.

Prevalence of corneal astigmatism before cataract surgery in Western Indian Population

Background

The prevalence and nature of corneal astigmatism among cataract surgery candidates has not been well-documented in Indian population. The purpose of the study is to analyse prevalence and presentation patterns of corneal astigmatism (CA) in cataract surgery candidates.

Methods

Keratometric values were measured in patients before cataract extraction. Descriptive statistics of CA were analysed including the assessment with age ranges.

Results

Mean CA of 223 eyes of 223 patients [mean age 61 ± 10 years (range, 29-90 years)] was 0.88 ± 0.61 (95% CI, 0.80-0.96) with 27.8%, 51.1% and 21.1% having with the rule (WTR), against the rule (ATR) and oblique astigmatism (OBL) respectively. Between 40 and 50 years, ATR exceeds WTR and reaches 100% by 80 years. A trend of less negative CA was seen up to 60 years and then increases up to 90 years. CA was below 0.25 dioptre (D) in 17.5% of eyes, between 0.25 and 1.25 D in 63.7% and ≥1.50 D in 18.8% of eyes.

Conclusions

Considering CA < 1.25 D in majority of cataract surgery candidates, it is preferable to perform inexpensive keratorefractive procedures rather expensive toric IOLs, especially in developing world.

Infection control in hospitals managing drug-resistant tuberculosis in Pakistan: how are we doing?

Setting: Ten hospitals managing drug-resistant tuberculosis (TB) in Pakistan. Objective: To assess the implementation of TB infection control (IC) practices and reasons for non-adherence to guidelines. Design: This was a descriptive study conducted between April and October 2016 with three components: 1) non-participant observation of service delivery areas (SDAs) (n = 82) in hospitals (n = 10) using structured checklists; 2) exit interviews with 100 patients (10 per hospital); and 3) interviews with 100 health-care workers (HCWs, 10/hospital). Results: Of the 82 SDAs, posters were displayed in 34 (41%), mechanical ventilation was implemented in 79% and functional ultraviolet germicidal irradiation (UVGI) was available in only 26%. Patient interviews showed 50-65% adherence to triage and use of personal protective measures. Key reasons for non-adherence were lack of adequate supplies, discomfort using N-95 masks, a lack of knowledge or training, perceived non-cooperation by patients, poor maintenance of mechanical ventilators and UVGI due to unstable electricity supply, a lack of clarity in roles (no-one designated in charge) and staff shortages and subsequent workloads. Adherence to natural ventilation usage was poor for reasons related to climate and privacy. Conclusion: Implementation of TBIC measures in hospitals was suboptimal. Urgent measures need to be put in place, including retraining of HCWs, addressing weaknesses in mask and poster supplies and constant supervision and monitoring.

Cryopreservation Of Nili-Ravi Buffalo Bull Sperm in Cryodiluent Supplemented with Lolium perenne Protein Preparations

BACKGROUND

Semen from the Nili-Ravi buffalo bull, Bubalus bubalis, shows poor survival after freeze storage compared to bovine (Bos taurus and Bos indicus) semen. Freeze-susceptibility distinctions in these two genera have been attributed to differences in sperm membranes.

MATERIALS AND METHODS

We measured the impact of protein preparations derived from a frost-resistant perennial grass, Lolium perenne, with ice recrystallization inhibition activity on the low temperature storage of B. bubalis semen.

RESULTS

When the L. perenne preparations (0.1, 1, 10 µg/mL) were added to buffalo semen [2 ejaculates per bull (N=3) per replicate (r=3)] in Tris-citrate extender (50×10⁶sperm mL^-1), there was no impact on semen quality, as measured by sperm motility and plasma membrane integrity, after storage at 4 degree C (P>0.05). However, when semen supplemented with the grass proteins (0.1 and 1 µg mL^-1) was evaluated after freezing and storage in liquid nitrogen for 24 h, post-thaw sperm progressive motility and plasma membrane integrity was higher (P<0.05) than in control samples. Post-thaw sperm viability and sperm acrosome integrity was similar (P > 0.05) to controls.

CONCLUSION

The improvement in cryopreserved buffalo sperm progressive motility and plasma membrane integrity suggests that the use of these easily-made preparations may improve fertility after cryopreservation and offers the prospect of improved conception rates after artificial insemination with cryopreservation.

The Maritime Medical Emergency Response Team: what do we really need?

Since 2006, the Defence Medical Services (DMS) pre-hospital care focus has been the Medical Emergency Response Team (MERT), which has enabled the projection of Damage Control Resuscitation (DCR) to the point of wounding as part of consultant- delivered care. Now in a period of contingency operations, the Royal Navy (RN)’s Role 2 medical capability, Role 2 Afloat (R2A) delivers DCR (including surgery) on a maritime platform. This article will focus on the development of the Maritime MERT component of R2A (termed Maritime In Transit Care (MITC) in Maritime Medical Doctrine) and will discuss the requirements based on experience of and preparation for an operation in 2016. Also discussed are the individual competencies and training required to be part of the Maritime MERT; it is hoped that this will simulate debate around this evolving team.

Establishing and maintaining a robust Role 2 Afloat organisation within the Royal Naval Medical Services

In 2009, the Royal Navy (RN) reconfigured the Role 2 maritime medical treatment capability, the Role 2 Afloat (R2A). This capability is now firmly established on a number of platforms in the fleet and was recently externally validated on RFA MOUNTS BAY prior to completion of an operational deployment supporting contingency operations in the Mediterranean. This article outlines the future challenges for R2A and offers suggestions on how to maintain a robust R2A organisation within the Royal Naval Medical Service (RNMS).

Antimicrobial resistance trends in blood culture positive Salmonella Paratyphi A isolates from Pondicherry, India

Enteric fever is a public health problem with the upsurge in the occurrence of Salmonella isolates that are resistant to ciprofloxacin. In this study, a total of 284 blood culture isolates of S. Paratyphi A were investigated. Of these isolates, 281 (98.9%) were nalidixic acid resistant. A high rate (6.3%) of high-level resistance (≥ 4 μg/mL) was found to ciprofloxacin. The isolates with ciprofloxacin minimum inhibitory concentrations (MICs) of ≥ 12 μg/mL had 4 mutations, 2 mutations within the quinolone resistance-determining region of gyrA and 2 mutations also in parC. According to the Clinical Laboratory Standards Institute 2012 MIC breakpoints, 75.0% of isolates were resistant to ciprofloxacin. Finally, 3 major pulsed-field gel electrophoresis patterns were observed among the S. Paratyphi A isolates. The spread of fluoroquinolone resistant S. Paratyphi A necessitates a change toward 'evidence-based' treatment for enteric fever. The research provides a perspective on the increasing prevalence of antimicrobial resistant S. Paratyphi A isolates in this region of India.

Optimization of process parameters for production of volatile fatty acid, biohydrogen and methane from anaerobic digestion

The anaerobic digestion process has been primarily utilized for methane containing biogas production over the past few years. However, the digestion process could also be optimized for producing volatile fatty acids (VFAs) and biohydrogen. This is the first review article that combines the optimization approaches for all three possible products from the anaerobic digestion. In this review study, the types and configurations of the bioreactor are discussed for each type of product. This is followed by a review on optimization of common process parameters (e.g. temperature, pH, retention time and organic loading rate) separately for the production of VFA, biohydrogen and methane. This review also includes additional parameters, treatment methods or special additives that wield a significant and positive effect on production rate and these products' yield.