A Comparative Study of Anterior Cruciate Ligament Reconstruction Versus Conservative Treatment

Background The anterior cruciate ligament (ACL) rupture is a common injury with an incidence of 68.6 in 100,000 patients per year. Despite extensive research on ACL rupture, there are insufficient high-quality studies to determine clear treatment strategies for adults lacking the ACL. This study aims to examine the functional differences between surgical and conservative treatment based on the quality of the surgical process. Methodology In this prospective, comparative study, a total of 136 patients aged between 18 and 35 years were enrolled per inclusion and exclusion criteria. Using the lottery system, patients were divided into the following two groups: group A (n = 71) and group B (n = 65). Group A was treated with arthroscopic ACL reconstruction and rehabilitation, whereas group B was treated conservatively (rehabilitation). Patient data, including age, sex, body mass index, International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Level (TAL) score, and complications were recorded and compared. Results The demographic data were comparable, where males had dominancy in both groups. The mean IKDC and KOOS scores were higher in group A at all follow-ups compared to group B. The scores gradually increased at every follow-up till six months. At the final follow-up, the IKDC and KOOS scores were higher in group A than in group B, and a significant difference was observed among both groups. The TAL score also gradually increased at every follow-up till 6 months. At the final follow-up, the TAL score was higher in group A than in group B, with a significant difference between the two groups (p = 0.0032). Complications in both groups were comparable. Conclusions This study showed that both the conservatively treated group and the rebuilt group had identical outcomes, with the exception of the conservative group having greater objectively quantifiable instability. However, at the final follow-up, patients reported feeling just as satisfied with their knee without surgery, demonstrating no subjective difference in activity levels or functional outcomes. Therefore, non-athletes with an ACL-insufficient knee should still choose conservative treatment.

Low-Dose Immunotherapy in Head and Neck Cancer: A Randomized Study

PURPOSE

The regimens approved for the treatment of advanced head and neck squamous cell carcinoma are accessible to only 1%-3% of patients in low- and middle-income countries because of their cost. In our previous study, metronomic chemotherapy improved survival in this setting. Retrospective data suggest that a low dose of nivolumab may be efficacious. Hence, we aimed to assess whether the addition of low-dose nivolumab to triple metronomic chemotherapy (TMC) improved overall survival (OS).

METHODS

This was a randomized phase III superiority study. Adult patients with recurrent or newly diagnosed advanced head and neck squamous cell carcinoma being treated with palliative intent with an Eastern Cooperative Oncology Group performance status of 0-1 were eligible. Patients were randomly assigned 1:1 to TMC consisting of oral methotrexate 9 mg/m² once a week, celecoxib 200 mg twice daily, and erlotinib 150 mg once daily, or TMC with intravenous nivolumab (TMC-I) 20 mg flat dose once every 3 weeks. The primary end point was 1-year OS.

RESULTS

One hundred fifty-one patients were randomly assigned, 75 in TMC and 76 in the TMC-I arm. The addition of low-dose nivolumab led to an improvement in the 1-year OS from 16.3% (95% CI, 8.0 to 27.4) to 43.4% (95% CI, 30.8 to 55.3; hazard ratio, 0.545; 95% CI, 0.362 to 0.820; P = .0036). The median OS in TMC and TMC-I arms was 6.7 months (95% CI, 5.8 to 8.1) and 10.1 months (95% CI, 7.4 to 12.6), respectively (P = .0052). The rate of grade 3 and above adverse events was 50% and 46.1% in TMC and TMC-I arms, respectively (P = .744).

CONCLUSION

To our knowledge, this is the first-ever randomized study to demonstrate that the addition of low-dose nivolumab to metronomic chemotherapy improved OS and is an alternative standard of care for those who cannot access full-dose checkpoint inhibitors.

The impact of atrial fibrillation on prognosis in aortic stenosis

Background

Atrial fibrillation (AF) and aortic stenosis (AS) are both highly prevalent and increasing with age. Various studies have focused on the complex relationship between these entities that frequently coexist. AS might induce adverse cardiac remodelling, which is associated with poor prognosis in severe AS. Left atrial remodelling, especially left atrial enlargement, is also an important risk factor for AF.

Purpose

To evaluate the additive prognostic value of AF besides markers of left atrial and left ventricular remodelling in patients with AS, irrespective of severity of AS and left ventricular ejection fraction (LVEF).

Methods

Patients with moderate and severe AS were selected and history of AF was assessed. Subgroups were defined according to LVEF (reduced (<50%) vs. preserved (≥50%)) and severity of AS (moderate vs. severe). The endpoint was all-cause mortality. Unadjusted Kaplan-Meier survival curves were plotted. Four multivariable Cox regression models were constructed.

Results

In total, 2849 patients with moderate and severe AS (mean age 72±12 years, 54.7% men) were evaluated of whom 686 (24.1%) had a history of AF. Regarding the defined subgroups, 1091 (38.3%) patients had severe AS and 2207 (77.5%) patients had preserved LVEF. During a median follow-up time of 60 months (interquartile range 30 to 97), 1182 (41.5%) patients died. Ten-year mortality rate in patients with AF was 46.8% compared with 36.8% in patients with sinus rhythm (SR) (Figure 1) (p<0.001). In subgroup analysis, patients with AF and severe AS, moderate AS or preserved LVEF had worse survival than those who maintained SR (p=0.015, p<0.001 and p<0.001 respectively). On univariable (HR: 1.42; 95% CI: 1.25 to 1.62; p<0.001) and multivariable Cox regression analysis (HR: 1.19; 95% CI: 1.02 to 1.38; p=0.026) adjusting for age, body mass index, hypertension, diabetes mellitus, coronary artery disease, chronic obstructive pulmonary disease, kidney function, New York Heart Association class, aortic valve replacement as a time-dependent covariate, left ventricular mass index, left ventricular end-diastolic volume index, LVEF, mean aortic valve gradient, tricuspid annular plane systolic excursion, AF is independently associated with mortality (Table 1; model 1). However, when correcting for LAVI, E/e' or both, AF is no longer independently associated with all-cause mortality (Table 1; model 2–4).

Conclusion

Patients with moderate or severe AS and AF have a significantly higher 10-year mortality rate than patients with SR. This finding is irrespective of AS severity and also apparent in the subgroup with preserved LVEF. Nonetheless, when correcting for markers of diastolic dysfunction, AF is not independently associated with outcome in patients with moderate or severe AS.

Funding Acknowledgement

Type of funding sources: None.

Prevalence and prognostic implications of discordant grading and flow-gradient patterns in moderate aortic stenosis

Background

The prognostic implications of discordant grading in severe aortic stenosis (AS) are well known. However, the prevalence of different flow-gradient patterns and their prognostic implications in moderate AS are unknown.

Purpose

To investigate the occurrence and prognostic implications of different flow-gradient patterns in patients with moderate AS.

Methods

Patients with moderate AS (aortic valve area 1.0–1.5 cm2) were divided in 4 groups, based on transvalvular mean gradient (MG), stroke volume index (SVi) and left ventricular ejection fraction (LVEF): concordant moderate AS (MG ≥20 mmHg); normal-flow, low-gradient discordant moderate AS (MG <20 mmHg, SVi ≥35 ml/m2); “classical” low-flow, low-gradient discordant moderate AS (MG <20 mmHg, SVi <35 ml/m2 and LVEF <50%) and “paradoxical” low-flow, low-gradient discordant moderate AS (MG <20 mmHg, SVi <35 ml/m2 and LVEF ≥50%). The primary endpoint was all-cause mortality.

Results

Of 1974 patients (age 73±10 years, 51% men) with moderate AS, 788 (40%) had discordant grading. Patients with discordant grading showed significantly higher mortality rates than patients with concordant grading (p<0.001), even in the subgroup of patients having preserved LVEF (p=0.028) or preserved SVi (p=0.002). Of the patients with discordant grading, 71% had normal-flow, low-gradient moderate AS, 14% had “classical” low-flow, low-gradient moderate AS, and 14% had “paradoxical” low-flow, low-gradient moderate AS (Figure 1). Patients with normal-flow, low-gradient moderate AS, “classical” low-flow, low-gradient moderate AS, and “paradoxical” low-flow, low-gradient moderate AS had worse survival rates than patients with concordant grading (p<0.001) (Figure 2). On multivariable analysis “paradoxical” low-flow, low-gradient (HR: 1.533; 95% CI: 1.133–2.075; p=0.006) and “classical” low-flow, low-gradient (HR: 1.926; 95% CI: 1.442–2.572; p<0.001) but not normal-flow, low-gradient moderate AS were independently associated with all-cause mortality.

Conclusion

Discordant grading is frequently (40%) observed in patients with moderate AS. Low-flow, low-gradient patterns account for an important proportion of the discordant cases and are associated with increased mortality. These findings underline the need for better phenotyping patients with discordant moderate AS.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Study on Status of Serum Biochemical and Hematological Parameters in COVID-19 Positive Patients Attending a Tertiary Care Hospital

Background Coronavirus disease 2019 (COVID-19) presents clinically a variety of pathological and clinical organ dysfunctions, ranging in severity from asymptomatic to fatal. The care and monitoring of COVID-19 patients may benefit from the use of biochemical and hematological markers. Objective To observe the alteration of serum biochemical and hematological parameters in COVID-19 positive patients, attending a Tertiary Care Hospital. Method A descriptive cross-sectional study was conducted on all COVID-19 positive patients attending Nobel Medical College Teaching Hospital, Biratnagar, Nepal from 15th December 2021 to 15th February 2022. The test results of different serum biochemical and hematological parameters done for these patients were recorded in clinical laboratory services and obtained retrospectively for the analysis. The data were entered in MS excel and analyzed by SPSS version 20. Result Out of 1537 COVID-11699 declared positive patients, 712 (46.32%) were male and 825 (53.68%) female. Mean age of COVID positive patients was 40.03±20.08 years. The level of serum SGOT, SGPT, ALP and GGT was significantly elevated in 39.9%, 42.8%, 32.3% and 47.2% of COVID positive patients respectively. Blood Urea, creatinine, uric acid and sugar level were significantly elevated in 63%, 56.1%, 33.1% and 47.6% patients respectively. The serum level of LDH, D-dimer, CRP and procalcitonin (PCT) were significantly increased in 52.1%, 75.9%, 71.6% and 61.2% of patients respectively. The serum value of total cholesterol, triglyceride, HDL and LDL were significantly lowered in 52.2%, 43.8%, 70.1% and 60.3% of patients respectively. RBC concentration and level of hemoglobin was reduced in 56.6% and 53.6% of COVID positive patients respectively whereas total leukocyte count was elevated in 80.7% with increase in neutrophil in 87.9% and decrease in lymphocyte in 79.4%. Conclusion A portion of COVID-19 positive patients showed drastically altered test results for various serum biochemical and hematological markers, although many of them had normal findings.

Metronomic systemic PCm (paclitaxel, carboplatin + metronomic) neoadjuvant chemotherapy in head and neck cancer

e18073

Background: Neoadjuvant chemotherapy (NACT) in head and neck cancers (HNC) with taxane, platinum, 5-FU (TPF) regimen is both toxic as well as difficult to use in resource-constrained settings. We used a novel combination of weekly chemotherapy and oral metronomic chemotherapy (OMCT) and assessed the efficacy and safety of this combination as NACT in locally advanced HNC patients. Methods: This is a retrospective analysis of prospectively maintained data. 56 patients with technically unresectable HNC received NACT with paclitaxel (80mg/m2) plus carboplatin (AUC2) - weekly schedule and OMCT (methotrexate 9mg/m2 once a week, celecoxib 200mg twice daily, and erlotinib 150mg once daily) - PCm regimen. Patients were assessed clinically and radiologically after a minimum of six cycles for resectability. The radiological response was evaluated as per RECIST 1.1. We report the response rate, resectability, survival, and tolerance of this NACT regimen. Results: The median age of the patients was 41 years. Fifty-two patients (92.9%) were male. Buccal mucosa (60.7%) and oral tongue (17.9%) were the commonest sites of primary seen followed by alveolus (10.7%), the floor of mouth (5.4%), and larynx (5.4%). AJCC 2017 stage IVA and IVB disease were present in 64.3% and 35.7% of patients respectively. Edema up to zygoma (44.6%), high ITF involvement (19.7%), technically unresectable nodal disease (16.1%) and disease reaching up to vallecula (12.5%), or hyoid bone (5.4%), and nodal encasement (180-270 degree) of the internal carotid artery (1.8%) were the reasons for technical unresectability. The median number of NACT administered was six. The tumor showed partial response in 54 (96.4%) patients, 2 (3.6%) patients had stable disease and none of the patients had tumor progression. Surgery was planned in 47 (83.9%) patients after NACT, however due to logistic issues only 35 (62.5%) patients could undergo surgery. Pathological complete response was seen in 27 (48.21%) patients. After a median follow-up of 7.36 months, median PFS was not reached in the whole cohort and surgery group of patients, whereas it was 5.23 (95% CI, 4.08 -6.38) months in the non-surgery group. Median OS was not reached in our cohort. Common grade 3/4 toxicities (CTCAE 5.0) observed were oral mucositis in 6 (10.7%) patients, diarrhea in 4 (7.1%), and febrile neutropenia in 1 (1.7%) patients. Conclusions: Weekly scheduled PCm is an efficacious and well-tolerated regimen and can easily be administered in resource-constrained settings.

Prognostic implications of left ventricular diastolic dysfunction in moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Moderate aortic stenosis (MAS) is associated with an increased risk of adverse events. Although left ventricular (LV) diastolic dysfunction (DDF) has shown to carry an unfavorable prognosis in severe AS, the prognostic value of LV DDF in MAS has not been investigated.

Purpose

To investigate the prognostic impact of LV DDF in patients with MAS and preserved LV ejection fraction (EF).

Methods

LV diastolic function was evaluated in patients with MAS (aortic valve area >1.0 and ≤1.5cm2)  and preserved LVEF (≥50%) using echocardiography according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as all-cause mortality and a composite endpoint of all-cause mortality and aortic valve replacement (AVR).

Results

Of 1247 patients (age 74 ± 10 years, 47% men) with MAS and preserved LVEF, 396 (32%) had normal diastolic function, 316 (25%) had indeterminate diastolic function and 535 (43%) had DDF. Patients with DDF were more likely to be female, had more comorbidities (hypertension, atrial fibrillation, chronic kidney disease) and were more symptomatic (NYHA ≥2) than patients with normal diastolic function. Patients with DDF also had smaller aortic valve area and higher peak aortic velocities than patients with normal/indeterminate diastolic function. During a median follow-up of 53 (26 – 81) months, 484 (39%) patients died. For the composite endpoint, 770 patients (62%) underwent AVR (n = 376) or died (n = 394) during a median follow-up of 37 (IQR 15 – 62) months. Patients with DDF had significantly lower survival rates (p <0.001) and event-free survival rates (p = 0.015) compared to patients with normal/indeterminate diastolic function (Figure 1). On multivariable analysis, DDF was independently associated with all-cause mortality (HR: 1.368; 95% CI: 1.085 – 1.725; p = 0.008) and the composite endpoint of all-cause mortality and AVR (HR: 1.241; 95% CI: 1.035 – 1.488; p = 0.020) (Figure 2).

Conclusion

LV DDF is associated with worse outcomes in patients with MAS. Assessment of LV diastolic function may contribute significantly to risk stratification of patients with MAS. Abstract Figure.  Abstract Figure.

Prognostic value of left ventricular global longitudinal strain in patients with moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Impaired left ventricular (LV) global longitudinal strain (GLS) is associated with worse outcomes in patients with severe aortic stenosis, but its prognostic value in patients with moderate aortic stenosis (MAS) is largely unknown.

Purpose

To investigate the prognostic implications of LV GLS in patients with MAS and preserved LV ejection fraction (EF).

Methods

LV GLS was evaluated by speckle tracking echocardiography in 621 patients (age 71 ± 12 years, 59% men) with MAS (aortic valve area 1.0 – 1.5cm2) and preserved LVEF (≥50%). Impaired LV GLS was defined as an LV GLS value <16%, based on spline curve analysis (i.e. where the hazard ratio for all-cause mortality was ≥1). Clinical outcomes were defined as all-cause mortality and a composite endpoint of all-cause mortality and aortic valve replacement.

Results

Patients with LV GLS <16% (n = 282) were significantly older, more likely to be male and had more comorbidities (diabetes mellitus, atrial fibrillation, more impaired renal function) compared to patients with LV GLS ≥16% (n = 339). In terms of echocardiographic data, patients with LV GLS <16% had larger LV volumes, lower LVEF and higher E/e’. During a median follow-up of 53 (27 – 102) months, 199 (32%) patients died. For the composite endpoint, 409 patients (66%) underwent AVR (n = 290) or died (n = 119) during a median follow-up of 29 (IQR 14 – 54) months. Patients with LV GLS <16% experienced significantly lower survival rates (p < 0.001) and event-free survival rates (p = 0.001) compared to patients with LV GLS ≥16% (Figure 1). On multivariable analysis, LV GLS was independently associated with all-cause mortality (HR 2.442; 95% CI: 1.762 – 3.384; p < 0.001) and the composite endpoint of all-cause mortality and aortic valve replacement  (HR 1.862; 95% CI: 1.498 – 2.315; p = 0.040) (Figure 2).

Conclusions

In patients with MAS and preserved LVEF, reduced LV GLS is associated with an increased risk of all-cause mortality and the composite endpoint of all-cause mortality and AVR. Assessment of LV GLS may be useful in the risk stratification of these patients. Abstract Figure. Kaplan-Meier curves  Abstract Figure. Cox regression analysis

Left ventricular remodeling patterns in patients with moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Moderate aortic stenosis (MAS) is associated with an increased risk of adverse events. Although left ventricular (LV) adverse remodeling is associated with worse outcomes in patients with severe AS, the prognostic significance of different patterns of LV remodeling in MAS has not been investigated.

Purpose

To investigate the association between different patterns of LV remodeling on outcomes in patients with MAS.

Methods

Patients with MAS (aortic valve area >1.0 and ≤1.5cm2) were stratified into 4 groups according to the pattern of LV remodeling: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH) or eccentric hypertrophy (EH). Clinical outcomes were defined as all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR).

Results

Of 1931 patients (age 73 ± 10 years, 52% men) with MAS, 344 (18%) had NG, 469 (24%) CR, 698 (36%) CH and 420 (22%) EH. Patients with CH were more likely to be female, had more hypertension, were more symptomatic (NYHA ≥III) and had more pronounced LV diastolic dysfunction, whereas patients with EH had more coronary artery disease, were more symptomatic (NYHA ≥III) and had lower LV ejection fraction than patients with NG. Patients with CH had higher aortic mean pressure gradients and peak aortic jet velocities than patients with NG. During a median follow-up of 51 (IQR 25 - 83) months, 833 (43%) patients died. For the composite endpoint, 1286 (67%) patients underwent AVR (n = 613) or died (n = 673) during a median follow-up of 35 (IQR 14 - 60) months. Patients with CH and EH had significantly lower survival rates (p < 0.001; Figure 1) and event-free survival rates (p = 0.004) compared to patients with NG/CR. On multivariable analysis, CH was independently associated with all-cause mortality (HR:1.267; 95% CI:1.024 – 1.568; p = 0.029), whereas both CH (HR:1.293; 95% CI:1.090 – 1.533; p = 0.003) and EH (HR:1.222; 95% CI:1.013 – 1.474; p = 0.036) were associated with the composite endpoint of AVR and all-cause mortality (Figure 2).

Conclusions

In patients with MAS, different patterns of LV remodeling are observed with CH being independently associated with an increased risk of all-cause mortality. Risk stratification according to the different patterns of LV remodeling may help to identify patients with MAS who are at increased risk of adverse events and may benefit from closer follow-up. Abstract Figure. Kaplan-Meier curves  Abstract Figure. Cox regression analysis

Assessment of chin morphology in different skeletal dysplasia – A cross-sectional study

Objective:

The objective of the study is to evaluate the morphology of the symphyseal region of adult skeletal Class II and Class III malocclusion as compared with Skeletal Class I subjects.

Materials and Methods:

The symphyseal width and height were evaluated using data from 80 lateral cephalograms of the age range of 18 years to 25 years. Average growing Skeletal Class II (n = 30) and Class III (n = 20) subjects were used as a comparison group. Average growing normal occlusion samples (n = 30) were used as controls.

Results:

Alveolar height was similar in all groups. The width of the symphyseal region including basal width, the width of the cervical region of the lower central incisor at the cementoenamel junction, and symphysis width were found to be similar in all groups. There is no significant difference in gonial angle in both Class II and III groups as compared to control. Articular angle showed no significant difference. Mandibular incisor dentoalveolar height (L1-AH) was found to be significantly higher in the Class II group (P < 0.05).

Conclusions:

There are no definite morphological differences in the symphyseal region between average grower Class I, Class II, and Class III skeletal malocclusions except mandibular incisor dentoalveolar height (L1-AH) and incisor mandibular plane angle which is higher whereas ramus length and body length which is lesser in Class II group as compared with controls. Width of the cervical region of the lower central incisor at the cementoenamel junction (Id-Id’) and incisor mandibular plane angle was lower than control in Class III subjects.

Antimicrobial resistance in neonates with suspected sepsis

SETTING

Nobel Medical College and Teaching Hospital, Biratnagar, Nepal.

OBJECTIVE

To determine the pattern of antimicrobial resistance and hospital exit outcomes in neonates with suspected sepsis in a tertiary neonatal intensive care unit (NICU).

DESIGN

This hospital-based cohort study was conducted to follow patients from January to December 2019. All identified cases of suspected sepsis were enlisted from hospital records.

RESULTS

Sepsis was suspected in 177 (88%) of the 200 cases admitted in the NICU; 52 (29%) were culture-positive. Pseudomonas was the predominant organism isolated (n = 40; 78%), followed by coagulase negative staphylococcus (n = 12, 23%). Nine (17%) of the 52 isolates were resistant to the Access and Watch group of antibiotics, including some resistance to Reserve group drugs such as imipenem and linezolid. Most treated cases (n = 170, 96%) improved, although 7 (4%) left against medical advice.

CONCLUSION

Most of the pathogens were resistant to WHO Access and Watch antibiotics and occasional resistance was observed to Reserve group drugs. Most sepsis was caused by Gram-negative bacilli. Improving turnaround times for antibiotic sensitivity testing using point-of-care testing, and a greater yield of culture-positive results are needed to enhance the management of neonatal sepsis.

Sex differences in left ventricular remodeling in patients with severe aortic valve stenosis

Background

Women with severe aortic valve stenosis (AS) have better long-term outcomes after transcatheter aortic valve implantation (TAVI) but worse survival after surgical aortic valve replacement compared to men. Whether this is related to sex differences in left ventricular (LV) remodeling is unknown.

Purpose

To examine sex differences in LV remodeling and outcomes in patients with severe AS undergoing TAVI.

Methods

Patients with severe AS who underwent TAVI between 2007 and 2018 with a pre-procedural multidetector row computed tomography (MDCT) scan were included. LV volumes, mass and function were analyzed with MDCT. Patients were classified into 4 LV remodeling patterns based on LV mass index and LV mass-to-volume ratio: 1) normal geometry, 2) concentric remodeling, 3) concentric hypertrophy and 4) eccentric hypertrophy. The primary endpoint was all-cause mortality after TAVI.

Results

A total of 289 patients (age 80±6 years, 54% male) were included. Women showed smaller LV volumes and mass compared to men. Concentric hypertrophy (50%) was the most frequent pattern of LV remodeling followed by eccentric hypertrophy (33%), normal geometry (13%) and concentric remodeling (4%). Concentric remodeling was more frequently observed in men compared to women (91% vs. 9% respectively, p=0.011). However, no sex differences were observed in the remaining LV remodeling patterns (Figure 1). During a median follow-up of 3.8 (IQR 2.2–5.1) years after TAVI, 87 patients died. Women demonstrated better outcome after TAVI compared to men (log-rank χ2=4.29, p=0.038). The survival benefit of women over men was mainly present among patients with concentric hypertrophy (log-rank χ2=4.91, p=0.027, Figure 2).

Conclusion

LV concentric and eccentric hypertrophy are similarly observed in men and women with severe AS. Women demonstrated better outcome after TAVI as compared to men, particularly among those with LV concentric hypertrophy. However, the outcome benefit of females after TAVI seems not to be related to sex-differences in LV remodeling.

Funding Acknowledgement

Type of funding sources: None. Distribution of sex in LV remodelingAll-cause mortality after TAVI

Impact of left atrial strain assessed with feature-tracking computed tomography on long-term mortality after transcatheter aortic valve implantation

Background

Aortic stenosis (AS) induces left atrial (LA) remodeling through the increase of left ventricular (LV) filling pressure. Peak left atrial longitudinal strain (PALS) has been proposed as a prognostic marker in patients with AS. Novel feature-tracking (FT) software allows to assess LA strain from multidetector computed tomography (MDCT) dataset.

Purpose

To investigate the association between PALS using FT MDCT and moratlity in patients who underwent transcatheter aortic valve implantation (TAVI).

Methods

A total of 369 Patients (mean 80±7 years, 51% male) who underwent preprocedual MDCT before TAVI and had suitable data for measureing PALS using dedicated FT software were included. Patients were classified into 4 groups according to PALS quartiles; PALS more than 19.3% (Q1), 19.3% or less to more than 15.0% (Q2), 15.0% or less to more than 9.1% (Q3), and 9.1% or less (Q4). The primary outcome was all-caurse mortality.

Results

During median follow-up of 45 [22 - 68] months, 124 patients (34%) were died. On multivariable Cox regression analysis, PALS is an independently associated with all-cause mortality (HR: 0.958 [95% CI: 0.925–0.993], P=0.006). Kaplan-Meier analysis showed the worse outcome of the quatile with more impaired PALS (Logrank P&lt;0.001). Compared to Q1, Q3 and Q4 had higher risk of mortality after TAVI (HR: 2.475 [95% CI: 1.411–4.340] for Q3, HR: 3.253 [95% CI: 1.878–5.633] for Q4).

Conclusion

In this retrospective study, PALS measured with FT MDCT was strongly associated with all-cause mortality after TAVI. LA functial assessment using MDCT may have a importan role for risk stratification in patients referred to TAVI.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant 2018 K-M curve according to PALS quartiles

Sex-differences in left ventricular remodeling and mechanics after aortic valve surgery in patients with severe aortic valve disease

Background

Sex-differences in left ventricular (LV) remodeling in patients with aortic valve disease have been reported. However, sex-differences in LV remodeling and mechanics in response to aortic valve replacement (AVR) remained largely unexplored.

Purpose

The present study aimed to evaluate the sex-differences during the time course of LV remodeling and LV mechanics (by LV global longitudinal strain (GLS)) after aortic valve replacement.

Methods

Patients with severe aortic valve disease (aortic stenosis (AS) or aortic regurgitation (AR)) undergoing AVR with echocardiographic follow-up at 1,2, and/or 5 years were evaluated. LV mass index, LV ejection fraction, LV GLS and stroke volume (SV) were measured. Linear mixed models analyses were used to assess changes in LV mass index, LVEF, LV GLS and SV between time points. The models were corrected for age, LV end-diastolic diameter at baseline and time between echocardiograms.

Results

A total of 211 patients (61±14 years, 61% male) with severe aortic valve disease (AS 63% or AR 39%) were included. Before AVR, men had larger LV mass index and higher SV compared to women. Both men and women had a preserved LV ejection fraction (54±12 and 56±9, P=0.102, respectively), but moderately impaired LV GLS (14.6±4.1 and 16.1±4.1, P=0.009, respectively). After AVR, both groups showed LV mass regression, improvement in LV ejection fraction and LV GLS. LV mass index and SV remained higher in men. During follow-up women showed significantly better LV GLS compared to men (P=0.030, figure 1).

Conclusion

In men and women with severe aortic valve disease undergoing AVR, the time course of changes in LV mass regression, LV ejection fraction, LV GLS and SV are similar. During follow-up LV mass index remained larger in men and women showed significantly better LV GLS.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The department of Cardiology received unrestricted research grants from Abbott Vascular, Bayer, Bioventrix, Biotronik, Boston Scientific, Edwards Lifesciences, GE Healthcare and Medtronic. Victoria Delgado received speaker fees from Abbott Vascular, Edwards Lifesciences, GE Healthcare, MSD and Medtronic. Nina Ajmone Marsan received speakers fees from Abbott Vascular and GE healthcare. Jeroen J Bax received speaker fees from Abbott Vascular. The remaining authors have nothing to disclose.

Weight loss and its impact on outcome in head and cancer patients during chemo-radiation

BACKGROUND

Weight loss during chemotherapy and its impact on the cancer outcomes have been invariably reported in the literature. We also did a post-hoc analysis of a randomized phase III trial to see the same.

MATERIALS AND METHODS

The database of a recently published randomized study comparing cisplatin-radiation with nimotuzumab cisplatin-radiation was used for this analysis. Week-wise weight loss during the course of treatment was noted. The impact of severe weight loss (grade 2-3) on progression-free survival (PFS), locoregional control (LRC) and overall survival (OS) was studied using the Kaplan Meier method. Binary logistic regression analysis was used to see the effect of various factors.

RESULTS

Out of a total of 536 patients, weight loss was captured in 524. Out of these 524 patients, any degree of weight loss was seen in 293 (55.91%) patients. Grade 1 weight loss was noted in 192 (36.6%) patients, grade 2 in 96 (18.3%) and grade 3 in 5 (1%) patients. The 2-year PFS was 53% and 57.1% in severe and non-severe weight loss groups respectively (p-value = 0.36). The 2-year LRC was 60% in patients with severe weight loss, while it was 63.5% in those with non-severe weight loss (p-value = 0.47). The 2-year OS was 59.3% versus 62.2% in severe and non-severe weight loss cohorts respectively (p-value = 0.21). None of the factors was found to be associated with severe weight loss.

CONCLUSION

Severe weight loss was uncommon in our patients. Weight loss during treatment was not associated with poor survival outcomes.

Post hoc analysis of a randomized controlled trial comparing concurrent chemoradiation with cisplatin versus nimotuzumab-cisplatin, focusing on acute oral mucositis

BACKGROUND

Acute oral mucositis has been infrequently studied in the patients with head and neck squamous cell carcinoma (HNSCC) receiving once-weekly cisplatin-based chemoradiotherapy (CRT). Hence, this analysis was conducted to explore the various aspects of the same.

RESULTS

The overall incidence of mucositis was 96.9% (n = 508) and of grade 3-5 mucositis was 61.3% (n = 321). The overall incidence of oral mucositis was similar in both the arms (CCRT and NCRT) (p value = 0.58) while grade 3-5 mucositis was more common in the NCRT arm (p value = 0.01). Out of all factors listed, the presence of nimotuzumab was the only significant risk factor for the development of grade 3 or more oral mucositis (p value = 0.01); (OR = 1.64, 95%CI 1.15-2.32). Delays in the treatment delivery were similar in both the arms.

CONCLUSION

Acute oral mucositis is a common occurrence in locally advanced-HNSCC patients receiving chemoradiotherapy. Nimotuzumab is a significant factor for development of grade 3 and above oral mucositis.

A real-world data of Immune checkpoint inhibitors in solid tumors from India

Background

Checkpoint inhibitors (Nivolumab and Pembrolizumab) are approved for multiple indications in solid tumors. However access to these therapies is limited in low and middle income countries. Hence we performed an audit to identify accessibility, adverse event rates, compliance, progression free survival and overall survival in solid tumors.

Methods

This was a single center retrospective analysis of prospective data base of patients with non‐melanoma solid tumors who were treated with immunotherapy from August 2015 to November 2018. Adverse events during immunotherapy were documented and graded using CTCAE (Common terminology criteria for adverse events), v. 4.02. The response rates to immunotherapy, toxicities and the time to onset and resolution of toxicities were also evaluated as secondary endpoints.

Results

Out of 9610 patients, only 155 patients (1.61%) could receive immunotherapy. The most common malignancies included metastatic non‐small cell lung cancer, metastatic renal cell carcinoma, metastatic urothelial carcinoma and relapsed/recurrent head and neck squamous cell carcinoma. Median overall survival in patients who received immunotherapy in non‐melanoma solid malignancies was 5.37 months (95% CI, 3.73–9.73). Poor performance status at baseline was the only adverse prognostic factor. The median progression free survival was 2.57 months (95% CI, 1.73–3.83). Immunotherapy was well tolerated with most common side effects being fatigue 14.8% and anorexia 5.8%. The cumulative incidence of immune related adverse events like hepatitis, pneumonitis, colitis and nephritis was less than 10%.

Conclusion

Real‐world data in Indian setting confirms the benefit of immunotherapy in patients with advanced non‐melanoma solid tumors.

3D Echocardiography Provides Highly Accurate 3D Printed Models in Congenital Heart Disease

Cardiac 3D printing is mainly performed from magnetic resonance imaging (MRI) and computed tomography (CT) 3D datasets, though anatomic detail of atrioventricular (AV) valves may be limited. 3D echo provides excellent visualization of AV valves. Thus, we tested the feasibility and accuracy of 3D printing from 3D echo in this pilot series of subjects with congenital heart disease (CHD), with a focus on valve anatomy. Five subjects with CHD were identified. 3D echo data were converted to 3D printable files and printed in collaboration with 3D Systems Healthcare (Golden, Colorado). A novel technique for valve modeling was utilized using commercially available software. Two readers (KM, SA) independently measured valve structures from 3D models and compared to source echo images. 3D printing was feasible for all cases. Table 1 shows measurements comparing 2D echo to 3D models. Bland Altman analysis showed close agreement and no significant bias between 2D and digital 3D models (mean difference 0.0, 95% CI 1.1 to - 1.1) or 2D vs printed 3D models, though with wider limits of agreement (mean difference - 0.3, 95% CI 1.9 to - 2.6). Accuracy of 3D models compared to 2D was within < 0.5 mm. This pilot study shows 3D echo datasets can be used to reliably print AV and semilunar valve structures in CHD. The 3D models are highly accurate compared to the source echo images. This is a novel and value-added technique that adds incremental information on cardiac anatomy over current methods.

Coughing up: "Adenosquamous carcinoma lung with unusual initial presentation as an ulceroproliferative growth" - case report and review of literature

Lung carcinoma is the most common carcinoma seen in males with the skin being a rare metastatic site. Adenosquamous carcinoma as a rare histologic subtype, showing cutaneous metastasis is an unusual event with no reports in the literature till date. Skin metastasis is an alarming sign, carries poor prognosis, and is associated with shortened survival. Herein, we report a case of 60-year-old male who presented with isolated cutaneous metastasis as a chronic nonhealing ulcer over the sternal region for 3 years (unusual) in the first place, without any other associated symptoms and clinical evidence of the primary. Wide local excision of the lesion was performed after proper workup which revealed metastatic adenosquamous carcinoma. The patient was advised systemic chemotherapy. A high index of suspicion along with clinico-radio-pathological correlation in these cases is of utmost importance and forms the basis of accurate diagnosis.

Lymphopenia during chemoradiation-foe or friend

Background

Severe lymphopenia during treatment is considered to be a poor prognostic factor. The current literature lacks information regarding its impact on various outcomes in locally advanced head-and-neck cancer patients in a prospective setting.

Methods

We recently published a randomised study comparing cisplatin–radiation with nimotuzumab cisplatin–radiation. The database of this study was used for the present analysis. The impact of severe lymphopenia (grade 4 lymphopenia) on progression-free survival (PFS), locoregional control (LRC) and overall survival (OS) was studied using the Kaplan–Meier method and Cox regression analysis. The binary logistic regression analysis was used to see the effect of various factors on the development of severe lymphopenia.

Results

We had a total of 536 patients, of which 521 patients (97.7%) developed lymphopenia. Grade 1 lymphopenia was noted in 10 (1.9%) patients, grade 2 in 100 (18.8%), grade 3 in 338 (63.1%) and grade 4 in 73 (13.7%) patients. The median PFS was 20.53 and 60.33 months in severe and non-severe lymphopenia, respectively (hazard ratio, 0.797; p-value = 0.208). The median duration of LRC was 56.3 months in severe lymphopenia, whereas it was not reached in non-severe lymphopenia (hazard ratio, 0.81; p-value = 0.337). The median OS was 28.46 versus 47.13 months in severe and non-severe lymphopenia, respectively (hazard ratio, 0.76; p-value = 0.11). Of various risk factors, gender was significantly associated with severe lymphopenia.

Conclusion

The occurrence of severe lymphopenia was not significantly associated with the outcomes. Gender is the only risk factor significantly linked to severe lymphopenia.

Excellent response to erlotinib in breast carcinoma with rare EGFR mutation-a case report

Triple negative breast carcinoma is a problematic subtype with poor outcomes. Many clinical trials are underway to find possible target to increase treatment options. Epidermal growth factor receptor (EGFR) has emerged as one such molecule which is over expressed in some of these patients and can be targeted by tyrosine kinase inhibitors. We describe a diagnostically challenging case of metastatic breast carcinoma, with extensive lung disease and poor Eastern Cooperative Oncology Group (ECOG) performance status, which expressed an uncommon EGFR mutation (Exon 21L861Q) and which benefitted from erlotinib following failure of all primary treatment modalities. The case uncovers the presence of these unusual mutations in breast carcinoma and highlights the importance of performing molecular analysis and the appropriate targeted therapy. This approach can be an important problem-solving tool, especially in cases where the patient is not fit for the other standard treatment options.

Serum DHEA-S levels could be used as a comparable diagnostic test to assess the pubertal growth spurt in dentofacial orthopedics

Background

Pubertal growth spurt assessment guides the timing of intervention for correcting the skeletal discrepancies in dentofacial orthopedics. Serum hormones are being studied for the skeletal age assessment to avoid unnecessary radiographic exposure. The present study is to evaluate the relationship of serum hormones dehydroepiandrosterone-sulfate (DHEA-S), insulin-like growth factor (IGF-1), and cervical vertebral stages (CS stages) in the skeletal age assessment of orthodontics patients around the circumpubertal age.

Methods

A total of ninety subjects with age ranging from 7 to 21 years were selected and divided into two groups based on the sex (45 males, 45 females). They were further distributed in each group based on the six CS stages determined from the lateral cephalogram. Blood samples from each subject were collected to evaluate the serum DHEA-S and IGF-1 levels by using the enzyme-linked immunosorbent assay (ELISA). Collected data were analyzed in SPSS software with a test of normalcy, unpaired t test, and one-way analysis of variance (ANOVA) followed by the least significant difference (LSD) post hoc comparison test and univariate regression analysis.

Results

The highest mean serum hormone levels were found in CS 4 in group A (male) and CS 3 in group B (female). ANOVA results showed that there was a significant difference in the serum hormone levels among the different CS stages in both the groups for both the hormones. Statistically, a significant difference was found between each CS stages for both the hormones except in the DHEA-S levels between CS 5 and CS 6.

Conclusions

The mean serum DHEA-S levels followed a typical pattern from the CS 1 till CS 6 which was comparable and similar to the mean serum IGF-1 levels in respect to CS stages. Thus, serum DHEA-S levels could be used as a possible diagnostic test for the assessment of the skeletal pubertal growth spurt in dentofacial orthopedics.

Second malignancy post-chemoradiation in head and neck cancer patients

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Background: There is limited data available in the literature regarding incidence and treatment of second malignancy post-chemo-radiation (CTRT) in head and neck cancer patients. Hence we planned this analysis to address this lacuna in the current literature. Methods: We have already published a randomized study of 536 head and neck cancer patients, comparing radical CTRT with weekly cisplatin with or without nimotuzumab. The database of this study was used for the current analysis. Data regarding occurrence, site, stage, treatment details and outcomes were extracted from the database. Continuous variables were expressed in terms of the median with range, while non-continuous variables were reported in percentage. Kaplan Meier method was used for estimating the overall survival (OS). Results: Out of 536 patients, 18 (3.35%) patients developed second malignancy. The most common site was head and neck (44.44%) followed by lung (27.77%), prostate, ovary, breast, gallbladder and thyroid. 16/18 (88.88%) patients developed metachronous, while 2/18 (11.11%) had synchronous second malignancy. Most of the patients (55.55%) presented with locally advanced and metastatic disease, while 44.44% of patients had early-stage disease. 8/18 (44.44%) patients received palliative treatment. Of these, 6/18 (33.33%) patients received best supportive care and 2/18 (11.11%) patients were given palliative chemotherapy and palliative radiotherapy. 10/18 (55.55%) patients received radical treatment in the form of radical surgery (22.22%), CTRT (11.11%) and radical radiotherapy (5.55%), while 16.66% patients were kept under observation only. The median OS after the diagnosis of second malignancy was 451 days (95% CI, 301.45-600.59). It was seen that median OS the diagnosis of second malignancy in the aerodigestive and non-aerodigestive system was 446 days (95% CI, 39.10 - 852.89) and 840 days (95% CI, 278.46 - 1401.53), log-rank test P-value = 0.24. Conclusions: Second malignancy is not an uncommon phenomenon in head and neck cancer patients after CTRT and if properly taken care of, the improved outcome can be expected.

Safety and efficacy of bevacizumab biosimilar in glioma

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Background: Anti-VEGF antibody Bevacizumab (Avastin: Roche Pharma AG) is the recommended drug for recurrent glioma. Multiple low-cost bio-similars of this drug are now available however their clinical efficacy has never been compared against the original molecule. The aim of the current analysis is to compare the overall survival (OS) between recurrent glioma patients with bio-similar and innovator molecule. Methods: Adult recurrent glioma patients treated with bevacizumab from 1st July 2015 to 30th July 2019 were identified from the Neuro-Medical Oncology database. These patients were either offered Avastin or Bevacizumab biosimilar (BevaciRel: Reliance Life sciences or Bryta: Zydus Oncosciences) depending upon the financial affordability. The primary endpoint of the study was OS. It was defined as the time in months from the start of bevacizumab to death. Progression-free survival (PFS) was defined as the time in months from the start of bevacizumab to progression or death. The time to event variables was estimated using Kaplan Meier method. The median with its 95% confidence interval (CI) was calculated using Brookmeyer and Crowley method. The estimates were compared between the original and bio-similar bevacizumab cohort using the log-rank test. The hazard ratio was calculated using COX regression analysis. Results: There were 82 patients, out of which 57 received innovator and 25 received bio-similar bevacizumab. At median follow up of 26 months, 76 patients had an event for progression. The median PFS was 3.66 (95% CI 2.08 to 5.25) and 3.3 months (95% CI 2.38 to 4.21) in innovator and bio-similar arm respectively (Log-rank test P-value = 0.072). The hazard ratio for progression was 0.61 (95% CI 0.35 to 1.05; P-value = 0.075). At the time of data cutoff, there were 69 deaths. The median OS was 5.53 (95% CI, 5.07 to 5.99) vs 7.33 months (95% CI, 5.63 to 9.03) in innovator and bio-similar arm respectively (Log-rank test P-value = 0.51). The hazard ratio for death was 1.21 (95% CI, 0.67 to 2.17; p-value = 0.51). Conclusions: In the brain tumor patients, both innovator and bio-similar bevacizumab seem to have similar clinical efficacy.

Carcinosarcoma (Metaplastic Carcinoma) Breast: A Rare and Aggressive Primary – Report of Two Cases with Review of Literature

Carcinosarcoma (CS) also known as metaplastic carcinoma of the breast is a rare and aggressive type of malignancy with controversial origin. Currently, there are no standard treatment guidelines outlined, owing to the rarity of the disease, but according to the available literature, surgery followed by adjuvant radiation therapy has the greatest benefit. We are presenting two cases of CS of breast developing metastasis. One of the cases presented with lung metastasis during the course of follow-up and responded significantly to chemotherapy, and the other is currently receiving chemotherapy. The cases are being presented here along with the literature review enlightening the current knowledge and available treatment options.

Radiation-Induced Malignancies: Our Experiences With Five Cases

Radiotherapy is one of the modalities of treatment of malignancies. Radiation-induced malignancies (RIMs) are late complications of radiotherapy, seen among the survivors of both adult and pediatric cancers. Mutagenesis of normal tissues is the likely basis for RIMs. Till date, RIM cannot be differentiated from primary cancers. We present a series of five patients who were treated at our institute between 2002 and 2016 and were subsequently diagnosed with RIM. Out of five patients, there were two cases of sarcomas, two of carcinomas and one neuroendocrine carcinoma of tongue (rare entity). Separate treatment guidelines are not available for RIM, so the treatment given was same as primary malignancies.

Gliosarcoma in Young Adults: A Rare Variant of Glioblastoma

Gliosarcoma is a rare central nervous system (CNS) malignancy. It is characterized by classical biphasic histological pattern with both glial and sarcomatous components, often seen in fifth and sixth decade of life. They are generally located in the supratentorial region. Due to its rarity, exact treatment recommendations are not available in literature. Since it is considered as a variant of glioblastoma multiforme (GBM), it is treated with surgery followed by adjuvant radiotherapy and temozolomide-based chemotherapy. We present a series of four cases of this rare malignancy that were treated at our institute.

Radiation-Induced Malignancies Making Radiotherapy a "Two-Edged Sword": A Review of Literature

Radiotherapy is one of the modalities of treatment of malignancies. Radiation-induced malignancies (RIMs) are late complications of radiotherapy, seen among the survivors of both adult and pediatric cancers. Mutagenesis of normal tissues is the basis for RIMs. The aim of this review of literature was to discuss epidemiology, factors affecting and different settings in which RIM occur.

QRS detection using adaptive filters: A comparative study

Electrocardiogram (ECG) is one of the most important physiological signals of human body, which contains important clinical information about the heart. Monitoring of ECG signal is done through QRS detection. In this paper, an improved QRS detection algorithm, based on adaptive filtering principle, has been designed. Enumeration of the effectiveness of various LMS variants used in adaptive filtering based QRS detection algorithm has been done through fidelity parameters like sensitivity and positive predictivity. Whole family of LMS algorithm has been implemented for comparison. Sign-sign LMS, sign error LMS, basic LMS and normalized LMS are re-implemented, while variable leaky LMS, variable step-size LMS, leaky LMS, recursive least squares (RLS), and fractional LMS are novel combination presented in this paper. After analysis of the obtained results, performance of leaky-LMS algorithm is found to be the best with sensitivity, positive predictivity, and processing time of 99.68%, 99.84%, and 0.45s respectively. Reported results are tested and evaluated over MIT/BIH arrhythmia database. Presented study also concludes that the performance of most of the variants gets affected due to low SNR but the Leaky LMS performs better even under heavy noise conditions.

A review of troponin assay performance in Wales: can the same (method-dependent) decision limits be used in different sites?

An audit of troponin measurement protocols in use in Wales showed significant variations in practice with no consensus on analytical methods, or in the selection of a decision limit for the diagnosis of myocardial damage. Peer review data on assay imprecision at concentrations approaching the analytical limit of detection are lacking. The objective of the study was to establish clinically relevant precision profiles for the troponin methods used throughout Wales, which could be used to develop a standardized approach to the selection of a decision limit. A series of five pools of human serum spiked with troponin I-T complex were prepared and stored at -7°C until despatch. Five sets of each pool were dispatched to all Welsh laboratories and stored at -20°C until analysis. The analysis protocol consisted of two replicates of each pool per batch, and two batches per day for five days ( n=20). All the laboratories performed all the measurements in the same week. The lowest concentration providing a 10% coefficient of variation (CV) was 0.02 µg/L for the Roche method and 0.11 µg/L for the Beckman AccuTnI. The lowest concentrations that could be distinguishable from the 99th percentile reference limit were 0.02 µg/L for the Roche method and 0.07 µg/L for the Beckman AccuTnI. Current methods do not achieve the 10% CV at the 99th percentile reference limit proposed by the European Society of Cardiology. Use of the lowest concentration that can be reliably distinguished from the 99th percentile reference limit offers a novel alternative decision limit, which provides a slightly lower concentration than at the 10% CV but maintaining confidence in the assay that false-positive rates will be minimized.

Hybrid method based on singular value decomposition and embedded zero tree wavelet technique for ECG signal compression

BACKGROUND AND OBJECTIVE

In the field of biomedical, it becomes necessary to reduce data quantity due to the limitation of storage in real-time ambulatory system and telemedicine system. Research has been underway since very beginning for the development of an efficient and simple technique for longer term benefits.

METHOD

This paper, presents an algorithm based on singular value decomposition (SVD), and embedded zero tree wavelet (EZW) techniques for ECG signal compression which deals with the huge data of ambulatory system. The proposed method utilizes the low rank matrix for initial compression on two dimensional (2-D) ECG data array using SVD, and then EZW is initiated for final compression. Initially, 2-D array construction has key issue for the proposed technique in pre-processing. Here, three different beat segmentation approaches have been exploited for 2-D array construction using segmented beat alignment with exploitation of beat correlation. The proposed algorithm has been tested on MIT-BIH arrhythmia record, and it was found that it is very efficient in compression of different types of ECG signal with lower signal distortion based on different fidelity assessments.

RESULTS

The evaluation results illustrate that the proposed algorithm has achieved the compression ratio of 24.25:1 with excellent quality of signal reconstruction in terms of percentage-root-mean square difference (PRD) as 1.89% for ECG signal Rec. 100 and consumes only 162bps data instead of 3960bps uncompressed data.

CONCLUSION

The proposed method is efficient and flexible with different types of ECG signal for compression, and controls quality of reconstruction. Simulated results are clearly illustrate the proposed method can play a big role to save the memory space of health data centres as well as save the bandwidth in telemedicine based healthcare systems.

An efficient closed-form design method for nearly perfect reconstruction of non-uniform filter bank

In this paper, an efficient closed form method for the design of multi-channel nearly perfect reconstruction of non-uniform filter bank with the prescribed stopband attenuation and channel overlapping is presented. In this method, the design problem of multi-channel non-uniform filter bank (NUFB) is considered as the design of a prototype filter whose magnitude response at quadrature frequency is 0.707, which is exploited for finding the optimum passband edge frequency through empirical formula instead of using single or multivariable optimization technique. Two main attributes used in assessing the performance of filter bank are peak reconstruction error (PRE) and computational time (CPU time). As compared to existing methods, this method is very simple and easy to implement for NUFBs. To implement this algorithm, a Matlab program has been developed, and several examples are presented to illustrate the performance of proposed method.

Design of two-channel filter bank using nature inspired optimization based fractional derivative constraints

In this article, a novel approach for 2-channel linear phase quadrature mirror filter (QMF) bank design based on a hybrid of gradient based optimization and optimization of fractional derivative constraints is introduced. For the purpose of this work, recently proposed nature inspired optimization techniques such as cuckoo search (CS), modified cuckoo search (MCS) and wind driven optimization (WDO) are explored for the design of QMF bank. 2-Channel QMF is also designed with particle swarm optimization (PSO) and artificial bee colony (ABC) nature inspired optimization techniques. The design problem is formulated in frequency domain as sum of L2 norm of error in passband, stopband and transition band at quadrature frequency. The contribution of this work is the novel hybrid combination of gradient based optimization (Lagrange multiplier method) and nature inspired optimization (CS, MCS, WDO, PSO and ABC) and its usage for optimizing the design problem. Performance of the proposed method is evaluated by passband error (ϕp), stopband error (ϕs), transition band error (ϕt), peak reconstruction error (PRE), stopband attenuation (As) and computational time. The design examples illustrate the ingenuity of the proposed method. Results are also compared with the other existing algorithms, and it was found that the proposed method gives best result in terms of peak reconstruction error and transition band error while it is comparable in terms of passband and stopband error. Results show that the proposed method is successful for both lower and higher order 2-channel QMF bank design. A comparative study of various nature inspired optimization techniques is also presented, and the study singles out CS as a best QMF optimization technique.

Cuckoo search algorithm based satellite image contrast and brightness enhancement using DWT-SVD

This paper presents a new contrast enhancement approach which is based on Cuckoo Search (CS) algorithm and DWT-SVD for quality improvement of the low contrast satellite images. The input image is decomposed into the four frequency subbands through Discrete Wavelet Transform (DWT), and CS algorithm used to optimize each subband of DWT and then obtains the singular value matrix of the low-low thresholded subband image and finally, it reconstructs the enhanced image by applying IDWT. The singular value matrix employed intensity information of the particular image, and any modification in the singular values changes the intensity of the given image. The experimental results show superiority of the proposed method performance in terms of PSNR, MSE, Mean and Standard Deviation over conventional and state-of-the-art techniques.

Cyclosporine in Stevens Johnson syndrome and toxic epidermal necrolysis and retrospective comparison with systemic corticosteroid

BACKGROUND

Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening dermatological emergencies. Many immunosuppressive modalities have been tried with variable results.

AIMS

To determine the efficacy of cyclosporine in cases of SJS and TEN and compare the efficacy with systemic corticosteroid in the same condition.

METHODS

Study was conducted at a tertiary hospital during 01 July 2011 to 30 June 2012. SCORTEN was assessed at the time of admission. Total body surface area (TBSA) assessment was like any burn patients. Cyclosporine was administered in the dose of 3 mg/kg body weight in three divided dosage for 07 days and then tapered over another 07 days. Data were compared to a historical series of SJS/TEN patients, managed by systemic steroids a year ago.

RESULTS

A total of 11 consecutive patients with a mean age of 32.09 and standard deviation (SD 16.17) were enrolled in to cyclosporine group, which were retrospectively compared to 6 patients with a mean age of 27.87 (SD 13.97) years in the corticosteroid group. The mean duration of re-epithelialization was 14.54 (SD 4.08) and 23 days (SD 6.68) in cyclosporine and corticosteroid group respectively (P = 0.009956). Mean hospital stay was 18.09 (SD 5.02) and 26 (SD 6.48) days in cyclosporine and corticosteroid group respectively (P = 0.02597). A total of 1.11 and 0.51 patients were expected to die against no death and two deaths in cyclosporine and corticosteroid group respectively (Standardized mortality ratio = 3.92) (P = 0.04321).

CONCLUSION

This study definitely suggests that cyclosporine has encouraging role in the management of uncomplicated cases of SJS, SJS-TEN overlap or TEN.

EEG/ERP adaptive noise canceller design with controlled search space (CSS) approach in cuckoo and other optimization algorithms

This paper explores the migration of adaptive filtering with swarm intelligence/evolutionary techniques employed in the field of electroencephalogram/event-related potential noise cancellation or extraction. A new approach is proposed in the form of controlled search space to stabilize the randomness of swarm intelligence techniques especially for the EEG signal. Swarm-based algorithms such as Particles Swarm Optimization, Artificial Bee Colony, and Cuckoo Optimization Algorithm with their variants are implemented to design optimized adaptive noise canceler. The proposed controlled search space technique is tested on each of the swarm intelligence techniques and is found to be more accurate and powerful. Adaptive noise canceler with traditional algorithms such as least-mean-square, normalized least-mean-square, and recursive least-mean-square algorithms are also implemented to compare the results. ERP signals such as simulated visual evoked potential, real visual evoked potential, and real sensorimotor evoked potential are used, due to their physiological importance in various EEG studies. Average computational time and shape measures of evolutionary techniques are observed 8.21E-01 sec and 1.73E-01, respectively. Though, traditional algorithms take negligible time consumption, but are unable to offer good shape preservation of ERP, noticed as average computational time and shape measure difference, 1.41E-02 sec and 2.60E+00, respectively.

Surgical-orthodontic treatment of a skeletal class III malocclusion

For patients whose orthodontic problems are so severe that neither growth modification nor camouflage offers a solution, surgery to realign the jaws or reposition dentoalveolar segments is the only possible treatment option left. One indication for surgery obviously is a malocclusion too severe for orthodontics alone. It is possible now to be at least semiquantitative about the limits of orthodontic treatment, in the context of producing normal occlusion as the diagrams of the “envelope of discrepancy” indicate. In this case report we present orthognathic treatment plan of an adult female patient with skeletal class III malocclusion. Patient's malocclusion was decompensated by orthodontic treatment just before the surgery and then normal jaw relationship achieved by bilateral sagittal split osteotomy.