Comparison of laparoscopic cholecystectomy in children at paediatric centres and adult centres: a systematic review and meta-analysis

INTRODUCTION

Paediatric laparoscopic cholecystectomy (LC) is performed by both paediatric and adult surgeons. The aim of this review was to compare outcomes at paediatric centres (PCs) and adult centres (ACs).

METHODS

A literature search was conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, for papers published between January 2000 and December 2020. Statistical analysis was performed using Stata® version 16 (StataCorp, College Station, TX, US).

RESULTS

A total of 92 studies involving 74,852 paediatric LCs met the inclusion criteria. Over half (59%) of the LCs were performed at ACs. No significant differences were noted in the male-to-female ratio, mean age or mean body mass index between PCs and ACs. The main indications were cholelithiasis (34.1% vs 34.4% respectively, p=0.83) and biliary dyskinesia (17.0% vs 23.5% respectively, p<0.01). There was no significant difference in the median inpatient stay (2.52 vs 2.44 days respectively, p=0.89). Bile duct injury was a major complication (0.80% vs 0.37% respectively, p<0.01). Reoperation rates (2.37% vs 0.74% respectively, p<0.01) and conversion to open surgery (1.97% vs 4.74% respectively, p<0.01) were also significantly different. Meta-analysis showed no significant difference in overall complications (p=0.92).

CONCLUSIONS

The number of LCs performed, intraoperative cholangiography use and conversion rates were higher at ACs whereas bile duct injury and reoperation rates were higher at PCs. Despite a higher incidence of bile duct injury at PCs, the incidence at both PCs and ACs was <1%. In complex cases, a joint operation by both paediatric and adult surgeons might be a better approach to further improve outcomes. Overall, LC was found to be a safe operation with comparable outcomes at PCs and ACs.

Landscaping tuberculosis multimorbidity: findings from a cross-sectional study in India

BACKGROUND

Multimorbidity, the concurrent presence of two or more chronic conditions is an emerging public health challenge. Till date, most of the research have focused on the presence and interaction of selected co-morbidities in tuberculosis (TB). There exist a critical knowledge gap on the magnitude of multimorbidity among TB patients and its impact on health outcomes.

METHODS

We undertook a cross-sectional study to assess the prevalence and patterns of multimorbidity among newly diagnosed TB patients in two states of India. A total of 323 patients were interviewed using a structured multimorbidity assessment questionnaire for primary care (MAQ-PC). MAQ-PC is already validated for Indian population and elicits 22 chronic conditions. We defined TB multimorbidity as the co-existence of TB with one or more chronic conditions and identified commonly occurring dyads (TB + single condition) and triads (TB + two conditions).

RESULTS

More than half (52%) of TB patients reported multimorbidity. Among dyads, depression, diabetes mellitus (DM), acid peptic disease (APD), hypertension, chronic alcoholism, arthritis and chronic back ache (CBA) were the most common co-occurring conditions while 'DM + arthritis', 'depression + APD', 'depression + DM' were the most commonly occurring triads among TB patients. Factors such as increasing age, low levels of education, alcohol abusers, drug-resistant TB and having health insurance were significantly associated with multimorbidity among TB patients.

CONCLUSIONS

Our findings suggest high prevalence of multimorbidity among newly diagnosed TB patients in India. The presence of concordant and discordant conditions with TB may increase the health complexity, thus necessitating appropriate care protocols. Given, the current situation, wherein TB and non-communicable diseases (NCD) services are delivered through collaborative framework between programmes, there is a need for addressing multimorbidity at the healthcare delivery level.

Safety and antidiabetic activity of Lagenaria siceraria (Molina) Standl. juice in streptozotocin -induced diabetic rats

ETHNOPHARMACOLOGICAL RELEVANCE

Diabetes and its complications have overwhelmed India's healthcare system. Current therapies are expensive and have adverse side effects, thus dietary changes and alternative treatments are needed. Lagenaria siceraria (Molina) Standl. Juice is used mainly for its nutritional and medicinal values, however toxicity of the juice and antidiabetic effects have been poorly characterized.

AIM OF THE STUDY

To investigate the toxicity, anti-diabetic and anti-inflammatory efficacy of Lagenaria siceraria (Molina) Standl. (LS) juice.

MATERIALS AND METHODS

In vitro antidiabetic (α-glucosidase, α-amylase and DPP-4 inhibitory) activities were screened using standard procedures. The glucose uptake test was carried out by using L6 rat skeletal muscle cell line. In vivo sub-acute toxicity of LS juice was assessed on Wistar rats. Wistar rats were induced with diabetes by a single intraperitoneal (I.P) injection of freshly prepared streptozotocin (55 mg/kg body weight). The animals were randomly divided into 6 groups: normal control, untreated diabetic control, diabetic rats. Different dose of 200 mg/kg, 400 mg/kg and 600 mg/kg body weight of LS juice were administered, one group of diabetic rats were administered with 2 IU/mL insulin. The rats were sacrificed on the 31st day of the experiment and various in vivo biochemical parameters were evaluated in the serum and tissue homogenates of diabetic rats.

RESULTS

Significant dose-dependent inhibition of α-amylase (22.6%), α-glucosidase (50.13%), and DPP-4 (61.50%) activity was observed by LS juice. LS juice (10 μg/mL) increased insulin-mediated 2NBDG (2-(N-(7-Nitrobenz-2-oxa-1,3-diazol-4-yl) Amino)-2-Deoxyglucose) absorption in L6 cells. Animals treated with LS juice showed no toxicity or unfavorable pharmacological effects. Lagenaria siceraria (Molina) Standl. Juice improved glucose tolerance in diabetic rats with reduced fasting blood glucose. Lipopolysaccharide induced NF-κB, TNF-α and IL-1β production was also decreased in rats fed with LS juice.

CONCLUSION

Lagenaria siceraria (Molina) Standl. Juice has demonstrated promising anti-inflammatory properties as well as the capacity to inhibit the digestion enzymes glucosidase and amylase. Our findings thus open new avenues for further research into the antidiabetic potential of LS juice.

Review of management practices of sinogenic intracranial abscesses in children

OBJECTIVE

This study aimed to evaluate the management practices and outcomes in children with sinogenic intracranial suppuration.

METHOD

This was a retrospective cohort study in a single paediatric tertiary unit that included patients younger than 18 years with radiologically confirmed intracranial abscess, including subdural empyema and epidural or intraparenchymal abscess secondary to sinusitis. Main outcomes studied were rate of return to the operating theatre, length of hospital stay, death in less than 90 days and neurological disability at 6 months.

RESULTS

A cohort of 39 consecutive patients presenting between 2000 and 2020 were eligible for inclusion. Subdural empyema was the most common intracranial complication followed by extradural abscess and intraparenchymal abscess. Mean length of hospital stay was 42 days. Sixteen patients were managed with combined ENT and neurosurgical interventions, 15 patients underwent ENT procedures alone and 4 patients had only neurosurgical drainage. Four patients initially underwent non-operative management. The rates of return to the operating theatre, neurological deficits and 90-day mortality were 19, 9 and 3, respectively, and were comparable across the 4 treatment arms. In the univariate logistic regression, only the size of an intracranial abscess was found be associated with an increased likelihood of return to the operating theatre, whereas combined ENT and neurosurgical intervention did not result in improved outcomes.

CONCLUSION

Sinogenic intracranial abscesses are associated with significant morbidity and mortality. The size of an intracranial abscess has a strong association with a need for a revision surgery.

Household drug-resistant TB contact tracing in Tajikistan

BACKGROUND: Tajikistan has a high burden of rifampicin-resistant TB (RR-TB), with 2,700 new cases estimated for 2021 (28/100,000 population). TB is spread among household members through close interaction and children exposed through household contact progress to disease rapidly and frequently.METHODS: We retrospectively analysed programmatic data from household contact tracing in Dushanbe over 50 months. We calculated person-years of follow-up, contact tracing yield, number needed to screen (NNS) and number needed to test (NNT) to find one new case, and time to diagnosis.RESULTS: We screened 6,654 household contacts of 830 RR-TB index cases; 47 new RR-TB cases were detected, 43 in Year 1 and 4 in Years 2 or 3. Ten were aged <5 years; 46/47 had TB symptoms, 34/45 had chest radiographs consistent with TB, 11/35 were Xpert Ultra-positive, 29/32 were tuberculin skin test-positive and 28/47 had positive TB culture and phenotypic drug susceptibility results. The NNS to find one RR-TB case was 141.57 and the NNT was 34.49. The yields for different types of contacts were as follows: 0.7% for screened contacts, 2.9% for tested contacts, 17.0% for symptomatic contacts and 12.1% for symptomatic contacts aged below 5 years.CONCLUSION: RR-TB household contact tracing was feasible and productive in Tajikistan, a low middle-income country with an inefficient healthcare delivery system.

Molecular surveillance detects high prevalence of the neglected parasite Mansonella ozzardi in the Colombian Amazon

Mansonellosis is an undermapped insect-transmitted disease caused by filarial nematodes that are estimated to infect hundreds of millions of people globally. Despite their prevalence, there are many outstanding questions regarding the general biology and health impacts of the responsible parasites. Historical reports suggest that the Colombian Amazon is endemic for mansonellosis and may serve as an ideal location to pursue these questions in the backdrop of other endemic and emerging pathogens. We deployed molecular and classical diagnostic approaches to survey Mansonella prevalence among adults belonging to indigenous communities along the Amazon River and its tributaries near Leticia, Colombia. Deployment of a loop-mediated isothermal amplification (LAMP) assay on blood samples revealed an infection prevalence of ∼40% for Mansonella ozzardi . This assay identified significantly more infections than blood smear microscopy or LAMP assays performed using plasma, likely reflecting greater sensitivity and the ability to detect low microfilaremias or occult infections. Mansonella infection rates increased with age and were higher among males compared to females. Genomic analysis confirmed the presence of M. ozzardi that clusters closely with strains sequenced in neighboring countries. We successfully cryopreserved and revitalized M. ozzardi microfilariae, advancing the prospects of rearing infective larvae in controlled settings. These data suggest an underestimation of true mansonellosis prevalence, and we expect that these methods will help facilitate the study of mansonellosis in endemic and laboratory settings.

Environmental Exposure: Effect on Maternal Morbidity and Mortality and Neonatal Health

Environmental factors are important causes that impair global pregnancy outcomes and are, importantly, responsible for maternal morbidity and mortality. However, apart from the direct reasons for maternal deaths, mainly obstetric and neonatal complications, such factors are ignored or given less importance. The recent surge in research on the impact of various environmental factors on pregnancy outcomes suggests the need for immediate attention to such factors and device-specific policies to counter the situation. Moreover, the recent coronavirus disease of 2019 (COVID-19) pandemic, global warming, and climate change showed a lack of preparedness to counter the impact of such events on maternal survival and safe and successful pregnancy outcomes. In the present review, we have emphasized the specific factors responsible for increased maternal and neonatal deaths and their association with specific environmental factors. Increased attention on maternal healthcare, preparedness to counter sudden environmental challenges and improvement of the conventional requirement for better maternal healthcare access and nutrition at a global level may improve the scenario.

Primary bedaquiline resistance in Karakalpakstan, Uzbekistan

BACKGROUND: Bedaquiline (BDQ) is widely used in the treatment of rifampicin-resistant TB (RR-TB). However, resistance to BDQ is now emerging. There are no standardised regimens for BDQ-resistant TB. This study aims to share experience in managing primary BDQ-resistant TB.METHODS: We performed a retrospective study of patients treated for RR-TB in Karakalpakstan, Uzbekistan, from January 2017 to March 2022. We identified patients with resistance to BDQ with no history of BDQ exposure. We describe baseline characteristics, treatment and follow-up of these patients.RESULTS: Twelve of the 1,930 patients (0.6%) had baseline samples resistant to BDQ with no history of BDQ exposure, 75% (9/12) of whom had been previously treated for TB. Ten (83.3%) were resistant to fluoroquinolones; respectively 66% and 50% had culture conversion by Month 3 and Month 6. The interim treatment outcomes were as follows: unfavourable treatment outcomes (3/12, 25%), favourable outcomes (2/12, 17%); the remaining seven (58%) were continuing treatment.CONCLUSIONS: A large proportion of the cases had previously been treated for TB and had TB resistant to quinolone. Both patients who had not experienced culture conversion by Month 3 had an unfavourable treatment outcome. Therefore, we recommend monthly monitoring of culture status for patients on treatment regimens for BDQ resistance.

Impact of COVID-19 Vaccination on Women During Pregnancy and Breastfeeding

Rapid development of anti-SARS-CoV-2 vaccinations in the late 2020s has significantly altered the trajectory in which the virus affects various patient demographics, especially the most susceptible ones. In light of ethical and conceptual safety considerations, pregnant women were initially barred from participating in clinical studies for the coronavirus disease 2019 (COVID-19) vaccination programs. However, the steady accumulation of reliable observational data from cohorts of pregnant women who received vaccinations enabled the research establishments to quickly address a number of open questions. Still, more than a year after vaccines were widely available, the safety concerns of expectant or nursing mothers are cited as the primary justification for refusing COVID-19 vaccination, and notably, the rate of vaccination in the said populations is known to be consistently lower than those of the general populace. In light of such a scenario, we have made an attempt to garner relevant studies that evaluated the effect of COVID-19 vaccination on pregnant and lactating mothers which may prove to be supporting evidence for its wide usage among the said population.

A small molecule potent IRAK4 inhibitor abrogates lipopolysaccharide-induced macrophage inflammation in-vitro and in-vivo

Increasing evidence supports vanillin and its analogs as potent toll-like receptor signaling inhibitors that strongly attenuate inflammation, though, the underlying molecular mechanism remains elusive. Here, we report that vanillin inhibits lipopolysaccharide (LPS)-induced toll-like receptor 4 activation in macrophages by targeting the myeloid differentiation primary-response gene 88 (MyD88)-dependent pathway through direct interaction and suppression of interleukin-1 receptor-associated kinase 4 (IRAK4) activity. Moreover, incubation of vanillin in cells expressing constitutively active forms of different toll-like receptor 4 signaling molecules revealed that vanillin could only able to block the ligand-independent constitutively activated IRAK4/1 or its upstream molecules-associated NF-κB activation and NF-κB transactivation along with the expression of various proinflammatory cytokines. A significant inhibition of LPS-induced IRAK4/MyD88, IRAK4/IRAK1, and IRAK1/TRAF6 association was evinced in response to vanillin treatment. Furthermore, mutations at Tyr262 and Asp329 residues in IRAK4 or modifications of 3-OMe and 4-OH side groups in vanillin, significantly reduced IRAK4 activity and vanillin function, respectively. Mice pretreated with vanillin followed by LPS challenge markedly impaired LPS-induced IRAK4 activation and inflammation in peritoneal macrophages. Thus, the present study posits vanillin as a novel and potent IRAK4 inhibitor and thus providing an opportunity for its therapeutic application in managing various inflammatory diseases.

miR-210-3p Promotes Obesity-Induced Adipose Tissue Inflammation and Insulin Resistance by Targeting SOCS1-Mediated NF-κB Pathway

Under the condition of chronic obesity, an increased level of free fatty acids along with low oxygen tension in the adipose tissue creates a pathophysiological adipose tissue microenvironment (ATenv), leading to the impairment of adipocyte function and insulin resistance. Here, we found the synergistic effect of hypoxia and lipid (H + L) surge in fostering adipose tissue macrophage (ATM) inflammation and polarization. ATenv significantly increased miR-210-3p expression in ATMs which promotes NF-κB activation-dependent proinflammatory cytokine expression along with the downregulation of anti-inflammatory cytokine expression. Interestingly, delivery of miR-210-3p mimic significantly increased macrophage inflammation in the absence of H + L co-stimulation, while miR-210-3p inhibitor notably compromised H + L-induced macrophage inflammation through increased production of suppressor of cytokine signaling 1 (SOCS1), a negative regulator of the NF-κB inflammatory signaling pathway. Mechanistically, miR-210 directly binds to the 3'-UTR of SOCS1 mRNA and silences its expression, thus preventing proteasomal degradation of NF-κB p65. Direct delivery of anti-miR-210-3p LNA in the ATenv markedly rescued mice from obesity-induced adipose tissue inflammation and insulin resistance. Thus, miR-210-3p inhibition in ATMs could serve as a novel therapeutic strategy for managing obesity-induced type 2 diabetes.

Leishmania LPG interacts with LRR5/LRR6 of macrophage TLR4 for parasite invasion and impairs the macrophage functions

Visceral leishmaniasis (VL) is a severe form of leishmaniasis, primarily affecting the poor in developing countries. Although several studies have highlighted the importance of toll-like receptors (TLRs) in the pathophysiology of leishmaniasis, the role of specific TLRs and their binding partners involved in Leishmania donovani uptake are still elusive. To investigate the mechanism of L. donovani entry inside the macrophages, we found that the parasite lipophosphoglycan (LPG) interacted with the macrophage TLR4, leading to parasite uptake without any significant alteration of macrophage cell viability. Increased parasite numbers within macrophages markedly inhibited lipopolysachharide-induced pro-inflammatory cytokines gene expression. Silencing of macrophage-TLR4, or inhibition of parasite-LPG, significantly stemmed parasite infection in macrophages. Interestingly, we observed a significant enhancement of macrophage migration, and generation of reactive oxygen species (ROS) in the parasite-infected TLR4-silenced macrophages, whereas parasite infection in TLR4-overexpressed macrophages exhibited a notable reduction of macrophage migration and ROS generation. Moreover, mutations in the leucine-rich repeats (LRRs), particularly LRR5 and LRR6, significantly prevented TLR4 interaction with LPG, thus inhibiting cellular parasite entry. All these results suggest that parasite LPG recognition by the LRR5 and LRR6 of macrophage-TLR4 facilitated parasite entry, and impaired macrophage functions. Therefore, targeting LRR5/LRR6 interactions with LPG could provide a novel option to prevent VL.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Chemical and mechanical interfacial degradation in bifacial glass/glass and glass/transparent backsheet photovoltaic modules

Glass/glass (G/G) photovoltaic modules are quickly rising in popularity, but the durability of modern G/G packaging has not yet been established. In this work, we examine the interfacial degradation modes in G/G and glass/transparent backsheet modules under damp heat (DH) with and without system bias voltage, comparing emerging polyolefin elastomer (POE) and industry-standard poly(ethylene-co-vinyl acetate) (EVA) encapsulants. We investigate the transport of ionic species at cell/encapsulant interfaces, demonstrating that POE limits both sodium and silver ion migration compared with EVA. Changes to the chemical structures of the encapsulants at the cell/encapsulant interfaces demonstrate that both POE and EVA are more susceptible to degradation in modules with a transparent backsheet than in the G/G configuration. Adhesion testing reveals that POE and EVA have comparable critical debond energies after the DH exposures regardless of system bias polarity. The results of this study indicate that the interfacial degradation mechanisms of G/G appear to be similar to those of conventional glass/backsheet modules. For emerging materials, our results demonstrate that POE offers advantages over EVA but that transparent backsheets may accelerate encapsulant degradation due to increased moisture ingress when compared with the G/G structure.

A study of degradation mechanisms in PVDF-based photovoltaic backsheets

Commercial backsheets based on polyvinylidene fluoride (PVDF) can experience premature field failures in the form of outer layer cracking. This work seeks to provide a better understanding of the changes in material properties that lead to crack formation and find appropriate accelerated tests to replicate them. The PVDF-based backsheet outer layer can have a different structure and composition, and is often blended with a poly(methyl methacrylate) (PMMA) polymer. We observed depletion of PMMA upon aging with sequential (MAST) and combined (C-AST) accelerated stress testing. In field-aged samples from Arizona and India, where PVDF crystallizes in its predominant α-phase, the degree of crystallinity greatly increased. MAST and C-AST protocols were, to some extent, able to replicate the increase in crystallinity seen in PVDF after ~ 7 years in the field, but no single-stress test condition (UV, damp heat, thermal cycling) resulted in significant changes in the material properties. The MAST regimen used here was too extreme to produce realistic degradation, but the test was useful in discovering weaknesses of the particular PVDF-based outer layer structure studied. No excessive β-phase formation was observed after aging with any test condition; however, the presence of β-phase was identified locally by Fourier transform infrared spectroscopy (FTIR). We conclude that both MAST and C-AST are relevant tests for screening outdoor failure mechanisms in PVDF backsheets, as they were successful in producing material degradation that led to cracking.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Acquired bedaquiline resistance in Karakalpakstan, Uzbekistan

BACKGROUND: The WHO recommends the use of bedaquiline (BDQ) in longer, as well as shorter, multidrug-resistant TB (MDR-TB) treatment regimens. However, resistance to this new drug is now emerging. We aimed to describe the characteristics of patients in Karakalpakstan, Uzbekistan, who were treated for MDR-TB and acquired BDQ resistance during treatment.METHODS: We performed a retrospective study of routinely collected data for patients treated for MDR-TB in Karakalpakstan between January 2015 and December 2020. We included patients on BDQ-containing regimens with baseline susceptibility to BDQ who developed BDQ resistance at any point after treatment initiation. Patients resistant to BDQ at baseline or with no confirmed susceptibility to BDQ at baseline were excluded.RESULTS: Of the 523 patients who received BDQ-containing regimens during the study period, BDQ resistance was detected in 31 patients (5.9%); 20 patients were excluded-16 with no prior confirmation of BDQ susceptibility and 4 who were resistant at baseline. Eleven patients with acquired BDQ resistance were identified. We discuss demographic variables, resistance profiles, treatment-related variables and risk factors for unfavourable outcomes for these patients.CONCLUSION: Our programmatic data demonstrated the acquisition of BDQ resistance during or subsequent to receiving a BDQ-containing regimen in a patient cohort from Uzbekistan. We highlight the need for individualised treatment regimens with optimised clinical and laboratory follow up to prevent resistance acquisition.

Lipid-induced monokine cyclophilin-A promotes adipose tissue dysfunction implementing insulin resistance and type 2 diabetes in zebrafish and mice models of obesity

Several studies have implicated obesity-induced macrophage-adipocyte cross-talk in adipose tissue dysfunction and insulin resistance. However, the molecular cues involved in the cross-talk of macrophage and adipocyte causing insulin resistance are currently unknown. Here, we found that a lipid-induced monokine cyclophilin-A (CyPA) significantly attenuates adipocyte functions and insulin sensitivity. Targeted inhibition of CyPA in diet-induced obese zebrafish notably reduced adipose tissue inflammation and restored adipocyte function resulting in improvement of insulin sensitivity. Silencing of macrophage CyPA or pharmacological inhibition of CyPA by TMN355 effectively restored adipocytes' functions and insulin sensitivity. Interestingly, CyPA incubation markedly increased adipocyte inflammation along with an impairment of adipogenesis, however, mutation of its cognate receptor CD147 at P309A and G310A significantly waived CyPA's effect on adipocyte inflammation and its differentiation. Mechanistically, CyPA-CD147 interaction activates NF-κB signaling which promotes adipocyte inflammation by upregulating various pro-inflammatory cytokines gene expression and attenuates adipocyte differentiation by inhibiting PPARγ and C/EBPβ expression via LZTS2-mediated downregulation of β-catenin. Moreover, inhibition of CyPA or its receptor CD147 notably restored palmitate or CyPA-induced adipose tissue dysfunctions and insulin sensitivity. All these results indicate that obesity-induced macrophage-adipocyte cross-talk involving CyPA-CD147 could be a novel target for the management of insulin resistance and type 2 diabetes.

Impact of Meconium-Stained Amniotic Fluid on Neonatal Outcome in a Tertiary Hospital

Objective

The aim of this study was to determine the perinatal outcome of pregnant patients complicated with meconium-stained amniotic fluid (MSAF) compared with clear amniotic fluid.

Methodology

This prospective cross-sectional study was conducted in the Department of Obstetrics and Gynecology in collaboration with the Department of Pediatrics at Indira Gandhi Institute of Medical Sciences, Patna, India, from September 2016 to January 2018. A total of 200 patients were included in the study after taking their written consent. Out of these 200 patients, 100 patients had MSAF, and the other 100 patients with clear liquor were taken as controls after fulfilling the inclusion and exclusion criteria. These two groups of patients were compared regarding various maternal and neonatal parameters. These parameters were compared and tested statistically for significance.

Results

Among the 100 patients with MSAF, 20 patients had grade 1 meconium (X), 22 patients had grade 2 meconium (Y), and 58 patients had grade 3 meconium (Z). The majority of patients in the MSAF group were primigravida and more than 25 years of age. In addition, 47% of patients in the MSAF group had some associated high-risk factors and 50% of patients had non-reassuring fetal heart rate patterns, and among these, 39 patients had grade 3 MSAF (X). In the MSAF group, 49% of patients had undergone lower segment cesarean section (LSCS), whereas in the non-MSAF group, it was 37%. Also, 30% of babies in the MSAF group and 13% in the non-MSAF group had neonatal intensive care unit (NICU) admission; 22% of babies in the MSAF group and 12% of babies in the non-MSAF group had an adverse neonatal outcome. Meconium aspiration syndrome was present in 14% of the patients in the MSAF group, and among these, two babies had neonatal death and both had severe birth asphyxia. In the non-MSAF group, there was one neonatal death due to neonatal sepsis. However, after statistically analyzing the neonatal outcome in both the groups, there was no statistical difference between the two groups (p<0.001).

Conclusion

MSAF is associated with increased frequency of operative delivery, poor neonatal outcomes, and increased NICU admission. Management of labor with MSAF requires appropriate intrapartum care with continuous fetal heart rate monitoring, and this can reduce unnecessary cesarean sections in patients with MSAF.

Time-resolved hadronic particle acceleration in the recurrent nova RS Ophiuchi

Recurrent novae are repeating thermonuclear explosions in the outer layers of white dwarfs, due to the accretion of fresh material from a binary companion. The shock generated when ejected material slams into the companion star's wind can accelerate particles. We report very-high-energy (VHE, [Formula: see text]) gamma rays from the recurrent nova RS Ophiuchi, up to a month after its 2021 outburst, observed using the High Energy Stereoscopic System. The VHE emission has a similar temporal profile to lower-energy GeV emission, indicating a common origin, with a two-day delay in peak flux. These observations constrain models of time-dependent particle energization, favoring a hadronic emission scenario over the leptonic alternative. Shocks in dense winds provide favorable environments for efficient acceleration of cosmic-rays to very high energies.

Introducing Clinical Pathology Course to Fourth Year Medical Students as a Bridge between Pre-clinical and Clinical Medical Sciences

There isn't any vertical integration of pre-clinical and clinical sciences subjects in the existing Kathmandu University MBBS curriculum. Many of the graduates are not able to correlate the clinico-pathological aspects of various diseases as a result the rational use of investigations for diagnosing various diseases is compromised. There are few published examples of implementation of pathology instruction courses during the clinical years of medical training but it is not universally practiced. This lack of exposure to pathology may lead to poor understanding of laboratory testing and the role of pathologists in patient care. To set and implement an exemplary vertical integration of pre-clinical science with clinical science. A 12 credit hours clinical pathology education course comprising clinical hematology, cytopathology and histopathology was developed. Students belonging from the ongoing fourth year MBBS course of Birat Medical College were enrolled in the course. All of the interactive lecture sessions were delivered via an e-learning interface, using the Zoom platform as the main teaching methods. Evaluation of students' achievement of learning objectives was conducted through distributing pre and post-test online multiple-choice questionnaires. Chi-square tests were used to compare the variables between pre-test and post-test questionnaire responses. Results suggested that the designed clinical pathology course is valuable. The pretest and post-test questionnaire responses revealed the positive impact regarding the importance of introducing clinical pathology courses within the clinical year of MBBS undergraduate curriculum. Response rate to the online session was 100%. The point of agreement between the pre-test and post-test questionnaire responses were highly achieved after intervention of the clinical pathology course. A statistically significant result (p < 0.05) between all of the pre-test and post-test questionnaire responses was noted. There was a strong positive recommendation for incorporating clinical laboratory medicine courses within the MBBS clinical science curriculum. The improvement observed among fourth-year MBBS students on learning the importance of clinical pathology courses was encouraging. This experience thus contributed to set and implement an exemplary vertical integration of pre-clinical science with clinical science.

Exploring the association of fibrinogen and CRP with the clinical spectrum of CAD and periprocedural outcomes in patients undergoing percutaneous coronary interventions

Background:

The pathophysiology of an atherosclerotic plaque is mediated by the mechanisms involving thrombus formation and systemic inflammation. While C-reactive protein (CRP) levels are useful in predicting a cardiovascular event in intermediate risk population, the usefulness of routinely measuring fibrinogen in patients with acute coronary syndrome (ACS) is debatable. Also, data on the association of these markers with periprocedural outcomes in patients undergoing percutaneous coronary interventions (PCI) is scarce.

Aims:

The study aimed to determine whether the levels of fibrinogen and CRP vary across the different spectra of CAD and whether they have any correlation with cardiac Troponin I levels.

Materials and Methods:

A total of 284 patients with coronary artery disease undergoing percutaneous coronary intervention were included in the study. Complete blood count, serum lipid profile, serum CRP, fibrinogen, and troponin I were measured for all patients.

Results:

Patients with STEMI had significantly higher levels of CRP as compared to those with unstable angina (USA) and chronic stable angina (CSA). Patients presenting with ACS had significantly higher baseline fibrinogen as compared to those with CSA. A significant positive correlation between CRP and admission Troponin I (r = 0.50; P < 0.05) as well as fibrinogen and admission troponin I (r = 0.30; P < 0.05) was observed. The CRP levels were significantly higher in 15 patients with periprocedural MI as compared to those who did not develop periprocedural MI.

Conclusions:

The levels of the markers of inflammation and atherothrombosis vary with presentation across varied spectra of CAD with generally higher levels in acute presentation and in those who develop periprocedural MI.

To study the association between various levels of cord serum albumin (CSA) and significant neonatal hyperbilirubinemia requiring interventions like phototherapy or exchange transfusion

Introduction:

Hyperbilirubinemia is most common normal physiological phenomenon in neonates affecting almost one third of newborn.it may lead to neuro disability leading to deafness and cerebral palsy which can be prevented if detected and treated as soon as possible. Albumin is produced in seventh week of intrauterine life and it can be measured by cord blood and in this study we can establish serum albumin with neonatal hyperbilirubinemia and can be treated by phototherapy or exchange transfusion.

Material and Method:

The study consists of 55 randomly selected eligible term neonates delivered at Rajendra Institute of Medical sciences from March 2019 to August 2020.

Conclusion:

In this study, in term neonates, level of serum albumin in umbilical cord less than 2.8 g/dl has no correlation with occurrence significant hyperbilirubinemia, so a level <2.8 gm/dl of serum albumin in umbilical cord blood can be used as critical value indicator in triaging predict the risk of occurring of significant hyperbilirubinemia in term neonates.level >3.4 gm/dl is considered safe in neonates who are the candidates for early discharge in the absence of other risk factors.

ADRENAL HISTOPLASMOSIS: AN EASTERN INDIAN PERSPECTIVE

CONTEXT

The clinical presentation of histoplasmosis is varied. Due to its propensity for adrenal involvement, histoplasmosis is an important differential diagnosis in any patient presenting with adrenal mass, bilateral in particular.

OBJECTIVE

Data on clinical presentation, pattern of adrenal involvement, radiological appearance and long-term follow-up of adrenal histoplasmosis are relatively sparse; hence we looked at it.

DESIGN

This record based single-centre retrospective study was conducted in one of the tertiary care hospitals, situated in eastern India catering the Gangetic delta.

SUBJECTS AND METHODS

Data on demographic characters, presenting manifestations, biochemical & hormonal parameters and radiological appearance of confirmed adrenal histoplasmosis cases (n=9), admitted between 2015-2019 have been retrieved. The treatment outcome and condition of patients after 1-4 years of follow-up has also been discussed.

RESULTS

Four out of the nine (44.4%) patients had predisposing immunocompromised conditions in the form of diabetes and/or chronic alcoholism while rest were immunocompetent. Seven out of nine patients (77.8 %) had signs and symptoms suggestive of adrenal insufficiency, while two (22.2%) presented with only pyrexia of unknown origin. All of them had bilateral adrenal mass, though the radiologically appearances were different. All patients received anti-fungal agents with/without hydrocortisone and/or fludrocortisone. One patient died (11.1%), while majority responded favourably to treatment. Adrenocortical function did not recover completely.

CONCLUSIONS

The possibility of adrenal histoplasmosis should always be considered in patients presenting with bilateral adrenal mass, irrespective of adrenal morphology. Treatment is effective, but many of them require supplemental hydrocortisone for quite a long period, if not lifelong. Mineralocorticoid deficiency, however, is not permanent.

Colposcopic evaluation of cervix in symptomatic women and its correlation with Pap smear. A prospective study at a tertiary care centre

Introduction

Back in India, cervical cancer is the second most frequent cancer in women (aged 15-45 years) following breast cancer, accounting for nearly 14% of all female cancer cases. The aim of this study is to yell the findings of pap smear with colposcopy and directed biopsy (if needed) and to evaluate the usefulness of colposcopy in discovering the premalignant and malignant lesions of the cervix.

Methods

This is a prospective observational analysis of 150 symptomatic women attending the gynecology OPD of Indira Gandhi Institute of Medical Sciences, Patna, for a period of one year from 2019 to 2020. Assessment of symptomatic women was completed with a pap smear, colposcopy, and biopsy in selected instances.

Statistical Analysis Used

MS Excel spreadsheet application, SPSS v23 (IBM Corp.), was used for data analysis.

Results

The expression age (years) has been 34.68 ± 8.05. The sensitivity and specificity of pap smear were 91.7% and 45.45%, respectively, whereas the sensitivity and specificity of colposcopy were 83.3% and 72.72%, respectively, in the present study.

Conclusions

Pap smear had low specificity as compared to colposcopy. Hence simultaneous use of colposcopy has shown to rise in the rate of carcinoma cervix discovery in symptomatic women.

Buccal Fat Pad Injury-Delayed Presentation

COVID-19 pandemic has been a major challenge for health care services all around the world. With increasing COVID-19 cases and lockdown enforcement, there has been a significant delay in the presentation of patients in the emergency department; also the fear in people of contracting COVID-19 from the hospital is an additional factor. The following case report describes such an incidence of delay in presentation of buccal fat pad injury patient to the emergency department.

198 Immediate Post-Operative PDE5i Therapy Improves Early Erectile Function Outcomes after Robot-Assisted Radical Prostatectomy (RARP)

Aim

To assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function, continence, or safety outcomes.

Method

Data was prospectively collected from a single surgeon in one tertiary centre and retrospectively evaluated. 158 patients were treated with PDE5i therapy post RARP over a two-year period.

Results

There were no significant differences in pre-operative characteristics between the therapy groups. Patients that had bilateral nerve sparing had a mean drop in Erectile Function (EF) score by 5.4 compared to 8.8 in the unilateral group. Additionally, 34.9% of bilateral nerve sparing patients returned to baseline compared to 12.1% of unilateral. Drop in EF scores and percentage return to baseline for unilateral nerve sparing was respectively 9 and 11.1% of immediate (day 1-2), 7 and 14.8% of early (day 3-14) and 9.7 and 9.5% of late (day &gt;14) therapy (p = 0.9 and p = 0.6). For bilateral nerve sparing this was respectively 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p = 0.017 and p = 0.045). Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication, or readmission outcomes.

Conclusions

Immediate PDE5i therapy should be considered in patients following nerve sparing RARP in order to maximise functional outcomes, especially in those undergoing bilateral nerve spare.

81 VIRTUAL: Virtual Interactive Surgical Skills Classroom – An Ongoing Randomized Controlled Trial

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention, and Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed.

Results

Data collection will be completed in January 2021. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusions

To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the virtual classroom’s suitability as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

Malaria, COVID-19 and angiotensin-converting enzyme 2: what does the available population data say?

The etiopathogenesis of COVID-19 and its differential geographic spread suggest some populations are apparently 'less affected' through many host-related factors that involve angiotensin-converting enzyme 2 (ACE2) protein, which is also the entry receptor for SARS-CoV-2. The role of ACE2 has been well studied in COVID-19 but not in the context of malaria and COVID-19. We have previously suggested how malaria might intersect with COVID-19 through ACE2 mutation and here we evaluate the currently available data that could provide a link between the two diseases. Based on the existing global and Indian data on malaria, COVID-19 and the suggested ACE2 mutation, the association could not be examined robustly, neither accepting nor refuting the suggested hypothesis. We strongly recommend targeted evaluation of this hypothesis through carefully designed robust molecular epidemiological studies.

O43 Virtual: virtual interactive surgical skills classroom: a randomized controlled trial (protocol)

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on surgical skills experience and confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention. Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts.

Result

Change in confidence, time to completion and a novel granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusion

This will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and beyond.

Take-home Message

This is the first RCT assessing virtual basic surgical skill classroom training and serves as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

Revealing x-ray and gamma ray temporal and spectral similarities in the GRB 190829A afterglow

Gamma-ray bursts (GRBs), which are bright flashes of gamma rays from extragalactic sources followed by fading afterglow emission, are associated with stellar core collapse events. We report the detection of very-high-energy (VHE) gamma rays from the afterglow of GRB 190829A, between 4 and 56 hours after the trigger, using the High Energy Stereoscopic System (H.E.S.S.). The low luminosity and redshift of GRB 190829A reduce both internal and external absorption, allowing determination of its intrinsic energy spectrum. Between energies of 0.18 and 3.3 tera-electron volts, this spectrum is described by a power law with photon index of 2.07 ± 0.09, similar to the x-ray spectrum. The x-ray and VHE gamma-ray light curves also show similar decay profiles. These similar characteristics in the x-ray and gamma-ray bands challenge GRB afterglow emission scenarios.

The significance of urgent ultrasound scan for shoulder dislocation in patients above the age of 40: A prospective British Elbow and Shoulder Society pathway implementation study

BACKGROUND

The highlight of the British Elbow and Shoulder Society pathway for the management of traumatic anterior shoulder instability is early imaging in patients aged over 40 years to assess rotator cuff integrity and early repair, if indicated to optimise function. The senior author set up a protocol in our institute to streamline the diagnostic process for this cohort of patients. This was a retrospective analysis from a prospectively collected database to highlight the importance of early specialist imaging.

METHODS

Our protocol is to perform urgent ultrasound scans for all suitable patients above 40 years after first-time traumatic shoulder dislocation. Demographics, associated injuries, ultrasound scan results, operations and functional outcomes were collated.

RESULTS

One year following the introduction of our protocol, 40 patients with a mean age of 67 (range, 42-89; SD = 13.1) had ultrasound. The incidence of full-thickness rotator cuff tears was 57.5% (n = 23). Eleven patients with confirmed full-thickness rotator cuff tears underwent surgery. The mean age of surgical patients was significantly younger than the non-surgical group (p = 0.004).

DISCUSSION

The use of early diagnostic imaging demonstrated a high incidence of full-thickness rotator cuff tears in this cohort of patients. This allowed early surgical repair to optimise function.

31 Immediate Post-Operative Phosphodiesterase-5 Inhibitors (PDE5i) Therapy Improves Early Erectile Function Outcomes After Robot Assisted Radical Prostatectomy (RARP)

Introduction

To assess whether the timing of post-RARP PDE5i therapy affects early erectile function, continence, or safety outcomes.

Method

Data from 158 patients treated with PDE5is post-RARP was prospectively collected over two years from a single surgeon at one tertiary centre and retrospectively evaluated. Therapy was started: immediately (day 1-2) in 29%, early (day 3-14) in 37% and late (after day 14) post-op in 34%. EPIC-26 Erectile Function (EF) scores were collected pre-op and post-op after a median 43-day follow-up interval.

Results

Drop in EF scores and percentage return to baseline post unilateral nerve sparing (UNS) compared to bilateral nerve sparing (BNS) RARP was respectively 9 and 11.1% versus 3.5 and 42.9% of immediate therapy, 7 and 14.8% versus 5.5 and 35.5% of early and 9.7 and 9.5% versus 7.3 and 25% of late. Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early and 26% and 54% for late.

Conclusions

Immediate post RARP PDE5i therapy may protect EF and should be considered clinically, with more benefits for BNS than UNS patients. Immediate or early, rather than late, PDE5i therapy improved early continence in BNS patients.

Statin reload before off-pump coronary artery bypass graft: Effect on biomarker release kinetics

Objectives

Statins confer protection from ischemia/reperfusion through various pathways including pleiotropic mechanisms. Following chronic administration, activation of intrinsic cellular mechanisms causes attenuation of these pleiotropic effects.

Methods

Since coronary artery bypass surgery (CABG) represents a reversible ischemia-reperfusion sequence, we assessed if statin reload is effective in patients undergoing off-pump CABG (n = 100) in limiting myocardial injury. Patients received loading dose of rosuvastatin (40 mg initiated 7 days before surgery) while nonloaded patients continued whatever statin dose they were receiving and served as controls. Cardiac biomarkers (Troponin-I, creatine kinase muscle/brain [CK-MB], and B-type natriuretic peptide [BNP]) were measured at 8, 24, and 48 h postoperatively. The primary end-point was the extent of perioperative myocardial injury (area under the curve [AUC]: AUC of each biomarker).

Results

Despite similar baseline levels, all biomarkers at 8, 24, and 48 h were significantly lower in the loaded group. The AUC for each biomarker was also significantly lower in the loaded group (cTnI 37.96 vs. 70.12 ng. hr/ml, CK-MB 229.64 vs. 347.04 ng. hr/ml, and BNP 5257.56 vs. 15606.68 pg. hr/ml, all P < 0.001). Delta cTnI (change from baseline to peak level) (1.00 ± 1.34 vs. 2.25 ± 2.59), delta CK-MB (4.54 ± 5.89 vs. 10.68 ± 9.95), and delta BNP (120.41 ± 172.48 vs. 449.23 ± 790.95) all P < 0.001 were also significantly lower in the loaded group. Those loaded with rosuvastatin had lower inotrope duration (22.9 ± 23.33 vs. 31.26 ± 25.39 h, P = 0.04) and ventilator support time (16.94 ± 6.78 vs. 23.8 ± 20.53 h, P = 0.03).

Conclusion

In patients undergoing off-pump CABG, statin reload can "recapture" cardioprotection in patients already on statins with favorable effect on release kinetics of biomarkers and postoperative outcomes.

Consensus statement from the international consensus meeting on post-traumatic cranioplasty

Background

Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach.

Methods

The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP.

Results

The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations.

Conclusions

This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.

Burnout and its correlates among nursing staff of intensive care units at a tertiary care center

Background:

Burnout syndrome has been widely reported in nursing staff. It is more pronounced in intensive care setting (up to 80%). This survey was designed to assess the prevalence of burnout and its correlates among critical care nurses.

Methods:

Anonymous questionnaire was distributed to all ICU nursing staff of a tertiary care teaching hospital. Questionnaire had 25 questions covering – demography, job characteristics, Visual Analogue Scale for stress, co-worker support, work–life balance, question for measuring burnout, job satisfaction, turnover intention, organizational commitment, for depression screening and psychosomatic symptoms. The burnout scale score was used to dichotomize into low burnout (<3) or high burnout (> = 3) group. These two groups were compared using Chi-square test, Fischer's exact test for categorical variables and independent t-test for continuous variables. Significant variables were entered in multivariate logistic regression analysis.

Results:

Out of 150 ICU nurses, 125 (83.3%) gave completely filled questionnaires which were evaluated. 47 (37.6%) participants reported experiencing high burnout. Binary logistic regression model revealed that lack of specialized ICU training (OR = 4.28, 95% CI: 1.62 to 11.34, P = 0.003), performing extra duty in last month (OR = 5.28, 95% CI: 1.90 to 14.67, P = 0.001), High physical symptoms in last 12 months (OR = 4.73, 95% CI: 1.56 to 14.36, P = 0.006) and mid-level experience (1–5 years) were significantly associated with burnout.

Conclusions:

Burnout is significantly prevalent (37.6%) among intensive care nurses. Specialized training and limiting work hours can help in mitigating this problem. High frequency of physical symptoms could be early indicators of burnout.

Towards validation of combined-accelerated stress testing through failure analysis of polyamide-based photovoltaic backsheets

Novel methods for advancing reliability testing of photovoltaic (PV) modules and materials have recently been developed. Combined-accelerated stress testing (C-AST) is one such method which has demonstrated reliable reproduction of some field-failures which were not reproducible by standard certification tests. To increase confidence and assist in the development of C-AST, and other new testing protocols, it is important to validate that the failure modes observed and mechanisms induced are representative of those observed in the field, and not the product of unrealistic stress conditions. Here we outline a method using appropriate materials characterization and modelling to validate the failure mechanisms induced in C-AST such that we can increase confidence in the test protocol. The method is demonstrated by applying it to a known cracking failure of a specific polyamide (PA)-based backsheet material. We found that the failure of the PA-based backsheet was a result of a combination of stress factors. Photo-oxidation from ultra-violet (UV) radiation exposure caused a reduction in fracture toughness, which ultimately lead to the cracking failure. We show that the chemical and structural changes observed in the backsheet following C-AST aging were also observed in field-aged samples. These results increase confidence that the conditions applied in C-AST are representative of the field and demonstrates our approach to validating the failure mechanisms induced.