Small Peptides Targeting BACE-1, AChE, and A-β Reversing Scopolamine-Induced Memory Impairment: A Multitarget Approach against Alzheimer's Disease

Based on the biochemical understanding of Alzheimer's disease, here, we report the design, synthesis, and biological screening of a series of compounds against this neuro-disorder. Adopting the multitarget approach, the catalytic processes of BACE-1 and AChE were targeted, and thereby, compounds 15, 22, 25, 26, 27, and 30 were identified with IC50 in the submicromolar range against these two enzymes. Further, compounds 15 and 25 displayed more than 50% inhibition of β-amyloid aggregation. Implying their physiological use, the compounds exhibited appreciable biological membrane permeability as observed through the parallel artificial membrane permeability experiment. Supporting these results, treatment of the mice with the test compounds reversed their scopolamine-affected memory impairment, where the highest healing effect was seen in the case of compound 25. Overall, the combination of molecular modeling and experimental studies provided highly effective molecules against Alzheimer's disease.

Design and Discovery of Novel NLRP3 Inhibitors and PET Imaging Radiotracers Based on a 1,2,3-Triazole-Bearing Scaffold

The NOD-like receptor (NLR) family pyrin-domain-containing 3 (NLRP3) inflammasome, an essential component of the innate immune system, has been emerging as a viable drug target and a potential biomarker for human diseases. In our efforts to develop novel small molecule NLRP3 inhibitors, a 1-(5-chloro-2-methoxybenzyl)-4-phenyl-1H-1,2,3-triazole scaffold was designed via a rational approach based on our previous leads. Structure-activity relationship studies and biophysical studies identified a new lead compound 8 as a potent (IC50: 0.55 ± 0.16 μM), selective, and direct NLRP3 inhibitor. Positron emission tomography (PET) imaging studies of [11C]8 demonstrated its rapid and high brain uptake as well as fast washout in mice and rhesus macaque. Notably, plasma kinetic analysis of this radiotracer from the PET/magnetic resonance imaging studies in rhesus macaque suggested radiometabolic stability. Collectively, our data not only encourage further studies of this lead compound but also warrant further optimization to generate additional novel NLRP3 inhibitors and suitable central nervous system PET radioligands with translational promise.

Axitinib in patients with advanced/metastatic soft tissue sarcoma (Axi-STS): an open-label, multicentre, phase II trial in four histological strata

BACKGROUND

Axitinib is an oral vascular endothelial growth factor receptor inhibitor with anti-tumour activity in renal, thyroid, and pancreatic cancer.

METHODS

Axi-STS was a pathologically-stratified, non-randomised, open-label, multi-centre, phase II trial of continuous axitinib treatment in patients ≥16 years, performance status ≤2, with pathologically-confirmed advanced/metastatic soft tissue sarcoma (STS). Patients were recruited within four tumour strata, each analysed separately: angiosarcoma, leiomyosarcoma, synovial sarcoma, or other eligible STSs. The primary outcome was progression-free survival at 12 weeks (PFS12). A Simon's two-stage design with activity defined as PFS12 rate of 40% determined a sample size of 33 patients per strata.

RESULTS

Between 31-August-2010 and 29-January-2016, 145 patients were recruited: 38 angiosarcoma, 37 leiomyosarcoma, 36 synovial sarcoma, and 34 other subtypes. PFS12 rate for each stratum analysed was 42% (95% lower confidence interval (LCI); 29), 45% (95% LCI; 32), 57% (95% LCI; 42), and 33% (95% LCI; 21), respectively. There were 74 serious adverse events including two treatment-related deaths of pulmonary haemorrhage and gastrointestinal bleeding. Fatigue and hypertension were the most common grade 3 adverse events.

CONCLUSIONS

Axitinib showed clinical activity in all STS strata investigated. The adverse event profile was acceptable, supporting further investigation in phase III trials.

CLINICAL TRIAL REGISTRATION

ISRCTN 60791336.

Germ cell cancer in pregnancy - Successfully treated with chemotherapy and surgery

A 31-year-old primigravida, with spontaneous singleton pregnancy, presented in 21 weeks of gestation with abdominal pain. Abdominal ultrasound (USS) and Magnetic Resonance Imaging (MRI) showed a 12 × 14cm large complex lesion arising from the right ovary suspicious for an ovarian malignancy. The radiological staging demonstrated no further metastatic disease; however, it also revealed a 6 cm lesion in the contralateral ovary, consistent with a dermoid cyst. After tumour board discussion the patient underwent a mid-line laparotomy with right oophorectomy, cytology, and peritoneal and omental staging, under oral tocolysis with indomethacin. The left presumed ovarian dermoid was left in situ to avoid additional surgical and obstetrical morbidity. Histology confirmed a grade 3 immature teratoma with primitive neuroepithelium focally present on the capsular surface and atypical cells in the cytology amounting to a stage 1 C2 disease at least. Due to high-risk disease, she was offered adjuvant treatment. The patient received one cycle of intravenous paclitaxel, etoposide, and cisplatin chemotherapy, in an adjuvant setting. She underwent an elective caesarean section at 36 weeks, with the safe delivery of a healthy baby girl. After 6 weeks of her delivery, she received three further cycles of etoposide, and cisplatin to complete her course of adjuvant chemotherapy. Three months after the last chemotherapy cycle, she underwent a laparoscopic removal of the left ovarian dermoid that had increased in size to 8 cm. Final histology revealed no immature elements. To this point, 2 years after initial diagnosis, both mother and child are healthy with no long-term complications. The patient has resumed her normal menstrual cycle and being in remission, she wishes soon to try for a second child. To our knowledge, this is the only reported case of ovarian immature teratoma in pregnancy treated successfully with surgery and adjuvant iv paclitaxel, etoposide, and cisplatin chemotherapy regime.

Improving neonatal health with family-centered, early postnatal care: A quasi-experimental study in India

Despite the global decline, neonatal mortality rates (NMR) remain high in India. Family members are often responsible for the postpartum care of neonates and mothers. Yet, low health literacy and varied beliefs can lead to poor health outcomes. Postpartum education for family caregivers, may improve the adoption of evidence-based neonatal care and health outcomes. The Care Companion Program (CCP) is a hospital-based, pre-discharge health training session where nurses teach key healthy behaviors to mothers and family members, including skills and an opportunity to practice them in the hospital. We conducted a quasi-experimental study to assess the effect of the CCP sessions on mortality outcomes among families seeking care in 28 public tertiary facilities across 4 Indian states. Neonatal mortality outcomes were reported post-discharge, collected via phone surveys at four weeks postpartum, between October 2018 to February 2020. Risk ratios (RR), adjusting for hospital-level clustering, were calculated by comparing mortality rates before and after CCP implementation. A total of 46,428 families participated in the pre-intervention group and 87,305 in the post-intervention group; 76% of families completed the phone survey. Among the 33,599 newborns born before the CCP implementation, there were 1386 deaths (NMR: 41.3 deaths per 1000 live births). After the intervention began, there were 2021 deaths out of 60,078 newborns born (crude NMR: 33.6 deaths per 1000 live births, RR = 0.82, 95% CI: 0.76, 0.87; cluster-adjusted RR = 0.82, 95% CI: 0.71, 0.94). There may be a substantial benefit to family-centered education in the early postnatal period to reduce neonatal mortality.

Can training over phone calls help improve outcomes for COVID-19 positive patients under home isolation? An analysis of the COVID-19 Care Companion Program in Punjab, India

Background

Phone-supported recovery of COVID-19 patients in home isolation could be an effective way of addressing COVID-19 in contexts with limited resources. The COVID-19 Care Companion Program (CCP) is one such intervention, designed to support patients and their caregivers in remote, evidence-based management of COVID-19 symptoms.

Objective

To estimate the effect of providing phone-based training to COVID-19 patients and their caregivers on the likelihood of hospitalizations and mortality.

Methods

A pragmatic randomized trial was conducted to assess the effect of a novel phone-based training program on COVID-19 home-isolated patient outcomes. The analysis compared the outcomes of death and hospitalizations in the teletraining intervention group (CCP) to those receiving standard of care (SoC).

Results

Logistic regression models adjusted for age, gender, education, occupation, and poverty, as measured by family possession of Below Poverty Line (BPL) card, were used to look at the effect of intervention on hospitalization and mortality. While the CCP intervention had no effect on 21-day mortality (OR 0.64; 95% CI, 0.19 to 2.12), it was associated with a 48% reduction in 21-day hospitalization (OR 0.52; 95% CI, 0.31 to 0.90).

Conclusion

COVID-19 CCP teletraining intervention reduced the rate of hospitalization, potentially reducing the burden on hospitals.

Alzheimer's Disease: Treatment of Multi-Factorial Disorders with Multi- Target Approach

Alzheimer's Disease (AD) is a common neurodegenerative disorder that is almost incurable with the existing therapeutic interventions. Due to the high-risk factors associated with this disease, there is a global pursuit of new anti-AD agents. Herein, we explore the biochemical pathways which are responsible for the initiation/propagation of the disease. It is observed that out of the two isoforms of β-secretase, β-site amyloid precursor protein cleaving enzyme 1 (BACE1) and β-site amyloid precursor protein cleaving enzyme 2 (BACE2) present in the brain, BACE1 plays the predominant role in the commencement of AD. Moreover, the catalytic activities of acetylcholinesterase and butyrylcholinesterase regulate the concentration of neurotransmitters, and they are needed to be kept under control during the signs of AD. Hence, these two enzymes also serve as potential targets for the treatment of AD patients. Keeping in view the multifactorial nature of the disease, we also reviewed the multitarget approach for the treatment of AD. It is tried to identify the common structural features of those molecules which act on different cellular targets during AD therapy.

A patent review of NLRP3 inhibitors to treat autoimmune diseases

INTRODUCTION

NOD-like receptor family pyrin domain containing 3 (NLRP3) can sense a plethora of exogenous and endogenous dangers. Upon activation, a multimeric protein complex, the NLRP3 inflammasome, is formed to initiate the innate immune responses. Emerging studies have implicated the pathophysiological roles of this protein complex in human disorders, highlighting that it represents a druggable target for therapeutics development.

AREAS COVERED

The current review summarizes the functional facets of the NLRP3 inflammasome, its association with autoimmune diseases, and recent patents on the development of NLRP3 inhibitors. Literature search was conducted using SciFinder and Google Patents with the key word NLRP3 and NLRP3 inhibitors.

EXPERT OPINION

Although significant advances have been made in understanding the NLRP3 inflammasome, more studies are still needed to elucidate the molecular mechanisms underlying its roles in autoimmune diseases. A number of NLRP3 inhibitors have been patented, however, none of them have been approved for clinical use. Due to the complex nature of the NLRP3 inflammasome, novel screening assays along with target engagement methods could benefit the drug discovery and clinical translation. In addition, clinical trials on NLRP3 inhibitors are still in their early stages, and continuous investigations are needed to fully assess their safety and effectiveness.

Garg scoring system to predict long-term healing in cryptoglandular anal fistulas: a prospective validation study

Purpose

Complex anal fistulas can recur after clinical healing, even after a long interval which leads to significant anxiety. Also, ascertaining the efficacy of any new treatment procedure becomes difficult and takes several years. We prospectively analyzed the validity of Garg scoring system (GSS) to predict long-term fistula healing.

Methods

In patients operated for cryptoglandular anal fistulas, preoperative magnetic resonance imaging (MRI) and postoperative MRI was done at 3 months to assess fistula healing. Scores as per the GSS were calculated for each patient at 3 months postoperatively and correlated with long-term healing to check the accuracy of the scoring system.

Results

Fifty-seven patients were enrolled, but 50 were finally included (7 were excluded). These 50 patients (age, 41.2± 12.4 years; 46 males) were followed up for 12 to 20 months (median, 17 months). Forty-seven patients (94.0%) had complex fistulas, 28 (56.0%) had recurrent fistulas, 48 (96.0%) had multiple tracts, 20 (40.0%) had horseshoe tracts, 15 (30.0%) had associated abscesses, 5 (10.0%) were suprasphincteric, and 8 (16.0%) were supralevator fistulas. The GSS could accurately predict long-term healing (specificity and high positive predictive value, 31 of 31 [100%]) but was not very accurate in predicting non-healing (negative predictive value, 15 of 19 [78.9%]). The sensitivity in predicting healing was 31 of 35 (88.6%).

Conclusion

GSS accurately predicts long-term fistula with a high positive predictive value (100%) but is less accurate in predicting non-healing. This scoring system can help allay anxiety in patients and facilitate the early validation of innovative procedures for anal fistulas.

Non-Locatable Internal Opening in Anal Fistula Associated with Acute Abscess and Its Definitive Management by Garg Protocol

Background

Definitive management of acute fistula-abscess (anal fistulas associated with acute abscess) is gaining popularity against the two-staged approach (early abscess drainage with deferred fistula management). However, locating an internal opening (IO) in acute fistula-abscess can be difficult. A recent protocol (Garg protocol) has been shown to be effective in managing anal fistulas with non-locatable IO.

Purpose

To test the efficacy of the Garg protocol in managing acute fistula-abscess with non-locatable IO.

Methods

Patients with acute fistula-abscess operated by a definitive procedure were included. A preoperative MRI was done in all patients. Patients in whom the IO was non-locatable after clinical, MRI, and intraoperative examination were managed by the three-step Garg protocol. Garg protocol: 1) Reassessment of MRI; 2) In non-horseshoe fistulas, the IO was assumed to be at the point where the fistula tract reached closest to the sphincter-complex; 3) In horseshoe fistulas, the IO was assumed to be located in the midline (anterior or posterior as per the horseshoe location). Low fistulas were treated by fistulotomy and high fistulas by a sphincter-sparing procedure. The long-term healing rate and change in continence (Vaizey scores) were evaluated.

Results

A total of 201 patients with acute fistula-abscess were operated over six years, and 19 were lost to follow-up. A total of 182 patients (154-males) were followed up (median-37 months). The IO was locatable in 133/182 (73.1%) (control group) and was non-locatable in 49/182 (26.9%) (study group). The study group was managed as per the Garg protocol. The age, sex-ratio, and fistula parameters were comparable in both groups. The long-term healing rate was 112/133(84.2%) in the IO-locatable group and 43/49 (87.8%) in the IO-non-locatable group (p=0.64, not-significant). The objective continence scores did not change significantly after surgery in both groups.

Conclusion

Acute fistula-abscess with non-locatable IO can be managed successfully by the Garg protocol without any risk of incontinence.

Incontinence after fistulotomy in low anal fistula: Can Kegel exercises help improve postoperative incontinence?

AimFistulotomy is the commonest procedure performed for low anal fistulas. The incidence of gas and urge incontinence after fistulotomy and whether Kegel exercises (KE) could help recover sphincter function after fistulotomy has not been studied before. Methods Patients operated by fistulotomy for low fistulas were recommended KE (pelvic contraction exercises) 50 times/day for one year postoperatively. Incontinence (solid, liquid, gas and urge) was evaluated objectively (Vaizeys scores) preoperatively [Pre-op Group], in the immediate postoperative period [Pre-KE Group] and at 6-months follow-up [Post-KE Group]. Incontinence scores in all three groups were compared to evaluate the efficacy of KE. Results101 MRI-documented low anal-fistula patients were included. There were 79 males (mean age 39.412.9 years) and median follow-up was 12 months (6-18months). Two patients were lost to follow-up. Fistulas healed in all the patients. Incontinence was present in 5/99 patients (mean incontinence scores-0.130.63) preoperatively and occurred in 20/99 (mean incontinence scores-1.032.18) patients postoperatively (Pre-KE Group). With KE, the incontinence improved completely in 10 and partially improved in other 10 (mean incontinence scores-0.311.09). Urge and gas incontinence accounted for most cases (80%). The mean incontinence scores deteriorated significantly after fistulotomy (pre-op vs pre-KE, p=0.000059, significant) but continence improved significantly with KE, thus the scores between pre-op and post-KE became comparable (pre-op vs post-KE, p=0.07, not significant).ConclusionsFistulotomy, even in low fistulas, can lead to significant increase in gas and urge incontinence. Regular Kegel exercises postoperatively can help recover lost sphincter function and can bring back continence comparable to preoperative levels.

Lignocellulolytic enzymes from Aspergillus allahabadii for efficient bioconversion of rice straw into fermentable sugars and biogas

The study was aimed at developing lignocellulolytic strain capable of efficient hydrolysis of mild alkali deacetylated (MAD) rice straw. The valorisation of lignin rich black liquor obtained during pre-treatment of rice straw into biogas was also evaluated. Study reports highly proficient cellulolytic Aspergillus allahabadii strain harbouring a spectrum of CAZymes based on comparative genome wide analysis that was subjected to strain breeding for developing a hyper producing strain. The secretome analysis showed up-modulation and several folds increase in the CAZyme activities in the culture extracts of the developed strain MAN 40 when compared to parent. The cellulolytic cocktail of the developed strain showed 1.52 folds higher saccharification of MAD rice straw when compared to Cellic CTec 3. Moreover, in-situ addition of cellulases derived from developed strains resulted in ∼3.7 folds higher methane production during anaerobic digestion of mixture of lignin rich black liquor and differently treated rice straw.

TUXEDO: A phase I/II trial of cetuximab with chemoradiotherapy in muscle-invasive bladder cancer

OBJECTIVE

To assess feasibility and preliminary efficacy of adding cetuximab to standard chemoradiotherapy for muscle-invasive bladder cancer.

PATIENTS AND METHODS

TUXEDO was a prospective, single-arm, open-label, phase I/II trial conducted in six UK hospitals. Cetuximab was administered with an initial loading dose of 400mg/m2 on day 1 of week -1, and then 7-weekly doses of 250mg/m2 . Radiotherapy schedule was 64Gy/32F with day 1 mitomycin C (12g/m2 ) and 5-fluorouracil (500mg/m2 /day) over days 1-5 and 22-26. Patients with T2-4aN0M0 urothelial cancer and a performance status (PS) of 0-1 were eligible. Prior neoadjuvant therapy was permitted. The phase I primary outcome was impact on radiotherapy treatment completion and toxicity experienced during treatment. The phase II primary outcome was local control at three-months post-treatment. ISRCTN identifier: 80733590.

RESULTS

Between Sept-2012 and Oct-2016, 33 patients were recruited; 7 in phase I, 26 in phase II. Three patients in phase II were subsequently deemed ineligible and received no trial therapy. Eight patients discontinued cetuximab due to adverse effects. Median age of patients was 70.1 years (range 60.6-75.1), 20 were PS 0, 27 male and 26 had already received neoadjuvant chemotherapy. In phase I, all patients completed planned radiotherapy, with no delays or dose reductions. Of the 30 evaluable patients in phase II, 25 had confirmed local control 3-months post treatment (77%, 95% CI: 58-90). During the trial there were 18 serious adverse events. The study was halted due to slow accrual.

CONCLUSION

Phase I data demonstrate it is feasible and safe to add cetuximab to chemoradiotherapy. Exploratory analysis of phase II data provides evidence to consider further clinical evaluation of cetuximab in this setting.

Efficacy of Kegel exercises in preventing incontinence after partial division of internal anal sphincter during anal fistula surgery

BACKGROUND

The transanal opening of intersphincteric space (TROPIS) procedure, performed to treat complex anal fistulas, preserves the external anal sphincter (EAS) but involves partial incision of the internal anal sphincter (IAS).

AIM

To ascertain the incidence of incontinence after the division of the IAS as is done in TROPIS and to evaluate whether regular Kegel exercises (KE) in the postoperative period can prevent incontinence due to IAS division.

METHODS

Patients operated on for high complex fistulas and having no preoperative continence problem (score = 0) were included in the study. All patients were operated on by the TROPIS procedure and were recommended KE (pelvic contraction exercises) 50 times/day. KE were commenced on the 10^th postoperative day and continued for 1 year. Incontinence was evaluated objectively (by modified Vaizey’s scores) in the immediate postoperative period (Pre-KE group) and on long-term follow-up (Post-KE group). The incontinence scores in both groups were compared to evaluate the efficacy of KE.

RESULTS

Of 102 anal fistula patients operated on between July 2018 and July 2020 were included in this study. There were 90 males, the mean age was 42.3 ± 12.8, and the median follow-up was 30 mo (18-42 mo). Three patients were lost to follow-up. There were 65 recurrent fistulas, 92 had multiple tracts, 42 had associated abscess, 46 had horseshoe fistula and 34 were supralevator fistulas. All were magnetic resonance imaging-documented high fistulas (> 1/3 EAS involved). Overall incontinence occurred in 31% patients (Pre-KE group) with urge and gas incontinence accounting for the majority of cases (28.3%). The mean incontinence scores in the Pre-KE group were 1.19 ± 1.96 (in 31 patients, solid = 0, liquid = 7, gas = 8, urge = 24) and in the Post-KE group were 0.26 ± 0.77 (in 13 patients, solid = 0, liquid = 2, gas = 3, urge = 10) (P = 0.00001, t-test).

CONCLUSION

Division of the IAS led to incontinence, mainly urge incontinence, and also to a mild degree of gas and liquid incontinence. However, regular KE led to a significant reduction in incontinence (both in the number of affected patients and the severity of scores in these patients).

Impact of family-centred postnatal training on maternal and neonatal health and care practices in district hospitals in two states in India: a pre-post study

BACKGROUND AND OBJECTIVES

The Care Companion Program (CCP) is an in-hospital multitopic skill-based training programme provided to families to improve postdischarge maternal and neonatal health. The states of Punjab and Karnataka in India piloted the programme in 12 district hospitals in July 2017, and no study to date has evaluated its impact.

METHODS

We compared telephonically self-reported maternal and neonatal care practices and health outcomes before and after the launch of the CCP programme in 11 facilities. Families in the preintervention group delivered between May to June 2017 (N=1474) while those in the intervention group delivered between August and October 2017 (N=3510). Programme effects were expressed as adjusted risk ratios obtained from logistic regression models.

RESULTS

At 2-week postdelivery, the practice of dry cord care improved by 4% (RR=1.04, 95% CI 1.02 to 1.06) and skin-to-skin care by 78% (RR=1.78, 95% CI 1.37 to 2.27) in the postintervention group as compared with preintervention group. Furthermore, newborn complications reduced by 16% (RR=0.84, 95% CI 0.76 to 0.91), mother complications by 12% (RR=0.88, 95% CI 0.79 to 0.97) and newborn readmissions by 56% (RR=0.44, 95% CI 0.31 to 0.61). Outpatient visits increased by 27% (RR=1.27, 95% CI 1.10 to 1.46). However, the practice of exclusive breastfeeding, unrestricted maternal diet, hand-hygiene and being instructed on warning signs were not statistically different.

CONCLUSION

Postnatal care should incorporate predischarge training of families. Our findings demonstrate that it is possible to improve maternal and neonatal care practices and outcomes through a family-centered programme integrated into public health facilities in low and middle-income countries.

Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study

INTRODUCTION

Supralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO).

METHODS

All consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO.

RESULTS

Out of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%).

CONCLUSIONS

The supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.

Combination of system biology and classical approaches for developing biorefinery relevant lignocellulolytic Rasamsonia emersonii strain

The objective of this study was to develop thermophilic fungus Rasamsonia emersonii using integrated system biology tools (genomics, proteomics and transcriptional analysis) in combination with classical strain breeding approaches. Developed hyper cellulolytic mutant strain M36 showed endoglucanase (476.35 U/ml), β-glucosidase (70.54 U/ml), cellobiohydrolase (15.17 U/ml), FPase (4.89 U/ml) and xylanase (485.21 U/ml) on cellulose/gram flour based production medium. Comparison of the expression profile at proteome and transcriptional level of the developed strain and wild type parent gave detailed insight into the up-regulation of different CAZymes including glycosyl hydrolases (GH5, GH6, GH7, GH3, GH10) and auxiliary enzymes (lytic polysaccharide monooxygenase, swollenin) at system level. Furthermore, the potential of lignocellulolytic enzyme produced by the developed strain and custom designed cocktail spiked with heterologously expressed lytic polysaccharide monooxygenase from Mycothermus thermophiloides were analyzed for the hydrolysis of biorefinery relevant unwashed pretreated rice straw slurry (PRAJ and IOCL) @17% substrate loading rate.

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas

Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.

Including video and novel parameter-height of penetration of external anal sphincter-in magnetic resonance imaging reporting of anal fistula

The main purpose of a radiologist’s expertise in evaluation of anal fistula magnetic resonance imaging (MRI) is to benefit patients by decreasing the incontinence rate and increasing the healing rate. Any loss of vital information during the transfer of this data from the radiologist to the operating surgeon is unwarranted and is best prevented. In this regard, two methods are suggested. First, a short video to be attached with the standardized written report highlighting the vital parameters of the fistula. This would ensure minimum loss of information when it is conveyed from the radiologist to the operating surgeon. Second, inclusion of a new parameter, the amount of external sphincter involvement by the anal fistula. This parameter is usually not included in the MRI report. This can be evaluated as the height of penetration of the external anal sphincter (HOPE) by the fistula. The external anal sphincter plays a pivotal role in maintaining continence. This parameter (HOPE) is distinct from the ‘height of internal opening’ and assumes immense importance as its knowledge is paramount to prevent damage to the external anal sphincter by the surgeon during surgery.

A Novel MRI and Clinical-Based Scoring System to Assess Post-Surgery Healing and to Predict Long-Term Healing in Cryptoglandular Anal Fistulas

Background

Anal fistulas cause great uncertainty and anxiety in patients and surgeons alike. This is largely because of the inability to accurately confirm postoperative fistula healing, especially long-term healing. There is no scoring system available that can objectively assess cryptoglandular anal fistulas for postoperative healing and can also accurately predict long-term healing.

Methods

Several parameters that could indicate anal fistula healing were assessed. Out of these, six parameters (four MRI-based and two clinical) were finalized, and a weighted score was given to each parameter. A novel scoring system (NSS) was developed. A minimum possible score (zero) indicated complete healing whereas the maximum weighted score (n = 20) indicated confirmed non-healing. Scoring was done with postoperative MRI (at least 3 months post-surgery), then compared with the actual healing status, and subsequently correlated with the final long-term clinical outcome.

Results

The NSS was validated in 183 operated cryptoglandular fistula-in-ano patients over a 3-year period in whom 283 MRIs (preoperative plus postoperative) were performed. The postoperative follow-up was 12–48 months (median-30 months). The NSS was found to have a very high positive predictive value (98.2%) and moderately high negative predictive value (83.7%) for long-term fistula healing. Additionally, its sensitivity and specificity in predicting healing were 93.9% and 94.7%, respectively.

Conclusion

Thus, this new scoring system is highly accurate and would be a useful tool for surgeons and radiologists managing anal fistulas. By objectivizing the assessment of postoperative healing, it can both ease and streamline management. Moreover, reliable prediction of recurrence-free long-term healing will greatly allay the apprehensions associated with this dreaded disease.

Anal fistula at roof of ischiorectal fossa inside levator-ani muscle (RIFIL): a new highly complex anal fistula diagnosed on MRI

BACKGROUND

As experience with anal fistula imaging (MRI) has increased, new pathways of fistula extension have been identified. A recently described pathway is the  'outer-sphincteric space' present between the external anal sphincter and its covering outer fascia. A new type of complex fistula is being described which is present in the outer-sphincteric space and continues superiorly along the lateral border of the external anal sphincter to the infero-lateral surface of the puborectalis and levator-ani. In effect, these outer-sphincteric fistulas are at the roof of the ischiorectal fossa inside the levator muscle (RIFIL). These fistulas are not transsphincteric fistulas as they remain inside the levator muscle and do not enter the ischiorectal fossa.

METHODS

The MRI scans of consecutive anal fistula patients operated over the last two years were analyzed retrospectively.

RESULTS

Of 419 operated fistula patients analyzed, 42(10%) had RIFIL and 377 non-RIFIL fistulas. Compared to non-RIFIL fistulas, there were significantly more recurrent, multiple tracts, horseshoe, supralevator, and suprasphincteric fistulas in the RIFIL group. RIFIL fistulas were significantly more complex than non-RIFIL fistulas(85.7% vs 38.5%, p < 0.00001) and the surgery failure rate was also significantly higher in the RIFIL group (30.6%) than in the non-RIFIL fistula (7.2%) group(p = 0.0001).

CONCLUSION

RIFIL are highly complex fistulas. Proper diagnosis by MRI, surgical access, and subsequent management of these fistulas is quite challenging and they are associated with poor prognosis. Missing their diagnosis would lead to higher recurrence rate. These have not been described previously and were perhaps confused with high transsphincteric infralevator fistulas in ischiorectal fossa.

Extreme horseshoe and circumanal anal fistulas-challenges in diagnosis and management

Objectives:

Extreme horseshoe anal fistulas are rare, and there are little data on the diagnosis and management of these fistulas.

Materials and Methods:

Patients with horseshoe anal fistula, in which the fistula tract encircled more than 75% of the anal circumference were included in the study. All patients were assessed by a preoperative magnetic resonance imaging (MRI). The patients were managed by a sphincter-sparing procedure. The continence was evaluated by an objective continence scoring system (Vaizey's scores).

Results:

1059 anal fistula patients were operated on over 7-years with a median follow-up of 36 months (range: 5–79 months). There were 47/1059 (4.4%) patients with extreme horseshoe anal fistulas. In 4/47 patients, the fistulas were complete circumanal (encircling anal canal completely). The mean age was 39.5 ± 10.9 years, M/F-41/6. The fistula was supralevator in 12/47 (25.5%), had an associated abscess in 28/47 (59.6%), and was recurrent in 33/47 (70.2%) patients. The tracts were intersphincteric in 27/47, transsphincteric in 2/47, and both (intersphincteric and transsphincteric) in 18/47 patients. All patients (n = 47) were managed by a sphincter-sparing procedure. Four patients were lost to follow-up. The fistula healed completely in 34/43 (79%) patients. There was no significant difference between preoperative and postoperative Vaizey's continence scores 0.031 ± 0.17 and 0.033 ± 0.18 respectively (P=0.90, Mann–Whitney U-test).

Conclusion:

Extreme horseshoe fistulas are rare, with an incidence of about 4% (in a referral practice). The missed diagnosis of circumferential tracts could lead to a recurrence. MRI was pivotal to confirm the diagnosis. Proper identification and management of internal opening and adequate drainage of all tracts were crucial for successfully treating extreme horseshoe fistulas.

A New Anatomical Pathway of Spread of Pus/Sepsis in Anal Fistulas Discovered on MRI and Its Clinical Implications

BACKGROUND

In the anal sphincter complex, the intersphincteric space between the internal and external sphincters is the only conventionally recognized pathway for the spread of sepsis. However, there is another unrecognized space discovered on MRI, the "outer-sphincteric space", between the external anal sphincter and its lateral fascia along which pus can spread. An abscess in the intersphincteric space is easily drained into the rectum via the transanal route and is more likely to spread into the supralevator space. Conversely, an abscess in the outer-sphincteric space is difficult to drain transanally into the rectum and is more likely to become a transsphincteric abscess/fistula.

METHODS

The MRIs of anal fistula patients operated over four years on intersphincteric abscesses were analyzed. The pattern of spread into the ischiorectal fossa and/or supralevator space and ease of drainage into the rectum through the transanal route were studied.

RESULTS

Thirty-six patients were operated on to drain their intersphincteric abscesses through the anal canal. Two distinct patterns were noted. Twenty patients had abscesses in the intersphincteric space, which were easily drained into the rectum. Of them, 6/20 had supralevator extension, while only 1/20 had spread to the ischiorectal fossa. In 16/36 patients, the abscess was in the outer-sphincteric space and could not be drained into the rectum. In 9/16 of these patients, pus spread into the ischiorectal fossa but supralevator spread did not happen in any patient.

CONCLUSION

Apart from the intersphincteric space, there is perhaps another unrecognized anatomical space - the outer-sphincteric space - discovered on MRI, through which pus can spread in anal fistulas or abscesses.

Resveratrol protects against inorganic arsenic-induced oxidative damage and cytoarchitectural alterations in female mouse hippocampus

Prolonged inorganic arsenic (iAs) exposure is widely associated with brain damage particularly in the hippocampus via oxidative and apoptotic pathways. Resveratrol (RES) has gained considerable attention because of its benefits to human health. However, its neuroprotective potential against iAs-induced toxicity in CA1 region of hippocampus remains unexplored. Therefore, we investigated the neuroprotective efficacy of RES against arsenic trioxide (As₂O₃)-induced adverse effects on neuronal morphology, apoptotic markers and oxidative stress parameters in mouse CA1 region (hippocampus). Adult female Swiss albino mice of reproductive maturity were orally exposed to either As₂O₃ (2 and 4 mg/kg bw) alone or in combination with RES (40 mg/kg bw) for a period of 45 days. After animal sacrifice on day 46, the perfusion fixed brain samples were used for the observation of neuronal morphology and studying the morphometric features. While the freshly dissected hippocampi were processed for biochemical estimation of oxidative stress markers and western blotting of apoptosis-associated proteins. Chronic iAs exposure led to significant decrease in Stratum Pyramidale layer thickness along with reduction in cell density and area of Pyramidal neurons in contrast to the controls. Biochemical analysis showed reduced hippocampal GSH content but no change in total nitrite (NO) levels following iAs exposure. Western blotting showed apparent changes in the expression levels of Bax and Bcl-2 proteins following iAs exposure, however the change was statistically insignificant. Contrastingly, iAs +RES co-treatment exhibited substantial reversal in morphological and biochemical observations. Together, these findings provide preliminary evidence of neuroprotective role of RES on structural and biochemical alterations pertaining to mouse hippocampus following chronic iAs exposure.

Fear vs. hope in India: Finding the silver lining amid the dark clouds of COVID-19

COVID-19 has been declared a global pandemic, and the associated high rates of morbidity and mortality have made individuals susceptible to mental health problems that affect their psychological well-being. Although individual strengths can shield the negative impact of adverse conditions, their protective role in the context of COVID-19 has not received much attention. This study examines the relationship between fear of COVID-19 and mental health via rumination through the lens of hope as a personal psychological strength. This study employed a two-wave longitudinal design. Data was collected from 412 Indian participants with a time interval of three months and analyzed using a two-step approach to structural equation modelling. Fear of COVID-19 was found to a have negative effect on mental health through rumination. However, results from moderation analysis support the role of hope as a buffer against the indirect negative impact of fear of COVID-19 on mental health outcomes. As one of the first studies to demonstrate the role of psychological strengths of individuals in coping with the direct and indirect psychological ramifications of COVID-19 over a period of time, it contains important implications for the development of mental health interventions in the face of this global crisis.

Guidelines on postoperative magnetic resonance imaging in patients operated for cryptoglandular anal fistula: Experience from 2404 scans

Magnetic resonance imaging (MRI) is considered the gold standard for the evaluation of anal fistulas. There is sufficient literature available outlining the interpretation of fistula MRI before performing surgery. However, the interpretation of MRI becomes quite challenging in the postoperative period after the surgery of fistula has been undertaken. Incidentally, there are scarce data and no set guidelines regarding analysis of fistula MRI in the postoperative period. In this article, we discuss the challenges faced while interpreting the postoperative MRI, the timing of the postoperative MRI, the utility of MRI in the postoperative period for the management of anal fistulas, the importance of the active involvement and experience of the treating clinician in interpreting MRI scans, and the latest advancements in the field.

Role of MRI to confirm healing in complex high cryptoglandular anal fistulas: long-term follow-up of 151 cases

AIM

Complex fistula-in-ano can recur even after complete clinical healing has occurred. 'Radiological healing' of fistula on MRI correlates well with long-term healing rates but no study has yet objectively quantified this. The aim of this study was to assess the accuracy of anal fistula healing as documented on MRI and to correlate it with long-term healing as evidenced on long-term follow-up.

METHODS

Patients with clinically healed anal fistulas who also had radiological healing checked by postoperative MRI were included in the study.

RESULTS

Three hundred and twenty-five patients operated for high complex fistula-in-ano were followed up for 14-68 months (median 38 months). Postoperative MRI was done to assess radiological healing of the fistula in 151 patients, and they were included in the study. The mean age was 39.4 ± 10.5 years (116 men). Five patients were lost to follow-up. The fistulas did not heal radiologically (on MRI) in 20 patients and recurred in all these patients. The fistulas healed radiologically (on MRI) in 126 patients. On long-term follow-up, 124/126 patients remained healed while 2/126 had a recurrence. In the first patient, the fistula recurred 40 months after complete radiological healing. In the second patient, the fistula recurred 10 months after complete radiological healing but pus from the fistula tested positive for tuberculosis (by real-time polymerase chain reaction) and he was excluded from the analysis. Thus, there was only one (1/125) recurrence on long-term follow-up.

CONCLUSIONS

Radiological healing on MRI correlates well with long-term healing in complex fistula-in-ano.

The new pathways of spread of anal fistula and the pivotal role of MRI in discovering them

Conventionally, in the pathophysiology of anal fistulas, there is only one space considered significant for the spread of pus in the sphincter complex: the intersphincteric space. However, with increasing experience in the high-resolution MRI, and more focus being given on managing fistulas through the intersphincteric space, two additional pathways of fistula spread have been identified. First is a newly described space labelled as the outer-sphincteric space. Second is a known anatomical space (inner intersphincteric space), but this space was considered as irrelevant from the point of view of fistula spread. The conventional intersphincteric space is present in between these two spaces and is referred as 'middle intersphincteric space' in this paper. These three distinct spaces have significant clinical implications as the pattern of spread of pus is quite different in each space, and the management also differs for fistula tract in each of these spaces.

Just-in-time postnatal education programees to improve newborn care practices: needs and opportunities in low-resource settings

Worldwide, many newborns die in the first month of life, with most deaths happening in low/middle-income countries (LMICs). Families’ use of evidence-based newborn care practices in the home and timely care-seeking for illness can save newborn lives. Postnatal education is an important investment to improve families’ use of evidence-based newborn care practices, yet there are gaps in the literature on postnatal education programmes that have been evaluated to date. Recent findings from a 13 000+ person survey in 3 states in India show opportunities for improvement in postnatal education for mothers and families and their use of newborn care practices in the home. Our survey data and the literature suggest the need to incorporate the following strategies into future postnatal education programming: implement structured predischarge education with postdischarge reinforcement, using a multipronged teaching approach to reach whole families with education on multiple newborn care practices. Researchers need to conduct robust evaluation on postnatal education models incorporating these programee elements in the LMIC context, as well as explore whether this type of education model can work for other health areas that are critical for families to survive and thrive.

Comparative Carcinogenic Effects of Folic Acid vs. 5-Methyltetrahydrofolate Supplementation on Colon Cancer Progression in a Rodent Model

Objectives

High folic acid (FA) intake may be associated with adverse health outcomes, including colon cancer promotion. 5-methyltetrahydrofolate (5MTHF) has been proposed as a safer alternative form of folate supplementation. We compared the effects of FA and 5MTHF supplementation on the progression of aberrant crypt foci (ACF; earliest colon cancer precursor).

Methods

Male Sprague Dawley rats (n = 120) received a control diet (1mg FA or equimolar 5MTHF) at weaning and ACF were induced by azoxymethane. Six weeks post-induction, rats were randomized to the control or supplemental (10mg FA or equimolar 5MTHF) diets for 18 weeks. Plasma folate concentrations were assessed using microbiological assay and compared. Colorectal tumor incidence, multiplicity and burden (sum of tumor diameters) were determined and compared.

Results

5MTHF resulted in higher plasma folate concentration compared to FA (p &lt; 0.05). Tumor incidence (adenoma, p = 0.5; adenocarcinoma, p = 0.60) did not differ between the folate forms. Both FA and 5MTHF supplementation resulted in a higher number of adenocarcinomas compared to respective controls. 5MTHF groups had higher tumor burden compared to the corresponding levels of FA (p &lt; 0.05).

Conclusions

5MTHF resulted in higher tumor burden than FA and was at least as effective as FA in increasing the number of adenocarcinomas in predisposed rats harboring ACF. 5MTHF does not confer a safer alternative to FA supplementation with regards to colon cancer promotion and may in fact have a higher colon tumor promoting effect than FA supplementation. Notwithstanding the inherent limitations associated with animal models, our study suggests that future studies are warranted to compare biochemical and biologic effects and safety of FA and 5MTHF supplementation.

Funding Sources

Canadian Institutes of Health Research.

Rationally designed TNF-α inhibitors: Identification of promising cytotoxic agents

Design and synthesis of new indole derivatives as tumor growth inhibiting agents via inhibiting the TNF-α is described. The preliminary results showed the inhibition of LPS induced production of NO, TNF-α and IL-6 by these compounds out of which compounds 2d and 2g exhibited appreciable cytotoxicity against the 60 cell lines panel of human cancer. The rationale behind the design of the molecules and the results of their biological studies are presented. 2009 Elsevier Ltd. All rights reserved.

Treatment of metastatic placental site trophoblastic tumor with surgery, chemotherapy, immunotherapy and coil embolization of multiple pulmonary arteriovenous fistulate

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Placental site trophoblastic tumor can be resistant to chemotherapy.

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Multidisciplinary care is required for management of advanced disease.

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Increased PD-L1 expression can help guide use of immunotherapies.

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Complete responses are possible with aggressive multidisciplinary management.

Placental Site Trophoblastic Tumor (PSTT) is a rare malignancy that often presents with extensive disease and can be resistant to traditional treatments. We present the case of a woman with stage IV PSTT who was initially managed with neoadjuvant chemotherapy followed by tumor debulking. Adjuvant therapy was guided by further pathologic analysis that revealed high levels of staining for PD-L1 as well as the presence of tumor infiltrating lymphocytes (TILs). Subsequently, the patient was treated with traditional chemotherapy with the EP/EMA regimen with the addition of pembrolizumab. The patient’s treatment course was complicated by the development of pulmonary arteriovenous malformations, autoimmune thyroiditis thought to be secondary to immunotherapy, and significant tinnitus secondary to platinum agents. Currently the patient is in follow up and remains in a complete remission.

Sinecatechins ointment as a potential novel treatment for usual type vulval intraepithelial neoplasia: a single-centre double-blind randomised control study

OBJECTIVE

To compare the safety and efficacy of 10% sinecatechins (Veregen® ) ointment against placebo in the treatment of usual type vulvar intraepithelial neoplasia (uVIN).

DESIGN

A Phase II double-blind randomised control trial.

SETTING

A tertiary gynaecological oncology referral centre.

POPULATION

All women diagnosed with primary and recurrent uVIN.

METHODS

Eligible patients were randomised 1:1 to receive either sinecatechins or placebo ointment (applied three times daily for 16 weeks) and were followed up at 2, 4, 8, 16, 32 and 52 weeks.

MAIN OUTCOME MEASURES

The primary outcome measure, recorded at 16 and 32 weeks, was histological response (HR). Secondary outcome measures included clinical (CR) response, toxicity, quality of life and pain scores.

RESULTS

There was no observed difference in HR between the two arms. However, of the 26 patients who were randomised, all 13 patients who received sinecatechins showed either complete (n = 5) or partial (n = 8) CR, when best CR was evaluated. In placebo group, three patients had complete CR, two had partial CR, six had stable disease and two were lost to follow up. Patients in the sinecatechins group showed a statistically significant improvement in best observed CR as compared with the placebo group (P = 0.002). There was no difference in toxicity reported in either group.

CONCLUSION

Although we did not observe a difference in HR between the two treatment arms, we found that 10% sinecatechins application is safe and shows promise in inducing clinical resolution of uVIN lesions and symptom improvement, thus warranting further investigation in a larger multicentre study.

TWEETABLE ABSTRACT

A randomised control study indicating that sinecatechins ointment may be a novel treatment for uVIN.

Transanal opening of the intersphincteric space: a novel sphincter-sparing procedure to treat 325 high complex anal fistulas with long-term follow-up

AIM

Sepsis in the intersphincteric plane behaves like an abscess in a closed space and is present in most complex fistulas. Ignoring this sepsis is a cause of recurrence. Complex fistulas can be successfully managed by transanal opening of the intersphincteric space (TROPIS) into the anal canal. The long-term efficacy of the TROPIS procedure was analysed in an exclusive cohort of high complex anal fistulas.

METHODS

All consecutive patients operated for a high complex fistula-in-ano were included prospectively. Preoperative MRI scans were obtained for all the patients. The intersphincteric space and internal opening was laid open into the anal canal while preserving the external sphincter. The external tracts were thoroughly curetted and cleaned. Fistula healing rate and objective incontinence scores (preoperatively and during long-term follow-up) were analysed.

RESULTS

A total of 325 patients (age 39.9 ± 10.9 years, 292 men) were operated with TROPIS and had a follow-up of 7-67 months (median 36 months). In the cohort, 67.4% (219) had recurrent fistulas, 82.8% (269) had multiple tracts, 36.3% (118) had horseshoe tracts, 37.5% (122) had associated abscesses and 24% (78) were supralevator fistulas. Nineteen patients were excluded. Fistulas healed completely in 78.4% (240/306) of patients and did not heal in 21.6% (66/306) of patients. 36/66 of these patients were operated again and the fistulas healed in 28 patients. Thus, the overall healing rate was 87.6% (268/306). The mean preoperative and postoperative incontinence scores were 0.085 ± 0.35 and 0.119 ± 0.48 respectively (P = 0.38). The healing rate of fistulas with associated acute abscesses was similar to the fistulas without abscesses (87% vs. 88%, P = 0.85).

CONCLUSION

Transanal opening of the intersphincteric space is a safe and highly effective sphincter-sparing procedure to manage high complex fistulas-in-ano.

Lessons learned from an audit of 1250 anal fistula patients operated at a single center: A retrospective review

BACKGROUND

A complex anal fistula is a challenging disease to manage.

AIM

To review the experience and insights gained in treating a large cohort of patients at an exclusive fistula center.

METHODS

Anal fistulas operated on by a single surgeon over 14 years were analyzed. Preoperative magnetic resonance imaging was done in all patients. Four procedures were performed: fistulotomy; two novel sphincter-saving procedures, proximal superficial cauterization of the internal opening and regular emptying and curettage of fistula tracts (PERFACT) and transanal opening of intersphincteric space (TROPIS), and anal fistula plug. PERFACT was initiated before TROPIS. As per the institutional GFRI algorithm, fistulotomy was done in simple fistulas, and TROPIS was done in complex fistulas. Fistulas with associated abscesses were treated by definitive surgery. Incontinence was evaluated objectively by Vaizey incontinence scores.

RESULTS

A total of 1351 anal fistula operations were performed in 1250 patients. The overall fistula healing rate was 19.4% in anal fistula plug (n = 56), 50.3% in PERFACT (n = 175), 86% in TROPIS (n = 408), and 98.6% in fistulotomy (n = 611) patients. Continence did not change significantly after surgery in any group. As per the new algorithm, 1019 patients were operated with either the fistulotomy or TROPIS procedure. The overall success rate was 93.5% in those patients. In a subgroup analysis, the overall healing rate in supralevator, horseshoe, and fistulas with an associated abscess was 82%, 85.8%, and 90.6%, respectively. The 90.6% healing rate in fistulas with an associated abscess was comparable to that of fistulas with no abscess (94.5%, P = 0.057, not significant).

CONCLUSION

Fistulotomy had a high 98.6% healing rate in simple fistulas without deterioration of continence if the patient selection was done judiciously. The sphincter-sparing procedure, TROPIS, was safe, with a satisfactory 86% healing rate for complex fistulas. This is the largest anal fistula series to date.

Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study

INTRODUCTION

Supralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO).

METHODS

All consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO.

RESULTS

Out of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p=0.47, Chi-square test). The overall healing rate was 18/21(86%).

CONCLUSIONS

The supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.

Increasing the human chorionic gonadotrophin cut-off to ≤1000 IU/l for starting actinomycin D in post-molar gestational trophoblastic neoplasia developing resistance to methotrexate spares more women multi-agent chemotherapy

Background

A human chorionic gonadotropin (hCG) cut-off of ≤300 IU/l for starting actinomycin D (ActD) in post-molar gestational trophoblastic neoplasia (GTN) patients developing methotrexate resistance (MTX-R) reduced the number of women needing toxic multi-agent chemotherapy (etoposide, MTX and ActD alternating weekly with cyclophosphamide and vincristine; EMA/CO) without affecting survival. Here we assess whether an increased hCG cut-off of ≤1000 IU/l spares more women EMA/CO.

Patients and methods

All post-molar GTN patients treated with first-line methotrexate and folinic acid (MTX/FA) were identified in a national cohort between 2009 and 2016. Data collected included age, FIGO score, the hCG levels at MTX-R, and treatment outcomes.

Results

In total, 609 GTN patients commenced treatment with MTX/FA achieving a complete response in 57% (348/609). Resistance developed in 25.1% (153/609) at an hCG ≤ 1000 IU/l and switching to ActD achieved remission in 92.8% without any major toxicity with the remaining 7.2% remitting on EMA/CO. Comparative analysis of patients switching at an hCG <100 versus 100-300 versus 300-1000 IU/l revealed a significant fall in the cure rate with second-line ActD from 97% (93/96) to 87% (34/39) to 78% (14/18), respectively, P = 0.009. However, by increasing the hCG cut-off from ≤300 to ≤1000 IU/l, 14 patients were spared EMA/CO chemotherapy. Moreover, in the present series, all post-molar GTN remain in remission.

Conclusion

This study demonstrates that increasing the hCG cut-off from ≤300 to ≤1000 IU/l for choosing patients for ActD following MTX-R spares more women with GTN from the greater toxicity of EMA/CO without compromising 100% survival outcomes.

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An hCG cut-off of ≤1000 IU/l for ActD over EMA/CO treatment in MTX-R GTN spares women toxicity without affecting survival.

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On developing MTX-R, as the hCG cut-off for selecting ActD versus EMA/CO rises, the complete response rate for ActD falls.

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Half of FIGO-7 patients were cured on single-agent treatment (MTX/FA or sequential ActD), warranting further investigation.

Utilization of Postnatal Care among Rural Women in Punjab

Background:

The postchildbirth period presents considerable challenges in the form of health risks for the mother and the newborn, yet postnatal care (PNC) remains seldom utilized maternal and newborn health intervention.

Objectives:

The present study aims to study the coverage of PNC among rural women in Punjab and understand the factors that determine the utilization of PNC services.

Materials and Methods:

From rural areas of seven districts of Punjab, a total of 420 respondents were questioned using semi-structured interview schedule. Binary logistic regression is employed to understand the factors that influence the utilization of complete PNC.

Results:

The utilization of complete PNC has remained mere 25.9% in the present study. The results of multivariate logistic regression reveal that variables district, caste, birth order, and type of delivery significantly influence the utilization of complete PNC.

Conclusion:

The utilization of PNC component is found to be abysmal as compared to antenatal component and institutional delivery among the study group. There is a need to create awareness regarding the necessity of PNC among the women.

A Simple Protocol to Effectively Manage Anal Fistulas with No Obvious Internal Opening

Purpose

In some anal fistulas, the internal/primary opening cannot be located even after examination and assessment on MRI or transrectal ultrasound. The efficacy of a simple new protocol to manage such therapeutically challenging fistulas was tested.

Patients and Methods

All anal fistula patients operated consecutively over 7 years were included in the study. A simple two-step protocol was followed for fistulas in which the internal opening was not locatable after clinical examination and MRI assessment. First, the MRI was reassessed. The site where the fistula was closest to the internal sphincter was noted. It was assumed that the internal-opening was located at that position and the fistula was treated accordingly. Second, in horseshoe anal fistulas with no apparent internal opening, it was assumed that the internal opening was located in the midline. Low fistulas were treated by fistulotomy and high fistulas by a sphincter-sparing procedure. Incontinence was evaluated by objective incontinence scores (Vaizey scores).

Results

A total of 757 patients were operated (median follow-up-33 months). Of these, 57 patients were excluded due to short or inadequate follow-up. In 154/700 (22%) patients, the internal opening could not be located while in 546/700 (78%), the internal opening was found. Both the groups were similar in all parameters. In the "internal-opening found" group, the fistula healed completely in 486/546 (89%) and in the 'internal-opening not found group', the fistula healed in 140/156 (90.9%) (p=1.01). The objective continence scores did not change significantly after surgery in both the groups.

Conclusion

This new protocol seems effective as a high cure rate could be achieved in 'internal-opening not found' fistulas which was comparable to fistula healing in the 'internal-opening found' group.

Role of water in cyclooxygenase catalysis and design of anti-inflammatory agents targeting two sites of the enzyme

While designing the anti-inflammatory agents targeting cyclooxygenase-2 (COX-2), we first identified a water loop around the heme playing critical role in the enzyme catalysis. The results of molecular dynamic studies supported by the strong hydrogen-bonding equilibria of the participating atoms, radical stabilization energies, the pK_a of the H-donor/acceptor sites and the cyclooxygenase activity of pertinent muCOX-2 ravelled the working of the water–peptide channel for coordinating the flow of H·/electron between the heme and Y385. Based on the working of H·/electron transfer channel between the 12.5 Å distant radical generation and the radical disposal sites, a series of molecules was designed and synthesized. Among this category of compounds, an appreciably potent anti-inflammatory agent exhibiting IC₅₀ 0.06 μM against COX-2 and reversing the formalin induced analgesia and carageenan induced inflammation in mice by 90% was identified. Further it was revealed that, justifying its bidentate design, the compound targets water loop (heme bound site) and the arachidonic acid binding pockets of COX-2.

An innovative approach of priming lignocellulosics with lytic polysaccharide mono-oxygenases prior to saccharification with glycosyl hydrolases can economize second generation ethanol process

Two Lytic polysaccharide Mono-Oxygenases (LPMOs), non-modular (PMO_08942) and modular (PMO_07920), from thermotolerant fungus Aspergillus terreus 9DR cloned and expressed in Pichia pastoris X33 and purified to homogeneity using ion-exchange chromatography were found to be of ~29 and ~40 kDa, respectively. Both LPMOs were optimally active at 50 °C; PMO_08942 was active under acidic condition (pH 5.0) and PMO_07920 at pH 7.0. Modular LPMO (PMO_07920) tethered to CBM-1 was found to be versatile as it showed appreciable activity on complex polysaccharide (both cellulose and xylans) as compared to non-modular (PMO_08942). The t_1/2 of PMO_08942 (~192 h, pH 5.0) and PMO_0792 (~192 h, pH 7.0) at 50 °C, suggests highly stable nature of these LPMOs. Fluorescently tagged modular AA9 was studied microscopically to understand interaction with pretreated biomass. Priming of biomass for up to 6 h with LPMOs prior to initiating hydrolysis with core cellulase enzyme resulted in significantly higher saccharification.