Post-cricoid and Upper Oesophagus Cancers Treated with Organ Preservation Using Intensity-modulated Image-guided Radiotherapy: a Phase II Prospective Study of Outcomes, Toxicity and Quality of Life

AIMS

To prospectively examine the outcomes, toxicity and quality of life (QoL) of patients with post-cricoid and upper oesophagus (PCUE) cancers treated with an organ-preservation approach of (chemo)-radiotherapy using intensity-modulated image-guided radiotherapy (IM-IGRT).

MATERIALS AND METHODS

This phase II prospective study was conducted at a tertiary cancer centre from February 2017 to January 2020. Forty patients with squamous cell carcinoma of PCUE of stage T1-3, N0-2, M0 were accrued. Gross exolaryngeal extension/dysfunctional larynx were major exclusion criteria. Patients received 63-66 Gy in once-daily fractions using volumetric modulated arc therapy with daily IGRT. Outcome measures included disease-related outcomes, patterns of failure, Radiation Therapy Oncology Group toxicities, feeding tube dependency and QoL.

RESULTS

The median follow-up was 22 months. Twenty-six (87.5%) patients had locoregionally advanced disease and 34 (85%) patients received (chemo)-radiotherapy. A complete response was observed in 26 (65%) patients. The 2-year locoregional control, event-free survival and cause-specific survival were 59.6%, 40.2% and 44.8%, respectively. The volume of primary tumour (GTVPvol) exceeding 28 cm³ had inferior overall survival (P = 0.005) on univariate analysis. Multivariable analysis showed GTVPvol and positron emission tomography-computed tomography maximum standardised uptake value to be independently predictive for event-free and overall survival. A feeding tube requirement at presentation was seen in 11 (27.5%) patients, whereas long-term feeding tube dependency at 6 months was seen in 10 (37%) patients. For QoL, a statistical improvement in pain, appetite loss and swallowing was observed over time.

CONCLUSION

Although the outcomes of PCUE cancers remain dismal, the use of state of the art diagnostic modalities, careful case selection and modern radiotherapy techniques improved outcomes as compared with before in this exclusive analysis of PCUE cancers.

Targeted and Enhanced Antimicrobial Inhibition of Mesoporous ZnO-Ag2O/Ag, ZnO-CuO, and ZnO-SnO2 Composite Nanoparticles

In this work, mesoporous (pore size below 4 nm) composite nanoparticles of ZnO-Ag₂O/Ag, ZnO-CuO, and ZnO-SnO₂ of size d ≤ 10 nm (dia.) have been synthesized through the in situ solvochemical reduction method using NaBH₄. These composite nanoparticles exhibited excellent killing efficacy against Gram-positive/negative bacterial and fungal strains even at a very low dose of 0.010 μg/mL. Additionally, by applying the in silico docking approach, the nanoparticles and microorganism-specific targeted proteins and their interactions have been identified to explain the best anti-bacterial/anti-fungal activities of these composites. For this purpose, the virulence and resistance causing target proteins such as PqsR, RstA, FosA, and Hsp90 of Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, and Candida albicans have been identified to find out the best inhibitory action mechanisms involved. From the in vitro study, it is revealed that all the composite nanoparticle types used here can act as potent antimicrobial components. All the composite nanoparticles have exhibited excellent inhibition against the microorganisms compared to their constituent single metal or metal oxide nanoparticles. Among the nanoparticle types, the ZnO-Ag₂O/Ag composite nanoparticles exhibited the best inhibition activity compared to the other reported nanoparticles. The microorganisms which are associated with severe infections lead to the multidrug resistance and have become a huge concern in the healthcare sector. Conventional organic antibiotics are less stable at a higher temperature. Therefore, based on the current demands, this work has been focused on designing inorganic antibiotics which possess stability even under harsh conditions. In this direction, our developed composite nanoparticles were explored for potential uses in the healthcare technology, and they may solve many problems in global emergency and epidemics caused by the microorganisms.

Effect of type 1 tympanoplasty on the quality of life of patients suffering from chronic otitis media (safe type)

Background

Chronic otitis media (COM) remains a major public health issue and is associated with relentless discharge from the ear, pain, significant functional limitation of hearing, leading to communication problems and frequent specialist visits.

Aims

To assess the improvement in quality of life of patients of COM (safe type) and surgical success in terms of graft uptake and improvement in hearing.

Patients and Methods

A prospective questionnaire-based outcome study was directed in 100 patients with COM who were treated with Type I Tympanoplasty at our institution between May 2018 and May 2020. All patients were asked to fill Modified Chronic Otitis Media 4 (COM-4) survey before operation and 3 months after operation. Preoperative and postoperative total ear scores, audiological results, postoperative graft uptake were assessed.

Results

The correlation between preoperative and postoperative assessment by questionnaire was statistically critical (P < 0.001). There was significant improvement in hearing postoperatively (P < 0.001). Effective graft uptake was seen in 80%.

Conclusion

The current study emphasizes that Type 1 Tympanoplasty fundamentally improves quality of life of patients in terms of physical suffering, hearing loss, emotional distress postoperatively.

Role of Short-Term Estradiol Supplementation in Symptomatic Postmenopausal COVID-19 Females: A Randomized Controlled Trial

Background:

Protective role of estrogen in COVID-19 was speculated once the epidemiological studies reported increased susceptibility of estrogen-deficient population – males and postmenopausal females to severe disease category and involvement of angiotensin-converting enzyme 2 receptors and renin–angiotensin– aldosterone system in pathophysiology.

Materials & Methods:

An open-label randomized controlled trial was planned to assess the efficacy of short-course oral estradiol in preventing the clinical progression to severe disease and reduce case-fatality rate and the hospital stay duration in estrogen-deficient postmenopausal women. The intervention group (n = 40) received 2 mg per day of estradiol valerate per orally for 7 days along with the standard care, while the control group (n = 40) received only the standard care.

Results:

A significant difference was observed in the rate of reverse transcriptase–polymerase chain reaction negativization in the intervention versus control group at day 5 and day 7 of admission (42.5% vs. 15%, P = 0.007; 72.5% versus 50%, P = −0.026). No significant difference was noted in the duration of hospitalization (P = 0.213). A significant decrease was noted in the mean values of inflammatory biomarkers – D-dimer, lactate dehydrogenase, and C-reactive protein on day 5 in the intervention group. Interleukin-6 also showed a declining trend on day 5 in the intervention group, while a rising trend was noted in the control arm. Only one case (2.5%) in the intervention group while seven in the control group (17.5%) progressed to the moderate category; however, the difference was not statistically significant (P = 0.057).

Conclusion

Oral estradiol in postmenopausal females can be a novel and efficient option for managing nonsevere COVID-19 infection.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Polymeric Nanoparticle Based Diagnosis and Nanomedicine for Treatment and Development of Vaccines for Cerebral Malaria: A Review on Recent Advancement

Cerebral malaria occurs due to Plasmodium falciparum infection, which causes 228 million infections and 450,000 deaths worldwide every year. African people are mostly affected with nearly 91% cases, of which 86% are pregnant women and infants. India and Brazil are the other two countries severely suffering from malaria endemicity. Commonly used drugs have severe side effects, and unfortunately no suitable vaccine is available in the market today. In this line, this review is focused on polymeric nanomaterials and nanocapsules that can be used for the development of effective diagnostic strategies, nanomedicines, and vaccines in the management of cerebral malaria. Further, this review will help scientists and medical professionals by updating the status on the development stages of polymeric nanoparticle based diagnostics, nanomedicines, and vaccines and strategies to eradicate cerebral malaria. In addition to this, the predominant focus of this review is antimalarial agents based on polymer nanomedicines that are currently in the preclinical and clinical trial stages, and potential developments are suggested as well. This review further will have an important social and commercial impact worldwide for the development of polymeric nanomedicines and strategies for the treatment of cerebral malaria.

Mobile versus fixed automated external defibrillators (AED deployment in a geographically dispersed population: analysis of the girona territori cardioprotegit project

Introduction/Aim

Public defibrillation doubles out-of-hospital cardiac arrest survival. However, the best way to provide public defibrillation coverage to geographically dispersed populations remains unknown. The aim of this study is to compare usage rates and effectivity between mobile versus fixed Automated External Defibrillators (AED).

Methods

This project is a prospective registry of the usage rate of public AED (542 fixed AED, 241 mobile AED) and the analysis of the electrocardiographic traces, from June 2011 until December 2019. We compared the usage rate, the proportion of shockable rhythms and defibrillation success between fixed versus mobile AED.

Results

Of 566 registered usages, we obtained 494 electrocardiographic traces, of which 108 (21%) were from fixed AED. The usage rate of fixed and mobile AED were 0.022use/AED-year and 0.177use/AED-year respectively. In Fixed AED group we observed a higher proportion of shockable rhythms (34.2% vs. 20.3%, p=0,01) and higher defibrillation success (79% vs. 63%, p=0,02). The proportion of patients with shockable rhythms who were transferred to a hospital were 62.1% and 50% in Fixed AED and Mobile AED group respectively (p=0,306).

Conclusions

In Fixed AED group we observed more shockable rhythms and higher defibrillation success rates. Mobile AED were 8 times more used.

Funding Acknowledgement

Type of funding sources: None.

Non-porous interpenetrating Co-bpe MOF for colorimetric iodide sensing

MOFs with their accessible voids/channels have been explored immensely for sensing due to their exclusive host-guest chemistry. However, unavailability of pores/voids in interpenetrating non-porous MOFs limits their applications in sensing. We herein report for the first time, hitherto, a non-porous MOF with an interpenetrating ladder structure for iodide sensing. A Co-bpe MOF was synthesized by hydrothermal reaction between cobalt nitrate and 1,2-bis(4-pyridyl)ethylene (bpe) in methanol and tested against colorimetric sensing of halides. The supramolecular structure of the Co-bpe MOF was stabilized through strong hydrogen bonding. We propose a double nucleophilic substitution reaction mechanism for iodide detection, which is one of its own kind. While Co-bpe showed a significant color change from dark maroon to dark green in the presence of iodide, the rest of halides did not display any pronounced colorimetric effect. The limit of detection (LOD) of this material was found to be 2.7 × 10^-7 M. This article focuses on the equal competency of non-porous MOF materials with the porous MOFs in sensing applications.

One-Pot Crystallization of 2D and 3D Cobalt-Based Metal-Organic Frameworks and Their High-Performance Electrocatalytic Oxygen Evolution

Developing highly competent and low-cost earth-plentiful metal-based oxygen evolution reaction (OER) electrocatalysts is critical for future electrochemical conversion technologies and renewable energy systems. Herein, two cobalt-based metal-organic frameworks (Co-MOFs), [Co₆(btc)₂(DMF)₆(HCOO)₆] (2D, MOF 1) and [Co₃(CHOO)₉{DMA}₃] (3D, MOF 2), where btc = 1,3,5-benzenetricarboxylic acid, DMF = N,N-dimethylformamide, and DMA = dimethylamine, have been crystallized under hydrothermal conditions, from a single reaction. MOF 1 shows an extraordinary OER performance with 175 mV overpotential to attain 10 mA cm^-2 current density with a low Tafel slope value of 80 mV dec^-1, whereas MOF 2 achieves 10 mA cm^-2 current density at 389 mV overpotential. Two different architecture-based MOFs have been synthesized from a single solution for the very first time. Also, the OER activity of MOF 1 overpowers the commercially used RuO₂ and surpasses most of the reported OER electrocatalysts. Post OER characterization of MOF 1 revealed the in situ formation of Co(OH)₂ and CoOOH, acting as active sites for the OER process.

Multi-objective Genetic Algorithm Based Deep Learning Model for Automated COVID-19 Detection Using Medical Image Data

Purpose

In early 2020, the world is amid a significant pandemic due to the novel coronavirus disease outbreak, commonly called the COVID-19. Coronavirus is a lung infection disease caused by the Severe Acute Respiratory Syndrome Coronavirus 2 virus (SARS-CoV-2). Because of its high transmission rate, it is crucial to detect cases as soon as possible to effectively control the spread of this pandemic and treat patients in the early stages. RT-PCR-based kits are the current standard kits used for COVID-19 diagnosis, but these tests take much time despite their high precision. A faster automated diagnostic tool is required for the effective screening of COVID-19.

Methods

In this study, a new semi-supervised feature learning technique is proposed to screen COVID-19 patients using chest CT scans. The model proposed in this study uses a three-step architecture, consisting of a convolutional autoencoder based unsupervised feature extractor, a multi-objective genetic algorithm (MOGA) based feature selector, and a Bagging Ensemble of support vector machines based binary classifier. The proposed architecture has been designed to provide precise and robust diagnostics for binary classification (COVID vs.nonCOVID). A dataset of 1252 COVID-19 CT scan images, collected from 60 patients, has been used to train and evaluate the model.

Results

The best performing classifier within 127 ms per image achieved an accuracy of 98.79%, the precision of 98.47%, area under curve of 0.998, and an F1 score of 98.85% on 497 test images. The proposed model outperforms the current state of the art COVID-19 diagnostic techniques in terms of speed and accuracy.

Conclusion

The experimental results prove the superiority of the proposed methodology in comparison to existing methods.The study also comprehensively compares various feature selection techniques and highlights the importance of feature selection in medical image data problems.

Encapsulated papillary variant of medullary carcinoma of thyroid with extensive cystic change: an extremely rare presentation

Papillary variant of medullary carcinoma of the thyroid is an unusual subtype with many diagnostic challenges. The authors report a case of papillary variant of thyroid medullary carcinoma in a 37-year-old female, who presented with complaints of pain in the thyroid nodule for the latter two months. Contrast enhanced computed tomography (CECT) neck revealed an enlarged and heterogeneously enhancing left lobe of thyroid. This was followed by hemithyroidectomy for suspicion of colloid goitre. Gross examination of the cut surface of the thyroid parenchyma had a sponge like appearance. On histopathology a diagnosis of encapsulated papillary variant of medullary carcinoma thyroid was made with the help of special stains and immunohistochemistry (IHC).

P–347 A comparative RCT of Intrauterine-GCSF versus Subcutaneous-GCSF in Thin Endometrium in IVF-ICSI Cycles

Study question

Does GCSF by intrauterine route leads to better result in the treatment of thin endometrium as compared to GCSF by the subcutaneous route, in IVF-ICSI Cycles?

Summary answer

Yes, GCSF by intrauterine route leads to better result in the treatment of thin endometrium as compared to subcutaneous-GCSF, in ART Cycles?

What is known already

GCSF, is a member of the colony stimulating factor family of cytokines and growth factors. GCSF receptors are expressed in high concentration on dominant follicle, particularly at preovulatory stage.The endometrium also shows an increased expression of these receptors. GCSF concentration rises in the follicular fluid at the same time. Serum levels of GCSF are found to be in direct correlation with levels of GCSF in follicular fluid. Serum levels increase progressively from the day the embryo-transfer to the day of implantation. GCSF has been found to be beneficial in patients with thin endometrium and recurrent implantation failure.

Study design, size, duration

This was a RCT conducted between 2018–2019. 30 patients with thin endometrium were enrolled in each group. In either group, GCSF was given if endometrium was less than 7mm on day 14, maximum of two doses were administered. Patients undergoing frozen embryo transfer were recruited in the study, after meeting the inclusion and exclusion criteria. Primary outcome measured was increase in endometrium thickness and the secondary outcome was the clinical pregnancy rate and abortion-rate.

Participants/materials, setting, methods

60 patients with thin endometrium were randomly divided into two groups. Group A: Inj. GCSF (300 mcg/1 ml) subcutaneously on Day 14 onwards alternate days for two doses. Group B: Inj. GCSF (300 mcg/1 ml) instilled slowly into the uterine cavity using an intrauterine insemination (IUI) catheter under USG guidance. Endometrial thickness was assessed after 48 h. If endometrial thickness was found to be &lt; 7 mm, a second infusion of GCSF was carried out.

Main results and the role of chance

In the subcutaneous group (group-A) the mean endometrial thickness before GCSF injection was 5.8 ± 0.6 mm and, after injection it increased to 6.9 ± 0.4 mm. Similarly, in the intrauterine group (group-B) the mean endometrial thickness before GCSF was 5.9 ± 0.7 which increased to a mean of 7.9 ± 0.5 after GCSF instillation. The difference between endometrial thickness before and after intrauterine infusion of GCSF was more than that in the subcutaneous group. In group-A, 08 patients conceived out of 30 patients ( clinical pregnancy rate 26.6%) and in group B 11 conceived out of 30 patients in whom GCSF was instilled intrauterine (pregnancy rate 36.6%). Thus, there was a difference in the clinical pregnancy rate in the two groups, the intrauterine group yielding a higher clinical pregnancy rate, but it was not statistically significant. Because of the thin endometrium, we found an abortion rate of 25% (2/8) in the subcutaneous-GCSF group, and an abortion rate of 18% (2/11) in the intrauterine GCSF group.

Limitations, reasons for caution

There are few potential limitations because of the small sample size. Confounders such as obesity, smoking and alcohol intake, presence of adenomyosis and endometriosis, were not taken into consideration. Though prevalence of obesity is usually low in Indian women. Habits of smoking and alcohol are exceedingly uncommon in Indian women.

Wider implications of the findings: Use of GCSF plays an important role in management of patients of thin endometrium undergoing embryo transfer. It is an easily available and economical preparation in developing countries and the intrauterine instillation of GCSF can be easily practiced in an ART unit with good results in resistant thin endometrium patients.

Trial registration number

Not applicable

P–168 RCT comparing the effect of Continuous ( Single Step ) embryo culture system versus a Sequential embryo culture system on the outcome of IVF/ICSI cycles

Study question

Is the outcome of IVF/ICSI cycles done with continuous (single step ) embryo culture system different from that with sequential embryo culture system ?

Summary answer

Yes the outcome of IVF / ICSI cycles done with continuous (single step ) embryo-culture system is better than that with sequential embryo-culture system .

What is known already

Embryo culture media are important factors in IVF, which can significantly influence the clinical outcome of IVF/ICSI cycles. However it is not clear which formulation is most optimal and whether sequential or continuous media (single step) should be favored. Sequential media complies with embryo demands based on developmental stage , taking into account metabolic changes embryos undergo in-vivo, while moving from the oviduct to the uterus. The embryos in the early cleavage stage prefer to use pyruvate to produce energy, whereas once development nears the blastocyst stage , the embryos start using glucose in the process of glycolysis .

Study design, size, duration

A prospective RCT was carried out at our centre between 2018–2019 and IVF-ICSI patients meeting inclusion criteria (at least six normal MII - Oocytes) were included in this study. The aim of study was to compare blastocyst formation rates after embryo-culture in two different culture media systems. 436 metaphase II Oocytes from 62 women were randomly and equally divided to be fertilized and cultured to the blastocyst stage in either sequential media or single-step media.

Participants/materials, setting, methods

In this prospective trial with sibling oocytes, 436 metaphase II oocytes from 62 women were randomly and equally divided to be fertilized and cultured to the blastocyst stage in either sequential media ( n = 218 MII oocytes) or a single medium ( n = 218 MII oocytes). In both groups, embryos were cultured in an interrupted fashion with media changes on day 3. Embryo transfer was performed on day 5.

Main results and the role of chance

Blastocyst formation rates on day 5 were significantly higher following culture in single step media 60.55% (132 / 218 ) as compared to sequential media 34.86% ( 76 / 218) . The percentage of good quality blastocysts was also significantly higher in single step media. In conclusion, culture in single step media was associated with higher blastocyst formation rates compared to sequential media , suggesting that the single medium may provide better support to the developing embryo. The proportion of poor quality embryos was significantly higher in the sequential media group. Results indicate that embryo culture in continuous media could be as efficient as embryo culture in sequential media. A significant difference observed was the proportion of poor quality embryos on day 5 , which was significantly higher when the embryos were cultured in sequential media. Our results suggest that the type of embryo culture media can influence the quality of embryos both at the cleavage stage and blastocyst stage. The use of continuous embryo culture media does not seem to cause an adverse effect; in fact, their use can lower the workload in busy IVF labs and lower the stress that embryos are exposed to during handling.

Limitations, reasons for caution

Although single-step-medium for extended culture has practical advantages and blastocyst formation rates appear to be higher, there is insufficient evidence to recommend either sequential or single-step media as being superior for the embryo-culture to days 5/6. Further studies comparing these two media systems in well-designed trials should be performed.

Wider implications of the findings: When employing sequential media for embryo culture , it is necessary to transfer the embryos from one medium to another ( cleavage stage medium to blastocyst stage medium) which increases stress related embryo damage . Therefore, single-step media is beneficial as the embryos can develop undisturbed till blastocyst stage.

Trial registration number

Not applicable

P–169 Does increasing the time interval between Oocyte-Retrieval and Oocyte-Denudation improve the results in ICSI cycles ?

Study question

What should be the optimal time interval which elapses between oocyte retrieval and denudation followed by ICSI , for optimal results in ART cycles ?

Summary answer

Our study suggests that an optimum interval between oocyte retrieval and oocyte denudation followed by ICSI, leads to better results in ART cycles.

What is known already

It is widely accepted that the best timing for OPU is 34–39 hours after ovulation trigger. Some studies suggest that preincubation time before ICSI can be beneficial when it comes to fertilization and pregnancy rates while late ICSI (fertilization) may have negative results due to oocyte ageing. Other studies claim that there is no significant difference in ART results when ICSI is performed between 2–6 hours post Oocyte-Retrieval (OR) . Few studies state that 1–3 hours of COC-culture prior to denudation and oocyte injection is better as far as fertilization , embryo quality and improved oocyte cytoplasmic maturity is concerned.

Study design, size, duration

RCT of 234 ICSI cycles was carried out between 2017–2019. Patients were divided into two groups-: A- Early denudation with ICSI and B- Late denudation with ICSI.Both the groups were comparable in terms of female age, number of oocytes, day of transfer, number of embryos transferred and embryo quality. Fresh or frozen embryos were transferred , which were always derived from the same stimulation cycle. Exclusion criteria were : Severe male factor / TESA / PESA.

Participants/materials, setting, methods

234 ICSI cycles with similar ovarian stimulation protocols were analyzed as per time range between triggering, OPU, denudation and ICSI. Patients were divided into two groups: A- Early denudation (1–2 hours after OPU) with ICSI (1–2 hours after denudation) and B- Late denudation (4–6 hours after Oocyte-Retrieval ) with ICSI (1–2 hours after denudation).Primary outcomes were oocyte maturation and fertilization rates and secondary outcomes were clinical pregnancy rate and abortion rates.

Main results and the role of chance

In group B ( Late denudation and ICSI), the mean fertilization rate was 67% and the Clinical Pregnancy rate was 46%. This was better than the mean fertilization rate of 56% and clinical pregnancy rate of 39% observed in group A ( Early denudation and ICSI). However the difference was not statistically significant. Therefore, ideal maturation rates were observed when denudation ( followed by ICSI ) was delayed and done 4–6 hours after Oocyte-Retrieval. In ICSI cycles in ART , ovarian stimulation is used to induce the simultaneous growth of multiple follicles, followed by final maturation and ovulation triggering with exogenous hCG. or GnRH-Agonist or both. Generally, oocyte retrieval (OR) is performed 34 - 36h later. In addition, 2–4 hours in culture of the cumulus oocyte complexes (COC) prior to oocyte injection is believed beneficial for fertilization and embryo quality, probably due to improved oocyte cytoplasmic maturity. However, in large ART centers with high workloads, following such definite time intervals is frequently very difficult.

Limitations, reasons for caution

In large busy centers , maintaining meticulous time intervals is difficult . As our study numbers are small, larger multicentric trials are required in order to confirm our findings and to provide more robust data . This data cannot be applied to IVM, TESE / PESE and severe male-factor infertility.

Wider implications of the findings: To achieve a successful fertilization, both nuclear and cytoplasmic maturity are required. Our Study indicates that a slight delay in denudation following Oocyte-Retrieval , will yield a higher number of good quality oocytes. A higher success rate can also be expected due to more number of embryos available for transfer.

Trial registration number

Not applicable

O-230 RCT comparing Recombinant-hcg trigger with Dual-trigger (GnRH-agonist and recombinant-hcg ) in improving clinical outcome in ICSI cycles in women with Diminished Ovarian Reserve

Study question

Does use of Dual-trigger (GnRH-agonist with recombinant-hcg) improve the clinical outcome in women with diminished ovarian reserve as compared to Recombinant-hcg trigger?

Summary answer

Yes, the use of Dual-trigger (GnRH-agonist with recombinant-hcg) improve the clinical outcome in women with diminished ovarian reserve as compared to Recombinant-hcg trigger.

What is known already

The population of poor responders has grown exponentially over the years and their management of ovarian stimulation remains one of the most challenging aspects. In GnRH antagonist down-regulated IVF-ICSI cycles, dual triggering for the final oocyte maturation with GnRH-a and a reduced dose of hCG improves the rate of fertilization and clinical pregnancy in women with diminished ovarian reserve. Further more, the benefit of lowered cycle cancellation rate would also enable greater percentage of patients with diminished ovarian reserve to reach the final stage of their ART treatment, thereby enhancing their chances of achieving a successful pregnancy .

Study design, size, duration

This RCT included GnRH antagonist ICSI cycles from 2018-2019. 82 women with diminished ovarian reserve (AMH ≤ 1.1 ng/ml and AFC ≤5) were included. The primary outcome measured was the oocyte fertilization rate, implantation rate and clinical pregnancy rate per oocyte retrieval cycle. Secondary outcome measured was embryo transfer cancellation rate and abortion rate per oocyte retrieval cycle.

Participants/materials, setting, methods

82 women with diminished ovarian reserve undergoing fresh embryo transfer were included and randomly divided in two groups - Group-A (hCG trigger/control group: n = 41); and Group-B (dual trigger/study group: n = 41). Both patient groups underwent controlled ovarian stimulation using antagonist. The final oocyte maturation was triggered either by recombinant hCG (Group-A) or by a combination of recombinant hCG and GnRH-agonist (Dual trigger) (Group-B).

Main results and the role of chance

The dual-trigger group had significantly higher fertilization rate (62.8 vs. 37.6%), higher clinical pregnancy rate (31.4% vs. 18.1%) as compared to the recombinant-hCG trigger group. In addition, the abortion rate(12.1% vs. 21.3%) and embryo transfer cancellation rate (8.3% vs. 16.1%) were both significantly lower in the dual trigger group. The baseline characteristics for the control and the study group were similar and there was no significant difference in the patient age, serum AMH level, and cause of infertility. The total r-FSH dose, duration of stimulation, endometrial thickness, and serum hormone profile on the day of trigger were also similar between the control and the study group. The main advantage of triggering with GnRH-a is that it induces a mid-cycle FSH surge which resembles the natural ovulatory cycle hormonal changes. Study shows that in GnRH antagonist ART cycles, dual triggering with GnRH-a and hCG could significantly improve the rate of fertilization and clinical pregnancy in diminished ovarian reserve women. Furthermore, the benefit of lowered cycle cancellation rate would also enable greater percentage of patients with diminished ovarian reserve to reach the final stage of their ART treatment thereby enhancing their chance of achieving a successful pregnancy as well as reducing their mental stress.

Limitations, reasons for caution

The main limitation of our study is the low patient number. Triggering with GnRH-a has become a significant part of contemporary ART practice, especially in high responders, oocytes donors and oncology patients. However, more RCTs are required in order to justify the use of GnRH-agonists in poor responders in ART cycles.

Wider implications of the findings

Results of our study concurred with other studies of dual triggering, calls for a possible paradigm shift in ovulation-triggering agent for GnRH-antagonist cycles. Diminished ovarian reserve patients are constituting a large part of clinical ART practice and for such patients, obtaining maximum mature oocytes and good embryos is vitally important.

Trial registration number

not applicable

AYUSH Preparations as Immunity Booster in the Management of SARS - CoV-2: A Review

:

In the 21st century, humans are in battle against a deadly contagious disease COVID 19, first reported in Wuhan, China. Coronavirus Disease designated as COVID 19 is caused by SARS COV 2 virus from beta coronavirus family. Although, there are no specific anti-viral drugs and vaccines against this pandemic disease, however many medicines are being repurposed for COVID 19 management but have shown a limited success. Traditional medicine systems from ancient times were used for their immense efficacy with minimal adverse effects compared to allopathic medicines. Thus, for COVID 19 management, researchers are focused on traditional medicines from Ayurveda, Chinese medicine, Unani, Siddha, and Homeopathy as adjuvant therapy as per anecdotal data regarding their usage in the treatment of Infectious disease. In India, all the traditional medicine systems are under AYUSH ministry and government has been highlighting AYSUH medicines for improving immune system against COVID 19. In this review, the authors emphasize on historical background of AYUSH medicines in the prevention and treatment of infectious diseases and the medicines recommended by AYUSH ministry for combating against COVID 19 as immunity boosters.

Understanding the Spatial Predictors of Malnutrition Among 0-2 Years Children in India Using Path Analysis

Background: Despite several programs and policies to turn down the burden of malnutrition in the country, the rank of India in the Global Hunger Index (GHI) is 102 among 117 countries, which indicates a serious hunger situation. It is essential to design more specific interventions by focusing on the key determinants that may directly or indirectly influence malnutrition in India. Methods: Utilizing data from the National Family and Health Survey-4 (NFHS) (2015-16), we developed a structural equation model to find the direct, indirect, and total effect of various determinants on stunting, wasting, and underweight. We used spatial analysis to identify local occurrences of factors that are critical in controlling malnutrition. A p-value of 0.05 was considered to be significant throughout the study. Analysis was performed using STATA (version 15.1MP) and GeoDa software (version 1.14). Results: A final sample of 90, 842 children of 0-24 months of age was selected for the analysis. The CFI and TLI values of 0.98 and 0.93, respectively, are indicative of a good fit model. Moran's I value of global spatial autocorrelation for the widespread presence of diarrhea, poor drinking water source, exclusive breastfeeding, low birth weight, no prenatal visits, poor toilet facility was observed to be 0.446, 0.638, 0.345, 0.439, 0.620, and 0.727, respectively. Conclusion: A robust direct relation was observed for diarrhea, exclusive breastfeeding, and children born with stunting, underweight, and wasting. The variables associated indirectly with the outcome variables were the education of the mother, residence, and desired pregnancy. The identification of hotspots through spatial analysis would help revive control strategies in the affected area according to geographical needs. It is extensively addressed that interventions related to health and nutrition during the first 1, 000 days of life is crucial to seize the upshoot of growth floundering among children.