Artificial Intelligence in Digital Histopathology for predicting patient prognosis and treatment efficacy in breast cancer

INTRODUCTION

Histological images contain phenotypic information predictive of patient outcomes. Due to the heavy workload of pathologists, the time-consuming nature of quantitatively assessing histological features, and human eye limitations to recognize spatial patterns, manually extracting prognostic information in routine pathological workflows remains challenging. Digital pathology has facilitated the mining and quantification of these features utilizing whole-slide image (WSI) scanners and artificial intelligence (AI) algorithms. AI algorithms to identify image-based biomarkers from the tumor microenvironment (TME) have the potential to revolutionize the field of oncology, reducing delays between diagnosis and prognosis determination, allowing for rapid stratification of patients and prescription of optimal treatment regimes, thereby improving patient outcomes.

AREAS COVERED

In this review, the authors discuss how AI algorithms and digital pathology can predict breast cancer patient prognosis and treatment outcomes using image-based biomarkers, along with the challenges of adopting this technology in clinical settings.

EXPERT OPINION

The integration of AI and digital pathology presents significant potential for analyzing the TME and its diagnostic, prognostic, and predictive value in breast cancer patients. Widespread clinical adoption of AI faces ethical, regulatory, and technical challenges, although prospective trials may offer reassurance and promote uptake, ultimately improving patient outcomes by reducing diagnosis-to-prognosis delivery delays.

Measuring the effectiveness of an integrated intervention package to improve the level of infection prevention and control: a multi-centre study in Bangladesh

BACKGROUND

Infection prevention and control (IPC) is a critical component of delivering safe, effective and high-quality healthcare services, and eliminating avoidable healthcare-associated infections (HAIs) in health facilities, predominantly in population-dense settings such as Bangladesh.

AIM

Our study aimed to assess the effect of an integrated intervention package in improving the IPC level of the health facilities in Bangladesh.

METHODS

We conducted a pre-post intervention study in six district hospitals (DHs) and 13 Upazila Health Complexes (UHCs) in the six districts of Bangladesh. Baseline and endline assessments were conducted between March and December 2021 using the adapted World Health Organization Infection Prevention and Control Assessment Framework (WHO-IPCAF) tool. The IPCAF score, ranging from 0-800, was calculated by adding the scores of eight components, and the IPC promotion and practice level was categorized as Inadequate (0-200), Basic (201-400), Intermediate (401-600) and Advanced (601-800). The integrated intervention package including IPC committee formation, healthcare provider training, logistics provision, necessary guidelines distribution, triage/flu corners establishment, and infrastructure development was implemented in all facilities.

RESULTS

The average IPCAF score across all the facilities showed a significant increase from 16% (95% CI: 11.5-20.65%) to 54% (95% CI: 51.4-57.1%). Overall, the IPCAF score increased by 34 percentage points (P<0.001) in DHs and 40 percentage points (P<0.001) in UHCs. Following the intervention, 12 (three DHs, nine UHCs) of 19 facilities progressed from inadequate to intermediate, and another three DHs upgraded from basic to intermediate in terms of IPC level.

CONCLUSION

The integrated intervention package improved IPCAF score in all facilities.

Image-based multiplex immune profiling of cancer tissues: translational implications. A report of the International Immuno-oncology Biomarker Working Group on Breast Cancer

Recent advances in the field of immuno-oncology have brought transformative changes in the management of cancer patients. The immune profile of tumours has been found to have key value in predicting disease prognosis and treatment response in various cancers. Multiplex immunohistochemistry and immunofluorescence have emerged as potent tools for the simultaneous detection of multiple protein biomarkers in a single tissue section, thereby expanding opportunities for molecular and immune profiling while preserving tissue samples. By establishing the phenotype of individual tumour cells when distributed within a mixed cell population, the identification of clinically relevant biomarkers with high-throughput multiplex immunophenotyping of tumour samples has great potential to guide appropriate treatment choices. Moreover, the emergence of novel multi-marker imaging approaches can now provide unprecedented insights into the tumour microenvironment, including the potential interplay between various cell types. However, there are significant challenges to widespread integration of these technologies in daily research and clinical practice. This review addresses the challenges and potential solutions within a structured framework of action from a regulatory and clinical trial perspective. New developments within the field of immunophenotyping using multiplexed tissue imaging platforms and associated digital pathology are also described, with a specific focus on translational implications across different subtypes of cancer. © 2024 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Perceptions of antibiotic stewardship programmes and determinants of antibiotic prescribing patterns among physicians in tertiary hospitals in Bangladesh: implications for future policy and practice

BACKGROUND

The concerning growth of antimicrobial resistance (AMR) renders common infections life-threatening due to irrational antibiotic use and a lack of effective antimicrobial stewardship programmes (ASPs).

AIM

To investigate the awareness, perceptions and practices of physicians regarding ASPs, AMR and antibiotic prescribing in tertiary care hospitals in Bangladesh.

METHODS

This hospital-based cross-sectional survey was conducted in 11 tertiary care hospitals across Bangladesh between September 2020 and January 2021. A semi-structured questionnaire was administered through face-to-face interviews for data collection. Descriptive and multi-variate analyses were performed using STATA Version 13.

RESULTS

In total, 559 physicians were enrolled in this survey. Overall, 40.6% [95% confidence interval (CI) 36.5-44.8] of physicians reported being aware of ASPs, and this figure was higher in public hospitals compared with private hospitals (43.8% vs 27.1%). None of the study hospitals had any ASP initiatives. More than half (55.1%) of the participants were willing to receive feedback from an ASP on their antibiotic selection. Only 30.9% of respondents stated that they wait for the findings of microbiological tests before prescribing antibiotics, although challenges included empiric use of broad-spectrum antibiotics, delayed laboratory results and the existence of drug-resistant patients. In contrast, physicians aware of ASPs were 33% (adjusted odds ratio 0.67, 95% CI 0.45-0.98; P=0.033) less likely to wait for laboratory results before prescribing antibiotics. However, 42.5% of physicians considered patient affordability of purchasing antibiotics when prescribing.

CONCLUSIONS

Physicians' fundamental knowledge of ASPs and rational antibiotic prescription were found to fall short of the standard. Context-specific and integrated ASP activities, availability and use of guidelines, and improved laboratory facilities are required to battle AMR in Bangladesh.

Analysis of Germin-like protein genes family in Vitis vinifera (VvGLPs) using various in silico approaches

Abstract Germin-like proteins (GLPs) play an important role against various stresses. Vitis vinifera L. genome contains 7 GLPs; many of them are functionally unexplored. However, the computational analysis may provide important new insight into their function. Currently, physicochemical properties, subcellular localization, domain architectures, 3D structures, N-glycosylation & phosphorylation sites, and phylogeney of the VvGLPs were investigated using the latest computational tools. Their functions were predicted using the Search tool for the retrieval of interacting genes/proteins (STRING) and Blast2Go servers. Most of the VvGLPs were extracellular (43%) in nature but also showed periplasmic (29%), plasma membrane (14%), and mitochondrial- or chloroplast-specific (14%) expression. The functional analysis predicted unique enzymatic activities for these proteins including terpene synthase, isoprenoid synthase, lipoxygenase, phosphate permease, receptor kinase, and hydrolases generally mediated by Mn+ cation. VvGLPs showed similarity in the overall structure, shape, and position of the cupin domain. Functionally, VvGLPs control and regulate the production of secondary metabolites to cope with various stresses. Phylogenetically VvGLP1, -3, -4, -5, and VvGLP7 showed greater similarity due to duplication while VvGLP2 and VvGLP6 revealed a distant relationship. Promoter analysis revealed the presence of diverse cis-regulatory elements among which CAAT box, MYB, MYC, unnamed-4 were common to all of them. The analysis will help to utilize VvGLPs and their promoters in future food programs by developing resistant cultivars against various biotic (Erysiphe necator and in Powdery Mildew etc.) and abiotic (Salt, drought, heat, dehydration, etc.) stresses.

Determinants of early sexual initiation among female adolescents in Bangladesh: evidence from a countrywide cross-sectional survey

OBJECTIVES

Early sexual initiation (ESI), defined as sexual activity that begins before 15 or 18 years of age, is one of the risky sexual behaviours that has been linked to increased likelihood of adverse consequences, such as sexually transmitted diseases, unintended pregnancies and unsafe abortions. However, to date, there are no studies investigating the prevalence and factors influencing ESI among adolescent females (aged 10-19 years) in Bangladesh. Thus, this study aimed to identify the potential determinants of ESI among adolescent females in Bangladesh based on data that are representative of the country.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Based on the availability of the data, the analysis included a weighted sample of 2051 adolescent females aged 15-19 years from the Bangladesh Demographic and Health Survey 2017/18. Initial selection of predictor variables was based on the bivariate analysis using the Chi-squared test. Univariate and multivariable logistic regression modelling were performed to measure the crude and adjusted effect of the selected predictor variables on ESI using the odds ratio (OR). The elasticity of the effects was calculated by their 95% confidence intervals (CIs).

RESULTS

Approximately 22% and 85% of female adolescents experienced ESI before the age of 15 and 18 years, respectively. Findings revealed that illiteracy (adjusted OR [AOR]: 3.61, 95% CI: 1.82-7.18), primary education (AOR: 2.08, 95% CI: 1.60-2.69), working status (AOR: 1.25, 95% CI: 0.98-1.60), living in Chittagong (AOR: 0.46, 95% CI: 0.27-0.79), living in Sylhet (AOR: 0.21, 95% CI: 0.08-0.56), reading newspapers (AOR: 0.63, 95% CI: 0.40-1.01), earlier marriage preference (AOR: 3.30, 95% CI: 2.31-4.71) and later marriage preference (AOR: 4.10, 95% CI: 3.01-5.59) were significantly linked with ESI before the age of 15 years. ESI before the age of 18 years was significantly association with primary education (AOR: 1.47, 95% CI: 1.01-2.13), religion (AOR: 0.55, 95% CI: 0.32-0.94), female household head (AOR: 1.93, 95% CI: 1.17-3.19), living in Rajshahi (AOR: 1.97, 95% CI: 0.95-4.08), being in the 'poorest' wealth category (AOR: 2.43, 95% CI: 1.45-4.07), being in the 'poorer' wealth category (AOR: 1.70, 95% CI: 1.06-2.72), being in the 'middle' wealth category (AOR: 1.76, 95% CI: 1.12-2.77), being in the 'richer' wealth category (AOR: 1.58, 95% CI: 1.02-2.44), earlier marriage preference (AOR: 15.71, 95% CI: 9.09-27.14), later marriage preference (AOR: 12.62, 95% CI: 8.82-18.06) and heard about family planning (AOR: 0.70, 95% CI: 0.47-1.04).

CONCLUSIONS

In Bangladesh, the prevalence of ESI among female adolescents is a public health concern. Due to the detrimental impact of ESI on the well-being of adolescents, it is crucial that policymakers consider the factors influencing ESI that have been identified in this study when designing health strategies. The findings from this study will help the development of evidence-based effective initiatives by policymakers in collaboration with governmental and non-governmental organisations.

Hand hygiene compliance and associated factors among healthcare workers in selected tertiary-care hospitals in Bangladesh

BACKGROUND

Hand hygiene (HH) is a fundamental element of patient safety. Adherence to HH among healthcare workers (HCWs) varies greatly depending on a range of factors, including risk perceptions, institutional culture, auditing mechanisms, and availability of HH supplies.

AIMS

This study aimed to evaluate HH compliance and associated factors among HCWs in selected tertiary-care hospitals in Bangladesh.

METHODS

During September 2020 to May 2021, we conducted non-participatory observations at 10 tertiary-care hospitals using the WHO's '5-moments for hand hygiene tool' to record HH compliance among physicians, nurses and cleaning staff. We also performed semi-structured interviews to determine the key barriers to complying with HH.

RESULTS

We observed 14,668 hand hygiene opportunities. The overall HH compliance was 25.3%, the highest among nurses (28.5%), and the lowest among cleaning staff (9.9%). HCWs in public hospitals had significantly higher odds of complying with HH practices than those in private hospitals (adjusted odds ratio: 1.73, 95% CI: 1.55-1.93). The odds of performing HH after touching a patient were 3.36 times higher compared with before touching a patient (95% CI: 2.90-3.90). The reported key barriers to performing HH were insufficient supplies (57.9%), skin reactions (26.3%), workload (26.3%) and lack of facilities (22.7%). Overall, observed HH supplies were available in 81.7% of wards for physicians and 95.1% of wards for nurses, however, no designated HH facilities were found for the cleaning staff.

CONCLUSIONS

HH compliance among HCWs fell significantly short of the standard for safe patient care. Inadequate HH supplies demonstrate a lack of prioritizing, promoting and investing in infection prevention and control.

Pitfalls in machine learning-based assessment of tumor-infiltrating lymphocytes in breast cancer: A report of the International Immuno-Oncology Biomarker Working Group on Breast Cancer

The clinical significance of the tumor-immune interaction in breast cancer is now established, and tumor-infiltrating lymphocytes (TILs) have emerged as predictive and prognostic biomarkers for patients with triple-negative (estrogen receptor, progesterone receptor, and HER2-negative) breast cancer and HER2-positive breast cancer. How computational assessments of TILs might complement manual TIL assessment in trial and daily practices is currently debated. Recent efforts to use machine learning (ML) to automatically evaluate TILs have shown promising results. We review state-of-the-art approaches and identify pitfalls and challenges of automated TIL evaluation by studying the root cause of ML discordances in comparison to manual TIL quantification. We categorize our findings into four main topics: (1) technical slide issues, (2) ML and image analysis aspects, (3) data challenges, and (4) validation issues. The main reason for discordant assessments is the inclusion of false-positive areas or cells identified by performance on certain tissue patterns or design choices in the computational implementation. To aid the adoption of ML for TIL assessment, we provide an in-depth discussion of ML and image analysis, including validation issues that need to be considered before reliable computational reporting of TILs can be incorporated into the trial and routine clinical management of patients with triple-negative breast cancer. © 2023 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Spatial analyses of immune cell infiltration in cancer: current methods and future directions: A report of the International Immuno-Oncology Biomarker Working Group on Breast Cancer

Modern histologic imaging platforms coupled with machine learning methods have provided new opportunities to map the spatial distribution of immune cells in the tumor microenvironment. However, there exists no standardized method for describing or analyzing spatial immune cell data, and most reported spatial analyses are rudimentary. In this review, we provide an overview of two approaches for reporting and analyzing spatial data (raster versus vector-based). We then provide a compendium of spatial immune cell metrics that have been reported in the literature, summarizing prognostic associations in the context of a variety of cancers. We conclude by discussing two well-described clinical biomarkers, the breast cancer stromal tumor infiltrating lymphocytes score and the colon cancer Immunoscore, and describe investigative opportunities to improve clinical utility of these spatial biomarkers. © 2023 The Pathological Society of Great Britain and Ireland.

Short-term Treatment Outcome of Patients with Acute ST-elevation Myocardial Infarction in a Tertiary Care Hospital

Outcome of acute ST-elevation myocardial infarction patients varies time to time. The present study was intended to find out the short-term treatment outcome of the patients admitted in hospital. This descriptive study was carried out in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from 15 January 2014 to 14 July 2014. A total of 100 patients admitted with Acute ST-elevation Myocardial Infarction confirmed on the presence of the (a) Typical chest pain of acute ST-elevation Myocardial Infarction (b) Electrocardiogram (ECG) evidence of ST segment elevation in two or more contiguous leads (c) Raised cardiac marker (Troponin I) were included in the study. Patients were randomly enrolled according to the inclusion and exclusion criteria and observe for one week. Data were processed and analyzed by using computer bases software SPSS version 19.0. Descriptive statistical methods were applied for data analysis. P value was considered as statistically significant when it is less than 0.05. Short-term treatment outcome of acute ST-elevation myocardial infarction include mechanical, arrhythmic, ischemic and inflammatory sequelae, as well as left ventricular mural thrombus. In addition to these broad categories, heart failure, arrhythmia, death are other common complications of AMI. The initiation of the complications usually results in explicit sign and symptoms of the acute MI patients. Learning of the complications in the post infarction period and the clinical syndromes develop with each complication, will allow the health care worker to evaluate and manage the complication appropriately.

DUODENAL LEIOMYOMA AS A RARE CAUSE OF GASTROINTESTINAL BLEEDING IN A NIGERIAN- CASE REPORT WITH PRESENTATION OF MINIMALLY INVASIVE THERAPEUTIC INTERVENTION

Findings from Nigerian pathological series have supported international reports about the rarity of the occurrence of duodenal leiomyomas. More recently, case reports from the country have detailed interventional radiological techniques being deployed successfully in the control of massive bleeding from the gastrointestinal system. The article seeks to document these rare elements coming together in a Lagos, Nigeria-based center in the case of bleeding duodenal leiomyoma in an elderly gentleman which was successfully controlled by selective transcatheter arterial embolization.

Exchange bias effect in polycrystalline Bi0.5Sr0.5Fe0.5Cr0.5O3 bulk

Bulk Bi_0.5Sr_0.5Fe_0.5Cr_0.5O₃ (BSFCO) is a new compound comprising the R3c structure. The structural, magnetic property and exchange bias (EB) details are investigated. The material was in the super-paramagnetic (SP) state at room temperature. Exchange bias usually occurs at the boundary between different magnetic states after field cooling (H_FC) acts on the sample. Here the result shows that changing H_FC from 1 to 6 T reduces the H_EB value by 16% at 2 K at the same time. Meanwhile, H_EB diminishes as the ferromagnetic layer thickness increases. The variation of (the thickness of ferromagnetic layer) t_FM with the change of H_FC leads to the tuning of H_EB by H_FC in BSFCO bulk. These effects are obviously different from the phenomenon seen in other oxide types.

Abstract 5787: Modelling the spatial heterogeneity of CD45-positive tumor infiltrating lymphocytes in early-stage, estrogen receptor-positive breast cancer

The frequency of lymphocytes infiltrating tumors is a known prognostic in estrogen receptor (ER) negative cancers. ER+ disease is putatively believed to be immune cold, however, there exists a subset of ER+ tumors with high immune infiltrate and with a significant spatial heterogeneity. The clinic impact of such infiltrate - especially between the Oncotype Dx Recurrence Score risk categories - remains unclear. Moreover, the distribution of tumor and stromal tissues, while noted as significantly heterogenous, is still ill-defined and not yet clinically used prognostically, despite evidence to support its utility. Using a cohort (n=450) of serial sections taken from early-stage, ER+/HER2- breast tumors of the Irish arm of the TAILORx clinical trial, we aimed to investigate the tumor architecture and spatial distribution of tumor immune infiltrate and proliferating tumor cells using digital image analysis. Antibodies against Ki67 (proliferation marker) and CD45 (leukocyte common antigen), and a routine Haematoxylin and Eosin stain were applied to serial sections of 450 full-face tumors via chromogenic immunohistochemistry, as outlined previously [1]. Digital image analysis was performed using open-source software, QuPath [2]. Pixel classifiers were trained and validated against an expert pathologist in order to define observed lymphocytes as tumor or stromal-infiltrating, and to establish a classifier to quantify the tumor-stroma ratio (TSR) and infiltrating tumor area. Distances of CD45-positive cells from tumor were computed, along with autocorrelation statistics [3,4] of CD45 and Ki67 hotspots; firstly in order to quantify spatial heterogeneity, and secondly to examine whether Ki67 as a component gene in the Oncotype Dx assay has a foundation in tumor biology or is being confounded by potentially Ki67-positive lymphocytes. Subdividing by Oncotype Dx risk categories, no significant difference in TSR was observed (p=0.09799), neither for intermediary risk patients receiving hormone therapy alone or in combination with chemotherapy (p=0.3873). While there was an observed trend overall (p=0.092), no significance was found for recurrence between intermediary risk subcategories (HT alone: p=0.393, HT+CT: p=0.288). However, in the cohort as a whole, median TSR was 0.3215 (range 0 - 5.023), with statistically significant differences in recurrence risk observed (cohort high v low by median TSR. HR: 6.356, 95CI: 2.263-17.84, p&lt;0.0001).

Citation Format: Zak Kinsella, Anna Blümel, Mairi Lucas, Andreas Lindner, Claudia A. Gonzalez, Arman Rahman, Joanna Fay, Tony O'Grady, Verena Murphy, John Crown, Cathy Kelly, William Gallagher, Darran O'Connor. Modelling the spatial heterogeneity of CD45-positive tumor infiltrating lymphocytes in early-stage, estrogen receptor-positive breast cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5787.

Effect of Duration of Hemostatic Compression on Radial Artery Occlusion after Transradial Percutaneous Coronary Intervention

Radial artery occlusion (RAO) is now a major concern in transradial approach (TRA). RAO limits future radial artery use for further TRA, for as a conduit during CABG, for invasive hemodynamic monitoring and for creation of arteriovenous fistula for hemodialysis in Chronic Kidney Disease (CKD) patients through same vascular approach. The effect of duration of hemostatic compression of RAO is unknown in Bangladesh. This prospective observational study was conducted in the department of Cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh (NICVD) from September 2018 to August 2019, to evaluate the effect of duration of hemostatic compression on the incidence of radial artery occlusion (RAO) after transradial percutaneous coronary intervention. A total of 140 patients underwent percutaneous coronary intervention (PCI) through TRA. RAO was defined as an absence of antegrade flow or monophasic flow or invert flow on Duplex study. In this study 70 patients (Group I) received 2 hours hemostatic compression after transradial PCI. Another 70 patients (Group II) received 6 hours hemostatic compression after transradial PCI. Radial arterial blood flow assessed at early (24 hours) and late (30 days) by color duplex study after the procedure in both groups. Early radial artery occlusion occurred in 4.3% of patients in Group I and 12.8% of patients in Group II, (p=0.04). Late radial artery occlusion occurred in 2.8% of patients in Group I and 11.4% of patients in Group II, the difference was statistically significant (p=0.04). From multivariate logistic regression analysis duration of hemostatic compression time 6 hours (p=0.01), post-procedural nitroglycerine use (p=0.03) and procedure time (p=0.03) were predictors of RAO. Shorter duration of hemostatic compression is associated with a lower incidence of early and late radial artery occlusion after transradial intervention.

Non-invasive classification of single and double-yolk eggs using Vis-NIR spectroscopy and multivariate analysis

1. This study was conducted to develop an efficient technique for separating double-yolked (DY) from single-yolked (SY) light brown broiler eggs with comparable shape and size, that were hard to distinguish merely by their external characteristics, using Vis-NIR transmission spectroscopy combined with multivariate analysis.2. Spectroscopic transmission (200-900 nm) was measured after collecting the eggs, and the yolk number was verified by breaking the eggs after boiling. The absorbance of important spectral wavelengths sensitive to yolk amount were identified using feature selection techniques (Principal Component Analysis and Genetic Algorithm).3. Discriminant analysis (DA) and support vector machine (SVM) classifiers were used to develop classification models for DY and SY eggs using the selected important spectral wavelengths.4. When compared to alternative nonlinear techniques, the developed model applying linear discriminant analysis produced greater accuracies in the first (96%) and second (100%) experiments, implying lower inter-egg variability from spectral data and a linear relationship between classes. However, the position and orientation of yolks in DY eggs may limit the classification accuracy of the eggs.

1,4-dihydroxy quininib modulates the secretome of uveal melanoma tumour explants and a marker of oxidative phosphorylation in a metastatic xenograft model

Uveal melanoma (UM) is an intraocular cancer with propensity for liver metastases. The median overall survival (OS) for metastatic UM (MUM) is 1.07 years, with a reported range of 0.84-1.34. In primary UM, high cysteinyl leukotriene receptor 1 (CysLT₁) expression associates with poor outcomes. CysLT₁ antagonists, quininib and 1,4-dihydroxy quininib, alter cancer hallmarks of primary and metastatic UM cell lines in vitro. Here, the clinical relevance of CysLT receptors and therapeutic potential of quininib analogs is elaborated in UM using preclinical in vivo orthotopic xenograft models and ex vivo patient samples. Immunohistochemical staining of an independent cohort (n = 64) of primary UM patients confirmed high CysLT₁ expression significantly associates with death from metastatic disease (p = 0.02; HR 2.28; 95% CI 1.08-4.78), solidifying the disease relevance of CysLT₁ in UM. In primary UM samples (n = 11) cultured as ex vivo explants, 1,4-dihydroxy quininib significantly alters the secretion of IL-13, IL-2, and TNF-α. In an orthotopic, cell line-derived xenograft model of MUM, 1,4-dihydroxy quininib administered intraperitoneally at 25 mg/kg significantly decreases ATP5B expression (p = 0.03), a marker of oxidative phosphorylation. In UM, high ATP5F1B is a poor prognostic indicator, whereas low ATP5F1B, in combination with disomy 3, correlates with an absence of metastatic disease in the TCGA-UM dataset. These preclinical data highlight the diagnostic potential of CysLT₁ and ATP5F1B in UM, and the therapeutic potential of 1,4-dihydroxy quininib with ATP5F1B as a companion diagnostic to treat MUM.

Knowledge, attitude and practices regarding dengue and its vector among medical practitioners in Malakand region, Pakistan

Abstract Dengue fever (DF) is increasingly recognized as one of the world’s major mosquito borne diseases and causes significant morbidity and mortality in tropical and subtropical countries. Dengue fever is endemic in most part of Pakistan and continues to be a public health concern. Knowledge, attitude and practices can play an important role in management of the disease. Current study was aimed to determine the level of knowledge, attitude and practices regarding dengue fever among health practitioners, to study the level of knowledge and attitude with preventive practices for dengue fever. A cross sectional study was carried out in medical practitioners of the four districts of Malakand region during October to November 2019. A pre-structured questionnaire was used to collect data from medical practitioners. Data was analyzed using Graph Pad version 5. Significant value was considered when less than 0.05 (at 95% confidence of interval). The results revealed that most of participants have seen dengue vector (62%), the media being the most quoted source of information. Nearly 81.2% participants were aware from transmission of dengue fever is by mosquito bite. Practices based upon preventive measures were found to be predominantly focused towards prevention of mosquito bites rather than elimination of breeding places. Although the knowledge regarding DF and mosquito control measure was quite high among the medical practitioners but this knowledge was not put into practice. Further studies are required to aware the people about dengue and its vector in order to get prevention and control.

Human health exposure and risks of arsenic from contaminated soils and brinjal fruits collected from different producers and retailers levels

A quantitative assessment was attempted to determine concentrations of total arsenic (As) in farmer's field soils and fruits of brinjal collected from two famous brinjals producing Upazila's, namely Melandaha and Islampur of Jamalpur district, Bangladesh. The study also evaluated cancer and non-cancer health risks for both males and females caused by dermal exposure of soils and dietary intake of brinjal grown in farmers' fields and sold at different markets of four country districts. The study findings revealed that 75% of soil sampling locations had enrichment factor (EFc) values > 1.5, indicating the anthropogenic sources of As, and 50% of the sites possessed EFc values within the range of 2.0-5.0 indicated moderate enrichment of As. The mean concentrations of As in brinjal grown in farmers' fields and retailers of different markets of four districts were 0.18 and 0.39 µg g^-1, respectively. The soils of the study area exhibited negligible risk in terms of the calculated hazard quotient, hazard index and incremental lifetiame cancer risk (ILCR) values for As due to dermal and ingestion exposures. In contrast, the same values for As due to the dietary intake of brinjal were thousands of times greater than the threshold level in 40% of farmers' field and all retailers' levels samples. Compared to the producer/farmers' field samples, the calculated average non-carcinogenic and carcinogenic health risks were more than twice in samples collected from different retailers. The present study suggests further pinpoint investigation of potential entry routes of As in the supply chain through future traceability studies.

Mapping the Immune Landscape in Metastatic Melanoma Reveals Localized Cell-Cell Interactions That Predict Immunotherapy Response

While immune checkpoint-based immunotherapy (ICI) shows promising clinical results in patients with cancer, only a subset of patients responds favorably. Response to ICI is dictated by complex networks of cellular interactions between malignant and nonmalignant cells. Although insights into the mechanisms that modulate the pivotal antitumoral activity of cytotoxic T cells (Tcy) have recently been gained, much of what has been learned is based on single-cell analyses of dissociated tumor samples, resulting in a lack of critical information about the spatial distribution of relevant cell types. Here, we used multiplexed IHC to spatially characterize the immune landscape of metastatic melanoma from responders and nonresponders to ICI. Such high-dimensional pathology maps showed that Tcy gradually evolve toward an exhausted phenotype as they approach and infiltrate the tumor. Moreover, a key cellular interaction network functionally linked Tcy and PD-L1+ macrophages. Mapping the respective spatial distributions of these two cell populations predicted response to anti-PD-1 immunotherapy with high confidence. These results suggest that baseline measurements of the spatial context should be integrated in the design of predictive biomarkers to identify patients likely to benefit from ICI.

SIGNIFICANCE

This study shows that spatial characterization can address the challenge of finding efficient biomarkers, revealing that localization of macrophages and T cells in melanoma predicts patient response to ICI. See related commentary by Smalley and Smalley, p. 3198.

Application of Artificial Intelligence Techniques to Predict Risk of Recurrence of Breast Cancer: A Systematic Review

Breast cancer is the most common disease among women, with over 2.1 million new diagnoses each year worldwide. About 30% of patients initially presenting with early stage disease have a recurrence of cancer within 10 years. Predicting who will have a recurrence and who will not remains challenging, with consequent implications for associated treatment. Artificial intelligence strategies that can predict the risk of recurrence of breast cancer could help breast cancer clinicians avoid ineffective overtreatment. Despite its significance, most breast cancer recurrence datasets are insufficiently large, not publicly available, or imbalanced, making these studies more difficult. This systematic review investigates the role of artificial intelligence in the prediction of breast cancer recurrence. We summarise common techniques, features, training and testing methodologies, metrics, and discuss current challenges relating to implementation in clinical practice. We systematically reviewed works published between 1 January 2011 and 1 November 2021 using the methodology of Kitchenham and Charter. We leveraged Springer, Google Scholar, PubMed, and IEEE search engines. This review found three areas that require further work. First, there is no agreement on artificial intelligence methodologies, feature predictors, or assessment metrics. Second, issues such as sampling strategies, missing data, and class imbalance problems are rarely addressed or discussed. Third, representative datasets for breast cancer recurrence are scarce, which hinders model validation and deployment. We conclude that predicting breast cancer recurrence remains an open problem despite the use of artificial intelligence.

953 Amyand's Hernia: The Fortuitous Intraoperative Diagnosis – a Case Report

Introduction

Amyand's hernia is a very rare form of inguinal hernia, in which the vermiform appendix is in the inguinal canal/hernia sac. Its incidence is less than 1% of groin hernias and is complicated by appendicitis in about 0.1% of cases. It is commoner in males, on the right side and has a bimodal age distribution – neonates and the elderly.

We present the case of an elderly gentleman with amyand's hernia diagnosed intraoperatively.

Case Presentation

A 78-year-old male with a background of systemic hypertension presented to the clinic with an 18-month history of painless right groin swelling. Physical examination revealed a full, non-tender abdomen. He had a 4cm soft, reducible right groin swelling, with visible and palpable cough impulse. A diagnosis of right inguinal hernia was made. Baseline blood workup and ECG were unremarkable. He was listed for a day case open hernia repair.

Intra-operatively, the right indirect hernia sac contained a grossly uninflamed appendix lying freely within it. Figure 1.

Appendicectomy was performed and a tension-free repair was done.

The post-operative period was uneventful. Histology of the excised appendix revealed reactive lymphoid hyperplasia and submucosal fibrosis.

Conclusion

As only about 1 in 60 cases of Amyand's hernia are diagnosed pre-operatively, usually as an incidental finding on imaging; the overwhelming majority are intra-operative findings.

Although rare, the vermiform appendix remains a possible content of the inguinal hernia sac, and it is important to be aware of likely complications and options of repair.

426 Conservative Management of Bilateral Undescended Testes in an Adult

Bilateral undescended testes are an uncommon finding in children and even a rarer phenomenon in adults. Undescent of the testes (UDT) has important consequences on fertility, testicular injury, hormonal concerns, testicular torsion, and testicular cancer risk, as well as psychological health.

We present the case of a then 21-year-old native caucasian who was referred to the urology clinic with an ‘empty scrotum’ in 2009. On examination, he had secondary sexual characteristics with expected pubertal transformation. Testes were palpated as small smooth ovoid masses in each groin with the inability to be reduced into the scrotum. The basic hormonal screen was within the normal range. Ultrasound of the scrotum and groins identified testes in the left and right inguinal canal, respectively. Semen analysis showed azoospermia.

Treatment wise no pharmacological therapies were warranted in view of normal hormonal function. The patient opted for conservative options for fertility in view of likely low success rates in atrophic testes including sperm extraction techniques After detailed discussions around the dilemmas of Bilateral UDT, a decision for a tailored surveillance regimen including ultrasound and self-examination was taken. Psychological counselling was declined by the patient as felt unwarranted. He continues to remain well in himself to date with his wife and adopted children.

Greater awareness of testicular self-examination amongst young men should be advocated. With established neonatal screening availability, UDT in adults is seldom heard of but it is a primary risk factor for testicular cancer. Proper counselling advice and prosthesis should be offered proactively.

425 Extra-Anatomical Detour Ureteric Stents: Our District General Hospital Experience of 50 Patients with a Minimum Follow Up of 6 Months

Aim

Extra-Anatomical Detour Stents offer a viable modality of decompression particularly in the context of malignancies; with the absent need for changes of stents, cosmetically better than nephrostomies and fewer admissions associated with blockages/infections. Our aim was to assess the safety and feasibility of performing detour stents in a district general hospital.

Method

A review of prospectively collected data on all patients undergoing detour stents between 2016 and 2021 was undertaken. This enabled a possible follow up period of 6 months, provided the patients remained alive. A statistical package was utilised for the analysis of the collected data.

Results

Fifty patients were identified to have undergone detour stent insertion with malignancy being the indication in 90% of cases. Seven patients required a further eleven procedures with the most common being due to repositioning of the stent (36%) or change of stent due to infection (27%). Four patients passed away within 60 days of their procedure. Four patients had their stents eventually replaced with nephrostomies and a patient no longer required the detour stent due to resolution of their obstructive pathology. Nine patients are currently being followed up and thirty-six patients from the original cohort passed away with functional detour stents. Their median survival time post-procedure was 164 days.

Conclusions

Extra-Anatomical Detour Stents offers patients with obstructing renal tract secondary to malignancy a better quality of life when compared with nephrostomy. Continued caseload and refinement of surgical technique would lead to further optimised surgical outcomes.

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.

CD45-positive tumor infiltrating lymphocytes in early-stage hormone-positive, HER2-negative (ER+/HER2-) breast cancer: Correlation with proliferation and prognostic signature scores

e12555

Background: Tumour infiltrating lymphocytes (TILs), have been associated in higher responses to treatment and are thought to be a prognostic marker in a number of cancer types. The role of TILs in breast cancer varies depending on the molecular subtype of the disease. In hormone positive, HER2-negative breast cancer, the significance of TILs is less clear, partly due to the paucity of data in this area. We aim to assess overall TILs in early-stage, hormone-positive, HER2-negative (ER+/HER2-) breast cancer and its relationship with proliferation index, Ki67, and the 21-gene recurrence score. Methods: Archival patient tissue samples of early-stage, ER+/HER2- breast cancer from the Irish arm of the TAILORx clinical trial were used. Full-face sections of these tumours were stained with anti-CD45 antibody (DAKA clone M0701) via the automated Leica Bond III system. A watershed cell-detection algorithm from the open-source digital pathology software, QuPath, was fine-tuned to identify true cell objects and positive immune markers. Optimised detection parameters were used to calculate the percentage of overall CD45+ cells (CD45%) within the tumour area. Patient TIL categories were dichotomised into High v Low CD45%, with 10% chosen as the threshold. CD45% was further correlated with proliferation index, clinical data, and 21-gene recurrence score. Results: 409 samples were included in the analysis. The mean CD45% was 5.96, with samples ranging from 0.13 to 78.86. The majority of samples were in the range of 0-10% of CD45% positivity with 89% (n = 367) patients in this category. Stratification of the cohort by 21-gene-recurrence score (RS) into Low, Intermediate and High, showed a statistically significantly high CD45% in patients with a High RS compared to Low RS (p = 0.0015). When divided by recurrence score group, high CD45% trended toward a lower disease free survival (DFS) when compared to low CD45%, with statistical significance found in those in the Intermediate RS chemotherapy treatment arm (p = 0.009). Conclusions: The role of TILs in ER+/HER2- breast cancer is still undefined. While a High RS was associated with a higher percentage of CD45-positive lymphocytes, the impact on recurrence and response to treatment remains unclear. Further studies to assess the role of different tumour infiltrating lymphocyte phenotypes, and the spatial distribution of assessed markers, are needed.

POS0039 MONOCYTE TRANSCRIPTOMICS AND TARGETED PROTEOMICS DEFINE HETEROGENEOUS SUBGROUPS IN WOMEN WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) AND SUBCLINICAL ATHEROSCLEROSIS

Background

Systemic lupus erythematosus (SLE), a chronic, inflammatory autoimmune disease, predominantly affects women with a 9:1 female:male incidence. Cardiovascular disease (CVD) is a leading cause of mortality in SLE via accelerated atherosclerosis: the build-up of cells and lipids in the vascular wall and the main pathology underlying CVD.

Objectives

To define molecular profiles of SLE with subclinical atherosclerosis using multi-omics data analysis and clinical data in a well-characterised cohort of CVD-free SLE women.

Methods

Multi-omics analyses were conducted to explore the molecular signatures of SLE patients with (SLE-P) and without (SLE-NP) subclinical atherosclerosis defined by non-invasive ultrasound scanning of the carotid and femoral arteries. SLE blood CD14+ monocyte transcriptomes were investigated by bulk RNA-sequencing (SLE-P N=13, SLE-NP N=8), and targeted serum cardiometabolic and cardiovascular proteomics (OLINK) were used to explore matched protein expression (SLE-P N=17, SLE-NP N=20) (no difference in disease activity between groups). Bioinformatics approaches, including pathway and disease module enrichment analyses and extended protein-protein interaction networks, further defined molecular profiles of SLE patients with atherosclerosis from patients that remained plaque free. Gene signature-derived interferon (IFN) scores were applied to investigate heterogeneous subgroups within the cohort as a measure of inflammation.

Results

Distinct monocyte gene and protein expression profiles were identified in SLE and enriched in biological pathways relating to extracellular mechanisms, including purinergic and cytokine signalling. Lipid regulatory mechanisms were enriched in SLE-P, whereas SLE-NP patient’s transcriptome and proteome profiles were defined by pathways relating to inflammation. Specifically, the type-I IFN pathway was exclusively reduced in SLE-P compared to SLE-NP. IFN scores derived from published IFN-responsive gene expression signatures stratified patients into significantly distinct subgroups (high versus low IFN-response, p=0.0001) with 66% (N=14) of patients showing high IFN expression across multiple signatures not associated with age, ethnicity, or disease activity. However, IFN scores did not predict the presence of sub-clinical atherosclerosis and further heterogeneity was revealed with 46% of SLE-P patients showing a low IFN response (N=6). Further, a measure of plaque lipid content (echogenicity) was inversely correlated with IFN score (grey scale median, p=0.03, r=-0.8) which may reflect distinct plaque phenotypes between these subgroups relating to clinical presentation and risk of cardiovascular events.

Conclusion

Lipid dysregulation is a key mechanism that drives atherosclerosis pathology and genes and proteins relating to lipid metabolism distinguished SLE patients with and without subclinical atherosclerosis. Differences in levels of interferons and other inflammatory molecules may contribute to unique patterns of gene expression between SLE patients. A distinct subset of SLE-P patients showed low interferon expression, which may be suggestive of a dampened immune response in early subclinical CVD. Further elucidating the complexity of lipid dysregulation, inflammation and immune function in atherosclerosis in SLE will help improve patient stratification towards investigating the efficacy of anti-atherosclerotic therapies.

Disclosure of Interests

None declared

Effects of mannan-oligosaccharide supplementation on gut health, immunity, and production performance of broilers

The study was designed to investigate the effect of mannan-oligosaccharide (MOS) supplementation on intestinal histomorphology, immunity against Newcastle disease virus (NDV) and productive parameters of broilers. A total of 1800, day old broiler chicks of Cobb-500 strain were selected and randomly assorted into 6 treatment groups: T1 (basal diet without antibiotics as negative control); T2 (basal diet plus antibiotics as positive control group); T3 (basal diet plus 200g/ton MOS); T4 (basal diet plus 400g/ton MOS); T5 (basal diet plus 600g/ton MOS) and T6 (basal diet plus 800g/ton MOS). Each treatment was having 6 replicates and the feed intake, body weight gain and feed conversion ratio (FCR) were recorded on weekly basis. Results showed that, MOS supplemented birds have significantly higher feed intake, weight gain and FCR (P < 0.05). Similarly, supplementation of MOS showed positive effect on villus height and crypt depth both in jejunum and ilium. Goblet cell density was unaffected by MOS addition (P < 0.05). Furthermore, birds fed with diets containing MOS, exhibited better productive performance in comparison to positive and negative control groups. In conclusion, MOS can replace antibiotic growth promoters (AGPs) as non-microbial performance-enhancing feed advocates.

A feasibility study evaluating the uptake, effectiveness and acceptability of routine screening of pregnant migrants for latent tuberculosis infection in antenatal care: a research protocol

INTRODUCTION

Globally, tuberculosis (TB) is a leading cause of death in women of reproductive age and there is high risk of reactivation of latent tuberculosis infection (LTBI) in pregnancy. The uptake of routine screening of migrants for LTBI in the UK in primary care is low. Antenatal care is a novel setting which could improve uptake and can lend insight into the feasibility and acceptability of offering opt-out screening for LTBI.

METHODS AND ANALYSIS

This is an observational feasibility study with a nested qualitative component. The setting will be the antenatal clinics in three hospitals in East London, UK . Inclusion criteria are pregnant migrant women aged 16-35 years attending antenatal clinics who are from countries with a TB incidence of greater than 150/100 000 including sub-Saharan Africa, and who have been in the UK for less than 5 years. Participants will be offered LTBI screening with an opt-out interferon gamma release assay blood test, and be invited to complete a questionnaire. Both participants and healthcare providers will be invited to participate in semistructured interviews or focus groups to evaluate understanding, feasibility and acceptability of routine opt-out LTBI screening. The primary analysis will focus on estimating the uptake of the screening programme along with the corresponding 95% CI. Secondary analysis will focus on estimating the test positivity. Qualitative analysis will evaluate the acceptability of offering routine opt-out LTBI screening to participants and healthcare providers.

ETHICS AND DISSEMINATION

The study has received the following approvals: Health Research Authority (IRAS 247388) and National Health Service Ethics Committee (19/LO/0557). The results will be made available locally to antenatal clinics and primary care physicians, nationally to NHS England and Public Health England and internationally through conferences and journals.

TRIAL REGISTRATION NUMBER

NCT04098341.

Adverse In-Hospital Outcome of Transradial PCI in Comparison to Transfemoral PCI in NSTEMI Patients during Index Hospitalization: A Single Center Study in Bangladesh

NSTEMI patients, in comparison to STEMI patients, are more at risk of bleeding, access site complication and MACE after PCI during index hospitalization. Because they get, multiple adjuvant anti-thrombotic agents before PCI than do the STEMI patients undergoing primary PCI. Transradial access (TRA) is proven to decrease those adverse in-hospital outcomes compared to transfemoral access (TFA) in STEMI patients. But very few studies were conducted in this regard considering NSTEMI patients. We observed prospectively the adverse in-hospital outcomes of total 180 NSTEMI patients who had undergone PCI through TRA (Group I = 80) and TFA (Group II = 100) during index hospitalization between October 2017 to September 2018 in National Institute of Cardiovascular Disease (NICVD), Dhaka, Bangladesh. Samples were selected purposively. Patients were followed up 2 hours after PCI and thereafter every day until discharge. Demographic and risk factor variables were almost same in both groups. TRA, compared with TFA, yielded less major bleeding (0% versus 3%, p=0.12) which was statistically non-significant. Minor bleeding was significantly less in Group I (2.5% versus 13.0%, p=0.04). Overall bleeding was also significantly less in Group I (2.5% and 10.0%; p=0.002). Access site complication was non-significantly less in Group I (0% versus 1%, p=0.91). TRA caused non-significant reduction in MACE (2.5% versus 5%; p=0.38) but significant reduction of total adverse in-hospital outcome (5% versus 20%, p=0.006%). In this study TRA seems to have less adverse in-hospital outcome than TFA in NSTEMI patients undergoing PCI during index hospitalization.

335 Early Initiation of Biochemical Venous Thromboembolism Prophylaxis Following Traumatic Spleen Injury Is Safe and Effectively Reduce VTE Events

Aim

This study examines the safety and timing initiating VTE prophylaxis post traumatic splenic injuries (TSI).

Method

Patients with TSI were identified from prospectively maintained Trauma Audit and Research Network (TARN) database from 2015–2020 in a single tertiary trauma centre. Clinical and radio-logical information were collected retrospectively. TSI were graded using American Association for the Surgery of Trauma (AAST) splenic injury scale. Chemical venous thromboprophylaxis initiation were categorised as not given, &lt;48h and &gt;48h following the injury.

Results

In total 102 patient were included out of 136 patients identified with TSI. 34 patients were excluded for lack of electronic data, palliative decision, or fatal condition on arrival. 12 patients out of 102 required operative management (OM) and 90 patients NOM. VTE prophylaxis was not given for 31 (30.4%). Medical reasons for this include severe brain injury and early discharge before 48 hours. VTE prophylaxis was initiated for 37 (36.3%) patients within 48 hours, and for 34 patients (33.3%) after 48 hours of admission. Seven patients developed thromboembolic events, majority of which (6/7) received VTE prophylaxis after 48 hours. Importantly, none of the patients who received VTE prophylaxis had rebleeding.

Conclusions

This study showed that early initiation of chemical VTE prophylaxis (&lt;48h) is safe, resulted in lower incidence of DVTs/PEs without increasing the risk of bleeding. Results from this study supports recommendation from other studies 1 to initiate chemical VTE prophylaxis after TSI as early as 24h post injury with no other contra-indications.

A250 NUTRISUP-PPN; PILOT RANDOMIZED CONTROL TRIAL OF ORAL AND PARENTERAL NUTRITION IN MALNOURISHED HOSPITALIZED PATIENTS

Background

Hospitalized malnourished patients experience poor outcomes. Despite this, health care practitioners are poor in identifying, monitoring and treating hospital malnutrition.

Aims

Our study determined the feasibility of a novel nutrition care pathway which both rapidly identifies and treats malnourished medical inpatients accounting for the obstacles for nutritional optimization by utilizing both peripheral parental nutrition (PPN) followed by oral nutritional supplementation (ONS) on a composite outcome of 30 day readmission, mortality and continued admission, as well other important clinical and nutritional outcomes. The study was registered under ClinicalTrials.gov Identifier no. NCT02632630

Methods

NutriSUP-PPN was a 2x2 factorial pilot randomized trial. In two large Canadian hospitals, we recruited 100 adult patients &gt; 18 years, &lt; 48 hours from admission to a general medicine ward who were moderately or severely malnourished. Patients received: 1. PPN for 5 days and then enhanced ONS until 30 days post randomization; 2. PPN for 5 days and then standard ONS until 30 days; 3. Standard care for intravenous (IV) fluid administration for 5 days and then enhanced ONS until 30 days; 4. Standard care for IV fluid administration for 5 days and standard ONS until 30 days.

Results

There was no significant differences between a composite outcome of 30 day readmission, continued admission or mortality between any interventional group and control. We did however note a trend in the PPN + ONS arm where only 4/22 patients versus 10/24 patients (p=0.16) in the control (no PPN, no enhanced ONS) experienced an adverse outcome which was largely driven by a reduction of readmission in the ONS + PPN arm We demonstrated feasibility in recruitment, adherence to protocol, and safety. The incidence of sepsis was greater in the PPN arm compared to control (15.5% versus 4.2%) but was not statistically significant. Improvement in nutritional status for interventional arms were not significant compared to control. However, there was a trend of improvement in preventing decline of nutritional status in both the enhanced ONS arm and PPN + enhanced ONS arm.

Conclusions

There are signals in our data, which suggest that the combination of PPN with ONS may improve both clinical and nutritional outcomes compared to PPN or ONS alone. We posit that a large, multi-center, definitive randomized control trial is now justified to determine if PPN for up to 5 days along with 30 days of ONS, versus standard of care, will improve a composite outcome of death, continued admission, and readmission at 30 days.

Funding Agencies

CAGAMOSO

Sex-Driven Differences in the Effectiveness of Individualized Clinical Management of Alzheimer's Disease Risk

BACKGROUND

The Comparative Effectiveness Dementia and Alzheimer's Registry (CEDAR) trial demonstrated that individualized, multi-domain interventions improved cognition and reduced the risk of Alzheimer's disease (AD). As biological sex is a significant risk factor for AD, it is essential to explore the differential effectiveness of targeted clinical interventions in women vs. men.

METHODS

Patients were recruited from an Alzheimer's Prevention Clinic. Subjects with normal cognition, subjective cognitive decline, or asymptomatic preclinical AD were classified as "Prevention". Subjects with mild cognitive impairment due to AD or mild AD were classified as "Early Treatment." The primary outcome was the change from baseline to 18-months on the modified-Alzheimer's Prevention Cognitive Composite. Secondary outcomes included a cognitive aging composite, AD and cardiovascular (CV) risk scales, and serum biomarkers. Subjects who adhered to > 60% of recommendations in the CEDAR trial were included in this a priori sub-group analysis to examine whether individualized intervention effects were modified by sex (n=80).

RESULTS

In the Prevention group, both women (p=0.0205) and men (p=0.0044) demonstrated improvements in cognition with no sex differences (p=0.5244). In the Early Treatment group, there were also no significant sex differences in cognition (p=0.3299). In the Prevention group, women demonstrated greater improvements in the Multi-Ethnic Study of Atherosclerosis risk score (MESA-RS) than men (difference=1.5, p=0.0013). Women in the Early Treatment group demonstrated greater improvements in CV Risk Factors, Aging and Incidence of Dementia (CAIDE) risk score (difference=2.3, p=0.0067), and the MESA-RS (difference=4.1, p<0.001).

CONCLUSIONS

Individualized multi-domain interventions are equally effective at improving cognition in women and men. However, personally-tailored interventions led to greater improvements in calculated AD and CV risk, and CV blood biomarkers, in women compared to men. Future study in larger cohorts is necessary to further define sex differences in AD risk reduction in clinical practice.

Factors associated with severe envenomation of snakebite cases at emergency department, Hospital Sultan Abdul Halim, Kedah, Malaysia

INTRODUCTION

Snakebite envenomation is a medical emergency and cases continue to be encountered in Malaysian hospitals. This study aims to determine the prevalence of snakebite presentations and the associated factors with severe envenomation of snakebite in Sungai Petani, Kedah, Malaysia.

MATERIALS AND METHODS

This was a retrospective, crosssectional study involving snakebite patients presented at the Emergency Department (ED), Hospital Sultan Abdul Halim (HSAH), Kedah from 1 July 2015 to 30 June 2019. The cases were extracted from the computerized system and the case records of patients were retrieved from the Medical Record Unit. Patients that met the study criteria were included and their sociodemographic features, clinical presentations including use of anti-venom were collected. Logistic regression analysis was performed to determine the factors associated with severe envenomation.

RESULTS

A total of 220 snakebite cases with the mean age of patients was 39.66 (SD±21.79) years old. Majority of them were Malay and males. 41.4% of snakebite cases occurred in late evenings and the mean time-lapsed to arrive at HSAH was 108.6 minutes. 81.4% of snakebite cases occurred while engaging in outdoor activities and 43.6% of the snakebite cases involved work-related incidents. 58.2% of the patients were bitten in the lower limb. 78.6% of patients were bitten by the identified snake species, predominantly from Viperidae family. The prevalence of severe envenomation was 50.9%. Malay ethnicity (adj. OR =2.549, 95% CI =1.277,5.089), bite to the upper limb (adj. OR =2.125, 95% CI =1.192, 3.790), and bite by snakes from Viperidae family (adj. OR =3.017, 95% CI =1.613, 5.642) were found to have significant associations with severe envenomation of snakebite.

CONCLUSION

The prevalence of severe envenomation was more than 50% of snakebite cases. Malay ethnicity, upper limb snake bites, and snakebite from a Viperidae family had a higher chance of severe envenomation.

Milk-alkali syndrome: The forgotten diagnosis for altered sensorium

Milk-alkali syndrome (MAS) is one of the causes of hypercalcaemia. We report a case of a 75-year-old lady with a history of thyroidectomy, presented with an altered mental state and had an extremely high calcium concentration of 4.96mmol/L. The hypercalcemia was attributed to the ingestion of large doses of calcium supplements, including calcium carbonate and calcium lactate, leading to MAS. She was managed with intravenous fluids, diuretics and withdrawal of calcium supplements. The patient responded well to treatment and regained consciousness. Details of the case including clinical presentations, electrocardiogram (ECG) findings and treatment plan, are discussed in this article.

Impact of Myocardial Blush Grade on In-Hospital Outcome after Primary Percutaneous Coronary Intervention

Primary percutaneous coronary intervention (PPCI) is the optimal reperfusion strategy in patients with ST elevation Myocardial Infarction (STEMI). However, despite achieving TIMI 3 flow after PPCI, some patients have less optimal perfusion at the myocardial tissue level, as assessed by Myocardial Blush Grade (MBG) and consequently show adverse outcome. This prospective observational study was performed in the National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh from March 2016 to February 2017. Total 74 patients with STEMI who underwent primary PCI and achieved TIMI 3 flow were included among them 37 patients were taken with low MBG (grade 0 or 1) in Group I and other 37 patients with high MBG (grade II or III) were taken in Group II. Mean age of Group I and Group II were 53.70±9.17 and 51.49±9.41 years respectively (p=0.536). Male to female ratio was 5.7:1. Smoking (59.5% versus 35.1%, p=0.036) and diabetes mellitus (43.2% versus 18.9%, p=0.024) were significantly higher in low MBG group than high MBG group. Multi vessel involvement (24.3% versus 5.4%, p=0.022) and anterior MI (72.9% versus 51.4%, p=0.047) were significantly higher in low MBG group. LVEF was significantly lower in low MBG group than high MBG group (49.92?6.60% versus 58.84?4.55%, p=0.003). Among the complications acute heart failure was found significantly higher in low MBG group than high MBG group (8.1% versus 0.0%, p=0.048) along with total adverse in hospital outcome (24.3% versus 5.4%, p=0.041). In study population total mortality was 2.7% and all were in low MBG group (5.4%). Multivariate logistic regression analysis showed MBG was an independent predictor of adverse in hospital outcome after PPCI (OR 6.553, 95% CI 1.984-21.643, p=0.002). Low MBG is associated with more adverse in hospital outcome after PPCI. So, along with TIMI 3 flow following PPCI we have to assess MBG for evaluation of complete reperfusion and further outcome.

Impacts of mining on local fauna of wildlife in District Mardan & District Mohmand Khyber Pakhtunkhwa Pakistan

Mining is vital for human sustenance and a crucial sector in the state economy. However, its impacts on the environment and biodiversity cannot be underestimated. Which are potent to the attract government's attention. Environment and wildlife are subject to the harmful impacts of mining and its related activities. In this study, districts, namely Mardan and Mohmand have been targeted with respect to mining impacts. The assessment was carried out on wildlife adversely affected by the mining sector. The fauna has been keenly observed to bring the calculated risks and threat perception of the regional wildlife. Total 9 species of mammals, 21 species of birds, were recorded in District Mardan. While in District Mohmand 2 species of mammals, 9 species of birds, and 4 species of reptiles were studied. The Study explored that mining primarily responsible for land degradation. Which lead to food and agriculture losses. Several other factors like blasting, pollution, hunting, deforestation, habitat loss was also observed. Deforestation surfaced one of the major causes for extinction of fauna in the said region. preemptive measures are needed to seize the man-made catastrophe.

Residue level and health risk assessment of organophosphorus pesticides in country bean and bitter gourd collected from Cumilla, Bangladesh

Organophosphorus pesticides are one of the most commonly used pesticide classes in agriculture in the management of insect pests due to their high efficacy. The extensive use of organophosphorus pesticides can contaminate both the atmosphere and food, which may lead to health problems. In this study, the residue level of organophosphorus pesticides, and their health risk assessment was evaluated on country bean and bitter gourd. Out of forty analysed samples of the country bean, two samples contained multiple residues, seven samples contained single residue. On the other hand, out of forty samples of bitter gourd, one sample contained multiple residues and three samples contained single residue. Among the organophosphorus pesticides, diazinon was the most frequently detected organophosphorus pesticide in country bean and bitter gourd. The highest short-term risks or acute risk (aHI) was below 1.83%, and the highest long-term risk or chronic risk (HQs) was below 10.46% for the country bean and bitter gourd, respectively. Short- and long-term risk assessment results showed that the intake risks of country bean and bitter gourd were acceptable. The health hazard results showed that country bean and bitter gourd consumption in Cumilla, Bangladesh does not pose an acute or chronic risk to human health. However, a routine monitoring system must be established to control the contamination of vegetables with pesticides.

Comparative analysis of brain in relation to the body length and weight of common carp (Cyprinus carpio) in captive (hatchery) and wild (river system) populations

Cyprinus carpio is the member of family cyprinidae commonly called common carp. This study was aimed to find out the comparison of brain of wild (river system) and captive (hatchery reared) population of common carp. A total of thirty samples (15 from hatchery and 15 from river Swat) were collected. All the specimens were examined in Laboratory of Parasitoloy, Zoology Department, University of Malakand. Findings indicated that wild population were greater in brain size and weight as compared to hatchery reared population. The fish samples collected from captive environment (hatchery) were showing more weight and length as compared to wild population of common carps. The mean value of total weight of hatchery fishes 345±48.68 and the mean value of brain weight of hatchery reared fishes 0.28±0.047. The mean value of wild fish's total body weight 195.16±52.58 and the mean value of brain weight of wild fishes are 0.45±0.14. Present research calls for the fact that fish in dependent environmental conditions possess brain larger in size as compared to its captive population, it is due to use and disuse of brain in their environmental requirements.

Iced towel - a novel method to revert supraventricular tachycardia in a paediatric patient

Supraventricular tachycardia (SVT) is the commonest tachyarrhythmia among paediatric age group. Modified Valsalva manoeuvre can be attempted in a stable child. We discuss here a case of a 6-year-old boy who presented with stable SVT and iced towel was applied to his face to revert the tachyarrhythmia. This method was well tolerated by the child without any complications. The SVT was successfully reverted, and pictures were taken to capture the simple but effective method.

Exploration of Zingiber officinale effects on growth performance, immunity and gut morphology in broilers

The current study aimed to determine the effects of different levels of Zingiber officinale as a herbal feed additive on growth performance, carcass characteristic, serum biochemistry, total bacterial count (TBC), gut morphology, and immunological parameters of broilers. A total of 1500, day-old broiler chicks (Hubbard) were equally accredited to five treatment groups, each with six replicates (50 birds/replicate). Five experimental diets were prepared using basal diet i.e. with antibiotics positive control (PC), 3 g/kg ginger (group A), 6 g/kg ginger (group B), 9 g/kg ginger (group C) and without antibiotics negative control (NC). Group A and C showed significantly (p<0.05) higher feed intake (FI) as compared to other groups. Group C showed significantly (p<0.05) lower Total bacterial count (TBC) followed by group B as compared to NC. Carcass characteristics showed non-significant effects among different treatments. Mean villi length and width were significantly (p <0.05) higher in all ginger supplemented groups as compared to the control groups. Blood serum parameters including cholesterol, triglycerides, and low-density lipoproteins (LDL) were significantly (p<0.05) lower in groups B and C in comparison with the control groups. Whereas high-density lipoproteins (HDL) was significantly higher in group B as compared to the others. In conclusion, ginger supplementation @0.6% in the basal diet significantly improved growth performance and gut morphometry of broilers. It also showed a positive impact on cholesterol, triglycerides and gut microbes. Therefore, ginger could be a better substitute for antibiotic growth promoters.