Lipoma of the gastrointestinal tract: a tertiary care centre experience

INTRODUCTION

Gastrointestinal (GI) lipomas are rare; however, they are frequent enough to be considered in the differential diagnosis of gut tumours. Here, we present our experience with GI lipomas managed at our institute over the last three years.

METHODS

This is a retrospective cohort study of patients with GI lipomas managed between January, 2020 and April, 2023 at a tertiary care centre. Clinical presentation, location, and details of surgical procedure were analysed.

RESULTS

Ten patients were included, six of whom had lipoma in the colon, one in the stomach, and one each in the duodenum, jejunum, and ileum. The mean age at the time of presentation was 48.8 years (range, 19-77 years), and strong male preponderance (4:1) was noted. Preoperative diagnosis of lipoma on cross-sectional imaging was possible in all patients. All patients were symptomatic and were managed surgically.

CONCLUSIONS

While GI lipomas are generally considered to be indolent and benign tumours, they can potentially lead to severe complications. The utilisation of computed tomography and magnetic resonance imaging has brought about a significant transformation in diagnosing this condition, enabling preoperative identification in most cases. The surgery offers a definitive treatment with minimal risk of postoperative complications.

Pharmacogenetic guided versus standard warfarin dosing for routine clinical care with its pharmacoeconomic impact: a randomized controlled clinical trial

BACKGROUND

Empirical use of pharmacogenetic test(PGT) is advocated for many drugs, and resource-rich setting hospitals are using the same commonly. The clinical translation of pharmacogenetic tests in terms of cost and clinical utility is yet to be examined in hospitals of low middle income countries (LMICs).

AIM

The present study assessed the clinical utility of PGT by comparing the pharmacogenetically(PGT) guided- versus standard of care(SOC)- warfarin therapy, including the health economics of the two warfarin therapies.

METHODS

An open-label, randomized, controlled clinical trial recruited warfarin-receiving patients in pharmacogenetically(PGT) guided- versus standard of care(SOC)- study arms. Pharmacogenetic analysis of CYP2C9*2(rs1799853), CYP2C9*3(rs1057910) and VKORC1(rs9923231) was performed for patients recruited to the PGT-guided arm. PT(Prothrombin Time)-INR(international normalized ratio) testing and dose titrations were allowed as per routine clinical practice. The primary endpoint was the percent time spent in the therapeutic INR range(TTR) during the 90-day observation period. Secondary endpoints were time to reach therapeutic INR(TRT), the proportion of adverse events, and economic comparison between two modes of therapy in a Markov model built for the commonest warfarin indication- atrial fibrillation.

RESULTS

The study enrolled 168 patients, 84 in each arm. Per-protocol analysis showed a significantly high median time spent in therapeutic INR in the genotype-guided arm(42.85%; CI 21.4-66.75) as compared to the SOC arm(8.8%; CI 0-27.2)(p < 0.00001). The TRT was less in the PG-guided warfarin dosing group than the standard-of-care dosing warfarin group (17.85 vs. 33.92 days) (p = 0.002). Bleeding and thromboembolic events were similar in the two study groups. Lifetime expenditure was ₹1,26,830 in the PGT arm compared to ₹1,17,907 in the SOC arm. The QALY gain did not differ in the two groups(3.9 vs. 3.65). Compared to SOC, the incremental cost-utility ratio was ₹35,962 per QALY gain with PGT test opting. In deterministic and probabilistic sensitivity analysis, the base case results were found to be insensitive to the variation in model parameters. In the cost-effectiveness-acceptability curve analysis, a 90% probability of cost-effectiveness was reached at a willingness-to-pay(WTP) of ₹ 71,630 well below one time GDP threshold of WTP used.

CONCLUSION

Clinical efficacy and the cost-effectiveness of the warfarin pharmacogenetic test suggest its routine use as a point of care investigation for patient care in LMICs.

Perception of robotic-assisted surgery (RAS) among medical students: a systematic review and meta-analysis

INTRODUCTION

Robotic surgery, also known as robotic-assisted surgery (RAS), involves a camera and a small surgical instrument attached to a robotic arm. A trained surgeon operates the robot from a viewing screen while being in the same room.

METHODOLOGY

This review was prepared following Cochrane collaboration guidelines and reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. Two authors independently searched and appraised the studies published in PubMed, cumulative index to nursing and allied health literature (CINAHL), Embase, Clinical Key, and Google Scholar. Pooled data analyzed and reported in RevMan software version-5.4.

RESULTS

This systematic review and meta-analysis comprised 1400 medical students, from 8 studies. The participants' age ranged from 23 to 49 years. Similarly, the sample size ranged from 25 and 300. The pooled prevalence of the existing studies revealed that 29.8% of medical students, were favorable towards RAS. Effect size (ES), 95% confidence intervals (CI) and heterogeneity (I2) [ES = 29.8, 95% CI 16.4-43.2, I2 = 95.1%, P < 0.00]. About 40% of Australian medical students' positive opinion on RAS [ES = 40.4, 95% CI 25.7-55.2]. Similarly, 34.2% of students from Saudi Arabia [ES = 29.8, 95% CI 22.4-90.8, I2 = 99.3%, P < 0.00], 27.8% students from Canada [ES = 27.8, 95% CI 15.9-39.6], 24.8% from USA [ES = 24.8, 95% CI 6.9-42.7, I2 = 77.3%, P < 0.00] and 24% [ES = 24, 95% CI 18-30] from India favorable towards RAS.

DISCUSSION

Medical students from developed nations display favorable attitudes towards RAS. However, implementing of revised curriculum at the beginning of the graduation level sparks medical students' attitude towards robotic surgery.

A Novel Method for Prediction of Raised Intracranial Pressure Through Automated ONSD and ETD Ratio Measurement From Ocular Ultrasound

The paper presents a novel framework for the prediction of the raised Intracranial Pressure (ICP) from ocular ultrasound images of traumatic patients through automated measurement of Optic Nerve Sheath Diameter (ONSD) and Eyeball Transverse Diameter (ETD). The measurement of ONSD using an ocular ultrasound scan is non-invasive and correlates with the raised ICP. However, the existing studies suggested that the ONSD value alone is insufficient to indicate the ICP condition. Since the ONSD and ETD values may vary among patients belonging to different ethnicity/origins, there is a need for developing an independent global biomarker for predicting raised ICP condition. The proposed work develops an automated framework for the prediction of raised ICP by developing algorithms for the automated measurement of ONSD and ETD values. It is established that the ONSD and ETD ratio (OER) is a potential biomarker for ICP prediction independent of ethnicity and origin. The OER threshold value is determined by performing statistical analysis on the data of 57 trauma patients obtained from the AIIMS, New Delhi. The automated OER is computed and compared with the conventionally measured ICP by determining suitable correlation coefficients. It is found that there is a significant correlation of OER with ICP (r = .81, p ≤ .01), whereas the correlation of ONSD alone with ICP is relatively less (r = .69, p = .004). These correlation values indicate that OER is a better parameter for the prediction of ICP. Further, the threshold value of OER is found to be 0.21 for predicting raised ICP conditions in this study. Scatter plot and Heat map analysis of OER and corresponding ICP reveal that patients with OER ≥ 0.21, have ICP in the range of 17 to 35 mm Hg. In the data available for this research work, OER ranges from 0.17 to 0.35.

Disseminated tuberculosis, CMV viraemia & haemophagocytic-lymphohistiocystosis syndrome in an adult patient with anti- IFNγ autoantibodies - case report and brief review

We report a case of an adult female with disseminated tuberculosis, cytomegalovirus viraemia and haemophagocytic-lymphohistiocystosis syndrome associated with neutralizing anti- interferon gamma (IFNγ) autoantibodies demonstrated by absent IFNγ stimulated STAT1 phosphorylation in the presence of patient sera. A brief review of immunodeficiency caused by anti-IFNγ autoantibodies is also described.

MEDITERRANEAN DIET AND ITS IMPACT ON THE ILLNESS CHARACTERISTIC OF YOUTH WITH IRRITABLE BOWEL CONDITION

Irritable Bowel Disorder (IBD) is a prevalent digestive illness that frequently affects young people and drastically decreases the Quality of Life (QoL). Adults with IBD indications may find relief from their symptoms through nutritional changes like the Mediterranean-style diet. Concerning the seriousness of symptoms, QoL, and additional pertinent results in young people with IBD, this investigation seeks to determine the impact of the Mediterranean-style diet. 200 individuals with IBD who met the Rome-IV criterion and were between the ages of 13 and 19 were enrolled in the present research. A Mediterranean-style diet was provided to the Study Group (SG), which consisted of 100 individuals, while the Control Group (CG), which consisted of 100 patients, followed the usual diet. Various laboratory and clinical characteristics were also assessed at the beginning and end of the study, in addition to IBD values. The Mediterranean-style diet has been demonstrated to be effective and tolerated well in kids and teenagers with IBD. The IBD -SSS (from 148±42.3 to 224±71) IBD -QoL (from 76.7±8.1 to 61.3±9.8), and cumulative IBD rating (from 29.3±11.7 to 32.6±12.1) all showed notable increases in individuals who followed well to this diet. The CG, in comparison, did not show any significant enhancements in these factors. This indicates that a Mediterranean-style diet might provide therapeutic advantages for IBD individuals, especially those who keep adherent to it, concerning symptom severity and QoL. The Mediterranean-style diet proved to be both secure and associated with notable improvements in IBD rates in young and adolescents with IBD.

INVESTIGATING THE EFFECT OF NICOTINE FROM CIGARETTES ON THE GROWTH OF ABDOMINAL AORTIC ANEURYSMS: REVIEW

Separating aneurysmal arterial disease from atherosclerosis and further occlusive artery conditions, it is a vascular degenerative disorder. Within the vascular tree, there is a regionalization of the propensity to produce aneurysms and the different locations result in different clinical processes. As the predominant risk factor for ubrenal abdominal aortic aneurysm (AAA), smoking is one of the most common manifestations of aneurysmal illness. For AAA compared to atherosclerosis, smoking is a far bigger risk factor. Along with contributing to the pathophysiology of AAA, smoking raises the likelihood that established AAA will rupture as well as its rate of expansion. The development of improved models for animals that are reliant on smoke or smoke constituents is helping to determine the mechanistic connection between AAA and smoking. According to the processes, there are long-lasting changes in the function of inflammatory and vascular smooth muscle cells. Focused on AAA, this review looks at the medical, epidemiology and mechanical evidence that links smoking to aneurysms.

ANXIETY SYNDROMES IN ADOLESCENTS WITH OPERATIONAL RESPIRATORY CONDITIONS: A PROSPECTIVE STUDY

Aim - determining the prevalence of anxiety disorders and their effect on disease progression and quality of life in adults with organic illnesses and functional disorders of the respiratory system treated in a pulmonology environment. A total of 135 young adults between the ages of 13 and 17 were analyzed. There were a total of 46 adolescents diagnosed with somatoform respiratory disorders (SRD), 45 adolescents diagnosed with bronchial asthma (BA), and 44 adolescents diagnosed with pneumonia. The Spielberger-Khanin anxiety questionnaire and the Nijmegen hyperventilation syndrome (HVS) scale were used for the research and diagnosis, respectively. The quality of life was measured using the asthma quality of life questionnaire (AQLQ). In comparison to adults with asthma (33.2%) and pneumonia (32.3%), adults with SRD (34.5%). There were mild immediate associations between the Spielberger scale and the Nijmegen HVS questionnaire for both trait and state anxiety, and mild inverse correlations between the Spielberger scale and the AQLQ for both state and trait anxiety. Adolescents with anxiety had a higher prevalence of trauma, pain, and social issues than their non-anxious counterparts who were referred to psychiatry. In adolescents, 5.1% had severe trait anxiety, and 19.3% had severe condition anxiety. Adolescents with SRD were twice as likely to suffer from extreme state and trait anxiety as the general population. It is hypothesized that anxiety problems are at the root of HVS and contribute to adults' dissatisfaction with their quality of life due to lung ailments. Although certain adolescents with anxiety disorders were referred for anxiety, this data nevertheless lends credence to the idea that using standardized and structured instruments regularly might help increase accuracy and detection rates in the clinic, regardless of the reason for referral. Complete evaluations are essential for this patient population due to the intricacy of their symptoms.

EFFECTS OF SOCIAL ESTRANGEMENT ON YOUNG PEOPLE'S MATURATION: A REVIEW OF THE RESEARCH

A major issue among adolescents in recent years has been social isolation, or the sensation cut off and alone from peers and society. The effects of social isolation on youngsters and adolescents are investigated with special attention paying to the possible negative effects on their physical and mental health. Multiple studies have shown a link between adversity in life domains and adolescent social isolation. Firstly, it can have a major effect on mental health, raising the probability of experiencing things like anxiety, sadness and even suicidal thoughts. Second, it prevents the development of vital social abilities, making it harder to make and keep close friends. In addition, social isolation is associated with worse academic performance, which in turn reduces the number of courses a student can take and the number of jobs they can have in the future. After looking over 520 papers, 15 were chosen for the systematic review. Four researches reported the implications on general health, while two investigations reported on ramifications affecting the Hypothalamic-pituitary-adrenal (HPA) axis area along with social and mental growth of children. In conclusion, social isolation affects youth development across a wide spectrum, including psychological well-being, interpersonal skills, and academic success. Children and adolescents who experience isolation are more likely to suffer from anxiety and sadness, according to the review's findings. Cortical levels rise and mental growth slows in socially isolated children. Children and adolescents should be monitored by health professionals during and after the COVID-19 pandemic to ensure that their mental and physical health needs are met.

APPLICATIONS OF THREE DIMENSIONAL FACIAL COMPUTED TOMOGRAPHY IN HEAD AND NECK REGION - A REVIEW

3D facial CT has evolved and revolutionized diagnosis leading to better management. The limitations of conventional 2D methods limit the therapeutic options related to leading to an erroneous treatment. Although 3D facial CT is expensive, its advantages outweigh the cons. They are used in surgery, prosthetic replacement, orthodontics and forensics.

Efficacy of Early Enteral Nutrition on Gastrointestinal Surgery Outcomes: A Systematic Review and Meta-Analysis

Congenital anomalies, congenital malformations, or birth defects can be defined as any structural or functional anomalies that develop prenatally and could be identified before, at birth, or later in life. Approximately 6% of babies are born with a congenital anomaly, which results in 2.4 million newborn deaths worldwide. This systematic review and meta-analysis ascertained the quantitative studies published in PubMed, ClinicalKey, Embase, CINAHL, Cochrane Library, and Google Scholar. Two authors independently screened and extracted the data from the primary studies that analyzed the efficacy of early enteral nutrition (EEN) on the postoperative outcome. This systematic review and meta-analysis adopted Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. The methodological quality of trials was assessed by Cochrane Collaboration's risk of bias tool. Six trials, representing 488 children, with age ranging from 10 days to 6.5 years, fulfilled the inclusion criteria. EEN has significantly shortened hospital stay, induced early fecal movement, and reduced postoperative wound infections in children with congenital gastrointestinal abnormalities undergoing gastrointestinal anastomosis compared with children who received late enteral nutrition. The review also found that the experimental group who received EEN had no significant impact on the anastomosis leakage, vomiting, and abdominal distension. EEN has some positive effects on postsurgery outcomes among children with congenital gastrointestinal anomalies undergoing gastrointestinal anastomosis.

Retroperitoneal yolk sac tumour encroaching the liver and adrenal gland with tumour thrombus in cavo-atrial region and hepatic veins

Paediatric germ cell tumours (GCT) are rare tumours and are unique because of varied clinical presentation and locations. Yolk sac tumour is the predominant malignant histology and a serum marker; alpha fetoprotein is used to see treatment response and recurrent disease. It is extremely rare to find a retroperitoneal GCT with tumour thrombus extending up to the cavo-atrial region with involvement of the hepatic veins. We report a case of retroperitoneal yolk sac tumour (RPYST) with extension to the liver and right adrenal gland along with tumour thrombus in the inferior vena cava and in the right and middle hepatic veins. The child was operated after satisfactory response to chemotherapy. Excision of the tumour along with the right adrenal gland and around 5 cm of retro-hepatic caval resection was done. Inferior vena cava resection was tolerated without reconstruction. Currently child is disease-free and symptom-free at 22 months of follow-up with normal serum marker.

Appendectomy in Management of Malrotation of Gut is it Necessary?

Introduction

Malrotation is a congenital anatomical anomaly that affects the normal positioning of the intestines. Traditional management of malrotation, as described by Ladd, consists of detorsion of the volvulus if present, division of Ladd's bands, widening of the mesenteric root, proper positioning of the small and large bowels, and a prophylactic appendectomy. This study was done to determine whether appendectomy should be an integral part of the Ladds procedure or if it can be avoided.

Materials and Methods

This retrospective observational study was conducted in one pediatric surgical unit in the tertiary care center of North India. All the cases of malrotation of the gut managed from January 2008 to December 2018 were reviewed. The details of the patients were recovered from the electronic data recording system of the hospital and manual operation theater records. The cases that have a follow-up of <5 years were not included in the study. The details were charted in an Excel Sheet for the analysis. No statistical test was performed because there was no event in patients in whom prophylactic appendectomy was not done.

Results

The data analysis revealed that a total of 66 malrotation patients were managed during this period, those who fulfilled the inclusion criteria. Among 66 cases included in the study, in 41 cases, prophylactic appendectomy was done, whereas in the rest 25, prophylactic appendectomy was not done. During the follow-up, none of the patients in whom the appendix was preserved presented with signs or symptoms related to appendicitis or any other complications.

Conclusion

Ladds procedure without appendectomy can be performed in view of the potential use of the appendix in the future, and with the fact that in the current era of advanced medicine, appendicitis can be diagnosed early due to the advancement of imaging and better record keeping.

IMPLICATION OF THREAT FACTORS AND PREEXISTING DISORDERS IN DIFFERENT ISCHEMIC STROKE SUBGROUPS IN ELDERLY PEOPLE: A SYSTEMATIC STUDY

Ischemic stroke is a major health issue, especially for the older population and it may have severe effects. Stroke diagnosis and treatment have advanced over the last 20 years, which has resulted in considerable reductions in death, long-term impairment, and the need for institutional care. Younger age groups have seen the majority of trials for acute, interventional, and preventive therapy. The purpose of this research was to identify distinct subgroups of older people who had suffered an ischemic stroke and examine the role that risk factors and previous illnesses played in their development. Ischemic stroke risk factors varied by age, gender and exhibited their own unique features. Smoking, cholesterol, and psychological/emotional stress were shown to have the greatest prevalence (p<0.06) among stroke patients aged 45-60. Smoking is associated with a significant (p<0.07) decline in health in elderly people. Our results imply that there are significant patterns of risk factors and preexisting illnesses among the various subgroups of older people who have had an ischemic stroke. Atherosclerotic (large-artery) and cardio embolic (small-artery) ischemic strokes were shown to be the most prevalent among the elderly. Strong associations were found between these subtypes and other risk factors, including higher cholesterol, diabetes, high blood pressure, and atrial fibrillation. This research emphasizes the need for individualized preventative methods and therapeutic therapy, as well as the need to recognize the variability of ischemic stroke in the elderly.

EARLY IMPLANT OUTCOMES IN ADULTS WITH DENTAL DECAY TREATED WITH PHOTODYNAMIC TREATMENT

A fast implant is a kind of implant to place in the cavity right away after dental extraction. These implants are shown to maintain cervical marrow and reduce the number of surgery operations required for patients. The Photodynamic treatment (PDT) uses antimicrobial processes to supplement nonsurgical periodontal therapy. Combined through the scaling and root planning (SRP), and PDT is more effective. This study aims to assess the effects of PDT on initial findings with dental implants (DI) placed in patients having gum disease with SRP against patients who do not at the 12-month follow-up point. An aggregate of 25 implants were inserted in 16 patients, 12 of whom were in the test group (TG) and 13 of whom were in the control group (CG). SRP is conducted toward rapid implant assignment in the control site, while PDT as an adjunct to SRP (SRP + PDT) is executed prior to instant implant insertion in test sites. At the beginning, 4 months, 8 months, and 12 months, gingival index, radiovisiographs, inquiring pocket intensity, clinical attachment level, and plaque index were obtained. Basic durability was assessed after implant insertion, and the recovery index was measured a week later. In this analysis, Analysis of Variance (ANOVA) technique is used to predict tooth decay earlier. The CG experienced 1.10 mm of mean marginal bone loss after the 12-month research period, compared to 0.97 mm for the (SRP + PDT) group. After reaching the CG and TG, the differences in plaque score and probe depth were noteworthy. Clinical indicators compared to the basis in a year revealed unquestionable improvement, including the probing depth gingival index, plaque index and clinical attachment level. Twelve months were spent monitoring the implants in both groups. The little bone loss improved, although it isn't clinically important. The endurance rate for rapid implants in the PDT grouping is the same as that of the group that underwent SRP. The impact of PTD is utilized as a supplement to SRP. Yet, the consequence is marginal. Because of the improved results with PDT, it is used successfully as an addition to SRP.

Radiation Therapy Sensitizes Head-and-Neck Cancer Cells to Killing by Chimeric Antigen Receptor (CAR)-NK Cells Targeting CD70

PURPOSE/OBJECTIVE(S)

CAR-T cell therapy is limited by toxicity, high cost, logistical manufacturing issues in the autologous setting and risk of GVHD in the allogeneic setting. Substitution of T cells with NK cells opens the possibility for an allogeneic off-the-shelf product with a better safety profile. However, the inadequate efficacy of CAR-NK cells against solid tumors can be extrapolated from experience with CAR-T cells. There is limited but promising preclinical evidence that radiation therapy (RT) enhances CAR-T cell tumoricidal activity against solid tumors. However, there is no data examining the potential synergy between RT and CAR-NK cell therapy.

MATERIALS/METHODS

We engineered CAR-NK cells with CD27 receptor as extracellular domain to target its natural ligand CD70, which is overexpressed in head-and-neck cancers (HNSCC). CAR-NK cell killing was assessed real-time through xCELLigence cytotoxicity assays. CD70+ OQ01 human HNSCCs were used for most experiments. FaDu is a CD70- HNSCC (negative ctrl). UMRC3 is a CD70+ kidney cancer cell line (positive ctrl). CD70 expression pre- and post-RT was assessed by flow cytometry and Western blot. Ionizing RT was compared at 5 doses: 0, 1.75, 3.5, 7, and 14 Gy. A single dose of 3.5 Gy was used for most experiments. Post-radiation effects were generally assessed at 3 days or 9 days post-RT. Intracellular staining was used to assess NK cell expression of IFN-γ, CD107a, and TNF-α by flow cytometry. CD27/CD70 interaction blockade was through α-CD27 pre-treatment of CAR-NK cells.

RESULTS

OQ01 HNSCCs heterogeneously express CD70 and are killed by CD70 CAR-NK cells in vitro. Pre-conditioning low-dose RT of 3.5 Gy applied to OQ01 HNSCCs 3 days prior to coculture with NK cells enhances CD70 CAR-NK cell killing, with ∼30% increased cytotoxicity against the tumor cells. Low-dose RT by itself did not induce acute cytolysis. As a possible mechanism for the increased sensitivity of irradiated OQ01 cells to CD70 CAR-NK cells, we found that RT enhances CD70 expression among HNSCCs in a dose-dependent manner. There was no increase in NK cell expression of IFN-γ, CD107a, and TNF-α with exposure to irradiated target cells. CD27/CD70 blockade does not solely abrogate RT-induced sensitization toward CAR-NK cell killing. Despite RT induction of transient increased expression of CD70, which normalizes by 9 days post-RT, there is persistent increase in RT-synergized target cell killing even at this later timepoint. Thus, altogether, RT sensitizes CD70-expressing HNSCC cells to CAR-NK cell killing in vitro.

CONCLUSION

This work represents the first preclinical study to identify the synergy of RT and CAR-NK cell therapy in solid tumors and is the first demonstration of CAR-NK cell activity against human HNSCCs. We show significantly enhanced potency of CAR-NK cells against irradiated tumor cells in vitro. Collectively, this research will be vital to guide efforts expanding into other target antigens and tumor types.

UNDERSTANDING THE VITAL DETERMINANTS SHAPING LEARNERS' PHYSICAL ACTIVITYAND PSYCHOEMOTIONAL WELLBEING IN THE COVID-19 PERIOD

The Corona Virus (COV-19) epidemic significantly affected the educational environment, requiring a quick transition to distance and blended learning methods. This extraordinary disruption had an incredible impact on pupil's levels of physical activity (PA), psycho-emotional health (PEH) and engagement with academic material. The research aims to examine the vital determinants that influenced various areas of learners' lives during CoV-19. The purpose of this 600-person study was to collect data on the subjects' overall health and PA levels for the CoV-19 pandemic. The SPSS application was used to process the questionnaire's collected data. The information given reveals the respondents' degree of PA throughout the quarantine. According to the breakdown, 15% indicated low levels of PA, 39% reported medium levels and 46% reported high levels. The data show that, despite the respondents' different levels of PA, little PA predominated for most of them. The limitations of distance learning throughout quarantine and the prevalent recommendation of leaving residence for necessary reasons were blamed for this tendency. There were fewer prospects for higher-intensity PA due to these circumstances.

AN INCREASED RISK OF HORMONAL DISORDERS, PRIMARILY DIABETES, IN INDIVIDUALS WITH Β -THALASSEMIA MAJOR: A RETROSPECTIVE ANALYSIS

β-Thalassemia major is an inherited blood condition marked by a serious anemia and a lifetime need for blood transfusions. The effects of β-thalassemia major on endocrine health, notably the risk of diabetes, remain largely unstudied, despite the fact that its haematological components are established. The purpose of this systematic analysis was to examine the incidence of reduced metabolism of glucose in β--thalassemia major. The articles were under the inclusion requirements, after which the data was retrieved. The main outcome was determined to be every prevalence (P) of DM (diabetes mellitus) in β-thalassemia major. In order to examine the percentage of aberrant glucose metabolism (GM) with individuals among β-thalassemia major, the P with the 95% CI (Confidence Interval) was utilized. In this retrospective investigation, we looked at a cohort of people with β-thalassemia major diagnoses to determine the incidence and risk of hormonal diseases, particularly diabetes. A specialist thalassemia facility treated 315 individuals with β-thalassemia major, and their medical records were examined. Age, gender, age at which a main diagnosis of β-thalassemia was made, the length of transfusion treatment, and concomitant diseases were gathered as part of the demographic and clinical data. Our research, which included 17 studies and 1500 cases altogether, showed that with β -thalassemia major had a considerably greater frequency of diabetes than people in general. With a mean beginning age of 30 years, diabetes was identified in 28% of the research cohort's participants. The combined meta-analysis showed that each year had a rather stable level of DM P in β-thalassemia major. In people with major β-thalassemia, the P of impaired fasting glucose (IFG), DM, and impaired glucose tolerance (IGT) was 17.22% (95% CI: 8.44%-26.02%), (6.57 (95% CI: 5.31%- 7.79%) and 12.47 % (95% CI: 5.97%-18.95%), respectively. Our research suggests that people with β-thalassemia major have a high chance of acquiring diabetes, particularly if they get extended transfusion treatment. For prompt diagnosis and care, early detection of diabetes and other hormonal problems in this group is crucial. In β-thalassemia major, there is a high frequency of endocrine problems, including improper GM. To stop growth and endocrine issues, treatment and preventative measures can be required.

EXPLORING CLINICAL VARIATIONS AND CO-MORBID TRENDS IN PD-MCI GROUPS

Parkinson's Disease in Mild Cognitive Impairment (PD-MCI) is a complex condition characterized by a variety of cognitive problems that coexist with the physical symptoms of Parkinson's disease (PD). This study aims to examine the different medical indicators and associated tendencies among different PD-MCI groups. We investigated 132 people who had been given PD-MCI diagnoses. Utilizing SPSS, statistical evaluations are carried out. In overall PD-MCI variants, this investigation found that visuospatial ability and attentional/executive performance are the most impaired cognitive areas. It was also noticed that distinct PD-MCI groups had variances in their neurological characteristics, in multi domain amnesia (Non-Memory) PD-MCI patients exhibiting especially severe issues with unstable posture and walking. The intricacy of PD- Mild Cognitive Impairment (MCI) is highlighted by those results, which also imply that the interplay between mental and physical signs may be controlled by a number of interrelated factors, such as particular cognitive areas, brain surfaces, and the general level of cognitive impairment.

How to suspect the presence of high-risk esophageal varices and when to start endoscopic surveillance in children with biliary atresia?

BACKGROUND AND AIM

Portal hypertension determines the outcome of children with biliary atresia (BA) and is common even after a successful Kasai portoenterostomy (KPE). However, there are no clear-cut guidelines on the age of starting surveillance and the modality (endoscopy vs non-invasive tests [NITs]). In this cohort study, we analyzed our database to find out the utility of NITs in detecting high-risk esophageal varices in BA.

METHODS

From June 2010 to May 2022, consecutive children of BA who underwent upper gastrointestinal (UGI) endoscopy were included. Esophageal varices were classified as high-risk (grade II with red-color signs or grade III or IV irrespective of red-color signs. NITs such as splenomegaly (clinical and USG), platelet count, aspartate transaminase to platelet ratio index (APRI), and platelet-to-spleen diameter ratio were compared between cases with high-risk and low-risk varices.

RESULTS

A total of 110 children, 75 boys (66 successful KPE and 44 failed/KPE not performed) were enrolled. The median age at KPE was 85 days (IQR 63-98). Thirteen (11.8%) children presented with UGI bleeding. The first endoscopy revealed gastroesophageal varices in 75.4% of cases, and 32% of them had high-risk varices. Multivariate analysis revealed failed KPE, history of UGI bleeding, bigger spleen size (> 3.5 cm), lower platelet count (< 150 000), and higher APRI (> 2) are independent predictors of the presence of high-risk esophageal varices.

CONCLUSION

Endoscopy is the best in predicting the presence of high-risk varices that might bleed; hence, early surveillance endoscopy should be started in children with splenomegaly, thrombocytopenia, and high APRI score to prevent variceal bleeding.

Development and validation wise assessment of genotype guided warfarin dosing algorithm in Indian population

OBJECTIVES

A study was conducted to develop and validate the warfarin pharmacogenetic dose optimization algorithm considering the clinical pharmacogenetic implementation consortium (CPIC) recommendations for the Asian ethnicity population.

METHODS

The present prospective observational study recruited warfarin-receiving patients. We collected a three ml blood sample for VKORC1, CYP2C9*2, CYP2C9*3, and CYP4F2 polymorphism assessment during the follow-up visits. Clinical history, sociodemographic and warfarin dose details were noted.

RESULTS

The study recruited 300 patients (250 in derivation and 50 in validation timed cohort) receiving warfarin therapy. The baseline characteristics were similar in both cohorts. BMI, presence of comorbidity, VKORC1, CYP2C9*2, and CYP2C9*3 were identified as covariates significantly affecting the warfarin weekly maintenance dose (p<0.001 for all) and the same were included in warfarin pharmacogenetic dose optimization algorithm building. The algorithm built-in the present study showed a good correlation with Gage (r=0.57, p<0.0001), and IWPC (r=0.51, p<0.0001) algorithms, widely accepted in western side of the globe. The receiver operating characteristic curve analysis showed a sensitivity of 73 %, a positive predictive value of 96 %, and a specificity of 89 %. The algorithm correctly identified the validation cohort's warfarin-sensitive, intermediate reacting, and resistant patient populations.

CONCLUSIONS

Validation and comparisons of the warfarin pharmacogenetic dose optimization algorithm have made it ready for the clinical trial assessment.

Congenital pulmonary airway malformation manifesting with severe respiratory distress and pneumothorax in a neonate

Congenital pulmonary airway malformation (CPAM) is congenital pulmonary anomaly characterized by multicystic areas, over-distension, and proliferation of terminal bronchioles with lack of normal alveoli. Clinical presentation may vary from mild respiratory symptoms to severe respiratory distress and frequent pneumothoraxes. We report a rare case of neonatal CPAM type I manifested with neonatal respiratory distress and pneumothorax, which was managed successfully with left lower lobectomy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01510-x.

A Case Report of High-Risk Percutaneous Coronary Intervention of Left Main Coronary Artery With Cardiogenic Shock

Acute total occlusion of the left main artery is a fatal event and is often accompanied by cardiogenic shock. Patients who experience this event have high mortality rates. Early percutaneous coronary intervention (PCI) with hemodynamic support has proven to improve clinical outcomes for these patients. Here we report a case of a 60-year-old man, who came into our emergency room with an acute anterior wall myocardial infarction accompanied by cardiogenic shock. He had a totally occluded left main artery on coronary angiography, necessitating cardiopulmonary resuscitation, followed by PCI with implantation of a drug-eluting stent along with hemodynamic support. Identification of typical ECG changes is crucial in patients with acute coronary syndrome caused by the occlusion of the left main coronary artery. A quick decision to perform a PCI procedure using early circulatory mechanical devices (intra-aortic balloon pump) is critical to patient survival.

A Survey on the Machine Learning Techniques for Automated Diagnosis from Ultrasound Images

Medical diagnostic systems has recently been very popular and reliable because of possible automatic detections. The machine learning algorithm is evolved as a core tool of computer-aided diagnosis (CAD) for automatic early and accurate disease detections. The algorithm follows region of interest (ROI) selection followed by specific feature extractions and selection from medical images. The selected features are then fed to suitable classifiers for disease identification. The machine learning algorithm's performance depends on the features selected and the classifiers employed for the job. This paper reviews different feature extraction selection and classification techniques for CAD from ultrasound images. Ultrasonography (USG), due to its portability and its non-invasive nature, is the prime choice of doctors for prescribing as an imaging test. A survey on the USG imaging based on four major diseases is performed in this paper, whose diagnosis followed by automatic detection. Various techniques applied for feature extraction, selection, and classification by different authors to achieve improved accuracy are tabulated. For medical images, we found texture based gray-level extracted features and SVM (support vector machine) classifiers to be more significant in improving classification accuracy, even achieving 100% accuracy in many research articles. However, many research articles also suggest the importance of student's t-test in improving classification accuracy by selecting significant features from extracted features. The proposed algorithm's accuracy also depends on the quality of medical images, which are frequently degraded by the introduction of noise and artifacts while imaging acquisition. So, challenges in denoising are added in this paper as a separate topic to highlight the role of the machine learning algorithm in removing noise and artifacts from the USG images.

The Transportation of Maxwell Fluid in the Rotating and Stretching System: Rotor-Stator Spinning Disc Reactor Applications

We have developed a mathematical model and obtained a numerical solution for the motion of a non-Newtonian Maxwell fluid between two disks having rotation and stretching velocity with convective boundary constraints, porous medium and thermal radiation. The present Maxwell fluid flow model with specified boundary constraints is not discussed so far. The proposed model has a lot of applications in electrical power generation, nuclear energy plants, astrophysical flows, space vehicles, geothermal extractions, and spinning disc reactor. The Von Karman similarity approach is used for the solution and validation of the solution is also provided. The solution is obtained numerically with finite difference method (FDM) based ND-solve command in Mathematica software. The effects of magnetic field, porous medium, radiation parameter, Deborah number, Prandtl number, and Reynolds number on skin friction, heat transfer, flow and temperature fields are discussed in detail. Due to the significant void fraction in the medium, porosity parameter shows unique trend compared to other parameters for the radial velocity profile. It has tendency to enhance the radial velocity near both the disc but in the middle part of system, porosity parameter retards radial velocity significantly.

Computer-Aided Diagnosis of Various Diseases Using Ultrasonography Images

This paper is an exhaustive survey of computer-aided diagnosis (CAD) system-based automatic detection of several diseases from ultrasound images. CAD plays a vital role in the automatic and early detection of diseases. Health monitoring, medical database management, and picture archiving systems became very feasible with CAD, assisting radiologists in making decisions over any imaging modality. Imaging modalities mainly rely on machine learning and deep learning algorithms for early and accurate disease detection. CAD approaches are described in this paper in terms of their significant tools; digital image processing (DIP), machine learning (ML), and deep learning (DL). Ultrasonography (USG) already has many advantages over other imaging modalities; therefore, CAD analysis of USG assists radiologists in studying it more clearly, leading to USG application over various body parts. So, in this paper, we have included a review of those major diseases whose detection supports "ML algorithm" based diagnosis from USG images. ML algorithm follows feature extraction, selection, and classification in the required class. The literature survey of these diseases is grouped into the carotid region, transabdominal & pelvic region, musculoskeletal region, and thyroid region. These regions also differ in the types of transducers employed for scanning. Based on the literature survey, we have concluded that texture-based extracted features passed to support vector machine (SVM) classifier results in good classification accuracy. However, the emerging deep learning-based disease classification trend signifies more preciseness and automation for feature extraction and classification. Still, classification accuracy depends on the number of images used for training the model. This motivated us to highlight some of the significant shortcomings of automated disease diagnosis techniques. Research challenges in CAD-based automatic diagnosis system design and limitations in imaging through USG modality are mentioned as separate topics in this paper, indicating future scope or improvement in this field. The success rate of machine learning approaches in USG-based automatic disease detection motivated this review paper to describe different parameters behind machine learning and deep learning algorithms towards improving USG diagnostic performance.

Evaluation of gingival displacement, bleeding and ease of application for polytetrafluoroethylene (PTFE) and conventional retraction cord - a clinical trial

OBJECTIVE

Conventional use of retraction cord in soft tissue management is effective only when the non-resilient nature of material does not jeopardize gingival health. Therefore this study aims to clinically evaluate the gingival displacement, ease of application and bleeding from polytetrafluoroethylene (PTFE) retraction cord.

PATIENTS AND METHODS

This study is a single-center, parallel-group, randomized controlled clinical trial (1:1). Sixty patients indicated for full coverage metal-ceramic restoration for first molars were enrolled and randomly allocated to experimental (PTFE Cord) and control (conventional plain retraction cord) groups. After crown preparation and isolation, a pre-displacement impression was made. Assigned gingival displacement material was applied for 5 minutes, followed by post-displacement impression. Casts were prepared and used for assessment of mean horizontal gingival displacement by measuring displacement using a stereomicroscope (20 x). Post-displacement gingival bleeding and ease of application were also assessed clinically. t-test and Chi-square tests were used for statistical assessment of gingival displacement, gingival bleeding and ease of application.

RESULTS

Gingival displacement, bleeding and ease of application were similar among study groups (p > 0.05). Mean gingival displacement in the experimental group was 197.1 µm, and 167.7 µm in the control group. Bleeding was observed in 30% and 20% of cases of experimental and control group, respectively. Ease of application was 'difficult' in 53.3% and 43.3% of cases of experimental and control group, respectively. Non-impregnated gingival retraction cord and PTFE cord displayed similar outcomes of gingival displacement, ease of placement and bleeding after cord removal.

CONCLUSIONS

Post-displacement bleeding and discomfort for PTFE cord placement suggest that this technique needs improvement. Therefore further studies are warranted to improve and investigate the physical and biological response to PTFE retraction cord.

Percutaneous coronary intervention of anomalous right coronary arteries arising from the left sinus of Valsalva: a single-centre experience from Northern India

Background

An anomalous right coronary artery (ARCA) arising from the left sinus of Valsalva is an uncommon congenital anomaly. The unusual location, take-off and intramural courses of ARCA pose a considerable technical challenge during percutaneous coronary intervention (PCI).

Aims

We sought to report our experience of PCI of ARCA in 35 cases of atherosclerotic occlusion.

Methods

The PCI database of 35 cases of ARCA was retrospectively analysed. The details about demography, clinical presentation, PCI procedure and clinical follow-up were noted.

Results

The mean age was 56.7±13.5 years. The clinical presentation included stable angina in 45.7%, unstable angina in 20% and acute myocardial infarction in 34.3% of patients. Vascular access was transradial in 37.1% of cases, transfemoral in 60% of cases, and transbrachial in 1 case (2.9%). Judkins left and Amplatz left were commonly used guide catheters. Two patients with balloon-uncrossable, calcified lesions required rotablation-assisted PCI. Intravascular imaging was performed in 12 patients (34.3%). Optical coherence tomography demonstrated a proximal intramural course in 3 patients, and a slit-like orifice in 4 patients. The mean radiation dose and fluoroscopy time were 877±687.3 mGy and 18.8±11.6 minutes, respectively. Twenty-eight (80%) patients had an asymptomatic median follow-up of 49 (interquartile range: 29.0-97.5) months.

Conclusions

We performed successful PCI in a cohort of 35 patients with ARCA, with favourable long-term clinical outcomes. The selection of an appropriate guide catheter and technical skills were important factors in achieving favourable results.

Neuroblastic tumours in children: Outcome from a referral centre in India

BACKGROUND

There is a paucity of uniform literature on the outcome of children with neuroblastic tumours from developing countries. This study aims to present the outcome in children having neuroblastic tumours.

MATERIALS AND METHODS

We retrospectively reviewed patients with neuroblastic tumours from January 2014 to March 2020. Data analysed were pertaining to the age, sex, presentation, site, stage, diagnostic evaluation performed, management and follow-up results, etc., The final outcomes were assessed as complete response; partial response (PR); no response (NR) and progressive disease. International Neuroblastoma Risk Group staging was used and patients were categorised on the basis of age, site and stage of tumour. Overall survival (OS) was calculated from the date of diagnosis to the date of last follow-up and event for OS was death.

RESULTS

Forty-seven patients were included with median age of 60 months (ranges of 2-180; mean = 61.87 ± 47.56). About 72.3% (n = 34) patients were males. Out of total, 6.4% (n = 3), 53.2% (n = 25) and 38.3% (n = 18) were in stage L1, L2 and M, respectively, whereas 2.1% (n = 1) patients were in stage MS. Surgery was performed in 25 (53.19%) patients, but gross total excision was achieved in 48.90% (n = 23) patients. Onlu 10.60% (n = 5) patients were referred, whereas 14.89% (n = 7) patients reported recurrences. Mean and median follow-up time of the patients was 24.64 ± 16.04 and 18 months (range: 3-60 months). Out of total, 53.2% (n = 25) and 29.8% (n = 14) patients had complete and PRs, respectively, whereas 17% (n = 8) patients had NR. Out of the total 47 patients, 8 (17%) achieved events (deaths), whereas the rest, 39 (83%) patients, were censored. Mean event-free OS time was 50.04 months.

CONCLUSION

There was a significant difference in patient deaths in recurrence and non-recurred patients (4/7, 57.1% vs. 4/40/, 10%, P = 0.011). Survival time was significantly higher in patients with stages L1-L2 as compared to Stage 4. Stage and age were found predictors of survival.

How should we secure the cystic duct during laparoscopic cholecystectomy? A UK-wide survey of clinical practice and systematic review of the literature with meta-analysis

INTRODUCTION

It is currently unknown which method of cystic duct closure is most effective at reducing the risk of bile leak after laparoscopic cholecystectomy. The aims of this work were to determine the most common closure methods used in the UK and review available evidence on which method has the lowest risk of bile leak.

METHODS

We conducted an online survey through the Association of Upper Gastrointestinal Surgeons (AUGIS). We also undertook a systematic review using PubMed, EMBASE, MEDLINE and the Cochrane Library for studies that compared different methods for cystic duct occlusion and reported postoperative bile leak.

FINDINGS

There was significant variation in practice between consultant surgeons. For routine laparoscopic cholecystectomy metal clips were used most (64%) followed by locking polymer clips (33%) and suture ties (3%). In cases of a dilated cystic duct, preferences were locking polymer clips (60%), suture ties (30%) and metal clips (5%). We included six studies in our review with a total of 8,011 patients. Metal clips were associated with an increased odds of bile leak compared with locking polymer clips (OR 5.66, 95% CI 1.13-28.41, p=0.04) or suture ties (OR 4.17, 95% CI 0.72-24.31, p=0.12). Most studies were retrospective, unlikely to be adequately powered, and vulnerable to selection bias.

CONCLUSIONS

Limited available evidence suggests that metal clips have the highest risk of bile leak, but results are not strong enough to recommend a change in current clinical practice. A trial is now required to determine the best method of cystic duct closure.

Imaging Breast Microcalcifications Using Dark-Field Signal in Propagation-Based Phase-Contrast Tomography

Breast microcalcifications are an important primary radiological indicator of breast cancer. However, microcalcification classification and diagnosis may be still challenging for radiologists due to limitations of the standard 2D mammography technique, including spatial and contrast resolution. In this study, we propose an approach to improve the detection of microcalcifications in propagation-based phase-contrast X-ray computed tomography of breast tissues. Five fresh mastectomies containing microcalcifications were scanned at different X-ray energies and radiation doses using synchrotron radiation. Both bright-field (i.e. conventional phase-retrieved images) and dark-field images were extracted from the same data sets using different image processing methods. A quantitative analysis was performed in terms of visibility and contrast-to-noise ratio of microcalcifications. The results show that while the signal-to-noise and the contrast-to-noise ratios are lower, the visibility of the microcalcifications is more than two times higher in the dark-field images compared to the bright-field images. Dark-field images have also provided more accurate information about the size and shape of the microcalcifications.

Low-latency and High-Reliability FBMC Modulation scheme using Optimized Filter design for enabling NextG Real-time Smart Healthcare Applications

This paper presents a prototype filter design using the orthant optimization technique to assist a filter bank multicarrier (FBMC) modulation scheme of a NextG smart e-healthcare network framework. Low latency and very high reliability are one of the main requirements of a real-time e-healthcare system. In recent times, FBMC modulation has gotten more attention due to its spectral efficiency. The characteristics of a filter bank are determined by t's, prototype filter. A prototype filter cannot be designed to achieve an arbitrary time localization (for low latency) and frequency localization (spectral efficiency), as time and frequency spreading are conflicting goals. Hence, an optimum design needed to be achieved. In this paper, a constraint for perfect or nearly perfect reconstruction is formulated for prototype filter design and an orthant-based enriched sparse ℓ1-optimization method is applied to achieve the optimum performance in terms of higher availability of subcarrier spacing for the given requirement of signal-to-interference ratio. Larger subcarrier spacing ensures lower latency and better performance in real-time applications. The proposed FBMC system, based on an optimum design of the prototype filter, also supports a higher data rate as compared to traditional FBMC and OFDM systems, which is another requirement of real-time communication. In this paper, the solution for the different technical issues of physical layer design is provided. The presented modulation scheme through the proposed prototype filter-based FBMC can suppress the side lobe energy of the constituted filters up to large extent without compromising the recovery of the signal at the receiver end. The proposed system provides very high spectral efficiency; it can sacrifice large guard band frequencies to increase the subcarrier spacing to provide low-latency communication to support the real-time e-healthcare network.

Coalescence of Anderson-localized modes at an exceptional point in 2D random media

In non-Hermitian settings, the particular position at which two eigenstates coalesce in the complex plane under a variation of a physical parameter is called an exceptional point. An open disordered system is a special class of non-Hermitian system, where the degree of scattering directly controls the confinement of the modes. Herein a non-perturbative theory is proposed which describes the evolution of modes when the permittivity distribution of a 2D open dielectric system is modified, thereby facilitating to steer individual eigenstates to such a non-Hermitian degeneracy. The method is used to predict the position of such an exceptional point between two Anderson-localized states in a disordered scattering medium. We observe that the accuracy of the prediction depends on the number of localized states accounted for. Such an exceptional point is experimentally accessible in practically relevant disordered photonic systems.

Balloon Mitral Valvotomy With the Accura Double-Lumen Balloon Catheter: Immediate and One-Year Clinical Outcomes

Objective

Despite the decline in the incidence of rheumatic heart disease in developed countries, the disease still remains endemic among individuals of low socioeconomic status. The aim of the study is to assess immediate and one-year outcomes of balloon mitral valvotomy using the double-lumen Accura balloon (Vascular Innovations Co., Nonthaburi, Thailand) in patients with mitral valve stenosis.

Methods

This was a single-centre, observational, investigator-initiated retrospective study. All consecutive patients undergoing balloon mitral valvotomy with the Accura balloon between January 2015 and June 2020 were included. The primary endpoint was procedural success defined as an increase in mitral valve area (MVA) ≥50% from basal valve area or final valve area of ≥1.5 cm², in the absence of mitral regurgitation grade >2. Clinical, echocardiographic, and haemodynamic parameters were assessed at the one-year follow-up.

Results

A total of 62 patients underwent balloon mitral valvotomy. The mean age was 34.9 ± 8.0 years, and 54 (87.1%) patients were female. Mean Wilkins' echo score was 7.5 ± 0.5. Procedural success was achieved in 59 (96.7%) patients. Mean MVA increased from 0.75 ± 0.14 cm² to 1.64 ± 0.21 cm², and mean mitral valve gradient decreased from 24.9 ± 5.5 mmHg to 7.30 ± 1.40 mmHg. Atrial fibrillation, mitral valve replacement, and moderate to severe mitral regurgitation occurred in 36 (59.0%), two (3.3%), and two (3.3%) patients, respectively. No death, cerebrovascular accidents, restenosis, or redo procedures occurred.

Conclusion

Balloon mitral valvotomy using the double-lumen Accura balloon is safe in patients with mitral valve stenosis.

Analysis of Unsteady Magnetohydrodynamic 3-D Rotating Flow and Transfer of Heat in Carbon Nanotube-Water Nanofluid: An Engineering Application

We have analysed unsteady Magnetohydrodynamic (MHD) 3-D rotating flow of Carbon Nanotube (CNT) water nanofluid past a stretching surface dealing with thermal radiation mechanism of heat transfer and heat source/sink. The mathematical model consists of a system of non-linear coupled Partial Differential Equations (PDEs). Numerical solution is obtained and discussed in detail. The influence of flow dominant parameters on the temperature profiles and flow-field are also discussed in detail using tables and graphs. Results are justified by previously published results in the limiting sense. Various crucial results are obtained, for example, unsteadiness parameter accelerates the fluid velocities in both directions near the sheet and reverse behaviour is noticed away from the sheet. However, fluid rotation causes reduction in primary velocity but it tends to accelerate secondary velocity near the sheet. Insertion of nanoparticle volume fraction intensifies fluid velocity and attenuates fluid temperature. We also found that multi-Walled Carbon Nanotubes (MWCNTs) offer more resistance for primary skin friction and less resistance for secondary skin friction when compared with Single-Walled Carbon Nanotubes (SWCNTs).

Development of portable and robust cataract detection and grading system by analyzing multiple texture features for Tele-Ophthalmology

This paper presents a low cost, robust, portable and automated cataract detection system which can detect the presence of cataract from the colored digital eye images and grade their severity. Ophthalmologists detect cataract through visual screening using ophthalmoscope and slit lamps. Conventionally a patient has to visit an ophthalmologist for eye screening and treatment follows the course. Developing countries lack the proper health infrastructure and face huge scarcity of trained medical professionals as well as technicians. The condition is not very satisfactory with the rural and remote areas of developed nations. To bridge this barrier between the patient and the availability of resources, current work focuses on the development of portable low-cost, robust cataract screening and grading system. Similar works use fundus and retinal images which use costly imaging modules and image based detection algorithms which use much complex neural network models. Current work derives its benefit from the advancements in digital image processing techniques. A set of preprocessing has been done on the colored eye image and later texture information in form of mean intensity, uniformity, standard deviation and randomness has been calculated and mapped with the diagnostic opinion of doctor for cataract screening of over 200 patients. For different grades of cataract severity edge pixel count was calculated as per doctor's opinion and later these data are used for calculating the thresholds using hybrid k-means algorithm, for giving a decision on the presence of cataract and grade its severity. Low value of uniformity and high value of other texture parameters confirm the presence of cataract as clouding in eye lens causes the uniformity function to take lower value due to presence of coarse texture. Higher the edge pixel count value, this confirms the presence of starting of cataract as solidified regions in lens are nonuniform. Lower value corresponds to fully solidified region or matured cataract. Proposed algorithm was initially developed on MATLAB, and tested on over 300 patients in an eye camp. The system has shown more than 98% accuracy in detection and grading of cataract. Later a cloud based system was developed with 3D printed image acquisition module to manifest an automated, portable and efficient cataract detection system for Tele-Ophthalmology. The proposed system uses a very simple and efficient technique by mapping the diagnostic opinion of the doctor as well, giving very promising results which suggest its potential use in teleophthalmology applications to reduce the cost of delivering eye care services and increasing its reach effectively. Developed system is simple in design and easy to operate and suitable for mass screening of cataracts. Due to non-invasive and non-mydriatic and mountable nature of device, in person screening is not required. Hence, social distancing norms are easy to follow and device is very useful in COVID-19 like situation.

Glycated haemoglobin and the risk of postoperative complications in people without diabetes: a prospective population-based study in UK Biobank

Summary

The aim of our study was to clarify the association between glycated haemoglobin (HbA_1c) and postoperative outcomes in people without an existing diagnosis of diabetes. Half a million adults were recruited into the UK Biobank prospective cohort study between March 2006 and October 2010. We divided participants into three groups: no diagnosis of diabetes and HbA_1c < 42 mmol.mol⁻¹; no diagnosis of diabetes and elevated HbA_1c (≥ 42 mmol.mol⁻¹ with no upper limit); and prevalent diabetes (regardless of HbA_1c concentration) at recruitment. We followed up participants by linkage with routinely collected hospital data to determine any surgical procedures undertaken after recruitment and the associated postoperative outcomes. Our main outcome measure was a composite primary outcome of 30‐day major postoperative complications and 90‐day all‐cause mortality. We used logistic regression to estimate the odds of the primary outcome by group. We limited analyses to those who underwent surgery within one year of recruitment (n = 26,653). In a combined effects logistic regression model, participants not known to have diabetes with HbA_1c ≥ 42 mmol.mol⁻¹ had increased odds of the primary outcome (OR [95% CI] 1.43 [1.02–2.02]; p = 0.04), when compared with those without diabetes and HbA_1c < 42 mmol.mol⁻¹. This effect was attenuated and no longer statistically significant in a direct effects model with adjustment for hyperglycaemia‐related comorbidity (OR [95% CI] 1.37 [0.97–1.93]; p = 0.07). Elevated pre‐operative HbA_1c in people without diabetes may be associated with an increased risk of complications, but the association is likely confounded by end‐organ comorbidity. In contrast to previous evidence, our findings suggest that to prevent adverse postoperative outcomes, optimisation of pre‐existing morbidity should take precedence over reducing HbA_1c in people without diabetes.

60 Neoadjuvant Imatinib Mesylate – an Ace of Spaces for Surgical Management of an Oesophago-Gastric Junction Gastro-Intestinal Stromal Tumour

Introduction

Oesophageal gastro-intestinal stromal tumours (GISTs) are rare, accounting for less than five percent of all GIST, with the majority of these occurring at the oesophago-gastric junction (OGJ). Due to the anatomical location and size of these tumours at presentation, surgical resection is often a major undertaking.

Neoadjuvant treatment with tyrosine kinase inhibitors, such as Imatinib mesylate, have the potential to downstage such tumours, thereby limiting the extent of subsequent surgical resection. This may therefore reduce any potentially associated morbidity and mortality.

Case Description

We report the case of a 75-year-old gentleman who presented with a large OGJ GIST, which presented with dysphagia. The tumour was deemed too large for local excision due to the risk of compromising the lumen at the OGJ in attempting to obtain a clear resection margin. Given the patient’s co-morbidity, oesophagectomy or total gastrectomy was deemed too major an undertaking. Therefore, endoscopic biopsies were obtained with a view to possible neoadjuvant therapy. These confirmed DOG-1 and Exon-11 mutations, suggesting sensitivity to Imatinib mesylate. A standard dose regime of 400mg daily for a planned 36-month course was commenced. Subsequent imaging showed a substantial decrease in tumour bulk and the decision was made to perform a local excision. A local enucleation procedure was performed, and the patient made a sound recovery.

Post-operative histology of resected tumour showed almost complete tumour regression.

Discussion

This significant response to neoadjuvant Imatinib mesylate therapy demonstrates clear potential for its use in similar cases, where radical resection would cause significant morbidity and risk mortality.

43 The Value of Endoscopic Ultrasound (EUS) in the Investigative Pathway of Acute Idiopathic Pancreatitis (AIP)

Introduction

The British Society of Gastroenterology (BSG) guidelines on the management of acute idiopathic pancreatitis (AIP) state the incidence of idiopathic cases to be no more than 30%. However, before a firm diagnosis of AIP is made, Endoscopic Ultrasound (EUS) may be used to determine occult causes. This approach may help prevent recurrent attacks which may evolve into chronic pancreatitis.

Method

Retrospective analysis over a one-year period of cases of AIP in a tertiary referral centre was performed to see the incidence of AIP and the role of EUS. Patients with an identifiable cause for pancreatitis were excluded, leaving only those who had received a diagnosis of AIP and the diagnostic value of EUS was examined.

Results

Of the 101 patients diagnosed with AIP, 19% (n=19) underwent an EUS successfully. 79% (n=15) had no underlying cause of pancreatitis identified on EUS. In the remaining 21% of cases (n=4), microlithiasis, ductal stones, and pus requiring drainage were common findings. Of these patents, only 1 was referred for surgery. In the patient group with negative findings on EUS, 4% were unaffected, 2% were referred for surgery, 2% died and 7% had recurrent episodes of pancreatitis.

Conclusions

The results of this study show that EUS is a valuable modality in patients with suspected AIP, with a positive diagnostic rate of 21%. Therefore, we propose EUS needs to be included in the investigative pathway of all suspected AIP. Although EUS is a relatively scarce resource, further research is required to establish guidelines for the investigation of suspected AIP.