Wear performance of Ti-based alloy coatings on 316L SS fabricated with the sputtering method: Relevance to biomedical implants

BACKGROUND

This investigation was conducted to encapsulate 316L SS with a Ti-based alloy coating.

OBJECTIVE

The aim was to fabricate a coating using TiN, TiO2, and TiCoCr powders on 316L SS through the physical vapor deposition (PVD) sputtering process.

METHODS

The powders were consecutively coated on 316L SS through the PVD sputtering process with coating durations of 30, 60, and 90 min. Further microhardness, surface roughness, microabrasion, and adhesion strength tests were also carried out.

RESULTS

A 60% improvement in abrasion resistance was observed in TiCoCr-coated samples compared to the uncoated substrate. The X-ray diffraction results confirmed the optimal formation of Ti alloy coatings with corresponding orientation over the SS substrates. Moreover, TiCoCr with a 90 min coating duration had much better surface characteristics than TiO2 and TiN.

CONCLUSION

The 90 min coating duration should be optimal for coating in steel for bio-implants.

A step towards rational design of carbon nanobelts with tunable electronic properties

Belt-shaped aromatic compounds are among the most attractive classes of radial π-conjugated nanocarbon molecules with unique physical and chemical properties. In this work, we computationally studied a number of all-carbon and heteroatom-bridged nanobelts, as well as their inclusion complexes with fullerene C60. Our results provide a useful guide for modulating the electronic properties of the nanobelts. An in-depth analysis of the ground and excited state properties of their complexes has allowed us to establish structure-property relationships and propose simple principles for the design of nanobelts with improved electron-donating properties suitable for photovoltaic applications.

Pre-Clinical Validation of Targeting Cholesterol Metabolism for Radiotherapy Sensitization in Head and Neck Cancer

PURPOSE/OBJECTIVE(S)

This study examines the potential benefits of targeting cholesterol metabolism in combination with radiation therapy (RT) for treating Head and Neck Squamous Cell Carcinoma (HNSCC). Despite advancements in RT delivery, 60% of patients still experience a relapse within 2 years, highlighting the need for improved treatment strategies. Our hypothesis is that a specific, biological response to RT by a subset of tumor cells drives radio-resistance and recurrence, and that targeting cholesterol metabolism may be an effective way to improve RT efficacy.

MATERIALS/METHODS

To identify radiation-induced biological responses, whole-genome RNA sequencing analysis was carried out on Cal27 (HPV-) and UMSCC47 (HPV+) cell lines after X-Ray (6MeV Linac) or proton (pencil beam scanning, center part of SOBP) radiations. Potential radio-resistance targets were identified by comparing RT-induced transcriptomic changes with publicly available GEO and TCGA transcriptomic data from human HNSCC samples. Cholesterol metabolism as a driver of HNSCC radio-resistance was validated in vitro by pharmacological and genetic approaches.

RESULTS

Transcriptomic analysis revealed a significant increase in 11 genes related to sterol and cholesterol in both the Cal27 and UMSCC47 cell lines after radiation exposure (pathway functional enrichment analysis, p = 2.05e-05). High expression of these RT-induced cholesterol gene signatures correlated with decreased overall survival among HNSCC patients based on the TCGA database (log rank p = 0.022, HR = 1.4). Moreover, a Gene Set Enrichment Analysis of the GSE23036 dataset (pre-treatment HNSCC tumors: locoregional recurrence vs. nonrecurrence) also linked cholesterol metabolism and local recurrence (p = 0.002, FDR = 0.07, NES = 1.72). Single-cell RNA sequencing data from the GSE164690 dataset revealed high expression of cholesterol metabolism genes in human HNSCC epithelial and mesenchymal fractions. In vitro studies demonstrated that RT increased the nuclear translocation of the master transcription factors controlling cholesterol gene expression SREBP2 and increased the expression of the SREBP2 target gene SQLE at the protein level. In accordance with this result, RT increased cellular cholesterol content and uptake in human (p = 0.027) and murine (p = 0.015) HNSCC cell lines. Drug or genetic targeting of SREBP2 reduced cellular cholesterol levels in HNSCC cells and increased toxicity when combined with RT in both 2D and 3D cell cultures compared to RT alone.

CONCLUSION

Targeting cholesterol metabolism in combination with RT could be beneficial for treating HNSCC. In vivo validation in immunocompetent mouse models and orthotopic patient-derived xenograft models is ongoing.

Aromaticity controls the excited-state properties of host-guest complexes of nanohoops

π-Conjugated organic molecules have exciting applications as materials for batteries, solar cells, light-emitting diodes, etc. Among these systems, antiaromatic compounds are of particular interest because of their smaller HOMO-LUMO energy gap compared to aromatic compounds. A small HOMO-LUMO gap is expected to facilitate charge transfer in the systems. Here we report the ground and excited-state properties of two model nanohoops that are nitrogen-doped analogs of recently synthesized [4]cyclodibenzopentalenes - tetramers of benzene-fused aromatic 1,4-dihydropyrrolo[3,2-b]pyrrole ([4]DHPP) and antiaromatic pyrrolo[3,2-b]pyrrole ([4]PP). Their complexes with C60 fullerene show different behavior upon photoexcitation, depending on the degree of aromaticity. [4]DHPP acts as an electron donor, whereas [4]PP is a stronger electron acceptor than C60. The ultrafast charge separation combined with the slow charge recombination that we found for [4]PP⊃C60 indicates a long lifetime of the charge transfer state.

Cancer care for Ukrainian refugees: Strategic impact assessments in the early days of the conflict

BACKGROUND

The invasion of Ukraine by Russia in February 2022 has resulted in destruction of healthcare infrastructure and triggered the largest wave of internally displaced populations and refugees since World War Two. Conflicts in transitioned countries such as Ukraine create new non-communicable disease (NCD) challenges, especially for cancer care for refugees and humanitarian assistance in host countries. In the early days, rapid attempts were made to model possible impacts.

METHODS

By evaluating open source intelligence used in the first three months of the conflict through snowball search methods, we aimed to address: (i) burden of cancer in Ukrainian population, specifically considering translating to the refugees population, and its cancer care capacity; ii) baseline capacity/strengths of cancer systems in initial host countries. Moreover, using a baseline scenario based on crude cancer incidence in Ukraine, and considering data from UNHCR, we estimated how cancer cases would be distributed across host countries. Finally, a surveillance assessment instrument was created, intersecting health system's capacity and influx of internally displaced populations and refugees.

FINDINGS AND CONCLUSIONS

The total new cancer patients per month in pre-conflict Ukraine was estimated as 13,106, of which < 1 % are paediatric cases. The estimated cancer cases in the refugee population (combining prevalent and incident), assuming 7.5 million refugees by July 2022 and a female:male ratio of 9:1, was 33,121 individuals (Poland: 19284; Hungary: 3484; Moldova: 2651; Slovakia: 2421; Romania: 5281). According to our assessments, Poland is the only neighbouring country classified as green/yellow for cancer capacity, i.e. sufficient ablility to absorb additional burden into national health system; Slovakia we graded as yellow, Hungary and Romania as yellow/red and Moldova as red.

The longitudinal loss of islet autoantibody responses from diagnosis of type 1 diabetes occurs progressively over follow-up and is determined by low autoantibody titres, early-onset, and genetic variants

The clinical usefulness of post-diagnosis islet autoantibody levels is unclear and factors that drive autoantibody persistence are poorly defined in type 1 diabetes (T1D). Our aim was to characterise the longitudinal loss of islet autoantibody responses after diagnosis in a large, prospectively sampled UK cohort. Participants with T1D [n = 577] providing a diagnosis sample [range -1.0 to 2.0 years] and at least one post-diagnosis sample (<32.0 years) were tested for autoantibodies to glutamate decarboxylase 65 (GADA), islet antigen-2 (IA-2A), and zinc transporter 8 (ZnT8A). Select HLA and non-HLA SNPs were considered. Non-genetic and genetic factors were assessed by multivariable logistic regression models for autoantibody positivity at initial sampling and autoantibody loss at final sampling. For GADA, IA-2A, and ZnT8A, 70.8%, 76.8%, and 40.1%, respectively, remained positive at the final sampling. Non-genetic predictors of autoantibody loss were low baseline autoantibody titres (P < 0.0001), longer diabetes duration (P < 0.0001), and age-at-onset under 8 years (P < 0.01--0.05). Adjusting for non-genetic covariates, GADA loss was associated with low-risk HLA class II genotypes (P = 0.005), and SNPs associated with autoimmunity RELA/11q13 (P = 0.017), LPP/3q28 (P = 0.004), and negatively with IFIH1/2q24 (P = 0.018). IA-2A loss was not associated with genetic factors independent of other covariates, while ZnT8A loss was associated with the presence of HLA A*24 (P = 0.019) and weakly negatively with RELA/11q13 (P = 0.049). The largest longitudinal study of islet autoantibody responses from diagnosis of T1D shows that autoantibody loss is heterogeneous and influenced by low titres at onset, longer duration, earlier age-at-onset, and genetic variants. These data may inform clinical trials where post-diagnosis participants are recruited.

The frictional layer in the observed momentum budget of the trades

Profiles of eddy momentum flux divergence are calculated as the residual in the momentum budget constructed from airborne circular dropsonde arrays ( ∼ 220 km) for 13 days during the EUREC 4 A/ATOMIC field campaign. The observed dynamical forcing averaged over all flights agrees broadly with European Centre for Medium-Range Weather Forecasts (ECMWF) Integrated Forecasting System (IFS) forecasts. In the direction of the flow, a mean flux divergence (friction) exists over a 1.5-km deep Ekman layer, and a mean flux convergence (acceleration) is present near cloud tops. The friction is countergradient between 1 and 1.5 km, where vertical wind shear exceeds the observed thermal wind. From the frictional profile, a 10-m momentum flux of ∼ 0.1 N · m - 2 is derived, in line with Saildrone turbulence measurements. A momentum flux divergence in the cross-wind direction is pronounced near the surface and acts to veer the wind, opposing the friction-induced cross-isobaric wind turning. Weaker friction and upper-level acceleration of easterly flow are observed when stronger winds and more vigorous convection prevail. Turbulence measurements on board the SAFIRE ATR-42 aircraft and the Uncrewed Aircraft System (UAS) RAAVEN reveal pronounced spatial variability of momentum fluxes, with a non-negligible contribution of mesoscales (5-30 km). The findings highlight the nontrivial impact of turbulence, convection, and mesoscale flows in the presence of diverse cloud fields on the depth and strength of the frictional layer.

Simple models for strictly non-ergodic stochastic processes of macroscopic systems

We investigate simple models for strictly non-ergodic stochastic processes [Formula: see text] (t being the discrete time step) focusing on the expectation value v and the standard deviation [Formula: see text] of the empirical variance [Formula: see text] of finite time series [Formula: see text]. [Formula: see text] is averaged over a fluctuating field [Formula: see text] ([Formula: see text] being the microcell position) characterized by a quenched spatially correlated Gaussian field [Formula: see text]. Due to the quenched [Formula: see text]-field [Formula: see text] becomes a finite constant, [Formula: see text], for large sampling times [Formula: see text]. The volume dependence of the non-ergodicity parameter [Formula: see text] is investigated for different spatial correlations. Models with marginally long-ranged [Formula: see text]-correlations are successfully mapped on shear stress data from simulated amorphous glasses of polydisperse beads.

Anti-PF4 VITT antibodies are oligoclonal and variably inhibited by heparin

Background

COVID-19 vaccines have been associated with a rare thrombotic and thrombocytopenic reaction, Vaccine-induced immune thrombotic thrombocytopenia (VITT) characterized by platelet-activating anti-PF4 antibodies. This study sought to assess clonality of VITT antibodies and evaluate their characteristics in antigen-based and functional platelet studies.

Methods

Anti-PF4 antibodies were isolated from five patients with VITT secondary to ChAdOx1 nCoV-19 (n=1) or Ad26.COV2.S (n=4) vaccination. For comparative studies with heparin-induced thrombocytopenia (HIT), anti-PF4 antibodies were isolated from one patient with spontaneous HIT, another with “classical” HIT, and two patients with non-pathogenic (non-platelet activating) anti-PF4 antibodies. Isolated antibodies were subject to ELISA and functional testing, and mass spectrometric evaluation for clonality determination.

Results

All five VITT patients had oligoclonal anti-PF4 antibodies (3 monoclonal, one bi- and one tri-clonal antibodies), while HIT anti-PF4 antibodies were polyclonal. Notably, like VITT antibodies, anti-PF4 antibodies from a spontaneous HIT patient were monoclonal. The techniques employed did not detect non-pathogenic anti-PF4 antibodies. The ChAdOx1 nCoV-19-associated VITT patient made an excellent recovery with heparin treatment. In vitro studies demonstrated strong inhibition of VITT antibody-induced platelet activation with therapeutic concentrations of heparin in this and one Ad26.COV2.S-associated VITT patient. Oligoclonal VITT antibodies with persistent platelet-activating potential were detected at 6 and 10 weeks after acute presentation in two patients tested. Two of the 5 VITT patients had recurrence of thrombocytopenia and one patient had focal seizures several weeks after acute presentation.

Conclusion

Oligoclonal anti-PF4 antibodies mediate VITT. Heparin use in VITT needs to be further studied.

Fluctuations of non-ergodic stochastic processes

We investigate the standard deviation [Formula: see text] of the variance [Formula: see text] of time series [Formula: see text] measured over a finite sampling time [Formula: see text] focusing on non-ergodic systems where independent "configurations" c get trapped in meta-basins of a generalized phase space. It is thus relevant in which order averages over the configurations c and over time series k of a configuration c are performed. Three variances of [Formula: see text] must be distinguished: the total variance [Formula: see text] and its contributions [Formula: see text], the typical internal variance within the meta-basins, and [Formula: see text], characterizing the dispersion between the different basins. We discuss simplifications for physical systems where the stochastic variable x(t) is due to a density field averaged over a large system volume V. The relations are illustrated for the shear-stress fluctuations in quenched elastic networks and low-temperature glasses formed by polydisperse particles and free-standing polymer films. The different statistics of [Formula: see text] and [Formula: see text] are manifested by their different system-size dependences.

Ensemble fluctuations matter for variances of macroscopic variables

Extending recent work on stress fluctuations in complex fluids and amorphous solids we describe in general terms the ensemble average [Formula: see text] and the standard deviation [Formula: see text] of the variance [Formula: see text] of time series [Formula: see text] of a stochastic process x(t) measured over a finite sampling time [Formula: see text]. Assuming a stationary, Gaussian and ergodic process, [Formula: see text] is given by a functional [Formula: see text] of the autocorrelation function h(t). [Formula: see text] is shown to become large and similar to [Formula: see text] if [Formula: see text] corresponds to a fast relaxation process. Albeit [Formula: see text] does not hold in general for non-ergodic systems, the deviations for common systems with many microstates are merely finite-size corrections. Various issues are illustrated for shear-stress fluctuations in simple coarse-grained model systems.

Comparative analyses of published cost effectiveness models highlight critical considerations which are useful to inform development of new models

Background: Comparative analyses of published cost effectiveness models provide useful insights into critical issues to inform the development of new cost effectiveness models in the same disease area.Objective: The purpose of this study was to describe a comparative analysis of cost-effectiveness models and highlight the importance of such work in informing development of new models. This research uses genotypic antiretroviral resistance testing after first line treatment failure for Human Immunodeficiency Virus (HIV) as an example.Method: A literature search was performed, and published cost effectiveness models were selected according to predetermined eligibility criteria. A comprehensive comparative analysis was undertaken for all aspects of the models.Results: Five published models were compared, and several critical issues were identified for consideration when developing a new model. These include the comparator, time horizon and scope of the model. In addition, the composite effect of drug resistance prevalence, antiretroviral therapy efficacy, test performance and the proportion of patients switching to second-line ART potentially have a measurable effect on model results. When considering CD4 count and viral load, dichotomizing patients according to higher cost and lower quality of life (AIDS) versus lower cost and higher quality of life (non-AIDS) status will potentially capture differences between resistance testing and other strategies, which could be confirmed by cross-validation/convergent validation. A quality adjusted life year is an essential outcome which should be explicitly explored in probabilistic sensitivity analysis, where possible.Conclusions: Using an example of GART for HIV, this study demonstrates comparative analysis of previously published cost effectiveness models yields critical information which can be used to inform the structure and specifications of new models.

King's Health Partners' Prostate Cancer Biobank (KHP PCaBB)

The KHP PCaBB was established in 2013 and recruits donors from the Urology or Oncology Departments at Guy's Hospital in London (UK). Prostate cancer patients may be approached to give their consent for biobanking at any point in their treatment pathway, which allows residual material from their earlier diagnosis to be transferred and used by the Biobank. Currently, patients are specifically asked to donate samples of blood and surplus prostate tissue as well as permitting access to their clinical and pathological data that continues to be added throughout the course of their disease. Between 2013 and 2015, 549 prostate cancer patients gave their consent to the biobank and, the tissue repository collected 489 blood samples, 120 frozen prostate tissue samples and 1064 formalin fixed paraffin embedded diagnostic blocks.Prostate cancer has become a chronic disease in a large proportion of men, with many men receiving multiple subsequent treatments, and their treatment trajectory often spanning over decades. Therefore, this resource aims to provide an ideal research platform to explore potential variations in treatment response as well as disease markers in the different risk categories for prostate cancer.A recent audit of the KHP PCaBB revealed that between 2013 and 2015, 1796 patients were diagnosed with prostate cancer at King's Health Partners (KHP), out of which 549 (30.6%) gave their consent to KHP PCaBB. Comparisons between demographic and clinical characteristics of patients who had consented compared to the total patient population revealed that the KHP PCaBB is demographically representative of the total prostate cancer patient population seen in Guy's and St Thomas' NHS Foundation Trust (GSTT). We observed no differences in distribution of ethnicity (p = 0.507) and socioeconomic status (p = 0.097). Some differences were observed in clinical characteristics, specifically with treatment type - which differed significantly between the patients who had given consent and total patient population.The KHP PCaBB has thereby amassed a rich data and tissue repository that is largely reflective of both the demographic and clinical diversity within the total prostate cancer patient population seen at KHP, making it an ideal platform for prostate cancer research.

Real World Evidence: A Quantitative and Qualitative Glance at Participant Feedback from a Free-Response Survey Investigating Experiences of a Structured Exercise Intervention for Men with Prostate Cancer

AIM

To explore patient experiences of a structured exercise intervention for men with prostate cancer (PCa).

SAMPLE

41 men with either localised or advanced PCa who had been referred for a structured exercise programme by their physician and then subsequently consented to a telephone survey.

METHOD

Participants underwent a 10-week supervised exercise programme within a large cancer centre hospital consisting of 8 sessions. They then completed a short multiple choice telephone survey, elaborating on their responses where appropriate. Views expressed by participants were analysed using an affinity diagram and common themes were identified.

RESULTS

Feedback from our telephone surveys was consistently positive and suggests that the structured exercise intervention provides exercise confidence, motivation to exercise, and social support and promotes positive health behaviour change in the context of exercise. Individual differences arose amongst participants in their perceived utility of the intervention, with 73.3% expressing a preference for structured exercise classes and 19.5% expressing a preference for exercising independently.

CONCLUSION

Design of a structured exercise intervention for patients with PCa should embrace the positive aspects outlined here but consider patients' individual differences. Ongoing feedback from patients should be utilised alongside traditional study designs to inform intervention design in this area.

Evaluation of kidney function and risk factors of retinopathy in Type 2 diabetes mellitus people in South Africa

AIM

Diabetic retinopathy (DR) is a disease of the retina and an important microvascular complication of diabetes, frequently causing blindness in adults. The study aims to evaluate kidney function and risk factors for the development of retinopathy in Type 2 diabetes mellitus (DM) patients.

METHODS

A total of 140 participants (54 Type 2DM without retinopathy, 44 with DR and 42 normal, healthy controls) consented to participate in the study. Fasting plasma glucose (FPG), glycosylated haemoglobin (HbA1c), lipid profile and renal function tests were measured using routine laboratory methods.

RESULTS

A significant increase in FPG, HbA1c, serum triglycerides (TG), serum urea, urine albumin, the urine albumin/creatinine ratio (UACR) and, a significant decrease in high-density lipoprotein cholesterol (HDL-C) was observed in DR patients, compared to controls. In multivariate logistic analysis, FPG, insulin treatment and UACR were the risk factors found to be significantly associated with the presence of retinopathy. According to the Receiver Operating Characteristic (ROC) curve analysis, the diagnostic performance of UACR≥1.45mg/mmol^-1l^-1 was the optimal cut-off point.

CONCLUSION

A mild alteration in renal function was observed in DR patients and UACR is found to be an important risk factor and can be a valuable marker for predicting DR.

An evaluation of the effectiveness of the Zambian Health Worker Retention Scheme (ZHWRS) for rural areas

BACKGROUND

Zambian Health Workers Retention Scheme (ZHWRS) commenced in 2003. The schemes' original aim was to retain and recruit Zambian doctors in rural and remote districts. The aim of the ZHWRS subsequently expanded to also include other health workers, in either rural or urban areas. The scheme was formulated to address, in part, the drastic shortage of health workers.

OBJECTIVES

To evaluate the effectiveness of the ZHWRS in achieving its aim.

METHODS

The data on the number of health workers recruited by the ZHWRS and the spatial distribution of them was reviewed. A survey of health workers was undertaken to elicit their views of their working conditions, their job satisfaction and the effectiveness of retention schemes in retaining or increasing the numbers of and overall satisfaction of health workers.

RESULTS

The ZHWRS has not been successful in recruiting sufficient numbers of health workers to reverse the shortage problem or even to meet the modest targets of the scheme itself. However, these improvements do not decrease the likelihood of Department of Health (DoH) workers leaving their rural based positions.

CONCLUSIONS

The ZHWRS has not fully met either its original or revised aims. The drastic shortage of health workers in Zambia continues.

An evaluation of ²²⁶Ra and ²²⁸Ra in drinking water in several counties in Texas, USA

Naturally Occurring Radioactive Material (NORM) or Technology Enhanced Naturally Occurring Radioactive Material (TENORM) can be a potential health risk. It is now well known that the underlying geology in many parts of Texas has given rise to levels of (226)Ra and (228)Ra that often exceed the limits set by the US Environmental Protection Agency. A detailed literature search was undertaken to assess the levels of (226)Ra and (228)Ra in all of the Texas counties. Several statistical evaluations of the data were performed. The Hickory aquifer in the Llano Uplift region of Texas has consistently had the highest number of (226)Ra and (228)Ra concentrations above the legal limit. As well many of the affected rural communities may not have the financial resources to rectify the problem.

Determination of ²²⁶Ra, ²²⁸Ra and ²¹⁰Pb in NORM products from oil and gas exploration: problems in activity underestimation due to the presence of metals and self-absorption of photons

Typical calibration of solid environmental samples for the determination of (226)Ra, (228)Ra and (210)Pb entails the use of standard reference materials which have a very similar matrix. However, TENORM samples from the oil and gas exploration contain unusually high amounts of calcium, strontium and barium which can severely attenuate the photons of (210)Pb and (226)Ra with their characteristic 46.1 keV and 186.2 keV gamma-rays, respectively and to some extent (228)Ra with the characteristic gamma-rays of 911.2 keV and 969.0 keV. We used neutron activation analysis to evaluate the content of TENORM for calcium, barium and strontium and then used a software program SELABS to determine the self-absorption. Our results confirm that even in Petrie containers with small dimensions the (210)Pb can be underestimated by almost by a factor of four while (226)Ra can be underestimated by 5%. The (228)Ra activities are virtually unaffected due to the higher energy gamma-rays. However, the implications for TENORM studies that employ large Marinelli containers having sample sizes between 0.25 and 1.0 L may be severely compromised by the presence of high Z elements in elevated concentrations. The usual spectral interferences on (226)Ra, (228)Ra and (210)Pb coming from other radionuclides in the (234)U, (235)U and (238)U decay chains are virtually nonexistent due the very high activity levels of (226)Ra, (228)Ra and (210)Pb in the tens of thousands of Bq/kg.

Carcinoma base of tongue: single institution 15 year experiences

AIMS

To report the outcome with radiotherapy and concomitant chemoradiotherapy in patients with locally advanced squamous cell carcinoma base of tongue treated and followed up at single institution over a period of 15 years.

MATERIALS AND METHODS

This study was carried out by auditing the medical records of 103 patients treated at our institution between 1991 and 2006. Mean age with standard deviation of patients in the Radiotherapy only (group I) and chemoradiotherapy (group II) was 55.26 ± 14.16 and 49.81 ± 12.16 years. 46 patients were treated with radiotherapy alone and 57 patients were treated with concurrent chemo radiotherapy using infusion cisplatinum 3 weekly and 5 fluorouracil twice weekly. Mean follow up was 13.35 months. All the patients characteristic and treatment characteristics were recorded.

RESULTS

There were 81 men and 22 women in the study. Group I contains 15 and 31 cases of stage III and IV tumors while group II contains 19 and 38 cases of stage III and IV respectively. Group II has shown improved loco regional control rate for the T3 and T4 tumors as compared to group I. Disease free survival and overall survival in the group II is 25.51 months and 22.53 months while group I has 8.67 months and 6.74 months respectively. Grade III mucosal toxicity incidence was higher in group II as compared to group I.

CONCLUSIONS

In locally advanced squamous cell carcinoma of base of tongue tumors concomitant chemoradiotherapy with infusional cisplatinum and 5 fluorouracil results in higher disease free and overall survival as compared to radiotherapy as single modality. This better tumor response with chemoradiotherapy comes at cost of higher incidence of mucosal toxicity.

Difficult intubation management in a child with I-cell disease

I-cell disease (mucolipidosis II) is a rare metabolic disorder resulting from the deficiency of a specific lysosomal enzyme, N-acetylglucosamine-1-phosphotransferease. Developmental delay and growth failure are common presentations of I-cell disease. Psychomotor deterioration is rapid and progressive. Some physical signs such as hip dislocations, inguinal hernia, hepatomegaly, joint limitation, and skin changes may be present at birth. Coarse facial features and skeletal abnormalities become more conspicuous with time. The life expectancy of children with this condition is poor, with death usually occurring around the fifth year. A case report of the anesthetic management of gingivectomy with multiple dental extractions in a 5-year-old Omani female with I-cell disease is presented. The problems faced and their management during anesthesia are described.

Anesthesia for gingivectomy and dental extractions in a child with I-cell disease--a case report

I-cell disease (mucolipidosis II) is a rare metabolic disorder resulting from the deficiency of a specific lysosomal enzyme, N-acetylglucosamine-1-phosphotransferease. Developmental delay and growth failure are common presentations of I-cell disease. Psychomotor deterioration is rapid and progressive. Some physical signs, such as hip dislocations, inguinal hernia, hepatomegaly, joint limitation, and skin changes may be present at birth. Coarse facial features and skeletal abnormalities become more conspicuous with time. The life expectancy of children with this condition is poor, with death usually occurring around the fifth year. A case report of the anesthetic management of gingivectomy with multiple dental extractions in a 5 years old Omani female, with I-cell disease, is presented. The problems faced and their management during anesthesia are described.

Two novel AIRE mutations in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) among Indians

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare recessive disorder resulting from mutations in the autoimmune regulator (AIRE) gene. There is no information on AIRE mutations in Indians. In a cross-sectional study, nine patients (eight families), from four referral hospitals in India, were studied for AIRE mutations by direct sequencing. We screened for new mutations in 150 controls by allele-specific PCR. The patients had 1-7 known components of APECED. Three patients had unusual manifestations: presentation with type 1 diabetes; chronic sinusitis and otitis media; and facial dysmorphism. All patients carried homozygous, probably recessive, AIRE mutations. Two unrelated patients from a small in-bred community (Vanika Vaisya) in south India carried an unreported missense mutation, p.V80G, in the N-terminal caspase recruitment domain. Another unique mutation, p.C302X, resulting in a truncated protein with deletion of both zinc-finger domains, was detected in a patient from Gujarat. Neither mutation was detected in controls. Other mutations, previously described in Caucasians, were: 13 base pair deletion (p.C322fsX372) in 4 (38%), and Finn-major (p.R257X) and p.R139X (Sardinian) mutation in one subject each. In conclusion, in this first series of APECED in Indians, we detected AIRE mutations previously reported in Caucasians, as well as unique mutations. Of these, p.V80G is possibly an ancestral mutation in an in-bred community.

Fractures of the atlas: can we rely on the NICE guidelines for imaging the cervical spine after head injury?

We describe a patient who was not thought to fulfil the NICE criteria for imaging the cervical spine after head injury but who had two fractures of the atlas, thus rendering the vertebral ring unstable. The reasons for missing this injury in the emergency department are discussed.

Effect of population ageing on emergency department speed and efficiency: a historical perspective from a district general hospital in the UK

OBJECTIVE

To examine changes in the rate of seeing patients between 1990 and 2004 and to see whether performance might be related to patient age, using data held on the patient administration system.

METHOD

Data collected in 1990 were compared with those collected in 2004. Age related data were examined for the following parameters: the number of patients arriving by ambulance; the time taken to process the attendance; the number of investigations; the number of emergency admissions; and the length of inpatient stay.

RESULTS

Emergency department (ED) performance has fallen markedly since 1990. Between 1990 and 2004, there was a 54% increase in total patients with a disproportionate 198% increase in patients aged more than 70 years, including a 671% increase in those aged more than 90 years. The time taken to manage patients increased with age. In 2004, there was a marked rise in investigation rates, and the probability of having investigations increased with age. In 2004, older patients (aged more than 70 years) were 4.9 times more likely to require admission to hospital than younger patients (aged 30 years or less). Their average length of stay was 6.9 times longer. Younger patients were 3.3 times more numerous than older patients but older patients occupied 9.8 times more emergency bed days.

CONCLUSIONS

Pressure on emergency care is associated with a disproportionate increase in the number of elderly patients and with an increased tendency to investigate them. Population ageing is of central importance in planning health services.

Pitfalls in the clinical diagnosis of vertebral fractures: a case series in which posterior midline tenderness was absent

OBJECTIVE

There is widespread belief among doctors that posterior midline tenderness is virtually a prerequisite for spinal fracture in alert, sober patients without any painful distracting injury or neurological deficit. This paper examines and challenges this belief.

METHODS AND RESULTS

We present three patients in whom significant thoracic and lumbar vertebral fractures were missed, or were thought to be "old", because of lack of posterior midline tenderness. We also present two further patients, one with a lumbar spine fracture and one with a cervical spine fracture, in whom posterior midline tenderness was absent but in whom the correct diagnosis was made. All these patients were sober and fully alert and none had a neurological deficit or a painful distracting injury.

CONCLUSION

The absence of posterior midline tenderness does not exclude significant spinal injury. We suggest that patients should satisfy both the Canadian and British guidelines before it is decided that imaging of the cervical spine is unnecessary.

Perforation of the oesophagus and aorta after eating fish: an unusual cause of chest pain

This report describes perforation of the oesophagus after eating fish complicated by perforation of the aorta six days later. The patient had not knowingly swallowed a fish bone. Aorto-oesophageal fistula is almost universally fatal. In the case described here, the fistula was demonstrated on contrast computed tomography before surgery, thus informing surgical management. The patient is the eighth reported survivor.

Facilities for chemical decontamination in accident and emergency departments in the United Kingdom

OBJECTIVE

To audit the facilities for chemical decontamination, with special reference to cyanide poisoning, in all major accident and emergency departments in the UK.

METHOD

A simple postal questionnaire was used to audit planning, premises, equipment, protection for staff, and stocks of specific antidotes to cyanide poisoning.

RESULTS

227 questionnaires from 261 departments (87%) were returned and used in the survey. Of the 227 departments who responded, 151 (66%) had a written plan; 168 (74%) departments had premises for decontamination; 55 (24%) were judged to have satisfactory premises; 146 (64%) departments had a shower or hose for decontamination; 60 (26%) departments had a decontamination trolley suitable for "stretcher" patients; 203 (89%) had some protective equipment for staff but only 77 (34%) had complete protection--that is, goggles, chemical resistant clothing, and breathing apparatus. In the authors' opinion only seven (3%) departments had satisfactory premises and equipment to treat "stretcher" patients and full protection for staff. A further 11 (5%) departments were equipped to manage ambulant patients at a similar level. Some 205 (90%) departments stocked one or more antidotes to cyanide and 77 (34%) stocked all four antidotes. Thirty four (15%) departments held all four antidotes to cyanide and had full protection for staff. Only five (2%) departments had satisfactory premises and equipment to treat "stretcher" patients, full protection for staff, and at least three of four antidotes.

CONCLUSIONS

Most departments had some equipment for chemical decontamination. However, there were major inconsistencies in the range of equipment held and these limited its usefulness. Only a small minority of departments was satisfactorily equipped to deal with a serious chemical incident.

Kangaroo Mother Care in very low birth weight infants

OBJECTIVE

This study was conducted (i) to study through a randomized control trial the effect of Kangaroo Mother Care (KMC) on breast feeding rates, weight gain and length of hospitalization of very low birth neonates and (ii) to assess the acceptability of Kangaroo Mother Care by nurses and mothers.

METHODS

Babies whose birth weight was less than 1500 Grams were included in the study once they were stable. The effect of Kangaroo Mother Care on breast feeding rates, weight gain and length of hospitalization of very low birth weight neonates was studied through a randomized control trial in 28 neonates. The Kangaroo group (n = 14) was subjected to Kangaroo Mother Care of at least 4 hours per day in not more than 3 sittings. The babies received Kangaroo Care after shifting out from NICU and at home. The control group (n = 14) received only standard care (incubator or open care system). Attitude of mothers and nurses towards KMC was assessed on Day 3 +/- 1 and on day 7 +/- 1 after starting Kangaroo Care in a questionnaire using Likert's scale.

RESULTS

The results of the clinical trial reveal that the neonates in the KMC group demonstrated better weight gain after the first week of life (15.9 +/- 4.5 gm/day vs. 10.6 +/- 4.5 gm/day in the KMC group and control group respectively p < 0.05) and earlier hospital discharge (27.2 +/- 7 vs. 34.6 +/- 7 days in KMC and control group respectively, p < 0.05). The number of mothers exclusively breastfeeding their babies at 6 week follow-up was double in the KMC group than in the control group (12/14 vs. 6/14) (p < 0.05).

CONCLUSION

KMC managed babies had better weight gain, earlier hospital discharge and, more impressively, higher exclusive breast-feeding rates. KMC is an excellent adjunct to the routine preterm care in a nursery.