Genomic analysis and biodesulfurization potential of a new carbon-sulfur bond cleaving Tsukamurella sp. 3OW

Direct combustion of sulfur-enriched liquid fuel oil causes sulfur oxide emission, which is one of the main contributors to air pollution. Biodesulfurization is a promising and eco-friendly method to desulfurize a wide range of thiophenic compounds present in fuel oil. Previously, numerous bacterial strains from genera such as Rhodococcus, Corynebacterium, Gordonia, Nocardia, Mycobacterium, Mycolicibacterium, Paenibacillus, Shewanella, Sphingomonas, Halothiobacillus, and Bacillus have been reported to be capable of desulfurizing model thiophenic compounds or fossil fuels. In the present study, we report a new desulfurizing bacterium, Tsukamurella sp. 3OW, capable of desulfurization of dibenzothiophene through the carbon-sulfur bond cleavage 4S pathway. The bacterium showed a high affinity for the hydrocarbon phase and broad substrate specificity towards various thiophenic compounds. The overall genome-related index analysis revealed that the bacterium is closely related to Tsukamurella paurometabola species. The genomic pool of strain 3OW contains 57 genes related to sulfur metabolism, including the key dszABC genes responsible for dibenzothiophene desulfurization. The DBT-adapted cells of the strain 3OW displayed significant resilience and viability in elevated concentrations of crude oil. The bacterium showed a 19 and 37% reduction in the total sulfur present in crude and diesel oil, respectively. Furthermore, FTIR analysis indicates that the oil's overall chemistry remained unaltered following biodesulfurization. This study implies that Tsukamurella paurometabola species, previously undocumented in the context of biodesulfurization, has good potential for application in the biodesulfurization of petroleum oils.

Molecular characterization and pathology of field isolates of foot-and-mouth virus in Swiss albino mice

Abstract Foot-and-mouth disease is responsible for severe economic losses to the livestock industry of Pakistan. This study aimed to use Swiss albino mice as a cost-effective experimental animal model to study different immunological and histopathological aspects of FMDV instead of natural targeted species like cattle. After isolation of field isolates FMDV on BHK-21 cell line, biological titer of the virus and mice infectious dose50 was calculated. Virus was injected in 45 Swiss albino mice (group A) through intraperitoneal route. The gross, histopathological and immunopathological lesions in heart, trachea and lungs were recorded at different day’s intervals. Histopathologically, the heart showed congestion, hemorrhages and necrosis of cardiac muscles. Trachea showed deciliated epithelium and lungs showed hemorrhages, bronchial edema and alveolar emphysema. Immunohistochemical studies revealed the presence of virus in cardiac muscles, tracheal and bronchial epithelium and alveolar lumen. The findings evoked a thought that laboratory animals could be an alternative to large animals to meet budget limitations for further research on foot-and-mouth-disease.

A perspective of the prevalent H9N2 virus with a special focus on molecular and pathological aspects in commercial broiler chicken in Punjab, Pakistan

Abstract Frequent outbreaks of avian influenza H9N2 virus in Pakistan revealed that this subtype has become endemic in the poultry industry and, besides economic losses, poses a threat to public health. The present study describes the molecular characterization and pathological alterations in naturally infected broiler chickens with the current H9N2 field strain and their phylogenomic dynamics. In this study, tissue samples (trachea, lung, kidney and intestine) from 100 commercial chicken flocks were collected from July 2018 to August 2019. Samples were subjected to molecular detection, phylogeny and subsequent pathological examination. The complete length of the HA gene was successfully amplified in five samples. Nucleotide sequencing revealed positive samples placed in a clade belonging to the B2 sub-lineage of the G1 genotype and categorized as LPAIV based on the amino acid sequence of the HA gene at the cleavage site (PAKSSR/G). Genetic analysis of the haemagglutinin (HA) gene revealed nt: 80.5%-99.5%; aa: 83.8%-98.9% homology to H9N2 strains reported previously from Pakistan, neighbouring countries, and (A/Quail/Hong Kong/G1/97). Gross lesions include a slight airsacculitis, mild hemorrhages, diffuse congestion and purulent exudate in tracheal mucosa, fibrinonecrotic cast in the trachea lumen and mild pulmonary congestion. Histopathological alterations include sloughing of epithelial cells and infiltration of inflammatory cells in the trachea, mononuclear cells (MNCs) infiltration, pulmonary congestion and exudate in the lumen of parabronchi, peritubular congestion in the kidneys with degeneration of tubular epithelial cells and degenerative changes in the intestinal villi epithelial cells and goblet cell hyperplasia. Immunohistochemistry analysis confirmed the presence of AIVH9N2 antigen in the trachea, lungs, kidney and intestine. Electron microscopy revealed ultrastructural changes in the trachea, including degenerated cilia, mitochondrial swelling and enlarged endoplasmic reticulum. Based on all essential analysis, the present study revealed the distribution of the H9N2 virus of G1 genotype in Punjab, Pakistan, with mild to moderate pathogenicity.

Preparation and evaluation of cytotoxic potential of paclitaxel containing poly-3-hydroxybutyrate-co-3-hydroxyvalarate (PTX/PHBV) nanoparticles

Paclitaxel (PTX) is a potent anticancer drug. In the present study, PTX was loaded in poly-3-hydroxybutyrate-co-3-hydroxyvalarate (PHBV) to fabricate the PTX/PHBV (drug-loaded) nanoparticles via the nanoprecipitation method. Blank PHBV nanoparticles were also prepared. The drug-encapsulation efficiency of PTX/PHBV nanoparticles was 45±0.4%. The PTX/PHBV nanoparticles exhibited a pH-sensitive release profile and followed a quasi-Fickian diffusion mechanism. Cytotoxic properties of PHBV and PTX/PHBV nanoparticles were checked against the MCF-7 and Caco-2 cell lines. The PHBV nanoparticle did not inhibit the proliferation of MCF-7 and Caco-2 cell lines, thus depicting their non-toxic and biocompatible nature. On the other hand, the PTX/PHBV nanoparticles demonstrated 1.03-fold higher cytotoxicity and 1.61-fold enhanced apoptosis after treatment with the PTX/PHBV nanoparticles versus free PTX. In summary, the PHBV nanoparticles could be a potential candidate for the delivery of PTX for cancer treatment.

Formulation and Characterization of Curcumin Niosomes: Antioxidant and Cytotoxicity Studies

Curcumin's applications in the treatment of conditions including osteoarthritis, dementia, malignancies of the pancreas, and malignancies of the intestines have drawn increasing attention. It has several wonderful qualities, including being an anti-inflammatory agent, an anti-mutagenic agent, and an antioxidant, and has substantially reduced inherent cytotoxicity outcomes. Although curcumin possesses multiple known curative properties, due to its limited bioavailability, it is necessary to develop efficient strategies to overcome these hurdles. To establish an effective administration method, various niosomal formulations were optimized using the Box-Behnken design and assessed in the current investigation. To examine the curcumin niosomes, zeta sizer, zeta potential, entrapment efficiency, SEM, antioxidant potential, cytotoxicity, and release studies were performed. The optimized curcumin niosomes exhibited an average particle size of 169.4 nm, a low PDI of 0.189, and high entrapment efficiency of 85.4%. The release profile showed 79.39% curcumin after 24 h and had significantly higher antioxidant potential as compared with that of free curcumin. The cytotoxicity results of curcumin niosomes presented increased mortality in human ovarian cancer A2780.

Experimental and in silico evaluation of Carthamus tinctorius L. oil emulgel: a promising treatment for bacterial skin infections

Purpose

The current study aimed to develop a topical herbal emulgel containing Carthamus tinctorius L. (CT) oil extract, which has been scientifically proven for its antibacterial and antioxidant activities for the ailment of bacterial skin infections.

Method

The CT emulgel was formulated by response surface methodology (RSM) and was evaluated by various parameters like extrudability, spreadability, pH, viscosity, and antibacterial and antioxidant activities. Molecular docking was also performed using AutoDock.

Results

Among all formulated CT emulgels, F9 and F8 were optimized. Optimized formulations had shown good spreadability and extrudability characteristics. Sample F8 had % inhibition of 42.131 ± 0.335, 56.720 ± 0.222, and 72.440 ± 0.335 at different concentrations. Sample F9 had % inhibition of 26.312 ± 0.280, 32.461 ± 0.328, and 42.762 ± 0.398 at concentrations of 250 µg/ml, 500 µg/ml, and 1,000 µg/ml, respectively, which shows that both samples F8 and F9 have significant antioxidant potential. Optimized CT emulgels F8 and F9 had significant antibacterial activity against Staphylococcus aureus and Escherichia coli at p-value = 0.00, the Emulgel-F8 shows zone of inhibition of 24 mm for E-coli and 19 mm for S-aureus. Emulgel-F9 shows zone of inhibition of 22 mm for E-coli and 15 mm for S-aureus while pure CT- Oil extract shows zone of inhibition of 25 mm for E-coli and 20 mm for S-aureus and ciprofloxacin used as standard shows 36mm zone of inhibition against both E-coli and S-aureus. The comparative investigation through molecular docking binding affinities and interactions of ligands with various target proteins provides insights into the molecular processes behind ligand binding and may have significance for drug discovery and design for the current study.

Conclusion

The current study suggests that C. tinctorius L.-based emulgel has good antioxidant and antibacterial activities against E. coli for the treatment of bacterial skin infections.

Mimosa pudica mucilage nanoparticles of losartan potassium: Characterization and pharmacodynamics evaluation

The current research was to develop nanoparticles based on Mimosa pudica mucilage (MPM) that could encapsulate losartan potassium (LP). Nanoparticles (NPs) produced through ionic-gelation method; the polymerization of the mucilage carried out using calcium chloride as cross-linking agent. The MPMLP-NPs demonstrated vastly enhanced pharmaceutical characteristics, presented discrete surface with spherical shape of 198.4-264.6 nm with PDI ranging 0.326-0.461 and entrapment efficiency was in the range of 80.65 ± 0.82-90.79 ± 0.96%. FTIR and DSC indicated the stability of drug during the formulation of nanoparticles. An acute oral toxicity investigation found no significant alterations in behavior and histopathology criteria. The MPMLP-NPs formulation revealed the better rates and sustained effect as assessed with the commercial product. Moreover, low dose of MPMLP-NPs showed similar anti-hypertensive effect as assessed with the marketed tablet.

O050 A ten-year review of methodological trends and outcomes in riskreducing mastectomy and associated reconstruction at a tertiary referral centre

Introduction

Risk-reducing mastectomy (RRM) is the removal of breast tissue to substantially decrease the risk of developing breast cancer in individuals with higher breast cancer susceptibility due to strong family history or genetic mutations. This retrospective study evaluates cases of RRM, and subsequent reconstruction performed at a tertiary referral centre over the last decade, with emphasis on mastectomy and reconstructive trends.

Methods

A retrospective review of all cases of RRM performed between January 2010 and January 2020, divided into two groups corresponding to the first half (group 1) and second half (group 2) of the decade was conducted. Data collected included demographics, genetic test results, family and personal history of breast cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and complications.

Results

A total of 167 patients (group 1=76, group 2=91) underwent RRM, with a significant increase in cases of RRM despite negative genetic test results (p=0.047). The proportion of nipple sparing techniques for RRM compared to more traditional skin-sparing techniques. Concomitantly, post-RRM reconstruction has progressively become solely implant-based, to coincide with a rise in ADM usage. This is consistent with national trends towards fewer complex autologous procedures.

Take-home message

Emergent trends in risk-reducing mastectomy and reconstructive techniques are occurring against a background of broadened indications for RRM and more frequent patient requests for RRM in the absence of any documented pathogenic gene mutation. As breast surgery continues to evolve, it is important to evaluate specific trends such as more conservative forms of mastectomy and novel techniques/devices for breast reconstruction to ensure optimal patient care and levels of satisfaction.

Neuroendocrine tumors and Survival- a meta-analysis

Introduction/Objective

Neuroendocrine tumors (NET) are a rare group of epithelial neoplasm present in gastrointestinal tract (GI) (67.5%), bronchopulmonary tree (25.3-30%) and in 15% cases primary sites cannot be identified. Although endoscopic screening, improvement in pathological techniques and early detection have shown improvement in NET survival rates, the prognosis is very poor. In this study we aimed to evaluate the effect of Gastrointestinal pancreatic NETs (GEP NETs) grade on overall survival.

Methods/Case Report

We searched observational studies describing the overall survival or prognostic factors of primary GEP NETs from May 2011 -May 2021 following PRISMA guidelines. Studies describing the effect of primary grade 3 GEP NETs on overall survival were included. Meta-analysis was performed and pooled hazard ratio and their 95% confidence interval (95%CI) were obtained. The forest plots were created using random effects models and sensitivity analysis was performed to account for the heterogeneity.

Results (if a Case Study enter NA)

Seven studies with 7692 confirmed patients were included. In our meta-analysis grade 3 GEP NET were associated with higher odds of poor survival (pooled HR: 2.73; 95% CI: 1.36–5.47; p = 0.005), with 92% heterogeneity between studies (p < 0.0001). To account for heterogeneity, sensitivity analysis was performed by removing two outlying studies (Fathi et al. and Foubert et al.) on funnel plots. The results after sensitivity analysis did not change and still showed significant association of grade 3 with poor survival (pooled HR: 4.53; 95% CI: 3.54–5.78; p < 0.00001), with no heterogeneity between studies (p = 0.72; I2 = 0%).

Conclusion

Our meta-analysis found that grade 3 GEP NETs is associated with poor survival and additional future studies are needed to identify other risk factors associated with poor survival in GEP NETs to improve the mortality.

142 Surgical Treatment of Chronic Femoral and Tibial Osteomyelitis: A Scoping Review

Aim

The management of osteomyelitis, an inflammatory process of the bone that causes destruction and necrosis, is complex, and many authors report different techniques. This scoping review aims to identify and summarise literature on the management of chronic femoral and tibial osteomyelitis to further the reader’s understanding of potential management strategies and thereby explore areas for further research.

Method

The Joanna Briggs Institute methodological framework was used. PubMed, EMBASE, MEDLINE, Emcare and CINAHL searches were conducted for articles reporting the management of chronic osteomyelitis of the femur and tibia. Two reviewers independently screened the title/abstract and full text against the pre-defined criteria.

Results

Altogether, 1223 articles were identified and 52 were finally included. Various management strategies were reported, and the main principles shared across these strategies included antibiotic therapy, removal of infected tissue and management of dead-space. 75.45% of patients presented with stage III or IV disease, using the Cierny-Mader classification. The most commonly isolated organism was Staphylococcus aureus. The proportion of patients who achieved remission without recurrences during follow-up period ranged between 59.3% - 100.0%.

Conclusions

Excellent outcomes, in terms of remission and lack of recurrence, were reported in the majority of studies. It is clear that specific patient and treatment-related factors may affect outcomes but further high-level research such as randomized control trials are required to investigate this further.

1238 Surgical Management of Chronic Osteomyelitis of the Femur and Tibia: A Scoping Review

Aim

This scoping review aims to map and summarise the literature on treatment of chronic femoral and tibial osteomyelitis, in order to enhance the reader’s understanding of potential treatment options, whilst also identifying areas of future research

Method

This scoping review was guided by the methodological framework of the Joanna Briggs institute. A computer-based search was conducted in PubMed, EMBASE, MEDLINE, Emcare and CINAHL, for articles reporting treatment of chronic tibial/femoral osteomyelitis. Title/abstract and full text screening was performed independently by two reviewers according to pre-defined criteria.

Results

A total of 1223 articles were identified, with 40 studies, involving 2,489 patients being finally included. A range of treatments are reported, with the key reported principles being removal of infected tissue, dead-space management and antibiotic therapy. The majority (76.2%) of patients presented with stage III or IV disease according to the Cierny-Mader classification and the most commonly cultured pathogen was Staphylococcus aureus. The proportion of patients achieving remission with no recurrence during follow up varies from 72.0% - 100.0%.

Conclusions

The majority of studies report excellent outcomes in terms of infection remission and lack of recurrence. However, using the current literature to identify specific patient and treatment related factors which may affect treatment results is challenging due to a number of potential confounding factors. Further high-level research such as randomized control trials and comparative studies are required to achieve this.

266 The Effect of the COVID-19 Pandemic on Emergency Theatre Mortality, Time to Intervention and Length of Stay in the First Phase of National Lockdown at a District General Hospital

Aim

This study aimed to investigate the patient population requiring emergency surgery during the first phase of lockdown due to COVID-19 in the United Kingdom and compare it to the equivalent population in the same calendar period for 2019. Thus, we aimed to evaluate the impact of the pandemic on emergency operations.

Method

We retrospectively reviewed patients undergoing surgery in emergency theatres at our district general hospital between March 23^rd and May 11^th in 2019 and 2020. Data collected included demographics (age/gender), National Confidential Enquiry into Patient Outcome and Death (NCEPOD) category and operation. The primary outcome was 90-day post-operative mortality; secondary outcomes included time to intervention and length of inpatient stay.

Results

132 (2020) versus 141 (2019) patients were included with no significant difference in age (p = 0.676) nor sex (p = 0.230). There was no difference in overall 90-day postoperative mortality (p = 0.196). Notably, time to intervention was faster for NCEPOD code 3 patients in 2020 than in 2019 (p = 0.027). Time to intervention in 2020 was longer for those dying within 90 days post-operatively compared to survivors (p = 0.02). There was no difference in length of stay between the years, both overall and when conducting subgroup analyses by NCEPOD category or procedures (fractured neck of femur (p = 0.776), laparoscopies (p = 0.866), laparotomies (p = 0.252)), except for upper limb trauma (p = 0.007).

Conclusions

Patients were appropriately prioritised with no overall change in mortality or length of stay. A national validation audit assessing outcomes of emergency operations during these challenging times would further elucidate risks posed to surgical patients requiring urgent care.

169 Clinical Outcomes of Radial Head Arthroplasty as Primary Treatment for Post-traumatic Mason Type 3 and 4 Fractures: A Long-term Follow-up

Aim

Radial head arthroplasty (RHA) is the favoured treatment for complex radial head fractures, enabling functional restoration of elbow kinematics. However, study of long-term outcomes associated with RHA is largely neglected. This study aimed to fill the gap in the literature by firstly, assessing functional outcomes, and secondly, determining complications and rates of revision and/or removal of prosthesis associated with RHA, at our district general hospital.

Method

We retrospectively reviewed a consecutive single-surgeon series of patients receiving RHA as primary treatment for radial head fractures graded either 3 or 4 according to the Mason-Johnston classification between 2004 and 2009. Function at final follow-up was assessed using Quick Disabilities of the Arm, Shoulder and Hand (q-DASH) score and Mayo Elbow Performance Score (MEPS).

Results

16 patients identified; 12 available for final follow-up. Mean follow-up time of 12.60 years (range: 10.67-16.08). Mean q-DASH score of 8.2 (range: 0-34.1). Mean MEPS of 85.83 (range: 50-100) with 11 (91.67%) reporting excellent/good results. All complications occurred within the first year post-operatively. Stiffness was the most common (50%) complication, but additional procedures improved objective range of movement in affected patients. Only one patient required implant revision throughout follow-up, which was due to prosthesis subluxation in the first month.

Conclusions

This study is amongst the first to examine clinical outcomes associated with RHA with an average follow-up >12 years. Our results emphasise good functional restoration and low implant failure rate. Regular follow-up particularly in the early post-operative period is essential in detecting and resolving complications.

Elucidating antiviral activity of Curcuma longa against H9 N2 influenza virus using embryonated chicken egg model

Curcumin is a potent antimicrobial herb used traditionally as a spice in culinary. This study was designed to evaluate the antiviral effects of curcuma longa extract against H₉ influenza virus. A total of 60 embryonated eggs were equally divided into 5 groups with 12 eggs in each group. Group 1 (G1) served as uninfected negative control. Whereas Group 2 (G2) was kept as positive control infected with known virus @ 0.2 ml with 10^-9.3 EID₅₀. Group 3 (G3) was offered Curcuma longa @ 0.2 mg/0.2 ml and H₉N₂ virus (@ 0.2 ml with 10^-9.3 EID₅₀. Similarly, Group 4 (G4) was inoculated with extract of Curcuma longa @ 0.2 mg/0.2 ml per egg, whereas Group 5 (G5) was given Ribazole @ 0.2 ml/ egg. The crude extract and virus were administered on the 15^th day of incubation and were checked after every 24 hours up to 96th hour post inoculation by random selection of 3 eggs. Death and survival rate were noted in all groups. Gross and histopathological lesions were also observed. Results revealed that Curcuma longa extract had significantly (p<0.05) reduced the mortality rate of embryos infected with H₉N₂ virus. In G3, increased lymphocytes and mild fatty changes were seen in liver. Whereas, mature RBCs, plasma cells and some lymphoblast's were observed in Spleen. Similarly, the bursa follicles were with lymphocytic aggregation. The G4 (Curcuma longa) and G5 (Ribazole) were with maximum embryo survival after 48 and 72 h post inoculation. This study revealed potential antiviral activity of Curcuma longa against H9N2 influenza viruses and can be opted as alternative to antibiotics and antiviral drugs to minimize the antimicrobial resistance in human and animal population.

Application of surfactants as anticorrosive materials: A comprehensive review

Corrosion is the degradation of a metal due to its reaction with the environment. One of the most efficient ways of securing metal surfaces from corrosion is the use of corrosion inhibitors. Their efficacy is connected to their chemical composition, their molecular structures, and their adsorption affinities on the metal surface. This review article focuses on the prospects of different types of monomeric and gemini surfactants, mixed surfactants systems, surfactants- additives mixed systems, inhibitors-surfactants (as additives) mixed systems, and ionic liquid based surfactants as promising corrosion-inhibiting formulations in the aqueous phase and the role of surfactants in developing protective coatings. The analysis starts with an accurate overview of the characteristics, types, and structure-property-performance relationship of anti-corrosion formulations of such inhibitors.

Portrayal of Punica granatum L. peel extract through High Performance Liquid Chromatography and antimicrobial activity evaluation

Increasing trend in antimicrobial resistance and failure of chemically synthesized antibiotics lead to discover alternative methods for the treatment of bacterial infections. Various medicinal plants are in use traditionally and their active compounds can be further applied for treatment of bacterial diseases. This study was designed to determine the antibacterial activity of Punica granatum (P. granatum L.) (pomegranate) peel extract against Enterobacteriaceae [Escherichia coli (E. coli), Salmonella Typhimurium (S. Typhimurium) and Shigella Dysenteriae (S. Dysenteriae)] and gram-positive bacterium [Staphylococcus aureus (Staph aureus)]. Methanolic extract of P. granatum L. peel was prepared by Soxhlet apparatus method. Total flavonoid and phenolic contents from the extract were determined by High Performance Liquid Chromatography (HPLC). The antibacterial activity of P. granatum L. peel extract was evaluated through agar well diffusion method. HPLC showed the range of phenolics (gallic acid, caffeic acid, benzoic acid, cinnamic acid) and flavonoid compounds. The chemical structures of flavonoid and phenolics found in the methanolic extract of P. granatum L. peel have been reported for the first time. The methanolic peel extract (50 ul) of yellow P. granatum L. showed 26, 10, 10 and 9mm zones of inhibition (ZOI) against S. aureus, S. Typhimurium, S. Dysenteriae and E. coli, respectively. The methanolic extract of red P. granatum L. (100 ul) showed 27, 8, 12 and 15 mm ZOI against Staph. aureus, S. Typhimurium, S. Dysenteriae and E. coli, respectively. Highest ZOI was observed against Staph. aureus. Many of the bacteria studied in the present work may cause serious gastrointestinal infections, which can lead to hemorrhagic diarrhea in children. These infections can be life-threatening to young children and the elderly. There is an incentive to find alternative control measures, such as plant and herbal extracts, especially in lesser-developed countries where traditional antibiotics may not be readily available.

O33 Outcomes of patients undergoing emergency surgery during the first phase of national lockdown in the United Kingdom due to COVID-19 pandemic: experience at a district general hospital

Introduction

This study aimed to assess the impact of the COVID-19 pandemic on emergency operations during the first phase of lockdown in the United Kingdom, compared to the equivalent population in the same calendar period in 2019.

Method

We retrospectively reviewed patients undergoing surgery in emergency theatres at our district general hospital between March 23rd and May 11th in 2019 and 2020. Data collected included demographics, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) category and procedure. The primary outcome was 90-day post-operative mortality; secondary outcomes included time to intervention and length of inpatient stay.

Result

132 patients (2020) versus 141 (2019) patients were included with no significant difference in age (P = 0.676), sex (P = 0.230), or overall 90-day postoperative mortality (P = 0.196). Notably, time to intervention was faster for NCEPOD code 3 patients in 2020 than 2019 (P = 0.027). Time to intervention in 2020 was longer for those dying within 90 days post-operatively compared to survivors (P = 0.02). There was no difference in length of stay between years, both overall and when comparing subgroups by NCEPOD category or procedures (fractured neck of femur (P = 0.776), laparoscopies (P = 0.866), laparotomies (P = 0.252)), except for upper limb trauma (P = 0.007).

Conclusion

This study is amongst the first describing the general case mix in emergency theatres in the UK. Patient pre-operative characteristics and demographics did not change. Our data confirms patient prioritisation according to NCEPOD recommendations and streamlining of surgical services, with no difference in overall mortality, time to intervention or length of stay compared to 2019.

Take-home Message

At this district general hospital, patients were appropriately prioritised, and our results show adaptation of hospital practice to emerging national guidelines during the first phase of lockdown. A national validation audit assessing morbidity and mortality outcomes for all NCEPOD patients may be facilitate further understanding of risks posed to patients requiring urgent surgery during these unprecedented times.

Polyethylene imine conjugated supramolecular stereocomplexed nanomicelles for intracellular delivery of rifampicin against Mycobacterium bovis

The main objective of this study was to investigate polyethylene imine (PEI) based stereocomplexed nanomiceles for intracellular delivery of rifampicin against Mycobacterium bovis (M. bovis) and their in vitro-in vivo evaluation. The formation of Rifampicin (Rif) loaded isotactic (PEI-g-PLLA and PEI-g-PDLA) and stereocomplexed nanomicelles (StM) of PEI conjugated poly l- and poly d-lactic acid via self-assembly was thoroughly explored. Synthesis of polymer graft was confirmed via FTIR and NMR. A 2-fold reduction in CMC of StM was observed along with decreased particle size in comparison to isotactic nanomicelles. In vitro, StM exhibited a higher encapsulation efficiency and 84 % of drug release in 48 h. at pH 5 with minimal initial burst release in comparison to isotactic nanomicelles. Minimum inhibitory concentration (MIC) of StM was found to be four folds lower in contrast to isotactic nanomicelles. Ex vivo studies exhibited a better uptake of StM and minimum cytotoxicity in murine alveolar macrophages. Following oral administration in mice, drug loaded StM exhibited highest distribution in macrophage rich organs, longer half-life, AUC, AUMC and MRT in comparison to isotactic nanomicelles indicating maximum bioavailability and efficacy of StM. In vivo antimycobacterial activity also demonstrated a higher reduction (2.38fold) in M. bovis CFU at reduced dosing frequency by drug loaded StM in comparison to control group. Thus, StM can be regarded as a simple, stable, efficient, and biocompatible carrier system for delivery of rifampicin to intracellular M. bovis with added advantage of reduced dosing frequency and improved patient compliance.

OP0057 A PERSONALISED RITUXIMAB RETREATMENT APPROACH BASED ON CLINICAL AND B-CELL BIOMARKERS IN ANCA-ASSOCIATED VASCULITIS

Background:

Time-to-relapse after rituximab for ANCA-associated vasculitis (AAV) is variable and optimal retreatment strategy has been unclear. We previously showed that repopulation of naïve B-cells at 6 months predicts sustained response [1].

Objectives:

In AAV following rituximab induction, to evaluate clinical and B-cell predictors of relapse in order to develop a retreatment algorithm.

Methods:

An observational study was conducted in 60 rituximab-treated AAV patients followed for over 10 years. Complete response (CR) was defined as Birmingham Vasculitis Activity Score v3.0 = 0. Retreatment was given on clinical relapse, defined as new features or worsening of persistent disease (not by biomarker status). Peripheral B-cell subsets were measured using highly sensitive flow cytometry. Predictors were tested using multivariable Cox-Regression.

Results:

Median times-to-retreatment for rituximab cycles 1-5 were 87, 71, 65, 59 and 86 weeks. Over 417 patient-years follow-up, 137 relapses occurred in 50 patients; 16 (in 14 patients) were major (renal=7, neurological=4, ENT=3 and respiratory=2). The major-relapse rate was 3.8/100 patient-years. In multivariable analysis, concomitant immunosuppressant [HR 0.48 (95% CI 0.24–0.94)], achieving CR [0.24 (0.12–0.50)] and naïve B-cell repopulation at 6 months [0.43 (0.22–0.84)] were associated with longer time-to-relapse. Higher baseline memory B-cells [1.01 (1.00–1.02)] were associated with a shorter time-to-relapse. AUROC for prediction of time-to-relapse was greater if guided by naïve B-cell repopulation than if ANCA and/or CD19+ return at 6 months had been used, 0.82 and 0.52 respectively.

Conclusion:

These data suggest that all patients should receive concomitant oral immunosuppressant. Those with incomplete response or with absent naïve B-cells should be retreated at 6 months. Patients with complete response and naïve repopulation at 6 months should not receive fixed retreatment. This algorithm could reduce hypogammaglobulinaemia due to unnecessary retreatment.

Figure 1.

A personalised retreatment algorithm for rituximab in ANCA-associated vasculitis

References:

[1]Md Yusof et al. Annals of rheumatic diseases (2015) PMID: 25854586.

Disclosure of Interests:

Jack Arnold: None declared, Edward Vital Speakers bureau: Roche, GSK and AstraZeneca, Consultant of: Roche, GSK and AstraZeneca, Grant/research support from: Roche, GSK and AstraZeneca, Shouvik Dass Speakers bureau: Roche and GSK, Aamir Aslam: None declared, Andrew Rawstron: None declared, Sinisa Savic: None declared, Paul Emery Speakers bureau: BMS, Abbott, Pfizer, MSD, Novartis, Roche and UCB, Consultant of: BMS, Abbott, Pfizer, MSD, Novartis, Roche and UCB, Grant/research support from: Abbott, BMS, Pfizer, MSD and Roche., Md Yuzaiful Md Yusof: None declared

Should COVID-19 patients >75 years be Ventilated? An Outcome Study

BACKGROUND

Elderly patients with COVID-19 disease are at increased risk for adverse outcomes. Current data regarding disease characteristics and outcomes in this population are limited.

AIM

To delineate the adverse factors associated with outcomes of COVID-19 patients ≥75 years of age.

DESIGN

Retrospective cohort study.

METHODS

Patients were classified into mild/moderate, severe/very severe and critical disease (intubated) based on oxygen requirements. The primary outcome was in-hospital mortality.

RESULTS

A total of 355 patients aged ≥75 years hospitalized with COVID-19 between 19 March and 25 April 2020 were included.Mean age was 84.3 years. One-third of the patients developed critical disease. Mean length of stay was 7.10 days. Vasopressors were required in 27%, with the highest frequency in the critical disease group (74.1%). Overall mortality was 57.2%, with a significant difference between severity groups (mild/moderate disease: 17.4%, severe/very severe disease: 71.3%, critical disease: 94.9%, P < 0.001).Increased age, dementia, and severe/very severe and critical disease groups were independently associated with increased odds for mortality while diarrhea was associated with decreased odds for mortality (OR: 0.12, 95% CI: 0.02-0.60, P < 0.05). None of the cardiovascular comorbidities were significantly associated with mortality.

CONCLUSION

Age and dementia are associated with increased odds for mortality in patients ≥75 years of age hospitalized with COVID-19. Those who require intubation have the greatest odds for mortality. Diarrhea as a presenting symptom was associated with lower odds for mortality.

COVID-19 pandemic did not affect emergency theatre patient demographic and length of stay in the first phase of UK countrywide lockdown in a district general hospital

INTRODUCTION

We aim to identify any changes in outcome for patients undergoing nonelective surgery at the start of the UK pandemic in our district general hospital. This was a single-centre retrospective cohort review of a UK district general hospital serving a population of over 250,000 people.

METHODS

Participants were all patients undergoing a surgical procedure in the acute theatre list between 23 March to 11 May in both 2019 and 2020. Primary outcome was 90-day postoperative mortality. Secondary outcomes include time to surgical intervention and length of inpatient stay.

RESULTS

A total of 132 patients (2020) versus 141 (2019) patients were included. Although overall 90-day postoperative mortality was higher in 2020 (9.8%) compared with 2019 (5.7%), this difference was not statistically significant (p=0.196). In 2020, eight patients tested positive for COVID-19 either as an inpatient or within 2 weeks of discharge, of whom five patients died. Time to surgical intervention was significantly faster for NCEPOD (National Confidential Enquiry into Patient Outcome and Death) code 3 patients in 2020 than in 2019 (p=0.027). There were no significant differences in mean length of inpatient stay.

CONCLUSIONS

We found that patients were appropriately prioritised using NCEPOD classification, with no statistically significant differences in 90-day postoperative mortality and length of inpatient stay compared with the 2019 period. A study on a larger scale would further elucidate the profile and outcomes of patients requiring acute surgery to generate statistical significance.

63 Chronic Femoral Osteomyelitis Case Series: Outcomes and Economic Impact at A United Kingdom Based Tertiary Centre

Introduction

Osteomyelitis refers to an inflammatory process affecting bone and bone marrow. This study reviews chronic femoral osteomyelitis treatment and outcomes, including economic impact.

Method

We retrospectively collected data from a consecutive series of 14 chronic femoral osteomyelitis patients treated between January 2013 and January 2020. Data collected include patient demographics, comorbidities, pathogens, complications, treatment protocol and costs. Functional outcome was assessed using EuroQOL five-dimensional interview administration questionnaire (EQ-5D-5L™) and EuroQOL Visual Analogue Scale (EQ-VAS™).

Results

Of these, 92.9% had one or more osteomyelitis risk factor, including smoking and diabetes. Samples from 78.6% grew at least one pathogen. Only 42.9% achieved remission after initial treatment, but 85.7% were in remission at final follow-up, with no signs of recurrence throughout the follow-up period (mean: 21.4 months). The average treatment cost was £39,249.50 with a net mean loss of £19,080.10 when funding was considered. The mean-derived EQ-5D score was 0.360 and the mean EQ-VAS score was 61.7, lower than their values for United Kingdom’s general population, p = 0.0018 and p = 0.013 respectively.

Conclusions

Chronic femoral osteomyelitis treatment is difficult, resulting in significant economic burden. With previous studies showing cheaper osteomyelitis treatment at specialist centres, our net financial loss incurred suggests the need for management at specialised centres.

125 The Fate of The Third Molar in The Line of a Mandibular Angle Fracture: A Retrospective Study at A Tertiary Centre

Aim: To evaluate the risk of complications associated with retaining or extracting an asymptomatic third molar in the line of an angle fracture. Aiming to seek a consensus whether third molars should be extracted or retained during surgical repair of mandibular angle fractures.

Method

A retrospective study was undertaken at the Queen Elizabeth Hospital, Birmingham. 150 patients across a span of three years underwent open reduction and internal fixation of mandibular angle fractures with third molar involvement. Patients were classified into two groups, tooth retention during angle fracture and tooth removal during angle fracture repair. Hospital records were evaluated to seek the rate of post-operative complications at follow-up

Results

162 angle fractures were identified with ipsilateral wisdom teeth present. In 37 cases the wisdom tooth was removed during surgery. 6 complications (16.2%) occurred in this group necessitating a return to theatre. In 125 cases the wisdom tooth was left in-situ. Complications necessitating a return to theatre occurred in 14 cases (11.1%).

Conclusions

This study indicates that retention of wisdom tooth overall did not significantly increase the risk of complications associated with angle fractures (p = 0.42). Where wisdom tooth pathology was noted its retention was associated with complications requiring a return to theatre (X2=4.40, p = 0.036).

Effects of different combinations of N, P and K at different time interval on vegetative, reproductive, yield and quality traits of mango (Mangifera Indica. L) cv. Dusehri

The experiment was carried out on mango cv. Dusehri to investigate the effect of N, P and K fertilizers on vegetative, reproductive growth, yield and fruit quality. Eight different fertilizer combinations such as T1 (control), T2 (N), T3 (P), T4 (K), T5 (NP), T6 (NK), T7 (PK) and T8 (NPK) were used. Individual or combine fertilizer application of N (1000 g), P (750 g) and K (750 g) were applied during growing season in February and August. All the treatments significantly influenced on vegetative growth, flowering, fruiting, yield and other physiochemical attributes of mango as compared to control. Least effect was observed with individual fertilizer application while combine fertilizer treatments enhanced most of the investigated parameters. Especially, qualitative traits showed non-significant differences between treated and untreated mango trees. However, among the different treatments T8 (NPK) showed significance for fruiting aspects such as maximum size of growth flushes (177.51 mm), total number of panicles/tree (845), total number of flowers/panicle (974), sex ratio (69.18%), fruit retention (13.85%), total number of fruits/tree (379), yield (82 kg/tree), fruit weight (197.5 g), pulp weight (135.5 g) and physiochemical parameters namely TSS (24.53), Vit. C (57.63 mg/100 mL) and total sugar (20.84%). In general, combine application of NPK (T8) were the most effective in enhancing fruiting aspects, yield, physiochemical characteristics as well as improved fruit quality of mango trees.

Rootstock mediates transcriptional regulation of citrulline metabolism in grafted watermelon

Citrulline is a non-essential amino acid, involved in key biological functions in plants and humans. Rootstocks have a major impact on citrulline accumulation in grafted watermelon. Information regarding rootstock induced changes in citrulline metabolism is elusive. To understand the regulatory mechanism, parallel changes in the expression profiles of citrulline metabolic genes and citrulline content of watermelon were monitored during the development of self-rooted watermelon and watermelon grafted onto pumpkin, wild and bottle gourd rootstocks. Results demonstrated that rootstocks regulated the expression profiles in different ways to influence the citrulline content. GAT, NAGPR, ASS3 ASS2 and Asl2 showed the negative correlation with citrulline content in pumpkin grafted watermelon. Pumpkin rootstock promoted the citrulline content by high down-regulation and synergistic effect of ASS2, ASS3, ASL1 and ASl2 genes. In wild grafted watermelon, citrulline was accumulated as a result of down regulation of GAT, NAGS and ASL2 genes, which showed an inverse correlation with citrulline. In gourd grafted watermelon, changes in citrulline content were observed to be linked with lower expressions of GAT, NAGK, ASS2, ASS3, ASL1 and ARG which were negatively correlated with citrulline content. Our study will provide the basis to understand the molecular mechanism of citrulline accumulation in various rootstocks.

Perspective of Covid-19 pandemic in South Asian countries

COVID-19 is rapidly spreading throughout the world since December 2019. It has hit South Asian countries with faded impact, which can be attributed to (a) availability of kits, (b) number of people tested for COVID-19, (c) immunity, (d) environmental conditions and (e) vaccination.

Genotypic correlation between post discharge Clostridiodes difficle infection (CDI) and previous unit-based contacts

BACKGROUND

Cases of Clostridiodes difficile infection (CDI) diagnosed after hospital discharge account for a substantial proportion of new infections. It is unclear whether post-discharge infections originate from hospital-based transmission.

METHODS

This was a Retrospective cohort study at a tertiary-care cancer center (non-outbreak setting). For all laboratory-identified cases of CDI in 2015-2016, patients with post-discharge (PD) CDI within eight weeks of their hospital stay were included in the study. Isolates from PD-CDI cases and their CDI-positive unit-based contacts were first genotyped by multilocus sequence typing (MLST). Common strains were further examined by core genome sequencing (CGS) to evaluate transmission links.

RESULTS

Of 173 cases examined by MLST, 50% of PD cases matched previous unit contacts. Next, 34 isolates, including 16 PD cases and their 18-unit contacts were examined by CGS. None were ≤3 single-nucleotide variants apart. Seventy percent of PD cases had in-hospital antibiotic exposure before CDI onset in the community.

CONCLUSION

Our study results suggest that symptomatic CDI cases are not a substantial source of transmission to PD cases. Frequent antibiotic exposure in post-discharge CDI cases is an important target for surveillance and stewardship efforts.

Outcomes in patients with severe COVID-19 disease treated with tocilizumab: a case-controlled study

BACKGROUND

COVID-19 is an ongoing threat to society. Patients who develop the most severe forms of the disease have high mortality. The interleukin-6 inhibitor tocilizumab has the potential to improve outcomes in these patients by preventing the development of cytokine release storm.

AIMS

To evaluate the outcomes of patients with severe COVID-19 disease treated with the interleukin-6 inhibitor tocilizumab.

METHODS

We conducted a retrospective, case-control, single-center study in patients with severe to critical COVID-19 disease treated with tocilizumab. Disease severity was defined based on the amount of oxygen supplementation required. The primary endpoint was the overall mortality. Secondary endpoints were mortality in non-intubated patients and mortality in intubated patients.

RESULTS

A total of 193 patients were included in the study. Ninety-six patients received tocilizumab, while 97 served as the control group. The mean age was 60 years. Patients over 65 years represented 43% of the population. More patients in the tocilizumab group reported fever, cough and shortness of breath (83%, 80% and 96% vs. 73%, 69% and 71%, respectively). There was a non-statistically significant lower mortality in the treatment group (52% vs. 62.1%, P = 0.09). When excluding intubated patients, there was statistically significant lower mortality in patients treated with tocilizumab (6% vs. 27%, P = 0.024). Bacteremia was more common in the control group (24% vs. 13%, P = 0.43), while fungemia was similar for both (3% vs. 4%, P = 0.72).

CONCLUSION

Our study showed a non-statistically significant lower mortality in patients with severe to critical COVID-19 disease who received tocilizumab. When intubated patients were excluded, the use of tocilizumab was associated with lower mortality.

Prevalence and molecular detection of contagious bovine pleuropneumonia in large ruminants in Punjab, Pakistan

Contagious bovine pleuropneumonia (CBPP) is a highly contagious disease of cattle caused by Mycoplasma mycoides subsp. mycoides. It is characterized by anorexia, fever, dyspnea, polypnea, cough, and nasal discharges. Gross lesions in the lung such as marbling, sequestra, thickening of interlobular septa, and consolidation are evident. Serological tests including complement fixation test and competitive enzyme-linked immunosorbent assay and molecular tests such as polymerase chain reactions are used for diagnostic purposes. In this study, lung samples of suspected large ruminants (cattle n=560, buffalo n=293) were collected from abattoirs of three districts of Punjab namely Lahore, Kasur and Jhang. PCR was performed with specific primers, targeting the 16S ribosomal RNA gene to detect the positive cases. The results indicated that 49 samples (8.75%) of cattle were positive, with maximum prevalence was observed in Jhang with 16 positive samples (10.06%), but CBPP was not detected in any buffalo sample. High prevalence of disease was seen in cattle of more than seven years of age, in female cattle, and in cross-bred cattle. Age and gender were found significantly associated (P<0.05) with the prevalence of the disease. Gene sequencing of identified 5 isolates of Mycoplasma mycoides subsp. mycoides had more than 99% similarities with the strains isolated from China, Italy, Australia and Tanzania and were categorized into a monophyletic group but strain isolated from Portugal had more than 55% variable regions, hence clustered separately. This study confirms the presence of contagious bovine pleuropneumonia in the country which can be a threat to the livestock export market and warrants the implementation of control measures to mitigate the economic losses associated with the disease.

Histopathological Investigation of Skin and Hides Damage of Small and Large Ruminants due to Naturally Infested Ticks

Ticks are important ectoparasites which transmit many disease pathogen to animals; these are labelled tick borne diseases (TBD). Tick induced damage to skin and hides has not received attention. Skin and hides are important for the leather product industry, particularly in Pakistan. Due to economic importance and financial loss by ticks in leather industry, the present study was designed to investigate skin and hides damage due to ticks at microscopic level. Naturally tick infested tissue samples of hides and skin were collected from slaughter houses. Primary lesions at tick feeding sites showed epidermal edema with adjacent dermal edema. Histopathological examination revealed degeneration of epidermal layer down to the basal layer. Epidermal and sub dermal layers often displayed focal necrosis infiltrated with neutrophils and mononuclear cells at tick bite sites. Hyperplasia of keratinocytes was also seen at sites of ruptured epidermis. Quality of leather depends upon the grain (Outer) surface skin/hides. Ticks infestation damages the outer surface, due to bites, inflammatory responses, and secondary bacterial infections that often become established at feeding sites. Control of ticks should be given consideration to reduce infestation induced losses in the leather industry in Pakistan.

Pathogenesis and tissue tropism of Newcastle disease virus and avian influenza virus (H9N2) in single and mixed infections

Newcastle disease (ND) and avian influenza (AI) are globally considered as a serious threat to the chicken and other avian species. The paramyxovirus type 1 and orthomyxovirus type A are RNA viruses, which cause ND and AI infection, respectively.

Long-term outcomes of saline boluses in very preterm infants

BACKGROUND

Normal saline bolus is commonly used in clinical practice for treating hypotension in very preterm infants during resuscitation at an early age despite the paucity of high quality evidence supporting this practice.

OBJECTIVES

To determine the effects of early (<7 days after birth) saline boluses given to very preterm infant (VPI) from 23 to 31 weeks GA.

METHOD

This is a population-based cohort analysis of the use of normal saline boluses given to VPI. The outcomes were extracted from the Perinatal Follow-Up Program Database which included all VPI from Halifax County admitted to the NICU at the IWK Health Centre, Halifax, Nova Scotia, Canada between January 2006 to December 2010. We excluded infants with major congenital anomalies and those not offered resuscitation in the delivery room. Our primary outcome was the composite of death or disability by 18-36 months while secondary outcomes were neonatal death, BPD, CP, IVH, PVL, ROP, BSITD III (Bayley Scales of Infant and Toddler Development®, Third Edition) Cognitive, Motor and Language score.

RESULTS

Death or disability in those who received saline bolus occurred in 15 (53.6%) compared with 9 (32.1%) in non saline group. Significantly higher rates of CP (p = 0.04), lower scores on the BSITDIII for motor (p = 0.04) and language scales (p = 0.03) were noted for infants who received saline boluses. Cognitive scores approached significance (p = 0.05) with lower scores in the saline bolus group.

CONCLUSION

Significant differences were found between the two groups in terms of long term neurodevelopmental outcome and one of the short-term outcome (i.e. BPD). Given the limitations of this retrospective study and the small sample size, a larger cohort from Canadian Neonatal Network database is warranted to evaluate the effects of using normal saline boluses during early life on neurodevelopmental.

Efficacy of commercial vaccines against the prevalent strains of Newcastle disease and avian influenza (h9n2) infections in broilers in Pakistan

TThe efficacy of the two commonly used commercial vaccines for Newcastle disease (ND) and low path avian influenza (LPAI) H9N2 were evaluated against field virus in broiler chicks. One hundred one-dayold commercial broiler chicks were divided into four groups (A to D) with an equal number of birds per group. Group A and B were vaccinated against H9N2 and NDV, respectively, at day 7 of age while group C served as positive infected control for H9N2 and group D for NDV. Serum samples from birds in all groups were tested for presence of antibodies against H9N2 and NDV at day 21 of age. Subsequently, on day 28 of age, groups A and C were challenged with the field strain of H9N2 virus, and Group B and D with NDV. Birds were monitored for a period of 2 weeks for development of any clinical signs and mortality. The geometric mean titer were high in groups A (4.90) and B (7.3), and low in the unvaccinated groups C (0.7) and D (1.1). The highest and lowest value of H9N2 antibody titer detected through ELISA were 1.498 and 0.502, respectively. The S/P ratios greater than 0.5 were considered positive. The highest and lowest value for NDV antibody titer detected through ELISA were 783 and 882, respectively. Serum samples with titer greater than 396 were considered positive and indicated vaccination or other exposure to NDV. On histological examination severe congestion, necrosis, degeneration, hemorrhages and leukocyte infiltration were observed in intestine, lungs, trachea and bursa of Fabricius of the non-vaccinated group post-infection. Mild tissues changes were observed in the vaccinated group. It can be concluded from the findings that the commonly used commercial vaccines may provide effective protection against the circulating H9N2 and ND virus in broiler birds by producing protective antibody titer.

Targeting of BCR-ABL: Lessons learned from BCR-ABL inhibition

In 1960 researchers reported that balanced translocation between chromosomes 22 and 9 resulted in the generation of Philadelphia chromosome. This breakthrough revolutionized our knowledge related to leukemia biology and contemporary studies revealed that chromosomal translocation resulted in the fusion between the 5' segment of BCR gene and 3' segment of the ABL gene to form BCR/ABL fusion gene. Research over the years has progressively and systematically improved our understanding of the genetic and proteomic basis of Leukemia. Genome-wide profiling studies, including genome sequencing and microarray analysis, have helped us in identification of different intracellular signaling cascades that are frequently mutated in Leukemia.  We partition this multi-component review into different sections related to biochemical characteristics of BCR-ABL+ cells, underlying mechanism of generation of mutations and crosstalk of BCR-ABL with various intracellular signaling cascades. We also summarize how BCR-ABL encoding mRNA is negatively regulated by different miRNAs and the strategies which are currently being used to effectively target BCR-ABL protein. We also provide an overview of the natural products which have been used for targeting of BCR-ABL protein. Better understanding of the protein network of Philadelphia positive leukemic cells will prove to be helpful in getting a step closer to personalized medicine.