Prevalence of temporomandibular joint dysfunction among the indigenous population of India

Purpose

Primary dental care facilities and awareness about temporomandibular disorders are lacking among the indigenous population of Kerala. The aim of the study was to determine the prevalence of temporomandibular joint dysfunction (TMD) disorders among the indigenous populations of Kerala.

Methodology

This cross-sectional study included adults aged 18 years and above, visiting primary health care centre in the tribal hamlet in the town of Kalpetta, Wayanad District, Kerala, India, for reasons other than dental. Axis I and II of Research Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) was used to screen for TMD. A local language validated screening questionnaire was used. The clinical examination was carried out as per the DC/TMD by a calibrated examiner. The data was processed using SPSS and the frequencies and proportions for signs and symptoms of TMD were estimated.

Results

Among 198 adults screened, 23 (11.6 %) had TMD. Among these 60 % of the adults were aged 31-65 years and predominantly females (86.9 %). 39 % of these patients were dentulous. All affected adults experienced TMD related pain for more than 3 months with 90 % of them experiencing moderate-to-severe pain. Myofascial pain was the most prevalent type. Other findings included moderate anxiety levels in 34.8 % and abnormal oral behaviour and high physical symptoms in 40 % TMD patients.

Conclusion

TMD disorders were prevalent among the indigenous population and remained undiagnosed. The study highlights the need for screening and the availability of basic dental care for the indigenous populations.

EPA Consensus Project Paper: Do Implant Retained Prostheses Improve the Quality of Life of Patients with Extraoral Maxillofacial Defects - A Systematic Review

BACKGROUND

There is limited evidence available regarding patient satisfaction and quality of life assessment in patients with extraoral maxillofacial prostheses.

OBJECTIVES

This systematic review aims to understand the impact of extraoral implant retained prosthesis in improving the quality of life in patients with extraoral maxillofacial defects/abnormalities.

METHODS

A comprehensive search was performed of nine electronic databases up to August 2022, which yielded three articles that satisfied the inclusion criteria. The study characteristics and findings were extracted, and the included studies were assessed for quality.

RESULTS

Three cohort studies were selected. Despite the lack of uniformity in the quality of life instruments, there was a general trend in improvement in the quality of life for patients with implant retained extraoral prostheses. The studies were also deemed to be of high quality on assessment.

CONCLUSION

Given the limitations of this systematic review, there exists limited evidence indicating that implant prostheses may enhance the quality of life for individuals with extraoral maxillofacial defects or abnormalities.

Improved outcomes of large B-cell lymphoma patients treated with CD19 CAR T in the UK over time

The success of CD19 Chimeric antigen receptor (CAR) T-cell therapy in large B-cell lymphoma (LBCL) has been partially offset by toxicity and logistical challenges, which off-the-shelf agents like CD20xCD3 bispecific antibodies might potentially overcome. However, when using CAR T outcomes as the 'standard-of-care comparator̕ for relapsed/refractory (r/r) LBCL, a potential learning curve with implementing a novel, complex therapy like CAR T needs to be considered. To address this, we analysed 726 UK patients intended to be treated with CD19 CAR T for r/r LBCL and compared outcomes between the first year of the national CAR T programme (Era 1; 2019) and the more recent treatment era (Era 2; 2020-2022). We identified significant improvements for Era 2 versus Era 1 in dropout rate (17% vs. 27%, p = 0.001), progression-free survival (1-year PFS 50% vs. 32%, p < 0.001) and overall survival (1-year OS 60% vs. 40%, p < 0.001). We also observed increased use of bridging therapy, improvement in bridging outcomes, more tocilizumab/corticosteroid use, reduced high-grade cytokine release syndrome (4% vs. 9%, p = 0.01) and intensive care unit admissions (20% vs. 32%, p = 0.001). Our results demonstrate significant improvement in CAR T outcomes over time, highlighting the importance of using up-to-date clinical data when comparing CAR T against new treatment options for r/r LBCL.

Will preoperative combined MRI and high-resolution ultrasonography redefine brachial plexus imaging? A comparative study of preoperative MRI versus combined MRI and high-resolution ultrasonography in assessing usable C5, C6 root-stumps for intra-plexal nerve grafting

AIM

To compare the intraoperative findings with the preoperative imaging in detecting usable root stumps using magnetic resonance imaging (MRI) alone versus MRI combined with high-resolution ultrasonography (HRUS) in adults undergoing post-traumatic brachial plexus (BP) surgery. Further, when root stumps were present, the reliability of their measurements using both imaging methods was compared to their intraoperative length.

MATERIALS AND METHODS

A consecutive group of adults who were planned for post-traumatic BP surgery between July 2015 and April 2016 were evaluated prospectively. They underwent preoperative MRI and HRUS and the agreement (kappa value) between these imaging methods and their intraoperative findings in categorising roots were then compared. When stumps were present, the reliability of the extraforaminal measurements by each method were compared to their corresponding intraoperative stump length using intraclass correlation coefficients (ICC), and Bland-Altman plots.

RESULTS

Of the initial 60 patients, 48 patients with 82 roots were included in the study. Greater agreement was observed between HRUS and intraoperative findings in categorising BP root stumps (kappa value 0.70, SE 0.07) versus MRI and intraoperative findings (kappa value 0.42, SE 0.07). Similarly, there was a higher correlation between HRUS and intraoperative findings (ICC: 0.94, p<0.001) than that of MRI and intraoperative findings (ICC: 0.53, p<0.001) regarding stump length measurements.

CONCLUSION

Combining HRUS with MRI in the preoperative imaging of the adult BP injury can better predict the presence of usable nerve root stumps for intra-plexal nerve grafting. HRUS also gave reliable preoperative stump length measurements, and it was determined that a stump should be at least 1.3 cm to be deemed usable for nerve grafting.

Olfactomedin-4 + neutrophils exacerbate intestinal epithelial damage and worsen host survival after Clostridioides difficile infection

Neutrophils are key first responders to Clostridioides difficile infection (CDI). Excessive tissue and blood neutrophils are associated with worse histopathology and adverse outcomes, however their functional role during CDI remains poorly defined. Utilizing intestinal epithelial cell (IEC)-neutrophil co-cultures and a pre-clinical animal model of CDI, we show that neutrophils exacerbate C. difficile -induced IEC injury. We utilized cutting-edge single-cell transcriptomics to illuminate neutrophil subtypes and biological pathways that could exacerbate CDI-associated IEC damage. As such, we have established the first transcriptomics atlas of bone marrow (BM), blood, and colonic neutrophils after CDI. We found that CDI altered the developmental trajectory of BM and blood neutrophils towards populations that exhibit gene signatures associated with pro-inflammatory responses and neutrophil-mediated tissue damage. Similarly, the transcriptomic signature of colonic neutrophils was consistent with hyper-inflammatory and highly differentiated cells that had amplified expression of cytokine-mediated signaling and degranulation priming genes. One of the top 10 variable features in colonic neutrophils was the gene for neutrophil glycoprotein, Olfactomedin 4 (OLFM4). CDI enhanced OLFM4 mRNA and protein expression in neutrophils, and OLFM4 + cells aggregated to areas of severe IEC damage. Compared to uninfected controls, both humans and mice with CDI had higher concentrations of circulating OLFM4; and in mice, OLFM4 deficiency resulted in faster recovery and better survival after infection. Collectively, these studies provide novel insights into neutrophil-mediated pathology after CDI and highlight the pathogenic role of OLFM4 + neutrophils in regulating CDI-induced IEC damage.

One Sentence Summary

Utilizing single-cell transcriptomics, IEC-epithelial co-cultures, and pre-clinical models of CDI, we have identified a subset of neutrophils that are marked by OLFM4 expression as pathogenic determinants of IEC barrier damage after CDI.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Diastolic Blood Pressure and Cognitive Functioning: Differences by Systolic Blood Pressure Among US Adults

BACKGROUND

The role of diastolic blood pressure (DBP) with cognitive functioning is under-explored in relation to levels of systolic blood pressure (SBP).

METHODS

We studied 5466 participants from the National Health and Nutrition Examination Survey. Blood pressure was measured 3 times manually with a standardized sphygmomanometer and averaged. Cognitive functioning was measured using the digit symbol substitution test (DSST).

RESULTS

Participants were 60 years or older, 55% female, and 81% non-Hispanic White. Most participants had a DBP between 70 to <80 mmHg (33.7%), between 60 to <70 mmHg (29.3%), or <60 mmHg (18.8%). From multivariable linear regression analyses, each 5 mmHg increment of DBP was associated with significantly higher DSST scores among individuals with SBP <120 only (ß: 0.56, 95% CI: 0.09, 1.03).

CONCLUSIONS

Among older US adults, at non-elevated levels of SBP, higher DBP is associated with better cognitive performance.

Patient Reported Outcomes of Scalp and Forehead Reconstruction for Defects Following Oncological Resections (North-East Indian Tertiary Cancer Centre Study)

Background Approximately 1-2% of all scalp tumours are malignant, but they comprise up to 13% of all malignant cutaneous neoplasms. The current study presents our experience of reconstruction of scalp and forehead for malignant tumours treated at our centre. Methods This is a single institutional observational study conducted at a tertiary cancer centre in North East India. Post-operative outcomes related to quality of life of patients were measured with help of FACE-Q scales. Face-Q -Satisfaction with outcome and FACE-Q- appearance related psychosocial distress scores were analysed. Histograms were used for descriptive statistics. Data were checked for normality using Kolmogorov-Smirnova and Shapiro-Wilk test. For non-normal data Wilcoxon test was used. A p value less than 0.05 was considered as statistically significant at 5% level of significance. Results Mean age of patients was 57.6 ± 14.2 years. The mean defect size was 89.036 ± 81.77 cm2. The mean satisfaction with outcome scores and distress scores at 3-months was 54.9 ± 8.6 and 34.8 ± 8.5 respectively with a statistically significant p value of 0.001.Mean satisfaction scores and psychological distress scores were better at the end of three months when compared to at the time of discharge with a statistical significant p value of < 0.0001. Conclusion Scalp and forehead reconstructions for defects following oncological resections are technically challenging and if chosen carefully with meticulous planning, both local and free tissue transfers give satisfactory outcome in long term follow up. There are lots of reconstruction options for scalp and forehead defects and knowledge of the basic bio-geometry of the each flap is must.

Effectiveness of digital data acquisition technologies in the fabrication of maxillofacial prostheses - A systematic review

Objective

The systematic review was designed to review and analyze the outcomes of various digital data acquisition technologies used for treatment planning in the prosthetic rehabilitation of maxillofacial defects.

Methods

The review protocol was registered in PROSPERO data with registration number: CRD42020188415. The PICOS inclusion criteria was employed in the systematic review. An electronic search (PubMed, databases) yielded twenty-eight eligible case reports. The qualitative methodological assessment was done according to an article that provided criteria for special considerations in evaluating case reports. It consisted of four questions, each carrying grading of 0, 1, and 2. During the full-text screening, the reviewers shortlisted six outcomes (time, aesthetics, cost, dimensional accuracy, patient satisfaction, and fabrication process) and graded (0, 1, 3) according to the outcomes they met.

Results

The majority of the included case reports used LASER scanners. Auricular and orbital defects were the highest reported cases. In nasal and orbital defects, the mean outcome of the shorter time required for the fabrication was the highest. In auricular prostheses, the mean outcome of dimensional accuracy was highest. In facial prostheses, aesthetics, dimensional accuracy, and patient satisfaction had the highest mean outcome whereas, in obturators, the shorter time required, dimensional accuracy, and patient satisfaction had the highest mean outcome. A total of 18 studies were graded as highly significant studies according to the methodological qualitative assessment.

Conclusion

LASER scanning systems in nasal prostheses, LASER scanners and combination of CT scan and digital photography in auricular prostheses, digital photography and stereophotogrammetry in case of large facial defects and combination of MRI and CT scan for obturators appeared to be a superior method of digital data acquisition.

Effects of Prosthetic Rehabilitation on Temporomandibular Disorders: Protocol for a Randomized Controlled Trial

Background

Loss of teeth or occlusal imbalance is one of the proposed dental risk factors for temporomandibular disorders (TMDs). Losing some non–free-end teeth cause the original occluding tooth/teeth to supraerupt from the original upright position and causes neighboring tooth/teeth to shift in an angle, causing biomechanical imbalance on the mandible. Based on these sequelae, rehabilitation of missing teeth is the first step in managing TMD in edentulous patients. Even though the prevalence of TMD in association with edentulism and in rehabilitated patients has been increasing, proper guidelines for the management of such cases have not been established. This study describes the protocol to analyze the effect of prosthetic rehabilitation on patients with TMD.

Objective

This study aims to determine the effectiveness of prosthetic rehabilitation in the reduction of pain in edentulous patients with TMD and to determine the effect of the span of edentulism, the number of quadrants involved, pathological migration, the type of Kennedy classification, and the prosthetic status on temporomandibular joint dysfunction signs and symptoms.

Methods

In this randomized controlled trial, 300 patients diagnosed with TMD will be grouped into one of the three interventional groups based on the type of their edentulous state. The interventional groups are (1) partially edentulous arch: Kennedy Class I and II (prosthetic rehabilitation without splint); (2) partially edentulous arch: Kennedy Class III and IV (prosthetic rehabilitation with a splint); and (3) completely edentulous arches (prosthetic rehabilitation without splint). All three of the mentioned interventional groups have corresponding control groups that will receive symptomatic treatment and comprehensive counseling. The measured primary outcomes are pain and electromyogram, and the secondary outcomes include pain drawing, Graded Chronic Pain Scale, Jaw Functional Limitation Scale, Oral Behaviours Checklist, depression, physical symptoms, and anxiety. The outcome measurements will be recorded at baseline and at the end of 24 hours, 7 days, 28 days, and 3 months.

Results

Ethical approval was obtained from the Institutional Review Board of Amrita Institute of Medical Sciences, Kochi, India. Study participants’ recruitment began in May 2021 and is expected to conclude in March 2023. This clinical trial protocol was developed based on the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 Statement.

Conclusions

The purpose of this study is to gather data on prosthetic rehabilitation as a treatment for TMD. Obtaining this goal will aid in the development of evidence-based therapy protocols for prosthetic rehabilitation in TMD management.

Trial Registration

Clinical Trials Registry - India CTRI/2020/06/026169; http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=42381

International Registered Report Identifier (IRRID)

DERR1-10.2196/33104

Superhydrophilic multifunctional nanotextured titanium dental implants: in vivo short and long-term response in a porcine model

Current clinical demand in dental implantology is for a multifunctional device with optimum mechanical properties, improved biocompatibility and bioactivity, and having differential interactions with cells and pathogenic agents. This would minimise bacterial infection, biofilm formation and modulate inflammation, leading to a fast and durable osseointegration. The present study intends to establish the multifunctional behaviour of surface modified titanium dental implants that are superhydrophilic, with unique micro-nano or nanoscale topographies, developed by a facile hydrothermal technique. Here, the short and long-term performances of these textured implants are tested in a split mouth design using a porcine model, in pre- and post-loaded states. Quantitative and qualitative analyses of the bone implant interphase are performed through μ-CT and histology. Parameters that evaluate bone mineral density, bone contact volume and bone implant contact reveal enhanced bone apposition with better long-term response for the nano and micro-nano textured surfaces, compared to the commercial microtextured implant. Concurrently, the nanoscale surface features on implants reduced bacterial attachment by nearly 90% in vivo, outperforming the commercial variant. This preclinical evaluation data thus reveal the superiority of nano/micro-nano textured designs for clinical application and substantiate their improved osseointegration and reduced bacterial adhesion, thus proposing a novel dental implant with multifunctional characteristics.

Restoration of elbow flexion in adult traumatic brachial plexus injury - a quantitative analysis of results of single versus double nerve transfer

BACKGROUND

Restoration of elbow flexion is one of the key components of adult brachial plexus surgery. Nerve transfers are routinely used to attain elbow flexion.

PURPOSE

This study aims to quantify the recovery of elbow flexion power and to compare the outcome following single nerve transfer and double nerve transfer to branches of the musculocutaneous nerve in adult traumatic brachial plexus injury.

METHOD

We conducted a retrospective cohort study of patients with traumatic upper brachial plexus injury who underwent nerve transfer of the musculocutaneous nerve with either Ulnar nerve fascicles (SN) or both Ulnar and Median nerve fascicles (DN) for restoring elbow flexion. Patients with a minimum follow up of 18 months after surgery were included in this study. Elbow flexion strength was quantified using a force transducer and software module and the results were compared between the two groups.

RESULT

The median strength of elbow flexion was 14.3 Newton meter. In the SN group, the mean strength of elbow flexion was 5.4 ± 5 Nm, and for DN group it was 20.4 ± 9.9 Nm. Elbow flexion strength following DN procedure was significantly better when compared with SN.

CONCLUSION

The additional nerve transfer of median nerve fascicles with musculocutaneous nerve branch to the brachialis muscle does not add clinically obvious morbidity to the patient but has definite benefit as observed in this study. We advocate double fascicular nerve transfer for elbow flexion in upper brachial plexus injuries if the median and ulnar nerve functions are normal.

Bactericidal efficiency of micro- and nanostructured surfaces: a critical perspective

Micro/nanostructured surfaces (MNSS) have shown the ability to inactivate bacterial cells by physical means. An enormous amount of research has been conducted in this area over the past decade. Here, we review the various surface factors that affect the bactericidal efficiency. For example, surface hydrophobicity of the substrate has been accepted to be influential on the bactericidal effect of the surface, but a review of the literature suggests that the influence of hydrophobicity differs with the bacterial species. Also, various bacterial viability quantification methods on MNSS are critically reviewed for their suitability for the purpose, and limitations of currently used protocols are discussed. Presently used static bacterial viability assays do not represent the conditions of which those surfaces could be applied. Such application conditions do have overlaying fluid flow, and bacterial behaviours are drastically different under flow conditions compared to under static conditions. Hence, it is proposed that the bactericidal effect should be assessed under relevant fluid flow conditions with factors such as shear stress and flowrate given due significance. This review will provide a range of opportunities for future research in design and engineering of micro/nanostructured surfaces with varying experimental conditions.

Zinc Gluconate Induces Potentially Cancer Chemopreventive Activity in Barrett's Esophagus: A Phase 1 Pilot Study

BACKGROUND

Chemopreventive effects of zinc for esophageal cancer have been well documented in animal models. This prospective study explores if a similar, potentially chemopreventive action can be seen in Barrett's esophagus (BE) in humans.

AIMS

To determine if molecular evidence can be obtained potentially indicating zinc's chemopreventive action in Barrett's metaplasia.

METHODS

Patients with a prior BE diagnosis were placed on oral zinc gluconate (14 days of 26.4 mg zinc BID) or a sodium gluconate placebo, prior to their surveillance endoscopy procedure. Biopsies of Barrett's mucosa were then obtained for miRNA and mRNA microarrays, or protein analyses.

RESULTS

Zinc-induced mRNA changes were observed for a large number of transcripts. These included downregulation of transcripts encoding proinflammatory proteins (IL32, IL1β, IL15, IL7R, IL2R, IL15R, IL3R), upregulation of anti-inflammatory mediators (IL1RA), downregulation of transcripts mediating epithelial-to-mesenchymal transition (EMT) (LIF, MYB, LYN, MTA1, SRC, SNAIL1, and TWIST1), and upregulation of transcripts that oppose EMT (BMP7, MTSS1, TRIB3, GRHL1). miRNA arrays showed significant upregulation of seven miRs with tumor suppressor activity (-125b-5P, -132-3P, -548z, -551a, -504, -518, and -34a-5P). Of proteins analyzed by Western blot, increased expression of the pro-apoptotic protein, BAX, and the tight junctional protein, CLAUDIN-7, along with decreased expression of BCL-2 and VEGF-R2 were noteworthy.

CONCLUSIONS

When these mRNA, miRNA, and protein molecular data are considered collectively, a cancer chemopreventive action by zinc in Barrett's metaplasia may be possible for this precancerous esophageal tissue. These results and the extensive prior animal model studies argue for a future prospective clinical trial for this safe, easily-administered, and inexpensive micronutrient, that could determine if a chemopreventive action truly exists.

Biomimetic Properties of Engineered Periodontal Ligament/Cementum in Dental Implants

The conventional concept of osseointegrated dental implants based on direct connection to alveolar bone lacks a structured periodontal ligament (PDL) as in natural tooth. This limits the physiologic and functional efficiency of the implant in cushioning occlusal overload, orthodontic tooth movement, and proprioception. Development of bio-mimetic implants that can satisfy the bio-functional requirements of the natural tooth will be an innovative approach and preliminary researches in this area has been reported. This review includes in vivo studies which reported structural features and functional efficiency of an artificial PDL or cementum developed around dental implants. The electronic search identified 12 animal studies and one human trial which utilized retained or adjacent natural tooth roots, exogenous scaffold materials, dental progenitor cells derived from PDL of extracted tooth root as PDL substitutes. The result of the review is dominated by bio-hybrid implants that used dental follicles separated on the particular embryonic day and cell sheets from immortalized human cells. A summary of the currently available research on artificial PDL/cementum around dental implants highlights the potential need of autologous cell-derived tissues to bioengineer a fully functional implant design

Changes in Left Ventricular Mass and Cardiovascular Risk Factors after Kidney Transplantation

Left ventricular hypertrophy (LVH), the most common structural cardiac complication, is the single most important cause for sudden cardiac death. There are no published data from India looking at the changes in left ventricular mass and cardiac dysfunction after kidney transplantation. We aimed to determine the changes in the left ventricular mass and other cardiovascular risk factors in kidney transplant recipients. This was a prospective observational study. All patients who underwent kidney transplantation at Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, during the study period were included in the study. Measurement of clinical and biochemical parameters and echocardiography were done before, six months, and one year after transplantation. There was significant reduction in LV mass index (124.8 ± 39 vs. 102.2 ± 24.4 g/m², P <0.001) and improvement in ejection fraction (57.8 ± 7 vs. 60.1 ± 1.9, P = 0.015) at the end of six months. There were significant differences in the mean hemoglobin, systolic, and diastolic blood pressures (P <0.001) during the study. There was also a significant reduction in the number of antihypertensive drugs required for blood pressure control. There was a significant reduction in LVH in the study group. There was also improvement in systolic and diastolic functions of the heart. There was also a significant improvement in blood pressure control both in terms of mean blood pressure levels as well as in terms of the number of anti-hypertensive drugs needed for blood pressure control. Renal transplantation ameliorates cardiovascular risk in renal transplant recipients.

Dental Care Implications in Coronavirus Disease-19 Scenario: Perspectives

AIM

The aim of this review is to discuss the implications of COVID-19 on various aspects of dental care.

BACKGROUND

The COVID-19 pandemic had suspended dental practice globally for over 3 months. While dental practice is being resumed cautiously, standard infection control protocols that were traditionally overlooked are now being strictly implemented. Post-COVID-19, dental care is expected to see a drastic change in the way it is practiced.

REVIEW RESULTS

With a view on the natural history and disease dynamics of COVID-19, this review reports various aspects of dental care, viz., patient triaging, engineering and work practice controls, and administrative, financial, and ethical aspects of dental care during and after COVID-19 pandemic. Current evidence-based recommendations with regard to infection-control practices are discussed. A call for universal oral health care with suggestions regarding integration of medical and health care is also proposed.

CONCLUSION

COVID-19 is expected to be a watershed moment in the field of dentistry. While we expect to see positive changes in safe delivery of dental care, an increase in cost of availing care is imminent.

CLINICAL SIGNIFICANCE

The practice of dentistry and dental infection control has undergone dimensional changes due to bloodborne infectious diseases such as hepatitis B virus infections and human immunodeficiency virus epidemic. Due to these pandemics, many regulatory organizations have provided safety recommendations and guidelines that impact the dental practice. Currently, we are faced with a highly infective disease with a high mortality rate among people with comorbidities and of predominantly droplet transmission and no concrete safety recommendations and guidelines. This manuscript addresses multiple issues, gaps, and pragmatic solutions in controlling transmission of SARS-CoV-2 in dental settings, during and after the pandemic.

AB0596 PREDICTORS, LONG TERM CLINICAL AND TREATMENT OUTCOMES IN SOUTH ASIAN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOSITIS: A SINGLE CENTER STUDY

Background:

Idiopathic inflammatory myositis (IIM) are a heterogeneous group of immune-mediated disorders with varied presentations and multiple organ involvement. Data on long term outcome among South Asian patients with IIM is sparse.

Objectives:

To study the long term clinical outcome, treatment responses and factors predicting outcome among adult patients with IIM

Methods:

Patients diagnosed as ‘Idiopathic Inflammatory Myositis’ under the department of Clinical Immunology and Rheumatology at CMC, Vellore, India were screened retrospectively. Patients aged 18 years and above, satisfying Bohan and Peter criteria, having follow up of one year or more with atleast two outpatient or inpatient visits between January 2010 and April 2019 were included in this study. Those patients with connective tissue disease associated myositis were not included. Details on muscle weakness, extramuscular involvement, muscle enzymes and treatment administered were recorded at baseline, 3, 6, 12, 18, 24 months and yearly thereafter. After assessing their cumulative response, categorization of patients into complete and partial responders was done. Complete responders were defined as patients with persistent muscle power of more than 4/5 and/or MMT 8 more than 76/80, complete resolution of skin, articular and lung involvement (if any) as well as muscle enzymes less than twice the upper limit of normal without any documented flares during the entire follow up period. Patients not satisfying the said criterias were grouped as Partial responders. Disease free survival duration was also analyzed.

Results:

Out of 310 patients of IIM identified, 187 (60.3%) patients satisfied the inclusion criteria. Women were 2.2 times more than men and mean age at symptom onset was 35.7±12.6 years. Dermatomyositis was the predominant myositis subtype seen. All patients were put on steroids with the mean dose being 45.9 ± 18.6 mg/day. At baseline, the key immunosuppressants used were methotrexate in 44.9% and mycophenolate in 37.6% patients. The median follow up duration was 48 (25-80) months. An associated malignancy was diagnosed in 3.2% after a median duration of 24.5 months. Five patients expired after a median duration of 80 months from diagnosis. Normal muscle power was attained in 76.1% patients and 88.6% were vocational by the last follow up visit. Steroids were discontinued in 56.7% patients after a median duration of 24 months (p=0.0002). Discontinuation of the immunosuppressant was feasible in 10.2% patients after a median duration of 44 months. Assessment of the cumulative responses revealed a relapsing and remitting course in 45.9%. Outcome predictors in univariate analysis were Jo-1 status, presence of arthritis, interstitial lung disease and pericardial effusion at baseline. On multivariate analysis, absence of pericardial effusion (p=0.011) and interstitial lung disease (p=0.067) at baseline were found to be predictors of complete response. Disease free survival probability estimated at 5 years and 10 years was 91.6% and 72.4% respectively. Estimating the probability gender wise, males achieved disease free status earlier than females.

Conclusion:

A favorable clinical and functional outcome was seen in a significant proportion of these patients with IIM on long term follow up. Pericardial effusion and ILD were identified as predictors of poor clinical outcome.

References:

[1]Taborda AL, Azevedo P, Isenberg DA. Retrospective analysis of the outcome of patients with idiopathic inflammatory myopathy: a long-term follow-up study. Clin Exp Rheumatol. 2014 Apr; 32(2):188–93.

Acknowledgments:

Nil

Disclosure of Interests:

None declared

P0608TROPICAL FEVER ASSOCIATED ACUTE KIDNEY INJURY - RISK PREDICTION MODEL IN A RESOURCE LIMITED SETTING IN SOUTH INDIA

Background and Aims

Acute kidney Injury (AKI) is a serious medical condition estimated to affect more than 10 million people around the world annually, resulting in a 1.7- to 6.9-fold increased risk of hospital mortality. Out of 1.7 million deaths per year caused by AKI globally, around 1.4 million occur in low- and middle-income countries, sepsis being the leading cause. AKI occurs in 40–50% of patients with sepsis and increases the mortality six- to eight-fold. By comparing the prevalence of potential risk factors in populations of patients who had developed AKI with control groups with no AKI, several risk assessment tools have been proposed and generated for specific clinical settings such as intensive care units, cardiac surgery, general surgery, those undergoing radiological investigations involving intravenous contrast and those presenting to the emergency department. The AKI Risk Assessment (ARA F4) model incorporated newer biomarkers of kidney injury (TIMP-2, IGFBP7) along with clinical parameters to detect patients at risk for AKI as fast as possible and to prevent further damage. However, they are yet to be available freely in our country. To the best of our knowledge, no risk assessment tool in the setting of tropical fever associated AKI has been proposed till date.

The aim of this study is to provide a practical model to identify patients at high risk for tropical fever associated AKI in a resource limited setting in the absence of newer biomarkers.

Method

Ours is a retrospective, single center study. Patients who had an increase in serum creatinine (S.Cr) ≥0.3 mg/dL within 48 hours; or an increase in S.Cr to ≥1.5 times baseline, which is known or presumed to have occurred within the prior 7 days or a urine volume of &lt;0.5 mL/kg/h for 6 hours were included. We recruited 342 consecutive admissions with tropical fever associated AKI and evaluated them based on clinical and biochemical profiles.

Results

We analyzed data of 342 patients. Our population of patients had representation from all age groups, 72% were between 21 to 60 years, 20.4% were &gt;60years and 34.7% were females. There was a clear relationship between age and the number of AKI risk factors. Baseline serum creatinine was available for 117 patients, the average S.cr was 0.9591mg/dL and the average rise in S.cr was 1.22mg/dL. Leptospirosis (11.98%), dengue (84.79%), malaria (2.63%) and complicated malaria (0.29%) were the etiologies for AKI.

19,21 and 2 patients with leptospirosis had &lt;=5, 6 to 10 and &gt;10 risk factors respectively. 258,32 and 0 patients with dengue had &lt;=5, 6 to 10 and &gt;10 risk factors respectively. 8,1 and 0 patients with malaria had &lt;=5, 6 to 10 and &gt;10 risk factors respectively. One patient with complicated malaria had &lt;=5 risk factors.

15/42 with leptospirosis, 2/290 with dengue, none with malaria and 1/1 with complicated malaria required renal replacement therapy.

Five patients expired, out of which three were on renal replacement therapy. 3/286 with total risk score &lt;5, 14/53 with total risk score between 6-10 and one out of two with total risk score &gt;10 required renal replacement therapy.

Conclusion

Tropical fever associated AKI is a major public health burden in southern India. Our aim was to propose a risk stratification model to assess severity of tropical fever associated AKI and dialysis requirement in a resource limited setting.

In our study, the number of risk factors, incidence of AKI and dialysis requirement were more in people with leptospirosis. We also observed that as the risk scores went up, the need for hemodialysis increased irrespective of the etiology. In the absence of availability of newer biomarkers this risk prediction score is quite useful. Ours is the first risk assessment tool in tropical fever associated AKI in resource limited setting. We are planning on a prospective evaluation of the same in the near future to validate our Tropical fever associated Acute Kidney Injury Risk assessment (TAKIR) tool.

Figure

In-lined.

THU0523 CLINICAL UTILITY OF TESTING CONVENTIONAL AND NON-CONVENTIONAL ANTI-PHOSPHOLIPID ANTIBODIES IN SUSPECTED OBSTETRIC ANTI-PHOSPHOLIPID SYNDROME

Background:

Anti-phospholipid syndrome (APS) is an important cause for recurrent pregnancy losses (RPL). Conventional APS antibodies (aPLs) like lupus anti-coagulant (LA), anti-cardiolipin(ACL) and anti-beta 2 glycoprotein I (anti-β2 GP I) are not present in significant number of obstetric APS(OAPS) patients, leading to a state described as “ sero-negative” OAPS (SNOAPS). Recent literature shows non-conventional aPLs like Anti phosphatidylserine-prothrombin complex (Anti-PSPT) and Anti-Annexin V (Anti-Ann V) can be positive in up to 50% of SNOAPS patients

Objectives:

Testing the performance of conventional and non-conventional aPLs in suspected OAPS patients (obstetric events as defined in the Sydney classification criteria for APS)

Methods:

We performed a retrospective chart review of 101 patients who underwent combined testing for non-conventional aPLs for suspected OAPS from May 2016 to November 2019 at our department. Patients were categorized into OAPS cases (n=50, median age 31 years) and controls (n=51, median age 30 years) based on their fulfillment of clinical definition of OAPS events defined by Sydney criteria. Conventional aPLs were tested by methods adapted in Sydney criteria and Anti PSPT /Anti Ann V were tested by commercial ELISA. The sample size(n=101) has 95% confidence interval with a margin of error of 10% for the objective of the study.

Results:

36 cases (72%) were ‘sero-positive’ & 14 cases (28%) were truly ‘sero-negative’ for conventional aPLs. 5 (35.7%) of the SNOAPS patients were positive for Ant-PSPT and/or Anti AnnV antibodies. Performance of the various aPLs in suspected OAPS is displayed in Table 1 & Figure 1.

Table 1

showing the performance of the various conventional and non-conventional APLs in suspected obstetric APS cases

AntibodySensitivitySpecificityLikelihood Ratio(+)Likelihood Ratio (-)Positive Predictive ValueNegative Predictive ValueAccuracyYouden’s IndexLA50%94.1 %8.50.589.3%65.7%72.3%44.1%ACL32%98%16.30.794.1%59.5 %65.3%30 %anti β2 GP I IgM38.4%91.4 %4.50.783.3%57.1 %63.5%29.8%anti β2 GP I IgG24%96.1 %6.10.885.7%56.3%60.4%20.1%Anti PSPT28%96.1 %7.10.787.5%57.6 %62.4%24.1%Anti AnnV28%98 %14.30.793.3%58.1%63.4%26%Conventional APLs72%88.2%6.10.385.7%76.3 %79.8%60.2%Non-conventional APLS38%94.1%6.40.786.4%60.7 %66.3%32.1%All APLs82%86.3%6.000.2085.4%83 %84.2%68.3%Figure 1

showing the comparative diagnostic performance of Conventional aPL testing vs Combined testing along with non-conventional aPLs in suspected obstetric APS scenario

Conclusion:

In a delicate situation like RPL, performance of non-conventional aPLs on their own, though not as sensitive as conventional aPLs, still demonstrate better specificity. Non-conventional APLs can newly identify 1/3rd of SNOAPS as APS. The real value of testing Anti PSPT & Anti Ann V in RPL, is combined testing with conventional aPLs wherein they improve the sensitivity and accuracy of diagnosis of OAPS by 10% & 4.4 % respectively, with only 1.9% drop in specificity. Non-conventional aPLs should be tested in SNOAPS.

Disclosure of Interests:

None declared

AB0794 CLINICAL TRIAL DISCRIMINATION OF PHYSICAL FUNCTION INSTRUMENTS FOR PSORIATIC ARTHRITIS: A SYSTEMATIC REVIEW

Background:

Physical function is a core domain to be measured in randomized controlled trials (RCTs) of psoriatic arthritis (PsA). The discriminative performance of patient reported outcome measures (PROMs) for physical function (PF) in RCTs has not been evaluated systematically.

Objectives:

In this systematic review, the GRAPPA-OMERACT working group aimed to evaluate the clinical trial discrimination of PF-PROMs in PsA RCTs.

Methods:

We searched PubMed and Scopus databases in English to identify all original RCTs conducted in PsA. We limited the review to RCTs of biologic and targeted synthetic DMARDs. Groups of two researchers extracted data independently for PF-PROMs. We assessed quality in each article using the OMERACT good method checklist. Effect sizes (ES) for the PF-PROMs were calculated and appraised usinga priorihypotheses. Evidence supporting clinical trial discrimination for each PF-PROM was summarized to derive recommendations.

Results:

32 articles were included (Figure 1). Four PF-PROMs had data for evaluation: HAQ-Disability Index (DI), HAQ-Spondyloarthritis (S), Short Form 36-item Health Survey Physical Component Summary (SF-36 PCS), and the Physical Functioning domain (SF-36 PF) (Table 1). The ES for intervention versus (vs.) control arms for HAQ-DI ranged from -0.55 to -1.81 vs. 0.24 to -0.52; and for SF-36 PCS ranged from 0.30 to 1.86 vs. -0.02 to 0.63.

Table 1.

Summary of Measurement Properties Table for clinical trial discrimination

ArticlesHAQ-DIHAQ-SSF-36 PCSSF-36 PFAntoni 2005 (IMPACT); Gottlieb 2009 (UST)+Antoni 2005 (IMPACT2)++Kavanaugh 2006 (IMPACT2)+Mease 2005 (ADEPT); Genovese 2007 (ADA); Mease 2010 (ETN); Kavanaugh 2009 (GO-REVEAL); Kavanaugh 2017 (GO-VIBRANT); Gladman 2014 (RAPID-PsA); Mease 2015 (FUTURE1); McInnes 2015 (FUTURE2); Kavanaugh, 2016 (FUTURE2)-subgroup; Nash 2018 (FUTURE3); Mease 2017 (SPIRIT-P1); Nash 2017 (SPIRIT-P2); Deodhar 2018 (GUS); Mease 2016 (CLZ)++Mease 2000 (ETN); McInne, 2013 (PSUMMIT 1); Ritchlin 2014 (PSUMMIT 2); Araugo 2019 (ECLIPSA)++Gniadecki 2012 (PRESTA)+Mease 2019 (SEAM-PsA)+/-+McInnes 2014 (SEC)++Mease 2014 (BRO)++Mease 2011 (ABT)+/-+Mease 2017 (ASTRAEA)++Mease 2006 (ALC)+/-Mease 2017 (OPAL Broaden); Gladman 2017 (OPAL Beyond)++Mease 2018 (EQUATOR)++Mease 2018 (ABT-122)+Total available articles311244Total articles for evidence synthesis291232Overall rating+++

Color code in each box indicate study quality by OMERACT good methods. GREEN: “likely low risk of bias”; AMBER: “some cautions but can be used as evidence”; RED: “don’t use as evidence”. WHITE (empty boxes): absence of information from that study. (+): findings had adequate performance of the instrument; (+/-): equivocal performance; (-): poor performance (less than adequate).

Conclusion:

Clinical trial discrimination was supported for HAQ-DI and SF-36 PCS in PsA with low risk of bias; and for SF-36 PF with some caution. More studies are required for HAQ-S.

Disclosure of Interests:

Ying Ying Leung Speakers bureau: Novartis, Janssen, Eli Lilly, Richard Holland: None declared, Ashish Mathew: None declared, Christine Lindsay Employee of: Previously employed (worked) for pharmaceutical company., Niti Goel Shareholder of: UCB and Galapagos, Consultant of: VielaBio, Mallinckrodt, and IMMVention, Alexis Ogdie Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, BMS, Eli Lilly, Novartis, Pfizer, Takeda – consultant, Ana-Maria Orbai Grant/research support from: Abbvie, Eli Lilly and Company, Celgene, Novartis, Janssen, Horizon, Consultant of: Eli Lilly; Janssen; Novartis; Pfizer; UCB. Ana-Maria Orbai was a private consultant or advisor for Sun Pharmaceutical Industries, Inc, not in her capacity as a Johns Hopkins faculty member and was not compensated for this service., Pil Hoejgaard: None declared, Jeffrey Chau: None declared, Laura C Coates: None declared, Vibeke Strand: None declared, Dafna D Gladman Grant/research support from: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – consultant, Robin Christensen: None declared, William Tillett: None declared, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau

Rationale, study design and methodology of the LANDMARC trial: a 3-year, pan-India, prospective, longitudinal study to assess management and real-world outcomes of diabetes mellitus

AIM

India contributes towards a large part of the worldwide epidemic of diabetes and its associated complications. However, there are limited longitudinal studies available in India to understand the occurrence of diabetes complications over time. This pan-India longitudinal study was initiated to assess the real-world outcomes of diabetes across the country.

METHODS

The LANDMARC study is the first prospective, multicentre, longitudinal, observational study investigating a large cohort of people with type 2 diabetes mellitus across India over a period of 3 years. The primary objective of this ongoing study is to determine the proportion of people developing macrovascular diabetes complications over the duration of the study (36 months ± 45 days) distributed over seven visits; the secondary objective is to evaluate microvascular diabetes complications, glycaemic control and time-to-treatment adaptation or intensification. Overall, 6300 participants (aged 25-60 years) diagnosed with type 2 diabetes for at least 2 years will be included from 450 centres across India. Data will be recorded for baseline demographics, comorbidities, glycaemic measurements, use of anti-hyperglycaemic medications and any cardiovascular or other diabetes-related events occurring during the observational study period.

CONCLUSIONS

The LANDMARC study is expected to reveal the trends in complications associated with diabetes, treatment strategies used by physicians, and correlation among treatment, control and complications of diabetes within the Indian context. The findings of this study will help to identify the disease burden, emergence of early-onset complications and dose titration patterns, and eventually develop person-centred care and facilitate public health agencies to invest appropriate resources in the management of diabetes. (Trial Registration No: CTRI/2017/05/008452).

Etiopathogenesis of Trismus in Patients With Head and Neck Cancer: An Exploratory Literature Review

Trismus refers to a person's inability to normally open his or her mouth. Trismus can occur as a symptom due to tumor ingrowth or it can occur postsurgical following the treatment for head and neck cancer. Radiation-induced trismus is also a relatively common oral complication. This review aimed at reviewing the etiopathogenesis of trismus in patients with head and neck cancer. Of the 16 publications included after final screening, of which one was a nonrandomized control trial, one a randomized control trial, 6 prospective cohort studies, and 8 retrospective cohort studies. Among them, 6 articles addressed the possible mechanism for trismus related to tumor ingrowth, 8 articles suggested the likely reason for trismus in patients who had undergone radiation therapy and 2 articles addressed the postsurgical cause for trismus. This review highlights the possible involvement of infratemporal fossa as a predetermining factor for developing trismus related to tumor extension. The molecular mechanism of radiation-induced fibrosis is well studied in the literature.

9 The ‘Colchester Older Persons’ Evaluation for Surgery (COPES)’ Clinic: A Multidisciplinary Approach to Preoperative Management of Frail, Older Patients

Introduction

In 2014-15, 2.5 million patients over 75 years old underwent surgery compared to 1.5 million in 2006-7. The population is aging with increasing numbers of comorbidities, and associated frailty.1 The Royal College of Anaesthetists recommends that preoperative assessment for these complex older patients takes a “cross-specialty approach.”2 In Colchester the COPES clinic has been introduced in which selected high-risk patients are seen by a Consultant Anaesthetist and Consultant Geriatrician. This aims to medically optimise patients prior to surgery and to facilitate shared decision making.

Methods

The new clinic was introduced in October 2018. The following data was collected from COPES clinic letters from October to February 2018-19 (n=46):Patient/ surgery characteristics: age, comorbidities, frailty score and any cognitive impairmentInterventions: changes to medication, specialty referral, intravenous iron, diabetes optimisation, otherOutcomes of surgery following the COPES clinic

Patients were asked to complete feedback forms to evaluate the service.

Results

52% of patients had 4-6, and 28% had 7-9 comorbidities. The majority had Rockwood frailty scores of 4 or 5. 28% of patients had medications changed, 48% had specialty referrals, 17% received intravenous iron, 8.7% required diabetes optimisation and 28% of patients had investigations including echocardiograms, MRI and CT scans. 12/46 patients had surgery deemed unlikely to go ahead after shared decision making with patients in conjunction with the multidisciplinary team involved in their care. 2 patients died of their comorbidities after deciding not to proceed with surgery. 12/46 patients underwent surgery; 4 developed post-operative complications, none died and the mean length of stay was 3.38 days. The remaining 22/46 patients are awaiting surgery. Patient feedback questionnaires (n=10) were overwhelmingly positive. Everyone felt that they were treated with respect and that their fears were addressed and they were clear in the next steps in management.

Conclusions

The introduction of the ‘COPES’ clinic has helped address frailty and multiple comorbidities by optimising patients’ medical conditions and allowing alternatives to surgery to be considered. Patients were very satisfied with the COPES clinic and felt it has prepared them for upcoming surgery.

References

1. Lin H. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatrics, 2016.

2. RCoA. Guidelines for the Provision of Anaesthesia Services. www.pre-op.org/sites/default/files/GPAS%202016.pdf

Recurrent hyperactive ESR1 fusion proteins in endocrine therapy-resistant breast cancer

Background

Estrogen receptor-positive (ER-positive) metastatic breast cancer is often intractable due to endocrine therapy resistance. Although ESR1 promoter switching events have been associated with endocrine-therapy resistance, recurrent ESR1 fusion proteins have yet to be identified in advanced breast cancer.

Patients and methods

To identify genomic structural rearrangements (REs) including gene fusions in acquired resistance, we undertook a multimodal sequencing effort in three breast cancer patient cohorts: (i) mate-pair and/or RNAseq in 6 patient-matched primary-metastatic tumors and 51 metastases, (ii) high coverage (>500×) comprehensive genomic profiling of 287-395 cancer-related genes across 9542 solid tumors (5216 from metastatic disease), and (iii) ultra-high coverage (>5000×) genomic profiling of 62 cancer-related genes in 254 ctDNA samples. In addition to traditional gene fusion detection methods (i.e. discordant reads, split reads), ESR1 REs were detected from targeted sequencing data by applying a novel algorithm (copyshift) that identifies major copy number shifts at rearrangement hotspots.

Results

We identify 88 ESR1 REs across 83 unique patients with direct confirmation of 9 ESR1 fusion proteins (including 2 via immunoblot). ESR1 REs are highly enriched in ER-positive, metastatic disease and co-occur with known ESR1 missense alterations, suggestive of polyclonal resistance. Importantly, all fusions result from a breakpoint in or near ESR1 intron 6 and therefore lack an intact ligand binding domain (LBD). In vitro characterization of three fusions reveals ligand-independence and hyperactivity dependent upon the 3' partner gene. Our lower-bound estimate of ESR1 fusions is at least 1% of metastatic solid breast cancers, the prevalence in ctDNA is at least 10× enriched. We postulate this enrichment may represent secondary resistance to more aggressive endocrine therapies applied to patients with ESR1 LBD missense alterations.

Conclusions

Collectively, these data indicate that N-terminal ESR1 fusions involving exons 6-7 are a recurrent driver of endocrine therapy resistance and are impervious to ER-targeted therapies.

Evaluation of a wet processing strategy for mixed phumdi biomass conversion to bioethanol

Biorefineries typically use dry feedstock due to technical and logistic issues, but in unique cases where climatic conditions are unfavorable and where the biomass has to be processed without a holding time, wet processing might be advantageous. The present study evaluated the possibility of using the fresh (non-dried) mixed biomass harvested from Phumdis; which are floating vegetation unique to Loktak lake in Manipur, India, for bioethanol production. Pretreatment with dilute alkali (1.5% at 120 °C for 60 min) resulted in 36% lignin removal and an enhancement of cellulose content to 48% from 37%, and enzymatic hydrolysis released 25 g/L glucose. Fermentation of the hydrolysates was highly efficient at 95%, attained in 36 h and 80% in just 12 h. The new wet processing strategy could help in value addition of mixed phumdi biomass.

First two bilateral hand transplantations in India (Part 4): Immediate post-operative care, immunosuppression protocol and monitoring

Introduction:

Being able to counter immune-mediated rejection has for decades been the single largest obstacle for the progress of vascular composite allotransplantation (VCA). The human immune system performs the key role of differentiating the 'self ' from the 'non-self '. This, although is quintessential to eliminate or resist infections, also resists the acceptance of an allograft which it promptly recognises as 'non-self'.

Materials and Methods:

Pre-operative evaluation of the recipient evaluation included immunological assessment in the form of panel reactive antibodies (PRA), human leucocyte antigen (HLA) typing, donor-specific antibody detection assays (DSA) and complement-dependent cytotoxicity assays (CDC). Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy.

Results:

Both the recipients were managed by the standard triple drug therapy and have had only minor episodes of rejections thus far which have been managed appropriately.

Discussion:

Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Various groups have tried various other formulations and regimes as well.

Conclusion:

A comprehensive plan has to be drawn up for immunological screening, selection and the post-operative immunosuppressant usage. The ultimate goal of these immunosuppression modalities is to achieve a state of donor-specific tolerance.

IgA nephropathy presenting with pulmonary thromboembolism and renal artery infarct

Background: Venous and arterial thromboembolism are frequently seen in nephrotic syndrome. They generally occur during periods of sustained proteinuria in patients who are not responding to treatment and more commonly seen in minimal change disease and membranous nephropathy. Case Presentation: A 28-year-old male presented to cardiology department of our hospital with worsening breathlessness for 1 week. We found pulmonary embolism and an infarct in the lower pole of the right kidney by CT pulmonary angiogram. He had no previous history or features of nephrotic syndrome. Urine analysis showed numerous red blood cells, 3+ proteinuria and granular casts. Urine protein creatinine ratio was 5.2 g/g of creatinine. Serum creatinine was 2.61 mg/dL. Renal biopsy was suggestive of IgA nephropathy and patient was started on steroids and warfarin and responded to treatment. Conclusions: Patients with nephrotic syndrome can rarely present initially with venous and arterial thromboembolism. Rarely even IgA nephropathy can present with such thromboembolic episodes.

A compact low-cost low-maintenance open architecture mask aligner for fabrication of multilayer microfluidics devices

A custom-built mask aligner (CBMA), which fundamentally covers all the key features of a commercial mask aligner, while being low cost and light weight and having low power consumption and high accuracy, is constructed. The CBMA is composed of a custom high fidelity light emitting diode light source, a vacuum chuck, a mask holder, high-precision translation and rotation stages, and high resolution digital microscopes. The total cost of the system is under $7500, which is over ten times cheaper than a comparable commercial system. It produces a collimated ultraviolet illumination of 1.8-2.0 mW cm^-2 over an area of a standard 4-in. wafer, at the plane of photoresist exposure, and the alignment accuracy is characterized to be <3 μm, which is sufficient for most microfluidic applications. Moreover, this manuscript provides detailed descriptions of the procedures needed to fabricate multilayered master molds using our CBMA. Finally, the capabilities of the CBMA are demonstrated by fabricating two- and three-layer masters for micro-scale devices, commonly encountered in biomicrofluidic applications. The former is a flow-free chemical gradient generator, and the latter is an addressable microfluidic stencil. Scanning electron microscopy is used to confirm that the master molds contain the intended features of different heights.

Prognostic Significance of CEA and CA 19–9 inc Colorectal Cancer in Kuwait

Preoperative CEA and CA 19–9 levels have been used in the past as prognostic indicators in colorectal cancer, but Dukes’ stage is still considered to be the most important prognostic factor. Recent survival estimates may have been influenced by the fact that in the last decade adjuvant chemotherapy and postoperative irradiation have been included in the routine management of advanced-stage disease. In a heterogeneous Kuwaiti population higher reference levels (95th percentile) of CEA and CA 19–9 have been found than those usually employed. In the present study 62 patients with Dukes’ stage B + C could be analyzed for two-year disease-free survival (DFS). Relapse was observed in 19 patients, 28 patients were disease free and 15 patients with censored observations were included. No significant difference in DFS was observed in Dukes’ B (69%) versus Dukes’ C (48%) patients (p=0.09). On the other hand, Dukes’ stage B+C patients with elevated preoperative levels of CEA or CA 19–9 had a significantly poorer DFS than patients with normal levels. For CEA levels below or above the cutoff the DFS was 74% versus 23% (p=0.003); for CA 19–9 levels below or above the cutoff the DFS was 71% versus 33% (p=0.004). In 54 patients with Dukes’ stage B+C for whom preoperative levels of both CEA and CA 19–9 were available multivariate analysis revealed a decreasing risk of relapse in the following order: CEA and/or CA 19–9 elevated (chi-square 7.09; p=0.008), CA 19–9 elevated (chi-square 6.27; p=0.01), CEA elevated (chi-square 5.47; p=0.02), and Dukes’ C (chi-square 2.08; p=0.15 n.s.). Hence, novel treatment protocols may have improved the disease-free survival, but the use of adjuvant chemotherapy and/or radiotherapy is of questionable benefit in patients who have elevated levels of CEA and/or CA 19–9 prior to treatment.

Abstract P6-15-10: Withdrawn

This abstract was withdrawn by the authors.