An in-silico approach to unravel the structure of 3-deoxy-D-arabino-heptulosonate 7-phosphate synthase (DAHPS): a critical enzyme for sennoside biosynthesis in Cassia angustifolia Vahl

The laxative properties of senna are attributed to the presence of sennosides produced in the plant. The low production level of sennosides in the plant is an important impediment to their growing demand and utilization. Understanding biosynthetic pathways helps to engineer them in terms of enhanced production. The biosynthetic pathways of sennoside production in plants are not completely known yet. However, attempts to get information on genes and proteins engaged in it have been made which decode involvement of various pathways including shikimate pathway. 3-deoxy-D-arabino-heptulosonate 7-phosphate synthase (DAHPS) is a key enzyme involved in sennosides production through the shikimate pathway. Unfortunately, there is no information available on proteomic characterization of DAHPS enzyme of senna (caDAHPS) resulting in lack of knowledge about its role. We for the first time characterized DAHPS enzyme of senna using in-silico analysis. To the best of our knowledge this is the first attempt to identify the coding sequence of caDAHPS by cloning and sequencing. We found Gln179, Arg175, Glu462, Glu302, Lys357 and His420 amino acids in the active site of caDAHPS through molecular docking. followed by molecular dynamic simulation. The amino acid residues, Lys182, Cys136, His460, Leu304, Gly333, Glu334, Pro183, Asp492 and Arg433 at the surface interact with PEP by van der Waals bonds imparting stability to the enzyme-substrate complex. Docking results were further validated by molecular dynamics. The presented in-silico analysis of caDAHPS will generate opportunities to engineer the sennoside biosynthesis in plants.Communicated by Ramaswamy H. Sarma.

Technological Aspects of Nanoemulsions for Post-harvest Preservation of Fruits and Vegetables

Recent times have witnessed a growing demand for sustainable technology for food preservation that can retain its freshness, promises lower contents of additives and preservatives, safe consumption, eco-friendly milder processing technologies and eco-friendlier packaging solutions. Application of Biopolymers has served as the most sustainable and viable option to its synthetic counterparts. These biopolymers have been incorporated to develop biodegradable packaging like edible films and coatings owing to their biological origin. Nanoemulsion technology offers a leap forward to upgrade the features of conventional biodegradable packaging items. The present review discusses various trends and perspectives of nanoemulsion technology in post-harvest preservation for enhancing the shelf life of fresh fruits and vegetables. It investigates the interconnectedness between food preservation techniques, biodegradable packaging materials made from biopolymers, and nanoemulsions. It further addresses the preservation challenges post-harvest and underscores the limitations of conventional preservation methods, advocating for eco-friendly alternatives with a specific focus on the potential of nanoemulsions in enhancing food safety and quality. This review elaborates on the composition, formulation techniques, nanoemulsion products and role of nanoemulsions in the management of foodborne pathogens. Furthermore, it examines the potential health hazards linked to the use of nanoemulsions and stresses the significance of a regulatory framework for food safety. In conclusion, this review offers insights into the promising prospects of using nanoemulsions in food preservation.

Uncovering the Interaction Interface Between Harpin (Hpa1) and Rice Aquaporin (OsPIP1;3) Through Protein-Protein Docking: An In Silico Approach

Hpa1 (a type of harpin) is involved in T3SS (Type III Secretion System) assembly in the infection mechanism by Xanthomonas Oryzae pv. oryzae (Xoo). Hpa1 interacts with the plasma membrane components of plants thereby assisting effector proteins toward the cytoplasm, wherein effectors execute their pathological functions. Independently, harpins also induce hypersensitive response and systemic acquired resistance in plants. However, lack of knowledge regarding the plant-harpin interaction mechanism constrains the pathway of its agricultural application. Although an in vitro study proved that Hpa1 protein can interact with OsPIP1;3, a rice aquaporin, the structural basis of the interaction is yet to be discovered. The presented work is the first of its kind where an in silico approach is used for the PPI (protein-protein interaction) of harpin protein. The study discovered participation of Hpa1 N-terminal amino acids at the interface. Besides, MD simulation studies were performed to assess the stability. RMSD values were 0.35 ± 0.049, 0.73 ± 0.11, and 0.50 ± 0.065 nm for OsPIP1;3, Hpa1, and Hpa1-OsPIP1;3 complex, respectively. Additionally, Residue-wise fluctuations have also been studied post-MDS. Taken together, these findings not only give a solid foundation for a deeper knowledge of various interacting target molecules with Harpin protein orthologs but also bring a new avenue for the structural-functional relationship study of harpin proteins.

Patient Reported Fatigue Among Adolescent and Young Adult Cancer Patients Compared to Non-Cancer Patients: A Systematic Review and Meta-Analysis

Adolescent and young adult (AYA) cancer patients and survivors are a growing population due to more frequent diagnoses and improved survival. Fatigue is a common symptom experienced by cancer patients and it is often missed by health care professionals. Patient reported outcome measures (PROMs) can assist in evaluating patient reported fatigue. This systematic review aims to determine if AYA cancer patients report more fatigue than AYAs who have not been diagnosed with cancer. We used a subset of articles from a larger review that searched PubMed, EMBASE, CINAHL, and PsycINFO to determine which PROMs and domains are currently being used to evaluate AYA cancer. This study identified 175 articles related to PROMs in the AYA cancer population. Articles with PROMs reporting on fatigue/vitality were used in this review. From the original 175 articles, we identified 8 fatigue/vitality articles for this review. All eight articles found an increase in fatigue/decrease in vitality in the AYA cancer population compared to healthy controls. A meta-analysis was performed on four articles that used the same PROM tool (EORTC QLQ-C30). This found a statistically significant and clinically meaningful increase in mean fatigue of 12.5 95% confidence interval: 3.3-21.8 points (scale 0-100, higher number indicates more fatigue) in the AYA cancer group compared to healthy noncancer controls. Fatigue in the AYA cancer population is a significant issue, it is often undetected and underreported, and early interventions are needed to prevent the negative subsequent sequelae.

Bacteriophages as a potential substitute for antibiotics: A comprehensive review

Over the years, the administration of antibiotics for the purpose of addressing bacterial infections has become increasingly challenging due to the increased prevalence of antimicrobial resistance exhibited by various strains of bacteria. Multidrug-resistant (MDR) bacterial species are rising due to the unavailability of novel antibiotics, leading to higher mortality rates. With these conditions, there is a need for alternatives in which phage therapy has made promising results. Phage-derived endolysins, phage cocktails, and bioengineered phages are effective and have antimicrobial properties against MDR and extensively drug-resistant strains. Despite these, it has been observed that phages can give antimicrobial activity to more than one bacterial species. Thus, phage cocktail against resistant strains provides broad spectrum treatment and magnitude of effectivity, which is many folds higher than antibiotics. Many commercially available endolysins such as Staphefekt SA.100, Exebacase (CF-301), and N-Rephasin®SAL200 are used in biofilm penetration and treating plant diseases. The role of CMP1 phage endolysin in transgenic tomato plants in preventing Clavibacter michiganensis infection and the effectiveness of phage in protecting Atlantic salmon from vibriosis have been reported. Furthermore, phage-derived endolysin therapy, such as TSPphg phage exogenous treatment, can aid in disrupting cell walls, leading to bacterial cell lysis. As animals in aquaculture and slaughterhouses are highly susceptible to bacterial infections, effective phage therapy instead of antibiotics can help treat poultry animals, preserve them, and facilitate disease-free trade. Using bioengineered phages and phage cocktails enhances the effectiveness by providing a broad spectrum of phages and target specificity. Research is currently being conducted on clinical trials to confirm the efficacy of engineered phages and phage cocktails in humans. Although obtaining commercial approval may be time-consuming, it will be beneficial in the postantibiotic era. This review provides an overview of the significance of phage therapy as a potential alternative to antibiotics in combating resistant bacterial strains and its application to various fields and emphasizes the importance of safeguarding and ensuring treatment efficacy.

Physical function patient-reported outcomes among adolescent and young adult cancer survivors: A systematic review

BACKGROUND

The physical challenges faced by adolescents and young adults (AYA) after a cancer diagnosis may be different from those experienced by paediatric and older adult cancer patients. Patient-reported outcome measures (PROMs) are valuable tools that can be useful in exploring the experiences of AYAs and identifying important issues, recurrent themes and areas to potentially improve quality of life.

OBJECTIVE

We compared patient-reported physical function outcomes between AYAs diagnosed with cancer and non-cancer controls.

METHOD

This paper builds on a scoping review published in early 2023 and focuses on PROMs related to physical function.

RESULTS

This systematic review includes 16 studies that measured and reported on physical function PROMs in AYA cancer survivors compared with their cancer-free peers. Of these studies, 14 found that physical function in AYA survivors was significantly worse. This paper also includes a meta-analysis conducted on 5 studies using the EORTC-QLQ-C30 to measure physical function, which found that physical function score was an average of 7.03 (95% CI: -10.21, -3.86) points lower in the AYA cancer group, compared to their cancer free-peers, a difference that is clinically meaningful.

CONCLUSIONS

The results overwhelmingly demonstrate that AYAs post a cancer diagnosis have worse health-related quality of life from a physical function perspective than their cancer-free peers, providing a compelling argument for the need to address this issue. All but one of the studies were cross-sectional, which highlights the need for further assessment of this group longitudinally throughout their cancer journey.

Evaluation of the Existence of Post-COVID-19 Tachycardia in a Community Healthcare System

Background

Post-coronavirus disease 2019 (COVID-19) syndrome derives from lingering symptoms after an acute COVID-19 infection. Palpitation was one of the most common symptoms of post-COVID-19 syndrome that correlated with objective data such as persisting sinus tachycardia; but to our best knowledge, there is a scarcity of research regarding the association of COVID-19 and sinus tachycardia in the post-acute setting. Therefore, the purpose was to identify if there is an association between COVID-19 infection and sinus tachycardia in the post-acute phase, namely post-COVID-19 tachycardia (PCT) other than inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS).

Methods

This retrospective observational study entails 1,425 patients admitted for COVID-19 infection with the interest in finding an association with PCT. The prevalence of PCT was evaluated using descriptive statistics, predictions of patient characteristics and comorbidities were identified using multinomial logistic regression, and associations between patient comorbidities and characteristics were evaluated with corresponding Pearson Chi-square test and post hoc tests Phi and Cramer's V.

Results

The percentage of patients with PCT in our sample of interest was an average of 28.18%. There was a strong association of PCT with patients of age group less than 65 years. Other clinical characteristics, such as shorter length of stay, unknown smoking status, and patients with commercial type insurance, had significant association with PCT. COVID-19 severity categorized as "less severe", readmission rates within 30 days, and patients with less comorbidities were more likely to be associated with PCT.

Conclusions

PCT is likely a separate entity from IST and POTS, and an important entity under the umbrella of post-COVID-19 syndrome. It warrants further studies to elucidate the underlying pathophysiology and to confirm its presence as a distinct entity.

A Rare Case Presentation on Total Colonic Aganglionosis in a Female Infant of Indian Origin

Total colonic aganglionosis, also called total colonic Hirschsprung's disease, is a known congenital disorder caused by the migration of abnormal embryonic neuroblasts. RET, NRG1, and L1CAM genes are reported as pathological gene variants associated with the incidence of different variants of Hirschsprung's disease. Major clinical presentations are well documented as inefficiency to pass stools, vomiting, fever, persistent crying, and other features of intestinal obstruction. We present here the case of a two-day-old female infant of Indian origin and its diagnostic, clinical, and case management data.

Targeting allosteric binding site in methylenetetrahydrofolate dehydrogenase 2 (MTHFD2) to identify natural product inhibitors via structure-based computational approach

Cancer has been viewed as one of the deadliest diseases worldwide. Among various types of cancer, breast cancer is the most common type of cancer in women. Methylenetetrahydrofolate dehydrogenase 2 (MTHFD2) is a promising druggable target and is overexpressed in cancerous cells, like, breast cancer. We conducted structure-based modeling on the allosteric site of the enzyme. Targeting the allosteric site avoids the problem of drug resistance. Pharmacophore modeling, molecular docking, HYDE assessment, drug-likeness, ADMET predictions, simulations, and free-energy calculations were performed. The RMSD, RMSF, RoG, SASA, and Hydrogen-bonding studies showed that seven candidates displayed stable behaviour. As per the literature, average superimposed simulated structures revealed a similar protein conformational change in the αE'-βf' loop, causing its displacement away from the allosteric site. The MM-PBSA showed tight binding of six compounds with the allosteric pocket. The effect of inhibitors interacting in the allosteric site causes a decrease in the binding energy of J49 (active-site inhibitor), suggesting the effect of allosteric binding. The PCA and FEL analysis revealed the significance of the docked compounds in the stable behaviour of the complexes. The outcome can contribute to the development of potential natural products with drug-like properties that can inhibit the MTHFD2 enzyme.

A Paradigm Shift from International to Transnational Medical Education

In recent years, the number of medical students seeking international opportunities has grown. To satisfy these demands, collaborative international programs have been developed. However, the benefits of these programs are limited as they employ an international medical education (IME) approach where only the students are exchanged. In this commentary, we discuss the current models of IME and propose a paradigm shift to a transnational approach wherein the student, faculty, and curriculum are exchanged allowing for increased integration and awareness of cultural and educational approaches to treatment that can be retained and incorporated into future practice to advance healthcare across the globe.

Procalcitonin Use for Predicting Mortality and Morbidity of Patients Diagnosed With Sepsis Within the Intensive Care Unit

Objective Infections leading to severe sepsis and septic shock are among the top five causes requiring admission to the intensive care unit (ICU). Up to 40% of ICU admissions contain a sepsis diagnosis. Without a clear marker to diagnose and manage sepsis, procalcitonin has been extensively studied for its usefulness in the management of bacterial infections. These studies, however, have been focused toward how it can be used to help guide when antibiotics should be initiated and de-escalated. There, however, has not been a study on how this biomarker could be used to predict mortality, and morbidity and help guide a need for antibiotic escalation. Design A retrospective chart review was conducted on patients admitted to the ICU at Northeast Georgia Medical Center between January 1, 2019, to June 30, 2021. Inclusion criteria were all patients above the age of 18 admitted to the ICU with a diagnosis of sepsis and having at least two procalcitonin drawn within 10 days of each other. Exclusion criteria were any patient with a diagnosis of COVID-19. Data Analysis was conducted to identify how delta procalcitonin could identify mortality and morbidity and if there was any change in antibiotics based on the delta procalcitonin.  Conclusion There was a statistically significant association between a delta positive procalcitonin and increased ICU length of stay. There was no statistical significance in expiration based on the antibiotic change in relationship to delta positive change in procalcitonin.

Effects of Laser Bandwidth in Direct-Drive High-Performance DT-Layered Implosions on the OMEGA Laser

In direct-drive inertial confinement fusion, the laser bandwidth reduces the laser imprinting seed of hydrodynamic instabilities. The impact of varying bandwidth on the performance of direct-drive DT-layered implosions was studied in targets with different hydrodynamic stability properties. The stability was controlled by changing the shell adiabat from (α_{F}≃5) (more stable) to (α_{F}≃3.5) (less stable). These experiments show that the performance of lower adiabat implosions improves considerably as the bandwidth is raised indicating that further bandwidth increases, beyond the current capabilities of OMEGA, would be greatly beneficial. These results suggest that the future generation of ultra-broadband lasers could enable achieving high convergence and possibly high gains in direct drive ICF.

The intracortical excitability changes underlying the enhancing effects of rewards and punishments on motor performance

Monetary rewards and punishments enhance motor performance and are associated with corticospinal excitability (CSE) increases within the motor cortex (M1) during movement preparation. However, such CSE changes have unclear origins. Based on converging evidence, one possibility is that they stem from increased glutamatergic (GLUTergic) facilitation and/or decreased type A gamma-aminobutyric acid (GABAA)-mediated inhibition within M1. To investigate this, paired-pulse transcranial magnetic stimulation was used over the left M1 to evaluate intracortical facilitation (ICF) and short intracortical inhibition (SICI), indirect assays of GLUTergic activity and GABAA-mediated inhibition, in an index finger muscle during the preparation of sequences initiated by either the right index or little finger. Behaviourally, rewards and punishments enhanced both reaction and movement time. During movement preparation, regardless of rewards or punishments, ICF increased when the index finger initiated sequences, whereas SICI decreased when both the index and little fingers initiated sequences. This finding suggests that GLUTergic activity increases in a finger-specific manner whilst GABAA-mediated inhibition decreases in a finger-unspecific manner during preparation. In parallel, both rewards and punishments non-specifically increased ICF, but only rewards non-specifically decreased SICI as compared to neutral. This suggests that to enhance performance rewards both increase GLUTergic activity and decrease GABAA-mediated inhibition, whereas punishments selectively increase GLUTergic activity. A control experiment revealed that such changes were not observed post-movement as participants processed reward and punishment feedback, indicating they were selective to movement preparation. Collectively, these results map the intracortical excitability changes in M1 by which incentives enhance motor performance.

Fever in the returning traveler

Evaluation of febrile illness in a returning traveler is challenging as it requires careful history taking and knowledge of local epidemiology of endemic and epidemic diseases. Incorporating information of host characteristics for susceptibility of infections is also important for endemic mycosis apart from history of tick bites and animal exposures. Laboratory tests directed by clinical and laboratory parameters will help to reach final diagnosis.

Synthesis, in vitro cytotoxic activity and molecular docking study of Androstene and Estrone Derivatives

The development and discovery of steroidal drugs to cure cervical cancer is of the most important. The Claisen condensation of androstene and estrone with aromatic aldehydes was catalyzed by potassium tert. butoxide in tert. butanol to give the corresponding 2-arylidene and 16-arylidene estrone. Subsequently, the 16-arylidene estrone reacted with acid chloride in presence of quaternary amine in halogenated solvent resulting in the steroidal arylidene derivatives. Synthesis, Characterization and in vitro cytotoxic activity of arylidenes are rationalized. Fifteen compounds are synthesized and six of them were evaluated for cytotoxic activity against cervical cancer cell line. HT-3 cell line examination revealed a considerable growth inhibition. Compounds 4a, 4b, 6b, 8c, and 8d, which are estrone-based arylidenes, are the most potent of the series, with IC₅₀ value of 7.15, 10.76, 6.37, 3.56, and 1.55 µM/ml against HT-3 cell line. In addition, molecular docking studies were performed for the steroidal arylidenes to elucidate the binding interactions. Compound 4a, 4b, 6b, 8c and 8d showed excellent binding energy. Docking studies agreed well with in vitro studies. The end result offers an alternative approach to develop steroidal arylidenes that are more effective and are based on estrone, leading to the development of novel anticancer agents.

MANAGING ARTHRITIS PAIN: MEDICATIONS AND LIFESTYLE CHANGES

This study aims to characterize and contrast the triennial rates at which doctors prescribe PT, determine patient, doctor, and practicing characteristics related to every therapy suggestion, and assess pain relievers, lifestyle counseling, and PT as effective treatments for knee osteoarthritis (OA). We analyzed the National Ambulatory Medical Care Survey. Nonsteroidal anti-inflammatory drugs (NSAID), narcotics prescriptions, physical therapy referrals, and primary care physician visits for knee OA have been determined and evaluated. The average yearly rate after three years of therapy was determined. Using multivariable logistic modeling with adjustments for complicated sample design, we analyzed the relationships among patient, physician, and practice characteristics and treatments. Over time the patients were prescribed physical therapy to improve their lifestyle whereas the percentage of patients who were prescribed NSAIDs or drugs. Physical therapy, lifestyle therapy, and drugs were prescribed at similar rates across time for basic care doctor visits. There was an association between nonclinical characteristics and treatment suggestions, such as provider type, practice setting, and geographic proximity. Physical therapy (PT) and lifestyle counseling (LC) seem underused in patients with knee OA, but prescriptions for pain medication rose over the studied period. The treatment decisions varied due to variables outside of medicine. Increased usage of physical therapy and lifestyle changes, as well as decreased treatment variance for knee OA, are important areas for further study.

THE ROLE OF EXERCISE IN PREVENTING CHRONIC DISEASES: CURRENT EVIDENCE AND RECOMMENDATIONS

Regular exercise helps to enhance health outcomes and lower risk factors, making it a crucial element in the prevention of chronic diseases. By being physically active, people can improve their general health and delay the onset of a number of chronic illnesses. For understanding the relationship between increased physical activity or decreased physical inactivity and favorable health outcomes, observational studies are the main source of information. We will look for systematic analyses of randomized controlled trials with a main emphasis on outcomes linked to diseases in the Cochrane Database of systematic studies. Evaluation will be limited to those in a few key chronic conditions. Preventing chronic illness and achieving better results in the management or treatment of chronic illness are the main outcomes of interest. For each chronic condition (such as the control of glucose in diabetes or any change in hypertension blood pressure), these results will be summarized and displayed. The design and implementation of chronic conditions, physical exercise illness conditions, and adverse physical activity-related events are of secondary interest. Our findings should help decision-makers, guideline organizations, and academics identify the most effective physical activity programs for major chronic disease management and prevention. Exercise and physical activity (PA) offers a non-invasive approach to the management of chronic disorders. More physiological, biochemical, and molecular data on the positive effects of PA and exercise on health should constitute a primary focus of future studies.

Utilization of dietary mixed-linkage β-glucans by the Firmicute Blautia producta

The β-glucans are structurally varied, naturally occurring components of the cell walls and storage materials of a variety of plant and microbial species. In the human diet, mixed-linkage glucans [MLG - β-(1,3/4)-glucans] influence the gut microbiome and the host immune system. Although consumed daily, the molecular mechanism by which human gut Gram-positive bacteria utilize MLG largely remains unknown. In this study, we used Blautia producta ATCC 27340 as a model organism to develop understanding of MLG utilization. B. producta encodes a gene locus comprising a multi-modular cell-anchored endo-glucanase (BpGH16_MLG), an ABC transporter, and a glycoside phosphorylase (BpGH94_MLG) for utilizing MLG, as evidenced by the up-regulation of expression of the enzyme- and solute binding protein (SBP)-encoding genes in this cluster when the organism is grown on MLG. We determined that recombinant BpGH16_MLG cleaved various types of β-glucan, generating oligosaccharides suitable for cellular uptake by B. producta. Cytoplasmic digestion of these oligosaccharides is then performed by recombinant BpGH94_MLG and β-glucosidases (BpGH3-AR8_MLG and BpGH3-X62_MLG). Using targeted deletion, we demonstrated BpSBP_MLG is essential for B. producta growth on barley β-glucan. Furthermore, we revealed that beneficial bacteria, such as Roseburia faecis JCM 17581^T, Bifidobacterium pseudocatenulatum JCM 1200T, Bifidobacterium adolescentis JCM 1275T, and Bifidobacterium bifidum JCM 1254, can also utilize oligosaccharides resulting from the action of BpGH16_MLG. Disentangling the β-glucan utilizing capability of B. producta provides a rational basis on which to consider the probiotic potential of this class of organism.

Mental health of diplomatic personnel: scoping review

BACKGROUND

Diplomatic personnel frequently relocate as part of their roles, requiring them to adapt to various cultural and political conditions; many are also at risk of experiencing trauma from being deployed to high-threat postings. With diplomatic personnel having to balance the usual pressures of their work with the uncertainties of COVID-19 in recent years, it is particularly important now to understand how to protect their mental health.

AIMS

To synthesize existing literature on the well-being of diplomatic personnel to improve understanding of how to protect their mental health.

METHODS

A scoping review was carried out to explore what is already known about the well-being of staff working in diplomatic roles. Four databases were searched and reference lists, as well as one key journal, were hand-searched.

RESULTS

Fifteen relevant publications were included. There was little consensus as to how the psychological well-being of diplomatic personnel compares to other populations or which factors predict well-being. Diplomats' psychological responses to traumatic experiences appeared similar to those of other trauma-exposed occupational groups.

CONCLUSIONS

Further research is needed to better understand the well-being of diplomatic personnel, particularly those not deployed to high-threat posts.

Surgical outcomes of T4b oral cancers: assessment of prognostic factors and a need to re-evaluate the current staging system

T4b oral cancer is a broad umbrella term for all advanced oral cancers, the prognosis of which varies drastically for disease of the same stage, according to the extent of the masticator space involvement. This was a retrospective observational study including all consecutive T4b oral squamous cell carcinoma patients treated surgically between January 2015 and January 2016 and followed up until January 2020. The disease was classified as upper disease or lower disease based on the anatomical location in relation to an imaginary plane passing through the base of the retromolar trigone. The prime objective was to evaluate overall survival and prognostic factors affecting overall survival. The projected 5-year overall and disease-free survival rates were 40.7% and 35.6%, respectively. The assessment of prognostic factors revealed that lower disease (lower anatomical subsites), bone invasion, and lymph nodal spread significantly affected survival. Patients with disease in an upper anatomical location without bone and nodal involvement can achieve fairly good survival (projected 5-year overall survival of 64.2%) when compared to the other subsets of patients. We propose a re-evaluation of the current staging system based on the prognostic features, so that all patients are not considered under a single stage, since their survival differs significantly.

Effect of bariatric surgery on maternal cardiovascular system

OBJECTIVE

Bariatric surgery is a successful treatment for sustainable weight loss and has been associated with improvement in cardiovascular function. Pregnancy after bariatric surgery is becoming increasingly common; however, little is known about the maternal cardiovascular system postsurgery. The aim of this study was to investigate maternal cardiovascular adaptation to pregnancy in women with previous bariatric surgery, compared with that in women with no history of weight-loss surgery and an early-pregnancy body mass index (BMI) similar to the presurgery BMI of the postbariatric women.

METHODS

This was a prospective, observational, longitudinal study conducted from April 2018 to June 2020 including 30 pregnant women who had undergone bariatric surgery and 30 who had not, matched for presurgery BMI. Participants were seen at three timepoints during pregnancy: 12-14, 20-24 and 30-32 weeks' gestation. At all visits, maternal blood pressure (BP) was measured and cardiac geometry and function were assessed using two-dimensional (2D) transthoracic echocardiography. On a subset of patients (15 in each group), 2D speckle tracking was performed to assess global longitudinal and circumferential strain. Offline analysis was performed, and multilevel linear mixed-effects models were used for all comparisons.

RESULTS

Compared with the no-surgery group, and across all trimesters, pregnant women with previous bariatric surgery had lower BP, heart rate and cardiac output and higher peripheral vascular resistance (P < 0.01 for all). Similarly, the postbariatric group demonstrated more favorable cardiac geometry and diastolic indices, including lower left ventricular mass, left atrial volume and relative wall thickness, together with higher E-wave/A-wave flow velocity across the mitral valve and higher mitral velocity (E') at the lateral and medial annulus on tissue Doppler imaging (P < 0.01 for all). There was no difference in ejection fraction, although global longitudinal strain was lower in postbariatric women (P < 0.01), indicating better systolic function.

CONCLUSION

Our findings indicate better maternal cardiovascular adaptation in women with previous bariatric surgery compared with presurgery BMI-matched pregnant women with no history of weight-loss surgery. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Observation of a Strongly Isospin-Mixed Doublet in ^{26}Si via β-Delayed Two-Proton Decay of ^{26}P

β decay of proton-rich nuclei plays an important role in exploring isospin mixing. The β decay of ^{26}P at the proton drip line is studied using double-sided silicon strip detectors operating in conjunction with high-purity germanium detectors. The T=2 isobaric analog state (IAS) at 13 055 keV and two new high-lying states at 13 380 and 11 912 keV in ^{26}Si are unambiguously identified through β-delayed two-proton emission (β2p). Angular correlations of two protons emitted from ^{26}Si excited states populated by ^{26}P β decay are measured, which suggests that the two protons are emitted mainly sequentially. We report the first observation of a strongly isospin-mixed doublet that deexcites mainly via two-proton decay. The isospin mixing matrix element between the ^{26}Si IAS and the nearby 13 380-keV state is determined to be 130(21) keV, and this result represents the strongest mixing, highest excitation energy, and largest level spacing of a doublet ever observed in β-decay experiments.

Diagnosing low-mode (ℓ < 6) and mid-mode (6 ≤ ℓ ≤ 60) asymmetries in the post-stagnation phase of laser-direct-drive deuterium-tritium cryogenic implosions on OMEGA

Low- and mid-mode perturbations are possible candidates for performance limitations in cryogenic direct-drive implosions on the OMEGA laser at the Laboratory of Laser Energetics. Simulations with a 3D hydrocode demonstrated that hotspot imagers do not show evidence of the shell breakup in the dense fuel. However, these same simulations revealed that the low- and mid-mode perturbations in the dense fuel could be diagnosed more easily in the post-stagnation phase of the implosion by analyzing the peak in the x-ray emission limb at the coronal-fuel interface than before or at the stagnation phase. In experiments, the asymmetries are inferred from gated images of the x-ray emission of the implosion by using a 16-pinhole array imager filtered to record x-ray energies >800 eV and an x-ray framing camera with 40-ps time integration and 20-μm spatial resolution. A modal analysis is applied to the spatial distribution of the x-ray emission from deuterium and tritium cryogenic implosions on OMEGA recorded after the bang time to diagnose the low- and mid-mode asymmetries, and to study the effect that the beam-to-target ratio (R_b/R_t) has on the shell integrity.

Radical treatment for blastomycosis following unsuccessful liposomal amphotericin

Pulmonary blastomycosis is a respiratory disease that is caused by the fungus Blastomyces spp, which is acquired through inhalation of the fungal spores. Blastomycosis is relatively uncommon, with yearly incidence rate of 1-2 cases per 100 000 people. Blastomycosis is a disease that is endemic to the midwest and southern regions of the USA, most commonly affecting immunocompromised patients. About 50% of patients are asymptomatic, but for those who progress to acute respiratory distress syndrome (ARDS) mortality can be as high as 80%. Patients with severe blastomycosis are initially treated with intravenous amphotericin B, followed by long-term itraconazole maintenance therapy. In this Grand Round, we present the case of an immunocompetent 35-year-old man diagnosed with chronic pulmonary blastomycosis who had a poor response to 10 days of intravenous liposomal amphotericin B (L-AmB). He was endotracheally intubated and eventually cannulated for extracorporeal membrane oxygenation (ECMO), due to worsening respiratory function. L-AmB was replaced with a continuous infusion of intravenous amphotericin B deoxycholate (AmB-d). He improved significantly and was decannulated from ECMO on day 9 of AmBd continuous infusion and extubated on day 12 Although L-AmB is considered first-line treatment for blastomycosis, mortality remains high for patients with ARDS associated with blastomycosis. This case highlights the importance of considering AmB-d continuous infusions for patients with severe blastomycosis who might have poor clinical responses to L-AmB.

Structural differences in 3C-like protease (Mpro) from SARS-CoV and SARS-CoV-2: molecular insights revealed by Molecular Dynamics Simulations

Novel coronavirus SARS-CoV-2 has infected millions of people with thousands of mortalities globally. The main protease (Mpro) is vital in processing replicase polyproteins. Both the CoV's Mpro shares 97% identity, with 12 mutations, but none are present in the active site. Although many therapeutics and vaccines are available to combat SARS-CoV-2, these treatments may not be practical due to their high mutational rate. On the other hand, Mpro has a high degree of conservation throughout variants, making Mpro a stout drug target. Here, we report a detailed comparison of both the monomeric Mpro and the biologically active dimeric Mpro using MD simulation to understand the impact of the 12 divergent residues (T35V, A46S, S65N, L86V, R88K, S94A, H134F, K180N, L202V, A267S, T285A and I286L) on the molecular microenvironment and the interaction between crucial residues. The present study concluded that the change in the microenvironment of residues at the entrance (T25, T26, M49 and Q189), near the catalytic site (F140, H163, H164, M165 and H172) and in the substrate-binding site (V35, N65, K88 and N180) is due to 12 mutations in the SARS-CoV-2 Mpro. Furthermore, the involvement of F140, E166 and H172 residues in dimerization stabilizes the Mpro dimer, which should be considered. We anticipate that networks and microenvironment changes identified here might guide repurposing attempts and optimization of new Mpro inhibitors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11224-022-02089-6.

Predicting hot electron generation in inertial confinement fusion with particle-in-cell simulations

A series of two-dimensional particle-in-cell simulations with speckled laser drivers was carried out to study hot electron generation in direct-drive inertial confinement fusion on OMEGA. Scaling laws were obtained for hot electron fraction and temperature as functions of laser/plasma conditions in the quarter-critical region. Using these scalings and conditions from hydro simulations, the temporal history of hot electron generation can be predicted. The scalings can be further improved to predict hard x-rays for a collection of OMEGA warm target implosions within experimental error bars. These scalings can be readily implemented into inertial confinement fusion design codes.

Metastatic Grade 3 Neuroendocrine Tumor in Multiple Endocrine Neoplasia Type 1 (MEN1) Expressing Somatostatin Receptors

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) can occur in 30-90% of patients with Multiple Endocrine Neoplasia Type 1 (MEN1). However, only 1% of GEP-NETs are Grade 3 (G3). Given the rarity of these aggressive tumors, treatment of advanced G3 GEP-NETs in MEN1 is based on the treatment guidelines for sporadic GEP-NETs. We report a 43-year-old male with germline MEN1 followed at our institution with clinical features including hyperparathyroidism, a non-functional pancreatic NET, and Zollinger-Ellison Syndrome. On routine surveillances imaging, at age 40, computer tomography (CT/ positron emission tomography (PET)) imaging showed two arterially enhancing intraluminal masses on the medial aspect of the gastric wall. Anatomical imaging confirmed two enhancing masses within the pancreas and a rounded mass-like thickening along the lesser curvature of the stomach. The gastric mass was resected, and pathology reported a well-differentiated G3 NET with a Ki-67 &gt;20%. The patient continued active surveillance. Eighteen months later cross-sectional imaging studies showed findings consistent with metastatic disease within the right hepatic lobe and bland embolization was done. On follow-up scans, including 68Ga-DOTATATE (68Ga-DOTA(0)-Tyr(3)-octreotate) imaging, interval increase in number and avidity of metastatic lesions were compatible with disease progression. Given a paucity of treatment recommendations for G3 tumors in MEN1, the patient was counseled based on standard NET treatment guidelines and recommended 177Lu-DOTATATE treatment. PRRT (peptide receptor radionuclide therapy) with 177Lu-DOTATATE ( 177Lu-tetraazacyclododecanetetraacetic acid-octreotide) is an important therapeutic modality for patients with somatostatin receptor-positive (SSTR) NETs. However, prospective studies are needed to understand the role of PRRT in G3 NETs.

Bound on hot-spot mix in high-velocity, high-adiabat direct-drive cryogenic implosions based on comparison of absolute x-ray and neutron yields

In laser-driven implosions for laboratory fusion, the comparison of hot-spot x-ray yield to neutron production can serve to infer hot-spot mix. For high-performance direct-drive implosions, this ratio depends sensitively on the degree of equilibration between the ion and electron fluids. A scaling for x-ray yield as a function of neutron yield and characteristic ion and electron hot-spot temperatures is developed on the basis of simulations with varying degrees of equilibration. We apply this model to hot-spot x-ray measurements of direct-drive cryogenic implosions typical of the direct-drive designs with best ignition metrics. The comparison of the measured x-ray and neutron yields indicates that hot-spot mix, if present, is below a sensitivity estimated as ∼2% by-atom mix of ablator plastic into the hot spot.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

British Journal of Surgery Society.

AB1583-PARE QUALITATIVE INTERVIEWS OF SYMPTOMS, IMPACTS AND SELECTED PROMIS SHORT FORMS: A STUDY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background

Axial spondyloarthritis (axSpA) is characterised by inflammation of the sacroiliac joints and spine. Sleep disturbance, pain and fatigue are reported in the literature to be key symptoms and impacts of axSpA. Three customised Patient-Reported Outcomes Measurement Information System (PROMIS) Short Forms (Sleep Disturbance, Pain Interference and Fatigue), previously developed for use in rheumatoid arthritis, have been proposed for use in patients with axSpA to assess the key concepts.

Objectives

To conduct in-depth qualitative interviews to further understand the patient experience of axSpA and evaluate the content validity of the three PROMIS Short Forms to support their use as endpoints in axSpA clinical trials.

Methods

A non-interventional, cross-sectional qualitative (concept elicitation [CE] and cognitive debriefing [CD]) study was conducted in 28 adult patients with diagnosed axSpA, including radiographic axSpA (r-axSpA), also known as ankylosing spondylitis (AS, n=12), and non-radiographic axSpA (nr-axSpA, n=16). Patients took part in 90-minute telephone interviews. A semi-structured interview guide was used to assist discussions. The CE section used broad, open-ended questions to elicit information about symptoms and impact experienced by patients. The CD section involved a ‘think-aloud’ exercise in which patients read out each instruction, item and response option for the three PROMIS Short Forms and shared their feedback. Patients were also asked detailed questions about the relevance of the items, response options and recall period. Verbatim interview transcripts were subject to thematic and content analysis.

Results

Patients were from the United States (n=20) and Germany (n=8), mean age was 52.8 years, and 57% (n=16) were male; mean time since diagnosis of axSpA was 9.5 years (range 0.3–31.3 years). The CE section identified 12 distinct signs and symptoms that characterised patients’ experience of axSpA: pain, sleep problems, fatigue/tiredness, stiffness, swelling, vision/eye issues, restricted body movements, headache/migraine, spasms, change in posture/stature, balance/coordination problems and numbness. Pain, sleep problems and fatigue/tiredness were all reported to be experienced by ≥90% of patients, occurring simultaneously and exacerbating one another. 78% (n=21/27) of patients reported pain to be the most bothersome symptom, and 88% (n=23/26) described it as the symptom they would most like treatment to improve. Patients reported axSpA to impact their lives across six health-related quality of life (HRQoL) domains: physical functioning (100%), emotional wellbeing (89%), work/volunteering (79%), social functioning (75%), activities of daily living (61%) and cognitive functioning (54%). Impacts were most frequently described as being associated with pain, stiffness and fatigue. The experiences of symptoms and impacts were consistent between the AS and nr-axSpA patients. CD showed all three PROMIS instruments are conceptually comprehensive and well understood by patients with axSpA. No patients reported misunderstanding of instructions and/or items of the sleep disturbance instrument, and only one and four items had a small number of instances of misunderstanding for the fatigue and pain interference instruments, respectively. Across each instrument, all items were relevant to at least half of patients, and almost all patients reported the instruments to be appropriate for measuring their experience of sleep problems, pain and fatigue due to axSpA. Both AS and nr-axSpA patients confirmed the three PROMIS Short Forms to be relevant and appropriate for assessing their disease experience.

Conclusion

Pain, sleep problems and fatigue are pivotal symptoms of axSpA and associated with HRQoL impacts. Interpretability and content validity of the PROMIS customised Short Forms have been confirmed, with each deemed to adequately assess key impacts associated with axSpA, making them suitable for use in clinical trials of patients with axSpA.

Funding: GSK [209770]

Acknowledgements

Medical writing support was provided by Tony Reardon, of of Aura, a division of Spirit Medical Communications Group Limited (Manchester, UK), and was funded by GlaxoSmithKline.

Disclosure of Interests

Amy Findley Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, Jessica Middlehurst Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, Chloe Howse Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, Molly Clifford Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, William Neill Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, Sophi Tatlock Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, Wen-Hung Chen Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline

, Marguerite Bracher Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline, Dharm Patel Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline

A Rare Case of COVID-19-Induced Chronic Demyelinating Polyneuropathy

Chronic autoimmune demyelinating polyneuropathy (CIDP) is a rare autoimmune disorder in which the body's immune system attacks the myelin sheaths. Myelin sheaths are the fatty insulation covering and protecting the nerves, and damage to these can lead to neurological symptoms like numbness, tingling, and weakness. CIDP is a chronic disease in the Guillain-Barré syndrome spectrum. Numerous case reports of autoimmune diseases linked to coronavirus disease 2019 (COVID-19) have been seen since the onset of COVID-19 pandemic. We present one such challenging case of COVID-19-induced CIDP.

Non-mydriatic fundus photography as an alternative to indirect ophthalmoscopy for screening of diabetic retinopathy in community settings: a comparative pilot study in rural and tribal India

OBJECTIVES

The impending and increasing prevalence of diabetic retinopathy (DR) in India has necessitated a need for affordable and valid community outreach screening programme for DR, especially in rural and far to reach indigenous local communities. The present study is a pilot study aimed to compare non-mydriatic fundus photography with indirect ophthalmoscopy for its utilisation as a feasible and logistically convenient screening modality for DR in an older age, rural, tribal population in Western India.

DESIGN AND SETTING

This community-based, cross-sectional, prospective population study was a part of a module using Rapid Assessment of Avoidable Blindness and DR methodology in 8340 sampled participants with ≥50 years age. In this study, the diabetics identified were screened for DR using two methods: non-mydriatic fundus photography on the field by trained professionals, that were then graded by a retina specialist at the base hospital and indirect ophthalmoscopy by expert ophthalmologists in the field with masking of each other's findings for its utility and comparison.

RESULTS

The prevalence of DR, sight threatening DR and maculopathy using indirect ophthalmoscopy was found to be 12.1%, 2.1% and 6.6%, respectively. A fair agreement (κ=0.48 for DR and 0.59 for maculopathy) was observed between both the detection methods. The sensitivity and specificity of fundus photographic evaluation compared with indirect ophthalmoscopy were found to be 54.8% and 92.1% (for DR), 60.7% and 90.8% (for any DR) and 84.2% and 94.8% (for only maculopathy), respectively.

CONCLUSION

Non-mydriatic fundus photography has the potential to identify DR (any retinopathy or maculopathy) in community settings in Indian population. Its utility as an affordable and logistically convenient cum practical modality is demonstrable. The sensitivity of this screening modality can be further increased by investing in better resolution cameras, capturing quality images and training and validation of imagers.

TRIAL REGISTRATION NUMBER

CTRI/2020/01/023025; Clinical Trial Registry, India (CTRI).

Identification of natural inhibitors against prime targets of SARS-CoV-2 using molecular docking, molecular dynamics simulation and MM-PBSA approaches

The recently emerged COVID-19 has been declared a pandemic by the World Health Organization as to date; no therapeutic drug/vaccine is available for the treatment. Due to the lack of time and the urgency to contain the pandemic, computational screening appears to be the best tool to find a therapeutic solution. Accumulated evidence suggests that many phyto-compounds possess anti-viral activity. Therefore, we identified possible phyto-compounds that could be developed and used for COVID-19 treatment. In particular, molecular docking was used to prioritize the possible active phyto-compounds against two key targets namely RNA dependent RNA polymerase (RdRp) and main protease (Mpro) of SARS-CoV-2. In this study, an antiviral drug- Remdesivir (RdRp inhibitor) and Darunavir (Mpro inhibitor) are used as reference drugs. This study revealed that phyto-molecules- Mulberroside-A/C/E/F, Emblicanin A, Nimbolide, and Punigluconin showed high binding affinity against RdRp while Andrographolides, Mulberrosides, Anolignans, Chebulic acid, Mimusopic acid, and Punigluconin showed better binding affinity against Mpro as compared with the reference drug. Furthermore, ADME profiles validated the drug-likeness properties of prioritized phyto-compounds. Besides, to assess the stability, MD simulations studies were performed along with reference inhibitors for Mpro (Darunavir) and RdRp (Remdesivir). Binding free energy calculations (MM-PBSA) revealed the estimated value (ΔG) of Mpro_Darunavir; Mpro_Mulberroside E; RdRp_Remdesivir and RdRp_Emblicanin A were -111.62 ± 6.788, -141.443 ± 9.313, 30.782 ± 5.85 and -89.424 ± 3.130 kJmol-1, respectively. Taken together, the study revealed the potential of these phyto-compounds as inhibitors of RdRp and Mpro inhibitor that could be further validated against SARS-CoV-2 for clinical benefits.Communicated by Ramaswamy H. Sarma.