Development, validation, and evaluation of allergic rhinitis symptoms and impact assessment (ARSIA) questionnaire

INTRODUCTION

Allergic rhinitis (AR) is an inflammatory disease of the nasal mucosa. It is among the most common diseases globally and usually persists throughout life. Allergic Rhinitis and Its Impact on Asthma (ARIA) is a wellestablished guideline applicable to AR and was updated regularly since 2001, aiming to improve the care for AR patients. We proposed a new questionnaire that addresses the severity of allergic rhinitis symptoms, specifically nasal symptoms, and its impact on quality of life in terms of specific vital activities such as sleeping, working, school performance, leisure, or sport, based on the ARIA guideline. The objective was to develop, validate and evaluate Allergic Rhinitis Symptoms and Impact Assessment (ARSIA) questionnaire among allergic rhinitis patients in Hospital Sultan Abdul Halim, Sungai Petani (HSAH), and Hospital Universiti Sains Malaysia (HUSM).

MATERIALS AND METHODS

This is a prospective observational study to develop, validate and evaluate the ARSIA questionnaire based on ARIA guidelines. The sample will be obtained from the list of patients under follow-up in the ORL clinic HSAH and HUSM with ages of 18 to 60 years, patients clinically diagnosed with allergic rhinitis, and with positive skin prick test.

RESULTS

A total of 150 patients with a positive skin prick test participated in this study. In the 'nasal symptom' and 'impact on daily activities' domains, calculated Cronbach's alpha shows a value of 0.878 and 0.811 respectively. The inter-item correlation was calculated to analyse internal consistency reliability. Items B3 and B4 were dropped from the questionnaire as both showed a low correlation with other items. New Cronbach's alpha for the daily activities domain was 0.830, which showed better internal consistency reliability. All of the items were analysed for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Clinician diagnosis from the proforma was used as a comparison to the participant's responses. In the analysis, a cut-off points of 12 was used to classify the patient's nasal symptoms into intermittent or persistent, with a sensitivity of 75%, specificity of 86%, PPV of 95%, and NPV of 51%. Whereas, a cut-off point of 15 was used to classify the rhinitis impact on daily activities into mild or moderate/severe, with a sensitivity of 58%, specificity of 100%, PPV of 100%, and NPV of 42%. The only item in the 'control' domain has been dropped out following a consensus of experts and judgement as it has not been used in the clinician diagnosis and thus, is unable to test for sensitivity, specificity, PPV, and NPV.

CONCLUSION

This newly developed, validated, and evaluated questionnaire is a good tool for the evaluation of allergic rhinitis symptoms and their impact on daily activities. It is important to understand that AR symptoms could have a significant impact on daily activities. Although further study and testing are needed, it provides an initial means for evaluating the patient condition and control level, as well as patients' perception of their rhinitis control.

[A severe unilateral corneal ectasia in children]

PURPOSE

We report a case of unilateral Terrien's marginal degeneration in a 14-year-old girl.

CLINICAL CASE

Slit-lamp examination of the affected eye revealed 360° circumferential lipid deposits with 6mm of superior limbal distension, superficial neovascularization, a zone of corneal thinning from 3:00 to 9:00 with a zone of corneomalacia at 11:00. The remainder of the cornea was clear, without fluorescein staining or anterior chamber reaction.

DISCUSSION

Terrien's marginal degeneration (TMD) is typically known to occur bilaterally in men over the age of 40. Terrien's degeneration must be differentiated from other causes of peripheral corneal thinning; the primary differential diagnosis is Fuchs' marginal keratitis. Other causes of corneal thinning must be ruled out, including Mooren's ulcer. In Terrien's degeneration, there is no central mined edge in the thinning sulcus, the epithelium remains intact, and affected patients do not present with pain. Other differential diagnoses include pellucid marginal degeneration and sulcus degeneration, which are characterized by the absence of lipid infiltrates associated with the central region of the thinning zone, thus distinguishing them from TMD.

CONCLUSION

It is important to keep in mind that Terrien's marginal degeneration can occur in children.

Optical Coherence Tomography Image Classification Using Hybrid Deep Learning and Ant Colony Optimization

Optical coherence tomography (OCT) is widely used to detect and classify retinal diseases. However, OCT-image-based manual detection by ophthalmologists is prone to errors and subjectivity. Thus, various automation methods have been proposed; however, improvements in detection accuracy are required. Particularly, automated techniques using deep learning on OCT images are being developed to detect various retinal disorders at an early stage. Here, we propose a deep learning-based automatic method for detecting and classifying retinal diseases using OCT images. The diseases include age-related macular degeneration, branch retinal vein occlusion, central retinal vein occlusion, central serous chorioretinopathy, and diabetic macular edema. The proposed method comprises four main steps: three pretrained models, DenseNet-201, InceptionV3, and ResNet-50, are first modified according to the nature of the dataset, after which the features are extracted via transfer learning. The extracted features are improved, and the best features are selected using ant colony optimization. Finally, the best features are passed to the k-nearest neighbors and support vector machine algorithms for final classification. The proposed method, evaluated using OCT retinal images collected from Soonchunhyang University Bucheon Hospital, demonstrates an accuracy of 99.1% with the incorporation of ACO. Without ACO, the accuracy achieved is 97.4%. Furthermore, the proposed method exhibits state-of-the-art performance and outperforms existing techniques in terms of accuracy.

[Painful anisocoria in a five-year-old child: A rare diagnosis which must not be missed]

Congenital ectropion uveae (CEU) is a rare anomaly of the embryonic development of the anterior segment of the eye. We report the case of a 5-year-old child with an undiagnosed CEU who was treated urgently for an acute angle closure attack.

CASE DESCRIPTION

A 5-year-old child was referred urgently for evaluation of anisocoria with mydriasis of the right eye and severe headache. Brain imaging with contrast injection was initially performed in the pediatric emergency department and ruled out central nervous system pathology. The initial examination of the right eye revealed an intraocular pressure (IOP) of 37mmHg, corneal edema, congenital ectropion uveae, mydriasis with pupillary block, a closed angle on gonioscopy, and a clear lens. The examination of the left eye was unremarkable, with no visible CEU. The initial management consisted of medical treatment with topical glaucoma drops and miotics and acetazolamide at 10mg/kg/d. Re-evaluation under general anesthesia showed persistent mydriasis and no resolution of the pupillary block. Filtering surgery was performed in the absence of a complete response to medical treatment, allowing control of IOP without drops and complete regression of the corneal edema.

DISCUSSION

CEU is a rare malformation, and pressure complications represent an insignificant proportion of pediatric glaucoma cases. The acute presentation of acute angle closure in this potentially blinding short-term setting, however, makes detection and management difficult in very young children in a great deal of pain. Only one similar case has been reported in the pediatric literature.

CONCLUSION

Acute angle closure complicating CEU is exceptional and difficult to diagnose in a pediatric context. Parents of children with this predisposing condition should be informed of the need to consult urgently when clinical signs of elevated intraocular pressure appear.

Radical Nephroureterectomy Tetrafecta: A Proposal Reporting Surgical Strategy Quality at Surgery

Background

Standardized methods for reporting surgical quality have been described for all the major urological procedures apart from radical nephroureterectomy (RNU).

Objective

To propose a tetrafecta criterion for assessing the quality of RNU based on a consensus panel within the Young Association of Urology (YAU) Urothelial Group, and to test the impact of this tetrafecta in a multicenter, large contemporary cohort of patients treated with RNU for upper tract urothelial carcinoma (UTUC).

Design, setting, and participants

This was a retrospective analysis of 1765 patients with UTUC treated between 2000 and 2021.

Outcome measurements and statistical analysis

We interviewed the YAU Urothelial Group to propose and score a list of items to be included in the “RNU-fecta.” A ranking was generated for the criteria with the highest sum score. These criteria were applied to a large multicenter cohort of patients. Kaplan-Meier curves were built to evaluate differences in overall survival (OS) rates between groups, and a multivariable logistic regression model was used to find the predictors of achieving the RNU tetrafecta.

Results and limitations

The criteria with the highest score included three surgical items such as negative soft tissue surgical margins, bladder cuff excision, lymph node dissection according to guideline recommendations, and one oncological item defined by the absence of any recurrence in ≤12 mo. These items formed the RNU tetrafecta. Within a median follow-up of 30 mo, 52.6% of patients achieved the RNU tetrafecta. The 5-yr OS rates were significantly higher for patients achieving tetrafecta than for their counterparts (76% vs 51%). Younger age, lower body mass index, and robotic approach were found to be independent predictors of tetrafecta achievement. Conversely, a higher Eastern Cooperative Oncology Group score, higher clinical stage, and bladder cancer history were inversely associated with tetrafecta.

Conclusions

Herein, we present a “tetrafecta” composite endpoint that may serve as a potential tool to assess the overall quality of the RNU procedure. Pending external validation, this tool could allow a comparison between surgical series and may be useful for assessing the learning curve of the procedure as well as for evaluating the impact of new technologies in the field.

Patient summary

In this study, a tetrafecta criterion was developed for assessing the surgical quality of radical nephroureterectomy in patients with upper tract urothelial carcinoma. Patients who achieved tetrafecta had higher 5-yr overall survival rates than those who did not.

LC-ESI-QTOF-MS/MS Characterization and Estimation of the Antioxidant Potential of Phenolic Compounds from Different Parts of the Lotus (Nelumbo nucifera) Seed and Rhizome

Edible lotus (Nelumbo nucifera G.) is widely consumed in Asian countries and treated as a functional food and traditional medicinal herb due to its abundant bioactive compounds. Lotus rhizome peels, rhizome knots, and seed embryos are important byproducts and processing waste of edible lotus (Nelumbo nucifera G.) with commercial significance. Nevertheless, the comprehensive phenolic profiling of different parts of lotus is still scarce. Thus, this study aimed to review the phenolic contents and antioxidant potential in lotus seeds (embryo and cotyledon) and rhizomes (peel, knot, and pulp) grown in Australia. In the phenolic content and antioxidant potential estimation assays by comparing to the corresponding reference standards, the lotus seed embryo exhibited the highest total phenolic content (10.77 ± 0.66 mg GAE/g_f.w.), total flavonoid content (1.61 ± 0.03 mg QE/g_f.w.), 2,2-diphenyl-1-picrylhydrazyl (DPPH) scavenging activity (9.66 ± 0.10 mg AAE/g_f.w.), 2,2-azino-bis-3-ethylbenzothiazoline-6-sulfonic acid (ABTS) scavenging activity (14.35 ± 0.20 mg AAE/g_f.w.), and total antioxidant capacity (6.46 ± 0.30 mg AAE/g), while the highest value of ferric ion reducing antioxidant power (FRAP) activity and total tannin content was present in the lotus rhizome knot (2.30 ± 0.13 mg AAE/g_f.w.). A total of 86 phenolic compounds were identified in five parts of lotus by liquid chromatography coupled with electrospray ionization quadrupole time-of-flight mass spectrometry (LC-ESI-QTOF-MS/MS), including phenolic acids (20), flavonoids (51), lignans (3), stilbenes (2), and other polyphenols (10). The most phenolic compounds, reaching up to 68%, were present in the lotus seed embryo (59). Furthermore, the lotus rhizome peel and lotus seed embryo exhibit significantly higher contents of selected polyphenols than other lotus parts according to high-performance liquid chromatography (HPLC) quantification analysis. The results highlighted that byproducts and processing waste of edible lotus are rich sources of phenolic compounds, which may be good candidates for further exploitation and utilization in food, animal feeding, and pharmaceutical industries.

Efficacy of Metribuzin Doses on Physiological, Growth, and Yield Characteristics of Wheat and Its Associated Weeds

Weeds cause a serious constraint to wheat productivity. Chemical weed control is considered the most effective method to control weeds; however, a suitable dose and combination of herbicide with adjuvants play a vital role in controlling weeds and producing maximum wheat production. A field study was conducted to investigate the effectiveness of various doses of metribuzin alone or in combination with adjuvants [Bio-power (alkyl ether sulfates and sodium salts) and Ad-500 (fatty alcohol ethoxylate)] on the growth and yield of wheat and its associated weeds. Metribuzin at 175, 140, and 105 g a.i ha-1, each in combination with adjuvants (Bio-power or Ad-500) at 400 ml ha-1, were sprayed. A weedy check was also included as a control treatment. The wheat crop was infested with Fumaria indica, Melilotus indica, Anagallis arvensis, and Phalaris minor, and metribuzin with or without adjuvant was sprayed at two- to four-leaf stage of the weeds. The photosynthetic activity, weed population of each weed, and biomass of each weed was significantly affected by all herbicides along with the adjuvant. However, maximum inhibition of tested weeds was observed where metribuzin at 175 g a.i ha-1 + Bio-power at 400 ml ha-1 were sprayed. Metribuzin sprayed at 175 g a.i ha-1 with or without Bio-power recorded a maximum 1,000-grain weight, biological yield, and grain yield. Conclusively, metribuzin sprayed at 175 g a.i ha-1 + Bio-power at 400 at ml ha-1 have the potential to improve wheat yield by inhibiting weed growth, and Bio-power was superior to Ad-500 in improving the efficacy of metribuzin against weeds of wheat crop.

Enhanced microbial degradation of PET and PS microplastics under natural conditions in mangrove environment

In-situ bioremediation of mangrove soil contaminated with polyethylene terephthalate (PET) and polystyrene (PS) microplastics was investigated using indigenous microbial consortium with adequate capacity to degrade the plastics. Eight (8) bacteria were isolated from plastic/microplastic-inundated mangrove soil and screened for the ability to degrade PET and PS microplastics. Optical density at 600 nm and colony forming unit counts were measured to evaluate the growth response of the microbes in the presence of PS and PET microplastics at different times of exposure. Structural and surface changes that occurred post biodegradation on the microplastics were determined through EDS and SEM analysis. The obtained results demonstrated the elongation and disappearance of peaks, suggesting that the microbial consortium could modify both types of microplastics. The overall results of the microplastic degradation showed varied degrees of weight loss after 90 experimental days, with the treated plot recorded 18% weight loss. The augmented soil was increased in the concentrations of Si S, and Fe and decreased in the concentrations of C, O, Na, Mg, Al, Cl, and K after bioremediation.

Alteration in soil arsenic dynamics and toxicity to sunflower (Helianthus annuus L.) in response to phosphorus in different textured soils

Being analogue to arsenic (As), phosphorus (P) may affect As dynamics in soil and toxicity to plants depending upon many soil and plant factors. Two sets of experiments were conducted to determine the effect of P on As fractionation in soils, its accumulation by plants and subsequent impact on growth, yield and physiological characteristics of sunflower (Helianthus annuus L.). Experimental plan comprised of two As levels (60 and 120 mg As kg^-1 soil), four P (0-5-10-20 g phosphate rock kg^-1 soil) and three textural types (sandy, loamy and clayey) with three replications. Among different As fractions determined, labile, calcium-bound, organic matter-bound and residual As increased while iron-bound and aluminum-bound As decreased with increasing P in all the three textural types. Labile-As percentage increased in the presence of P by 16.9-48.0% at As60 while 36.0-68.1% at As120 in sandy, 19.1-64.0% at As60 while 11.5-52.3% at As120 in loamy, and 21.8-58.2% at As60 while 22.3-70.0% at As120 in clayey soil compared to respective As treatment without P. Arsenic accumulation in plant tissues at both contamination levels declined with P addition as evidenced by lower bioconcentration factor. Phosphorus mitigated the As-induced oxidative stress expressed in term of reduced hydrogen peroxide, malondialdehyde while increased glutathione, and consequently improved the achene yield. Although, P increased As solubility in soil but restricted its translocation to plant, leading to reversal of oxidative damage, and improved sunflower growth and yield in all the three soil textural types, more profound effect at highest P level and in sandy texture.

Anti-hyperglycemic and anti-hyperlipidemic effects of a methanolic extract of Debregeasia salicifolia in Alloxan-induced diabetic albino mice

Diabetes mellitus (DM), an endocrine syndrome characterized by high blood glucose levels due to abrogated insulin activity. The existing treatments for DM have side effects and varying degrees of efficacy. Therefore, it is paramount that novel approaches be developed to enhance the management of DM. Therapeutic plants have been accredited as having comparatively high efficacy with fewer adverse effects. The current study aims to elucidate the phytochemical profile, anti-hyperlipidemic, and anti-diabetic effects of methanolic extract D. salicifolia (leaves) in Alloxan-induced diabetic mice. Alloxan was injected intraperitoneally (150 mg kg-1, b.w), to induced diabetes in mice. The mice were divided into three groups (n=10). Group 1 (normal control) received normal food and purified water, Group II (diabetic control) received regular feed and clean water and group III (diabetic treated) received a methanolic extract of the plant (300 mg kg-1) for 28 days with a typical diet and clean water throughout the experiment. Blood samples were collected to checked serum glucose and concentration of LDL, TC, TG. The extract demonstrated significant antihyperglycemic activity (P<0.05), whereas improvements in mice's body weight and lipid profiles were observed after treatment with the extract. This study establishes that the extract has high efficacy with comparatively less toxicity that can be used for DM management.

Lichenoid uvula mass as a rare cause of hot potato voice and progressive dysphagia

Lichenoid uvula mass is an unusual entity and the clinicopathologic entities are important for the diagnosis. In this case report, we report an elderly lady presented with dysphagia and "hot potato voice" due to a lichenoid uvula mass. Apart from muffled voice, the other associated symptoms are dysphagia, sore throat, globus pharyngeus and snoring. She was a non-smoker, and not on any medications except for hypertension and dyslipidaemia. Apart from the enlarged uvula, other parts of the oral cavity, oropharynx and larynx were normal. She has no other signs such as cutaneous lesions. The mass was excised under general anaesthesia followed by resolution of symptoms. Awareness of this entity, the clinical and histopathological features should be highlighted to differentiate it from other diagnosis.

Current advances of functional phytochemicals in Nicotiana plant and related potential value of tobacco processing waste: A review

Tobacco is grown in large quantities worldwide as a widely distributed commercial crop. From the harvest of the field to the process into the final product, a series of procedures generate enormous amount of waste materials that are rarely recycled. In recent years, numerous potential bioactive compounds have been isolated from tobacco, and the molecular regulatory mechanisms related to the performance of some functionalities have been identified. This review describes the source of tobacco waste and expounds a large amount of biomass during the tobacco processing, and the necessity of exploring the reuse of tobacco waste. In addition, the review summarizes the bioactive compounds from tobacco that have been discovered so far, and links them to various functions from tobacco extracts, including anti-inflammatory, antitumor, antibacterial, and antioxidant, thus proving the potential value from tobacco waste reuse. In this regard, nornicotine in tobacco is the culprit of many health issues, while the polyphenols and polysaccharides often contribute to the health benefits of tobacco extract. In addition, it is hard to ignore that realization of these functions of tobacco extracts require the involvement of intestinal flora metabolism, which should be considered in the development of new product dosage forms.

Proteomic biomarker profiles and vascular dysfunction in angina with no obstructive coronary artery disease

Background

Coronary vascular dysfunction is a common cause of symptoms in patients with angina and no obstructed coronary arteries (ANOCA). Several endotypes have been defined but there are big gaps in our understanding of the underlying pathophysiology. Proteomic analyses may improve the understanding of the pathophysiology.

Purpose

Exploratory approach to 1) compare the proteomic biomarker profile across different types of vascular dysfunction in ANOCA and 2) assess the value of prediction models with protein biomarkers for vascular dysfunction in ANOCA.

Methods

We included 107 angina patients without previous coronary artery disease, left ventricular ejection fraction &gt;45% and no obstructive coronary artery disease (CAD) (&lt;50% stenosis of epicardial vessels) on coronary angiography. Three types of vascular dysfunction were assessed: 1) Vasomotor dysfunction (VMD) defined as epicardial or microvascular vasospasm on acetylcholine provocation, 2) Coronary microvascular dysfunction (CMD) defined as coronary flow velocity reserve (CFVR) ≤2.5 on echocardiography of the LAD on adenosine stimulation and 3) Reactive Hyperaemia Index (RHI) ≤1.67 as a measure of peripheral endothelial dysfunction. Blood samples were analysed for 184 protein biomarkers related to cardiovascular disease. Correlations between biomarkers and results of vascular function assessments were analysed with Pearson's correlation coefficient and visualized with volcano plots. Significantly correlated biomarkers (p&lt;0.05) were tested in prediction models for their incremental value over age and gender with C-statistics.

Results

CFVR was correlated to 24 biomarkers before (figure 1a) and 2 biomarkers after adjustment for age and gender. The basic prediction model had AUC of 0.68 and was not significantly improved by adding biomarkers (figure 2a). RHI was correlated to 27 biomarkers before (figure 1b) and 10 biomarkers after adjustment for age and gender. The clinical prediction model was significantly improved (p=0.037) by adding TRAIL R2 and IL-18, in addition to age and gender, with an AUC of 84.4 (figure 2b). VMD was correlated to 14 biomarkers before (figure 1c) and 6 biomarkers after adjustment for age and gender. The prediction model was significantly improved (p=0.011) by adding HSP-27, RARRES-2 and SERPINA-12 in addition to age and gender in prediction of VMD with an AUC of 85.4 (figure 2c).

Conclusion

Several biomarkers were associated with vascular dysfunction in ANOCA patients with little overlap between different endotypes. We identified biomarkers that may contribute to the understanding of the underlying pathophysiology and have applications for screening. Results need to be confirmed in larger studies.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Department of Cardiology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark.Department of Cardiology and Angiology, Robert Bosch Krankenhaus, Stuttgart, Germany

Orthopaedic Practices and Surgeries during COVID-19 in Pakistan - A Survey Based Study

Introduction:

The study aimed to target the current practices of the orthopaedic community in outpatient (OPD), emergency (ER) and surgical services (OT) during COVID-19.

Material and method:

This study surveyed 303 orthopaedic surgeons from all over Pakistan. The survey had 30 questions targeting the setup of outpatient, emergency and operation services in orthopaedic departments of different hospitals in Pakistan.

Result:

A total of 302 surgeons were included from 53 cities all over Pakistan. Between 35-48% of the respondents reported lack of availability of standard operating procedures in OPD, ER and in OT. Majority of the respondents noted that their OPD and surgical practice had been affected to some degree and 69% of the surgeons were only doing trauma surgery. This trend was higher in younger consultants of less than 45 years of age (p<0.001). Almost two-third of the surgeons, mostly senior (p=0.03) were using surgical masks as the only protective measure during various practices of OPD, ER and OT, while most of the setups were not assessing patients even for signs and symptoms of COVID. Almost 89% of the orthopaedic community is facing definite to mild stress during this pandemic and this has significantly affected the senior surgeons (p=0.01).

Conclusion:

Our study highlighted that COVID-19 has resulted in marked changes to the practices of the majority of Pakistani orthopaedic surgeons. Despite a sharp upsurge in the number of cases and mortality due to COVID-19, guidelines were still lacking at most of the settings and a substantial percentage of the orthopaedic community were not following adequate safety measures while attending to patients.

Health related quality of life and patient concerns in patients with osteoradionecrosis

The number of patients presenting with osteoradionecrosis (ORN) is likely to increase in future and health related quality of life (HRQOL) is a key outcome. This study aimed to report patient concerns and HRQOL in an osteoradionecrosis cohort over 12 years. Patients attended routine follow-up clinics between 2008 to 2020, where patient reported outcome (PRO) assessment was used before consultations as standard practice. The two PROs were the Patient Concerns Inventory (PCI) and the University of Washington quality of life questionnaire (UW-QOL v4). The study sample comprised 109 patients with ORN seen in 445 clinics when PCI and UW-QOL were used. At clinic, patients were in one of six ORN states: before ORN (26 with data), at diagnosis (12), and following treatment either improved (27), progressed (46), stable (63) or resolved (37). Worst HRQOL outcomes were reported in the progressive group with 50% reporting overall QOL as less than good. Pain was a major dysfunction (63%) as was physical and social-emotional functioning and this group reported many PCI issues, median (IQR) 7 (4-11). Kaplan-Meier estimates of survival with 95% CI after diagnosis with ORN were 96% (90-99%) at 12 months, 89% (81-94%) at 24 months and 73% (61-82%) at 60 months. This study indicates that ORN is a chronic condition with long-term survivorship consequences. More data through cohort studies and trials are needed to assist in decision making for individual patients.

Characteristics and health status of patients with and without confirmed HFpEF

Aims

Patients with heart failure with preserved ejection fraction (HFpEF) are usually older and multi-morbid and diagnosis can be challenging. The aims of this cohort study were to confirm diagnosis of HFpEF in patients with possible HFpEF recruited from primary care, to compare characteristics and health status between those with and without HFpEF, and to determine factors associated with health status in patients with HFpEF.

Methods

Patients with presumed HFpEF were recruited from primary care practices and underwent clinical assessment and diagnostic evaluation as part of a longitudinal cohort study. Health status was measured by Montreal Cognitive Assessment (MOCA), 6-minute walk test, symptoms, and the Kansas City Cardiomyopathy Questionnaire (KCCQ), and quality of life (QoL) by EQ-5D-5L visual analogue scale (VAS).

Results

151 patients (mean age 78.5±8.6 years, 40% women, mean EF 56% + 9.4) were recruited and 93 (61.6%) were confirmed HFpEF (those without HFpEF had other HF and cardiac diagnoses). Patients with and without HFpEF did not differ by age, MOCA, blood pressure, heart rate, NYHA class, proportion with atrial fibrillation, Charlson Comorbidity Index, or NT-ProBNP levels. Patients with HFpEF were more likely to be women, overweight or obese, frail, and to be more functionally impaired by 6 minute walk distance and gait speed than those without. Although not statistically significant, patients with HFpEF had clinically significant differences (&gt;5 points) on the physical limitations, symptom burden and clinical summary subscales of the KCCQ, but did not differ by other subscales or by EQ-5D-5L VAS (70±17 vs 73±19, p=0.385). More patients with HFpEF reported daytime dyspnoea (63% vs 46%, p=0.035) and fatigue (81% vs 61%, p=0.008), but not other symptoms compared to those without HFpEF. For both groups BMI was moderately negatively correlated with KCCQ subscale scores, and 6 minute walk distance was positively correlated with KCCQ subscales.

Conclusions

Nearly 40% were not confirmed as HFpEF indicating the challenges of diagnosis. Patients with confirmed HFpEF differed by sex, overweight/obesity, frailty, functional impairment, and symptoms but not by age or comorbidities from those without HFpEF. These differences were reflected in some subscale scores of the KCCQ, but not how patients reported their quality of life on the KCCQ QoL subscale and EQ-5D-5L VAS. Older patients with HFpEF reported relatively high QoL despite poor health status by functional impairment, frailty and symptoms.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Research School of Primary Care Research

Coronary flow velocity reserve predicts adverse outcome in patients with angina and no obstructive coronary artery disease

Background

Many patients with angina do not have obstructive coronary artery disease (CAD) when evaluated with coronary angiography. It is unknown whether echocardiographic coronary flow velocity reserve (CFVR) predicts an adverse outcome in these subjects. Previous CFVR studies have included heterogeneous patient subtypes both with and without CAD.

Purpose

To assess whether reduced CFVR predicts adverse outcome in women with angina and no CAD.

Methods

We evaluated 1853 women with angina and a coronary angiogram without stenosis. Exclusion criteria were previous myocardial infarction, coronary revascularisation, heart failure or valvular disease. Coronary microvascular function was assessed by echocardiographic CFVR. All patients were followed up for major adverse cardiovascular events.

Results

CFVR was obtained in 1681 patients (91%), median CFVR was 2.33 (IQR 2.00–2.74). During a median follow-up of 4.48 years, 96 adverse events occurred (acute myocardial infarction: 25; heart failure: 21; revascularisation: 8; stroke: 32; cardiovascular death: 10). In univariate Cox regression, CFVR (hazard ratio [HR] 2.04 [95% CI 1.39–2.94] per unit decrease in CFVR; p&lt;0.001), hypertension (HR 2.29 [95% CI 1.46–3.59]; p&lt;0.001) and diabetes (HR 2.13 [95% CI 1.31–3.45]; p=0.002) were associated with adverse outcome. These associations remained in age-adjusted multivariable regression. Exploratory analyses identified CFVR=2.24 as the optimal discriminating threshold. Stratification according to reduced CFVR and hypertension identified subgroups with better, intermediate and worse outcome (Figure 1). Outcome analyses excluding stroke yielded similar results.

Conclusion

Impaired CFVR predicts adverse outcome in women with angina and no CAD. Integrating CFVR and hypertension identifies high-risk patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Danish Heart Foundation

Living with Coronavirus (COVID-19): a brief report

The world will never be the same after the current COVID-19 pandemic. We may have to live with the coronavirus for a long time. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted in a major burden on the global health system and economy. This report describes the current COVID-19 landscape and its socioeconomic implications. Despite the concerns for second waves of infection, gradual lifting of lockdown restrictions has occurred worldwide to relieve economic pressures and likely contributes towards possibly surging of outbreak although region wise variation exists due to several other biological factors, such as testing capacity and basic healthcare facilities among susceptible population within that region. Different prediction models have been put forth to forecast the spread of the current outbreak. However, it is challenging to perceive the precise changes happening in the real world as every time dynamics differ same as other epidemics cannot possibly be exactly superimposed to COVID-19. Currently, to decrypt the conundrum for effective antiviral drug against SARS-CoV-2 is in full swing. Due to high rate of mortality and it expeditiously spread is it decisive to understand the biological properties, clinical characteristics, epidemiology, evolution, pathogenesis for vaccine development and pathogenicity studies against the viral curb. Instant diagnostic and adequate therapeutics serve as a major intervention for the management of pandemic containment. Our study aims to analyze the impact of current measures and to suggest appropriate administrative strategic planning rather than to make somewhat authentic prediction in relation to the current scenario. Our predictive analysis study should be helpful against prevention, cure and control of the current outbreak of COVID-19 till the availability of cure or vaccine.

The role of device-assisted therapies in the management of non-muscle invasive bladder cancer: A systematic review

OBJECTIVE

Despite optimal treatment, patients affected by non-muscle invasive bladder cancer (NMIBC) suffer from high risk of recurrence and progression. Intravescical device assisted therapies such as radiofrequency induced thermochemotherapeutic effect (RITE) and electromotive drug administration (EMDA) have shown promising effect in enhancing the effect of intravescical chemotherapies. The aim of the study was to assess clinical outcomes of these two devices in non-muscle invasive bladder cancer.

METHODS

A systematic literature review was performed in December 2019 using the Medline, Embase, and Web of Science databases. Only articles published in the last 10 years were considered (2009-2019). The articles were selected using the following keywords association: "bladder cancer" AND "EMDA' AND "synergo" AND "hyperchemotherapy" AND "electromotive drug administration", AND "radiofrequency induced thermochemotherapeutic" AND "RITE".

RESULTS

We found 16 studies published in the last ten years regarding the efficacy of RITE (12 studies) and EMDA (4 studies) in the treatment of NMIBC. Both RITE and EMDA showed promising results in the treatment of intermediate and high risk NMIBC as well as in patients affected by recurrent BCa after BCG failure. In high-risk BCG naïve NMIBC patients treated with EMDA recurrence and progression rates were 68% and 95%, respectively. Considering RITE, recurrence and progression range rates were 43%-88% and 62%-97%, respectively. Discordance results were reported regarding its effect on patients with carcinoma in situ. However, only few studies could be compared since differences exist regarding inclusion criteria with high patients' heterogeneity. Considering recurrence after BCG, recurrence and progression range rates were 29%-29.2% and 62%-83% for RITE and 25% and 75% for EMDA, respectively.

CONCLUSION

Delivery of intravescical hyperthermia seems to enhance the normal effect of intravescical chemotherapy instillation. Although prospective trials supported its effect on both BCG naïve and BCG failure patients, data are urgently required to validate these findings and to understand its effect on patients with carcinoma in situ.

LEVEL OF PROOF

3.

Primary middle ear tuberculosis mimicking cholesteatoma

Tuberculous granuloma in the middle ear is an unusual entity. Herein, we report a case with short presentation of otitis media with mastoid abscess but with a CT scan showing widespread bone destruction. The cause was determined to be middle ear tuberculosis. Awareness of this entity is important, as it may cause a delay in referral to an otorhinolaryngology specialist and, subsequently, a delay in initiating treatment. Therefore, it should be considered in the differential diagnosis, especially when the usual treatment fails to produce the desired result.

P2643Antiproteinuric efficacy of ACE inhibitors, selective MRAs and ACE inhibitor/selective MRA combination therapy in diabetic hypertensives with microalbuminuria

Background

There is increasing evidence suggesting use of Mineralocorticoid Receptor Antagonists (MRA) in combination with Angiotensin Converting Enzyme Inhibitors (ACEI) or Angiotensin Receptor Blockers (ARB) to have a protective effect on chronic kidney disease patients.

Purpose

The aim of our study was to compare the antiproteinuric efficacy of ACEI monotherapy, Selective MRA monotherapy and their combination in mildly hypertensive patients with type 2 diabetes mellitus (DM) and microalbuminuria.

Methods

Seventy five patients with established diagnosis of type 2 DM, mild hypertension (systolic BP 140–159 mmHg and/or diastolic BP 90–99 mmHg) and microalbuminuria (30–299mg/g) were randomly assigned to one of three groups of therapy; ramipril 10 mg monotherapy (25 patients), eplerenone 50 mg monotherapy (25 patients) and eplerenone/ramipril 50/10 mg combination therapy (25 patients).The duration of the study was 24 weeks. All patients had measurement of blood pressure, urinary albumin/creatinine ratio, renal function tests and serum K level at baseline and at the end of the study after 24 weeks. All patients were followed up monthly till the end of the study for detection of side effects and/or treatment failure.

Results

Both ramipril and eplerenone monotherapy significantly reduced microalbuminuria after 24 weeks nearly to the same extent (37% and 38% respectively) without significant difference between both groups (P=0.95). There was more significant reduction of microalbuminuria in the eplerenone/ramipril combination group (60%) compared with ramipril and eplerenone monotherapy groups (P=0.0001).All groups showed significant reduction of both systolic and diastolic BP with more significant reduction of systolic BP in combination group compared with monotherapy groups (P<0.0001).There was insignificant elevation of serum potassium level among the three groups with slightly higher non significant incidence of sustained hyperkalemia in combination group (P=0.5). All groups showed insignificant changes in serum creatinine and estimated glomerular filtration rate.

Conclusion

Addition of eplerenone (selective MRA) to an ACE inhibitor may confer further antiproteinuric benefit with low risk of hyperkalemia compared with MRA or ACEI monotherapy.

Acknowledgement/Funding

None

Outcomes of upper extremity versus lower extremity placed peripherally inserted central catheters in a medical-surgical neonatal intensive care unit1

OBJECTIVE

To compare outcomes of peripherally inserted central catheters (PICCs) placed in the upper extremity (UE) versus the lower extremity (LE) in a quaternary medical-surgical neonatal intensive care unit (NICU).

RESULTS

We analyzed a total of 365 PICCs of which 250 (68%) were removed for end of therapy and 115 (32%) were removed due to complications. Patients who had UE insertions compared to LE insertions were of lower gestational age (median (IQR)), 30 (26, 35) vs. 32 (27, 37) weeks respectively (p = 0.014). UE PICCs were more likely to be removed due to complications compared to LE PICCs (39.9% vs. 26.4%, RR 1.51, 95% CI 1.12 -2.03, p = 0.007). UE PICCs were more likely than LE PICCs to be removed for the complications of malposition, dislodgement, and pleural or pericardial effusions; while LE PICCs were more likely to be removed for phlebitis. There were no differences in the rates of sepsis at 13.0% vs. 12.8% for UE vs. LE respectively, or causal organisms for sepsis. Survival analysis demonstrated that LE PICCs had a longer time to removal for a complication (p = 0.031).

CONCLUSIONS

LE compared with UE PICCs were not associated with worse outcomes in a medical-surgical neonatal population that included a significant proportion of full-term neonates, and provide a valuable alternate site for central venous access. Increased awareness of the types of complications for UE compared with LE PICCs may help focus preventive and surveillance efforts based on PICC location, to improve safety and minimize the complications of NICU PICCs.

Non-genetic factors affecting pre-weaning growth and morphometric traits in Assam Hill goat

Aim:

This study aimed to determine the genetic and non-genetic factors affecting pre-weaning body weight (BW) and morphometry in Assam Hill goat along with the genetic parameters.

Materials and Methods:

The detailed information in respect of BW and body measurements of 960 animals at birth and 3 months of age belonging to three different populations of Assam Hill goat maintained at field units, namely, Batabari, Nahira, and Tetelia under “All India Coordinated Research Project on Goat Improvement” were utilized in the present study. The data were analyzed using least squares technique.

Results:

The least squares means for BW, height at withers (HW), heart girth (HG), and body length (BL) were 1.166±0.008 kg, 26.198±0.070 cm, 26.695±0.096 cm, and 29.482±0.119 cm at birth and 4.590±0.083 kg, 36.850±0.105 cm, 40.741±0.115 cm, and 39.703±0.108 cm at 3 months of age, respectively. Location had a significant effect on BW, HW, and BL at both birth and 3 months and on HG at 3 months of age. Season of birth exerted significant effect only on BL at birth, whereas the significant effect of sex was observed on HG and BL at 3 months of age. The heritability estimates for BW and body measurements were moderate indicating the scope of selection. The phenotypic and genetic correlations among BWs and body measurements at birth and 3 months of age were positive in direction and high in magnitude.

Conclusion:

On the basis of the present findings, it could be concluded that the weaning weight of kids can be considered for the selection of parent stock to increase productivity and eventually the economic efficiency. Further, animals with higher body measurements at initial phases of growth will perform better with respect to even BW at later stages of growth.

Drought Tolerance of Soybean (Glycine max L. Merr.) by Improved Photosynthetic Characteristics and an Efficient Antioxidant Enzyme Activities Under a Split-Root System

Water deficiency significantly affects photosynthetic characteristics. However, there is little information about variations in antioxidant enzyme activities and photosynthetic characteristics of soybean under imbalanced water deficit conditions (WDC). We therefore investigated the changes in photosynthetic and chlorophyll fluorescence characteristics, total soluble protein, Rubisco activity (RA), and enzymatic activities of two soybean varieties subjected to four different types of imbalanced WDC under a split-root system. The results indicated that the response of both cultivars was significant for all the measured parameters and the degree of response differed between cultivars under imbalanced WDC. The maximum values of enzymatic activities (SOD, CAT, GR, APX, and POD), chlorophyll fluorescence (Fv/Fm, qP, ɸPSII, and ETR), proline, RA, and total soluble protein were obtained with a drought-tolerant cultivar (ND-12). Among imbalanced WDC, the enhanced net photosynthesis, transpiration, and stomatal conductance rates in T2 allowed the production of higher total soluble protein after 5 days of stress, which compensated for the negative effects of imbalanced WDC. Treatment T4 exhibited greater potential for proline accumulation than treatment T1 at 0, 1, 3, and 5 days after treatment, thus showing the severity of the water stress conditions. In addition, the chlorophyll fluorescence values of FvFm, ɸPSII, qP, and ETR decreased as the imbalanced WDC increased, with lower values noted under treatment T4. Soybean plants grown in imbalanced WDC (T2, T3, and T4) exhibited signs of oxidative stress such as decreased chlorophyll content. Nevertheless, soybean plants developed their antioxidative defense-mechanisms, including the accelerated activities of these enzymes. Comparatively, the leaves of soybean plants in T2 displayed lower antioxidative enzymes activities than the leaves of T4 plants showing that soybean plants experienced less WDC in T2 compared to in T4. We therefore suggest that appropriate soybean cultivars and T2 treatments could mitigate abiotic stresses under imbalanced WDC, especially in intercropping.

[Congenital abnormalities of the optic disc]

Congenital abnormalities of the optic disc are not uncommon in clinical practice and should be recognized. Size abnormalities of the optic disc include optic disc aplasia, hypoplasia, megalopapilla, and optic disc cupping in prematurity. Among congenital excavations of the optic disc head, morning glory disc anomaly and optic disc pit can be complicated by serous retinal detachment; the papillorenal disc is an association of bilateral optic disc cupping and renal hypoplasia which should be ruled out; optic disc coloboma is caused by an abnormal closure of the embryonic fissure and can be complicated by choroidal neovascularization and retinal detachment. Other abnormalities that will be discussed are congenital tilted disc syndrome, duplicity of the optic disc head, congenital pigmentation of the optic disc head and myelinated retinal nerve fibers. All of these abnormalities can be associated with syndromes and neurological diseases, as well as other potentially blinding ophthalmological defects which can be secondarily complicated by amblyopia, strabismus and nystagmus. Thus, they should be recognized in order to plan for appropriate follow-up.

Effective removal of p-tert-Butylphenol and Pyridine, 3-(1-methyl-2-pyrrolidinyl)-, (S)- from landfill leachate using locust bean gum

The widespread distribution of persistent organic pollutants (POPs) in landfill leachate is problematic due to their acute toxicity, carcinogenicity and genotoxicity effects, which could be detrimental to public health and ecological systems. The objective of this study was to evaluate the effective removal of POPs - namely, p-tert-Butylphenol and Pyridine, 3-(1-methyl-2-pyrrolidinyl)-, (S)- - from landfill leachate using locust bean gum (LBG), and in comparison with commonly used alum. The response surface methodology coupled with a Box-Behnken design was employed to optimize the operating factors for optimal POPs removal. A quadratic polynomial model was fitted into the data with the R² values of 0.97 and 0.96 for the removal of p-tert-Butylphenol and Pyridine, 3-(1-methyl-2-pyrrolidinyl), (S)-, respectively. The physicochemical characteristics of the flocs produced by LBG and alum were evaluated with Fourier Transform Infrared (FTIR) spectroscopy and Scanning Electron Microscopy (SEM). The infrared spectra of LBG-treated floc were identical with LBG powder, but there was some variation in the peaks of the functional groups, signifying the chemical interactions between flocculants and pollutant particles resulting from POPs removal. The results showed that p-tert-Butylphenol and Pyridine, 3-(1-methyl-2-pyrrolidinyl)-, (S)- obtained 96% and 100% removal using 500 mg/L of LBG at pH 4. pH have a significant effect on POPs removal in leachate. It is estimated that treating one million gallons of leachate using alum (at 1 g/L dosage) would cost US$39, and using LBG (at 500 mg/L dosage) would cost US$2. LBG is eco-friendly, biodegradable and non-toxic and, hence, strongly recommended as an alternative to inorganic coagulants for the treatment of POPs in landfill leachate.

Removal of bisphenol A and 2,4-Di-tert-butylphenol from landfill leachate using plant- based coagulant

Landfill leachate contain persistent organic pollutants (POPs), namely, bisphenol A (BPA) and 2,4-Di-tert-butylphenol, which exceed the permissible limits. Thus, such landfill leachate must be treated before it is released into natural water courses. This article reports on investigations about the removal efficiency of POPs such as BPA and 2,4-Di-tert-butylphenol from leachate using locust bean gum (LBG) in comparison with alum. The vital experimental variables (pH, coagulant dosage and stirring speed) were optimised by applying response surface methodology equipped with the Box-Behnken design to reduce the POPs from leachate. An empirical quadratic polynomial model could accurately model the surface response with R² values of 0.928 and 0.954 to reduce BPA and 2,4-Di-tert-butylphenol, respectively. Fourier transform infrared (FTIR) spectroscopy and scanning electron microscopy (SEM) were performed on treated flocs for further understanding. FTIR analysis revealed that the bridging of pollutant particles could be due to the explicit adsorption and bridging via hydrogen bonding of a coagulation mechanism. SEM micrographs indicated that the flocs produced by LBG have a rough cloudy surface and numerous micro-pores compared with alum, which enabled the capture and removal of POPs from leachate. Results showed that the reduction efficiencies for BPA and 2,4-Di-tert-butylphenol at pH 7.5 were 76% and 84% at LBG dosage of 500 mg·L^-1 and 400 mg·L^-1, respectively. Coagulant dosage and pH variation have a significant effect on POPs reduction in leachate. Coagulation/flocculation using LBG could be applied for POPs reduction in leachate as a pre-treatment prior to advanced treatments.

Preservation of vascular endothelial repair in mice with diet-induced obesity

INTRODUCTION

Preservation of structural integrity of the endothelial monolayer and maintenance of endothelial cell function are of critical importance in preventing arterial thrombosis, restenosis and atherosclerosis. Obesity has been intimately linked with endothelial dysfunction, and reports of reduced abundance and functional impairment of circulating progenitor cells in obesity have led to the suggestion that defective endothelial repair contributes to obesity-related cardiovascular disease.

METHODS

C57BL/6 mice were fed a high-fat diet for either 3 or 6 months to induce obesity; metabolic phenotyping was then carried out before femoral artery wire injury was performed. Endothelial regeneration was then quantified. Mononuclear cells and myeloid angiogenic cells were cultured and characterized for pro-angiogenic properties.

RESULTS

No impairment of endothelial regeneration following mechanical endothelial injury in diet-induced obese mice when compared with chow-fed controls was observed, despite the induction of an adverse metabolic phenotype characterized by glucose intolerance and insulin resistance. Dietary-obese mice had increased numbers of circulating myeloid angiogenic cells, which retained normal functional properties including intact paracrine angiogenic effects.

CONCLUSION

Preserved endothelial regeneration despite metabolic dysregulation in dietary obese mice suggests that compensatory mechanisms mitigate the deleterious influence of insulin resistance on endothelial repair in obesity.

Kimura Disease: A differential diagnosis in a nephrotic child

Kimura disease presents as benign lesion and is commonly present among the Asian population. It is a disease with a favourable prognosis and a peak age of onset in the third decade. It is a chronic inflammatory disorder of unknown etiology that involves the lymph nodes and subcutaneous tissues of the head and neck region. We report a case of a 15-year-old boy with multiple Kimura lymphadenopathies involving the left posterior auricular region as well as the anterior and posterior triangles of the neck.

Evaluation and management of thromboprophylaxis in Moroccan hospitals at national level: the Avail-MoNa study

Venous thromboembolism (VTE) is a common clinical problem that is associated with substantial morbidity and mortality. The aim of this study was to describe the clinical practices in VTE prophylaxis in university and peripheral hospitals in Morocco. This is a national, cross-sectional, multicenter, observational study assessing the management of the VTE risk in selected Moroccan hospitals (four university and three peripheral). The thromboembolic risk of the selected patients was assessed according to the American College of Chest Physicians (ACCP) guidelines (2008). We hypothesized that interventions for VTE guideline implementation in those hospitals may improve prophylaxis use for hospitalized patients. A total of 1318 patients were analyzed: 467 (35.5%) medical and 851 (64.5%) surgical. The mean age of patients was 52.6 ± 16.5 years, and 52.7% were female. A total of 51.1% patients were considered to be at risk of VTE according to ACCP guidelines and were eligible for thromboprophylaxis (TP). Medical patients were more likely to present risk factors than surgical patients (53.6 vs. 50.7%, respectively). TP was prescribed for 53.1% of these patients, 57.4% in at-risk surgical patients and 50.3% in at-risk medical patients. TP was also prescribed for 42.9% of non-at-risk patients. The concordance between the recommended and the prescribed prophylaxis was poor for the total population (kappa = 0.110). TP did not improve sufficiently in our hospitals, even after implementation of the guidelines. New strategies are required to appropriately address TP in hospitalized patients.

Low Seroprevalence of Torque Teno Virus in HCV positive patients and phylogenetic analysis from Pakistani isolates

The torque teno virus (TTV) has a heterogeneous genome and its role in hepatitis C (HCV) infection is still controversial, therefore the purpose of the present study was to determine if there is any association between Hepatitis C and TTV co-infection and to determine the phylogenetic relationship between existing types in the Pakistani population. A total of 500 individuals (250 HCV positive patients and 250 healthy controls) were selected. DNA was extracted from serum samples and polymerase chain reaction (PCR) of the open reading frame 1 (ORF1) region of TTV was performed. Out of 500 samples 9 HCV positive index cases (3.6%) and 8 healthy samples (3.2%) were found to be positive for TTV. A comparison was made between TTV sequences reported from all over the world with the ones obtained in the present study by sequencing of TTV positive samples followed by phylogenetic analysis using maximum parsimony (MP) method. Our results indicated that the virus was undergoing divergent evolution as very high sequence diversity was found in the ORF1 gene. The study also shows that association between HCV and TTV was not found. Because the virus was found to be affecting both healthy individuals and HCV infected population with almost same frequency. Therefore a thorough screening of TTV virus at the population level is required in order to draw a comprehensive inference.