Feasibility of Combining Functional Mobilisation with Resistance and Endurance Training for Mechanically Ventilated Patients in Intensive Care Unit Setting-A Pilot Study

Background: Intensive-care-acquired weakness resulting in functional impairment is common in critical care survivors. This study aims to evaluate the feasibility of a combined early functional training with endurance and resistance training and its effect on the functional outcome. Methods: It is a pilot study performed in a 39-bed Medical and Surgical Intensive Care Unit (ICU). Patients who were premorbidly independent and were mechanically ventilated for ≥24 h were recruited to receive functional mobilisation (sit out of bed, ambulation), endurance (bed cycling), and resistance training (selected upper and lower limb muscle training using weights). The primary outcomes were feasibility of training, muscle strength, handgrip strength, quadricep strength, and Functional Status Score-Intensive Care Unit (FSS-ICU) collected at the first assessment in the ICU, at the ICU discharge, and at hospital discharge. Secondary outcomes were functional capacity (6-Minute Walk Distance) and quality of life measures, EQ-5D, at hospital discharge and at 3 months. Results: Out of the 11 patients, 6 (54.54%) patients achieved level 2 functional mobilisation, 2 (18.18%) patients achieved level 2 resistance training, and 1 (9.09%) patient achieved level 2 endurance training. There were no significant differences in the medical research council (MRC) score, quadricep strength, and handgrip strength between the first assessment in the ICU, at the ICU discharge, and at hospital discharge. However, there was a significant difference in FSS_ICU (p < 0.008) from the first assessment in the ICU up to hospital discharge. EQ-5D visual analogue scale also showed a change of 8.5% at 3-month follow-up. 6MWD showed significant difference (p < 0.043) at 3-month follow-up compared to that at hospital discharge. Conclusions: The study found low compliance to resistance and endurance training in patients with mechanical ventilation. However, functional mobilisation in terms of sit out of bed was possible in more than half of the recruited patients.

Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study

BACKGROUND

Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches.

METHODS

This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality.

RESULTS

There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis.

CONCLUSIONS

Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.

Blockchain security enhancement: an approach towards hybrid consensus algorithms and machine learning techniques

In this paper, we propose hybrid consensus algorithms that combine machine learning (ML) techniques to address the challenges and vulnerabilities in blockchain networks. Consensus Protocols make ensuring agreement among the applicants in the distributed systems difficult. However, existing mechanisms are more vulnerable to cyber-attacks. Previous studies extensively explore the influence of cyber attacks and highlight the necessity for effective preventive measures. This research presents the integration of ML techniques with the proposed hybrid consensus algorithms and advantages over predicting cyber-attacks, anomaly detection, and feature extraction. Our hybrid approaches leverage and optimize the proposed consensus protocols' security, trust, and robustness. However, this research also explores the various ML techniques with hybrid consensus algorithms, such as Delegated Proof of Stake Work (DPoSW), Proof of Stake and Work (PoSW), Proof of CASBFT (PoCASBFT), Delegated Byzantine Proof of Stake (DBPoS) for security enhancement and intelligent decision making in consensus protocols. Here, we also demonstrate the effectiveness of the proposed methodology within the decentralized networks using the ProximaX blockchain platform. This study shows that the proposed research framework is an energy-efficient mechanism that maintains security and adapts to dynamic conditions. It also integrates privacy-enhancing features, robust consensus mechanisms, and ML approaches to detect and prevent security threats. Furthermore, the practical implementation of these ML-based hybrid consensus models faces significant challenges, such as scalability, latency, throughput, resource requirements, and potential adversarial attacks. These challenges must be addressed to ensure the successful implementation of the blockchain network for real-world scenarios.

Development of bioactive and antimicrobial nano-topography over selective laser melted Ti6Al4V implant and its in-vitro corrosion behavior

Additive manufacturing (AM) or 3D printing of bone defect models is gaining much attention in the biomedical field as it could significantly facilitate the development of customized implants with a high degree of dimensional accuracy. Due to their satisfactory biocompatibility and minimal stress shielding effect, Ti6Al4V (Ti64) alloys are increasingly preferred in the development of such implants. However, their poor osseointegration abilities and lack of antibacterial properties often cause implant loosening and microbial infections, leading to implant failure. To address these drawbacks, we propose in this work a simple surface modification approach of customized Ti64 alloys (3D printed Ti6Al4V) that enables the formation of porous calcium titanate (CT) over their surface as well as the incorporation of silver nanoparticles (AgNPs) into the thus formed porous network. The successful CT formation with the incorporation of AgNPs throughout the 3D printed Ti64 surface and their influence in changing the morphological and mechanical behaviour were studied by Raman spectroscopy, SEM, AFM, Contact angle measurement, XPS, HR-TEM and nano-indentation. Antibacterial studies using Staphylococcus aureus and Escherichia coli, and in-vitro cell studies using MG-63 cell lines showed that surface modified samples resulting from the proposed method exhibit satisfactory antimicrobial property and are highly biocompatible. The obtained surface modified samples also showed a significant improvement in corrosion resistance as compared to unmodified 3D printed Ti64 alloys. The improvement in corrosion resistance was revealed by electrochemical impedance Spectroscopy (EIS). Obtained results emphasis that thus surface modified 3D printed Ti64 alloys are promising candidates for hard tissue implant applications.

Marker-assisted enhancement of bacterial blight (Xanthomonas oryzae pv. oryzae) resistance in a salt-tolerant rice variety for sustaining rice production of tropical islands

Introduction

Bacterial blight (BB) caused by Xanthomonas oryzae pv. oryzae is a major disease of rice, specially in the tropical regions of the world. Developing rice varieties with host resistance against the disease is the most effective and economical solution for managing the disease.

Methods

Pyramiding resistance genes (Xa4, xa5, xa13,and Xa21) in popular rice varieties using marker-assisted backcross breeding (MABB) has been demonstrated as a cost-effective and sustainable approach for establishing durable BB resistance. Here, we report our successful efforts in introgressing four resistance genes (Xa4, xa5, xa13, and Xa21) from IRBB60 to CARI Dhan 5, a popular salt-tolerant variety developed from a somaclonal variant of Pokkali rice, through functional MABB.

Results and discussion

Both BB and coastal salinity are among the major challenges for rice production in tropical island and coastal ecosystems. Plants with four, three, and two gene pyramids were generated, which displayed high levels of resistance to the BB pathogen at the BC3F2 stage. Under controlled salinity microplot environments, the line 131-2-175-1223 identified with the presence of three gene pyramid (Xa21+xa13+xa5) displayed notable resistance across locations and years as well as exhibited a salinity tolerance comparable to the recurrent parent, CARI Dhan 5. Among two BB gene combinations (Xa21+xa13), two lines, 17-1-69-334 and 46-3-95-659, demonstrated resistance across locations and years, as well as salt tolerance and grain production comparable to CARI Dhan 5. Besides salinity tolerance, five lines, 17-1-69-179, 46-3-95-655, 131-2-190-1197, 131-2-175-1209, and 131-2-175-1239, exhibited complete resistance to BB disease. Following multilocation testing, potential lines have been identified that can serve as a prospective candidate for producing varieties for the tropical Andaman and Nicobar Islands and other coastal locations, which are prone to BB and coastal salinity stresses.

Cerium Ion-Incorporated Titanium Metal Implants of Enhanced Bioactivity for Biomedical Applications

The enhancement in the performance of metallic bone implants based on commercially pure titanium (CP-Ti) by incorporation of cerium (Ce) ions onto the surface was evaluated. The incorporation of Ce ions onto the CP-Ti surface was carried out by a simple two-step chemical treatment method, where an initial NaOH treatment and then a subsequent treatment with different molar concentrations of ceric nitrate solution followed by heat treatment at 600 °C were carried out. The modified surfaces were observed using field emission scanning electron microscopy (FE-SEM), scanning electron microscopy-energy dispersive X-ray analysis (SEM-EDX), X-ray photoelectron spectroscopy (XPS), the laser Raman spectroscopic technique, high-resolution transmission electron microscopy (HR-TEM), and atomic force microscopy (AFM). The formation of a nanonetwork structure by the initial NaOH treatment and the replacement of Na ions with Ce ions along with different phases of TiO₂ was evident from the surface characterization results. The transition of rutile TiO₂ to anatase TiO₂ in the modified surface is evident from the Raman spectra with respect to the treatment of higher to lower concentrations of ceric nitrate solution. The presence of two different oxidation states of Ce (Ce³⁺ and Ce⁴⁺) and improvement in the surface wettability were also distinct in the modified samples. Thus, the incorporated Ce ions over the nanostructured titania network showed low cytotoxicity, good cell adhesion, and enhanced extracellular mineralization on MG-63 cells with better protein adsorption in BSA medium. Taken together, the thus-improved nanostructured surface morphology with the anatase TiO₂ phase and distinct extracellular mineralization in the Ce-incorporated Ti metal with good biocompatibility make it a promising candidate for bone implant applications.

Author Correction: Anti-amnesic and anti-cholinesterase activities of α-asarone against scopolamine-induced memory impairments in rats

Correction to: Eur Rev Med Pharmacol Sci 2022; 26 (17): 6344-6350. DOI: 10.26355/eurrev_202209_29660-PMID: 36111936-published online on September 15, 2022. After publication, the authors applied some corrections to the Acknowledgement section as the Grant Code was incorrect. The section has been amended as follows: -       The authors extend their appreciation to the Deanship of Scientific Research at King Khalid University for funding this work through Large Groups Project under grant number (RGP.2/125/44). There are amendments to this paper. The Publisher apologizes for any inconvenience this may cause. https://www.europeanreview.org/article/29660.

Anti-amnesic and anti-cholinesterase activities of α-asarone against scopolamine-induced memory impairments in rats

OBJECTIVE

Alzheimer's disease (AD) is a neurological ailment that causes memory loss and impairments and is linked to a drop-in acetylcholine level. Acetylcholinesterase (AChE) inhibitors are used for the management of AD. In our ongoing research to search for natural AChE inhibitors from medicinal plants, we found that the Acorus calamus possesses memory-enhancing properties. α-Asarone is the major compound isolated from the Acorus calamus and it has neuroprotective action in animal models, nonetheless, its anticholinesterase activity in different brain regions was not fully understood. The purpose of this research was to determine the anti-amnesic and anti-cholinesterase activities of α-asarone against scopolamine-induced memory impairments in rats.

MATERIALS AND METHODS

The anti-cholinesterase activity of α-asarone was determined using Ellman's method in different brain areas, such as the cortex, hippocampus, and striatum. In addition, the anti-amnesic effect of α-asarone was also investigated using elevated plus-maze, passive avoidance, and active avoidance tests.

RESULTS

The effect of α-asarone on memory impairment against scopolamine-induced (1 mg/kg body weight) amnesia was evaluated. Administration of α-asarone (15 and 30 mg/kg body weight) for 14 days to rats significantly ameliorated the scopolamine-induced memory impairment as measured in the elevated plus-maze, passive avoidance, and avoidance active tests compared to the scopolamine-treated group. In this study, we also show that α-asarone treatment significantly (p<0.05) reduced brain acetylcholinesterase activity in the cortex, hippocampus, and striatum brain regions of amnesic rats.

CONCLUSIONS

These results confirmed that α-asarone has anti-amnesic and anti-cholinesterase potential which may be useful for the management of AD.

Clinical impact of adjuvant chemotherapy and radiation for carcinoma stomach: Experience from a tertiary care center

Objectives

The main objectives of this study are (1) To assess the patient compliance for adjuvant radiotherapy and chemotherapy for carcinoma stomach, (2) Tolerance of adjuvant radiotherapy with the use of conformal techniques, and (3) Disease-free and overall survival benefits of adjuvant chemotherapy and radiation in carcinoma stomach.

Materials and Methods

Carcinoma stomach patients who registered in the institution during the period of December 2011-2014 were taken for the analysis. Treatment details of patients who received the planned adjuvant treatments, radiotherapy, and chemotherapy were collected. The treatment protocol was made as per the institutional multidisciplinary meeting decisions. The radiotherapy dose given was 45 Gy in 25 fractions using an intensity-modulated radiotherapy technique and concurrent chemotherapy offered with capecitabine 825 mg/m² twice daily. Adjuvant chemotherapy protocol was selected from the major clinical trial information.

Results

A total of 61 patients who satisfied the inclusion criteria were selected. Males 52 (85%) and females (15%). The median age of the patients was 57 years. Stage II patients were 52%, and 48% were stage III. All patients tolerated the planned dose of radiotherapy 45 Gy in 25 fractions, and 74% of patients tolerated six or more cycles of adjuvant chemotherapy. Mean follow-up period was 48 months, and the Kaplan-Meier survival analysis shows 3 and 5 years survival percentages were 57% and 48%, respectively.

Conclusion

Adjuvant chemotherapy and radiation using conformal technique are well-tolerated. These were reflected in the overall outcome and survival of the patients. Based on the surgical pathology findings, an individualized approach of adjuvant treatment protocol can improve the outcome.

Investigation on the performance and emissions profile of CI engine using cashew nut shell pyro oil–toluene–diesel blends

Abstract

This article examines the prospects of using toluene added cashew nut shell pyro oil–diesel blends as alternative fuels in CI engine. Effects of adding fixed proportion (by vol.) of toluene (TU) to various cashew nut shell pyro oil (CPO)–diesel (D) blends on the performance and exhaust emission characteristics of a direct injection, single cylinder, water cooled, naturally-aspirated, constant speed run, 4-stroke CI engine were investigated under varied brake power conditions. Tested fuels were neat diesel, CPOT5 (5% CPO + 5% TU + 90% D), CPOT10 (10% CPO + 5% TU + 85% D) and CPOT15 (15% CPO + 5% TU + 80% D). CPO was extracted through a lab-scale fast pyrolysis apparatus. Fuel samples were prepared and characterized according to ASTM standards. Owing to the features like low sensitivity, impressive anti pinging, etc., presence of toluene in an optimal CPO-diesel blend was expected to promote the engine characteristics. Set of experiments were conducted for each fuel mixture and the respective in-cylinder pressure, fuel consumption, exhaust emission levels, temperatures were recorded. At the rated power output condition, CPOT5 fuel had shown 1.67% increased brake thermal efficiency, 5% reduced brake specific fuel consumption, almost 3% reduced exhaust gas temperatures as well as reduced the exhaust emissions such as HC (from 91 to 87 ppm), CO (from 0.1 to 0.08%), NOx (from 458 to 426 ppm), smoke levels (from 72 to 69 BSN). CPOT5 showed improved combustion characteristics like reduced ignition delays and combustion durations, increased rates of cylinder pressure rise and heat release. However, overall attained improvements in the engine parameters were found to be not up to the mark which makes the chances of using CPOT5 as best alternative to diesel feeble.

Article highlights

Distinguishing three Dragon fruit (Hylocereus spp.) species grown in Andaman and Nicobar Islands of India using morphological, biochemical and molecular traits

Dragon fruit (Hylocereus spp.), an important tropical fruit belonging to the family Cactaceae, is rich in essential nutrients such as vitamins, minerals, complex carbohydrates, dietary fibres and antioxidants. This study aims to distinguish three dragon fruit species well adapted to Andaman and Nicobar Island through morphological (34 quantitative and 26 qualitative traits), biochemical (5 traits) and molecular (14 ISSR primers) characterization. Morphological characterization revealed that presence of considerable amount of genetic variations among them especially for fruit characters viz., colour of peel and pulp. Cladode characters such as number of spines (3–5), length of areoles (mm) as 1–4, margin ribs of cladode (convex or concave) and its waxiness (weak or strong white waxy or light waxy) could be used for identification of three Hylocereus spp. under present study. Highest co-efficient of variation (%) obtained for pulp weight (88.7), whereas, lowest in distance of anthers belowstigma (3.3). Fruit and pulp weight (g) ranged from 26.5–419.3 and 10.3–258.8 with mean value of 204.8 and 125.3, respectively. Comparatively, high phenol (71.3–161.3) and flavonoid (26.6–508.2) content observed in peels than pulp (32.5–130.0 and 45.0–258.2) of fruit indicating higher antioxidant potential. Highest total carotenoids (µg 100 g⁻¹), β-carotene (µg 100 g⁻¹) and xanthophyll (µg g⁻¹) content obtained in pulp on DGF3 (33.8), DGF4 (55.9) and DGF3 (32.7), whereas, in peel on DGF2 (24.3), DGF4 (18.5) and DGF2 (24.1), respectively. DPPH-based scavenging activity (%) revealed higher scavenging activity of peels (55.6–81.2) than pulp (36.0–75.3) extracts. Comparatively, ABTS-based scavenging activity (%) was found more than DPPH-based one. Sixteen ISSR primers screened, 14 were produced 178 reproducible amplified bands. Number of amplified bands varied from 5 in UBC887 to 19 in UBC811 with an average of 12.71 bands per primer. Range of polymorphic bands and % polymorphism observed were 1–13 and 20.0–92.8, respectively. The polymorphic information content value of ISSR marker ranged from 0.42 (UBC895) to 0.91 (UBC 856). Cluster analysis distinguished three different Hylocereus species on the basis of geographic origin and pulp colour by forming separate groups and two genotypes each showed 52% (DGF1 and DGF3) and 76% (DGF2 and DGF4) genetic similarity. Key traits identified for distinguishing three different Hylocereus species were: Pulp/ peel colour of fruits, number of spines and length of areoles in cladode. Genotypes with high carotenoid and xanthophylls content (DGF4 and DGF2) identified under present study may be of industrial importance for development of nutraceutical products to meet out the vitamin-A deficiency among humans in tropical regions needed future focus.

Phase I/II Study of Extreme Hypofractionated Stereotactic Body Radiation Therapy Boost to Prostate for Locally Advanced, Node-Positive and Oligometastatic Cancer

Introduction: Stereotactic body radiation therapy (SBRT) is increasingly being utilized to deliver escalated radiation doses for improving outcomes in various malignancies. We analyzed our cohort of locally advanced, node-positive, and bone oligometastatic prostate cancer patients, that were treated with a combination of pelvic RT using conventional fractionation (CF) and SBRT boost to prostate using extreme hypofractionation (EH), along with hormone therapy (HT).

Materials and Methods: Outcomes of 44 prospectively treated patients were analyzed. Volumetric modulated arc therapy (VMAT) was utilized to deliver a dose of 45 Gy to pelvic nodal region, 50 Gy to prostate, and 54-56 Gy to gross nodes in 25 fractions. EH boost 18 Gy in three fractions was delivered to the prostate using CyberKnife (Accuray, Sunnyvale, CA, USA) SBRT. Bone oligometastasis, if any, were treated to a dose of 16 Gy in two fractions, delivered on weekends. Serum prostate-specific antigen (PSA), multi-parametric magnetic resonance imaging (MRI) of pelvis, and prostate-specific membrane antigen-positron emission tomography (PSMA-PET) were used for response assessment during follow-up. HT was given as per standard guidelines.

Results: There were 33 (75%) locally advanced, nine (20.5%) node-positive, and two (4.5%) oligometastatic cases. At a median follow-up of 63.5 months, the five-year progression-free survival (PFS) was 88.2%, biochemical PFS (bPFS) was 91.4% and overall survival (OS) was 96.9%. Grade III or greater acute genitourinary and gastrointestinal toxicity was 2.3% each, and late toxicity was 4.5% and 0%, respectively.

Conclusion: Excellent five-year outcomes can be attained even for locally advanced, node-positive and bone oligometastatic prostate cancer, by means of dose-escalation using EH-SBRT boost to the prostate.

A Comprehensive Analysis of Traumatic Rib Fractures in an Acute General Hospital in Singapore

BACKGROUND

Rib fractures are common sequelae after blunt chest wall trauma. They can occur in isolation or association with life-threatening injuries to the head, thorax, and abdomen and may be complicated by hemothorax, pneumothorax, or lung contusions. Contiguous rib fractures can result in flail chest, which is associated with increased morbidity and mortality. This study aims to compare the risk factors, treatment modalities, and outcomes between patients with flail chest and nonflail chest postblunt trauma.

PATIENTS AND METHODS

Data were retrospectively collected from all patients admitted with rib fractures from January 2016 to December 2016 to the Department of General Surgery, Khoo Teck Puat Hospital, Singapore. The outcomes identified were mortality, pain scores on injury day 1, 3, 5, and 7, injury severity score, duration of mechanical ventilation, worst partial pressure arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, length of intensive care unit (ICU) stay, and pulmonary complications.

RESULTS

Motor vehicle accident was the most common cause of rib fractures (63.1%, n = 123). Patients with flail chest had more associated pneumothorax (53.8% vs. 35.2%) and lung contusions (53.8% vs. 30.2%) compared to those without flail chest and underwent more investigations such as inpatient-computed tomography scans (76.9% vs. 59.3%), interventions such as chest tube insertion (61.5% vs. 19.8%), and ICU admission (46.1 vs. 13.7%). Patients also had higher pain scores, used more analgesic modalities, and had increased inpatient mortality (30.8% vs. 4.4%).

CONCLUSION

Flail chest is associated with higher morbidity and mortality. Proactive management from a multidisciplinary team such as identification of high-risk patients in particular patients with flail chest, early admission to critical care, and protocols including multimodal pain management, respiratory support, and rehabilitation should be instituted.

Effectiveness of abdominal compression in reducing internal target motion during conformal radiotherapy for carcinoma stomach - A pilot study

AIM

: To assess the effectiveness of abdominal compression in reducing internal target motion during conformal radiotherapy for stomach cancer.

MATERIALS AND METHODS

A pilot study was conducted on five patients who received adjuvant radiotherapy for stomach cancer. All the patients had surgical clips and were offered radiotherapy and concurrent chemotherapy as per the institutional protocol. An abdominal compression device was developed consisting of a triangular Styrofoam's plate and an inflatable air bladder that was positioned over the patients' abdomen. The pneumatic pressure was set according to the patients' comfort. On the simulation day, patients had two computed tomography (CT)-scanning sessions, with and without abdominal compression. Target volumes and organs at risk (OAR) were delineated on the CT images without compression. On the treatment day, fluoroscopy was acquired with onboard imager (OBI) and movements of surgical clips with and without compression analyzed with the help of a tracker software. Observed values with and without abdominal compression were compared.

RESULTS

Abdominal compression usage has reduced the mean breathing excursion (MBE) in medio lateral(ML) direction from 5.92mm to 4.15 mm and in cranio caudal direction (CC) from 11.3mm to 7.2mm. The range of reduction by 29.85% in the ML and 36.86% in CC direction. The average residual breathing excursion was 1.766 mm (SD = 1.33 mm) in the ML and 4.02 mm (SD = 2.18 mm) in the CC direction, respectively.

CONCLUSION

Abdominal compression was useful in reducing internal target motion during stomach cancer conformal radiotherapy. The device we developed is patient friendly and cost-effective.

Prevailing practices in airway management: a prospective single-centre observational study of endotracheal intubation

INTRODUCTION

Airway management during anaesthesia has potential difficulties and risks. We aimed to investigate the utility of routine airway assessment for predicting difficult tracheal intubation, review the prevailing practice of videolaryngoscope use amongst anaesthetists in a teaching hospital and determine the incidence of intraoperative and postoperative airway-related complications.

METHODS

A prospective observational study of 1,654 patients undergoing general anaesthesia with endotracheal intubation over a seven-month period was performed. Data regarding airway and anaesthetic management was collected and analysed.

RESULTS

Videolaryngoscopes were used as the first-choice equipment in 60.5% of the cohort. The incidence of difficult intubation was 2.1%, of which 45.7% of cases were unanticipated. The sensitivity of airway assessment was 54.3%, with a positive predictive value of 8.1%. When difficult intubation was anticipated, more videolaryngoscopes were used as the first equipment of choice compared to the Macintosh laryngoscope (p < 0.001). In the Macintosh group, more patients required a change of airway equipment (p = 0.015), but the number of intubation attempts was similar (p = 0.293). The incidence of intraoperative (p = 0.920) and postoperative complications (p = 0.380) were similar in both groups.

CONCLUSION

Using the current predictors of difficult intubation, half of the difficult airways we encountered were unanticipated. Videolaryngoscopes were preferred when difficulty was anticipated and were also used in routine tracheal intubation.

Analysis of fatty acid methyl esters and oxidative stability of seed purpose watermelon (Citrullus lanatus) genotypes for edible oil

World's vegetable oil demand is increasing day by day and oil seed supply is limited to a dozen oil seed crops on commercial scale. Efforts were made to explore the potential of water melon a traditionally grown native crop of Indian arid zone having oil content over 30% and seed yield potential of 500-600 kg per hectare under rainfed conditions. An analysis was carried out to explore the suitability of watermelon [Citrullus lanatus (Thunb.)] oil for human consumption on the basis of fatty acid (FA) composition in selected genotypes. Total oil content ranged between 10.0 and 31.0%. Eleven FA were identified in seed oil. Linoleic, stearic, palmitic and oleic acid were found as major FA while myristic, heptadecanoic, arachidic, 9-hexadecenoic and 14-eicosenoic acid was present in traces. Linoleic acid single polyunsaturated FA contributor found in the range of 43.95% (WM-44) to 55.29% (WM-18). Saturated FA content ranged between 32.24 and 37.61%. Significant genetic variation was observed for mono-unsaturated FA. Metabolic capacity to inter-conversion of FA and nutritive value of watermelon oil was described on the basis of ratio of FA group. Total phenolics, antioxidant activity, peroxide value and oxidizability were also estimated along with oxidative stability of oil. Multivariate analysis showed that, oil content has positive correlation with linoleic acid. The Euclidean based UPGMA clustering revealed that genotypes WM-18 is most suitable for trait specific breeding program for high linoleic acid (n-6), desaturation ratio and oleic desaturation ratio with higher oil content and lowest palmitic acid.

Efficacy of Homologous, Platelet-rich Plasma Dressing in Chronic Non-healing Ulcers: An Observational Study

Background

Chronic non-healing ulcers are a frequent problem in developing countries and represent a heavy burden to the patients because they lack the necessary growth factors (GFs) to maintain the healing process and are frequently complicated by super, added infections. Traditional therapies, such as regular dressings and wound debridement, cannot provide satisfactory results since these treatments are not able to provide the necessary GFs. Platelet-rich plasma (PRP) helps in enhancing the wound healing by releasing various GFs. The aim was to evaluate the efficacy of PRP dressing in the treatment of chronic non-healing ulcers.

Methods

Patients attending the outpatient department on a regular basis and those admitted as inpatients for chronic wound management were included in the study. It was an observational study done in a tertiary health center for a period of one year. All patients with eligible criteria were treated with PRP at twice-weekly intervals for a maximum of 10 dressings. At the end of the five weeks period, the reduction in the size of the ulcers (area and volume) was assessed.

Results

A total of 104 cases with chronic non-healing ulcers of various causes were treated with homologous PRP twice weekly for a maximum of 10 dressings. In those 104 patients, non-healing ulcers in 85 patients (81.73%) were healed at the end of the last dressing. Non-healing ulcers in 13 patients (12.5%) were healed with skin grafting. Among those patients, the baseline mean ulcer area was 5.03 cm². For each visit, there was a reduction in the ulcer area. At the end of the last visit, the mean ulcer area was 1.69 cm², which was significant in this study.

Conclusion

Due to the lack of necessary GFs in chronic non-healing ulcers, PRP is safe and enhances the healing rates of chronic wounds, thereby reducing overall hospital stay and morbidity.

Effect of efflux pump inhibitors on drug susceptibility of ofloxacin resistant Mycobacterium tuberculosis isolates

BACKGROUND & OBJECTIVES

In drug resistant, especially multi-drug resistant (MDR) tuberculosis, fluoroquinolones (FQs) are used as second line drugs. However, the incidence of FQ-resistant Mycobacterium tuberculosis is rapidly increasing which may be due to extensive use of FQs in the treatment of various other diseases. The most important known mechanism i.e., gyrA mutation in FQ resistance is not observed in a significant proportion of FQ resistant M. tuberculosis isolates suggesting that the resistance may be because of other mechanisms such as an active drug efflux pump. In this study we evaluated the role of the efflux pumps in quinolone resistance by using various inhibitors such as carbonyl cyanide m-chlorophenyl hydrazone (CCCP), 2,4-dinitrophenol (DNP) and verapamil, in clinical isolates of M. tuberculosis.

METHODS

A total of 55 M. tuberculosis clinical isolates [45 ofloxacin (OFL) resistant and 10 ofloxacin sensitive] were tested by Resazurin microtitre assay (REMA) to observe the changes in ofloxacin minimum inhibitory concentration (MIC) levels in presence of efflux inhibitors as compared to control (without efflux inhibitor).

RESULTS

The MIC levels of OFL showed 2-8 folds reduction in presence of CCCP (16/45; 35.5%), verapamil (24/45; 53.3%) and DNP (21/45; 46.6%) while in case of isolates identified as OFL sensitive these did not show any effect on ofloxacin MICs. In 11 of 45 (24.5%) isolates change in MIC levels was observed with all the three inhibitors. Overall 30 (66.6%) isolates had reduction in OFL MIC after treatment with these inhibitors. A total of eight isolates were sequenced for gyrA gene, of which, seven (87.5%) showed known mutations. Of the eight sequenced isolates, seven (87.5%) showed 2 to 8 fold change in MIC in presence of efflux inhibitors.

INTERPRETATION & CONCLUSIONS

Our findings suggest the involvement of active efflux pumps of both Major Facilitator Super Family (MFS) family (inhibited by CCCP and DNP) and ATP Binding Cassette (ABC) transporters (inhibited by verapamil) in the development of OFL resistance in M. tuberculosis isolates. Epidemiological significance of these findings needs to be determined in prospective studies with appropriate number of samples/isolates.

jefA (Rv2459), a drug efflux gene in Mycobacterium tuberculosis confers resistance to isoniazid & ethambutol

BACKGROUND & OBJECTIVES

Drug efflux pumps have been contributing factor(s) in the development of multidrug resistance in various clinically relevant bacteria. During efflux pump gene expression studies on mycobacteria, we have found a previously uncharacterized open reading frame (ORF) Rv2459 to be overexpressed in drug stressed conditions. The objective of the present study was to investigate the role of this ORF as a drug efflux pump, which might add new information in our understanding about the alternative mechanisms of drug resistance in mycobacteria.

METHODS

The open reading frame Rv2459 of Mycobacterium tuberculosis encoding a probable drug efflux protein has been cloned using pSD5 E.coli-Mycobacterium shuttle vector and overexpressed in M. tuberculosis H(37)Rv. This ORF was named as jefA. Overexpression of this gene in clones has been verified by real-time reverse transcription PCR. Minimum inhibitory concentrations (MICs) of recombinant as well as non-recombinant clones were determined by resazurin microtitre assay plate method (REMA) with and without efflux pump inhibitors carbonyl cyanide m-chlorophenylhydrazone (CCCP) and verapamil.

RESULTS

In recombinant strains of M. tuberculosis, the overexpression of this gene led to an increase in MIC of anti-tubercular drugs isoniazid and ethambutol when tested by REMA. In the presence of CCCP and verapamil, the recombinant strains showed decrease in MIC for these drugs. Bioinformatic analysis has shown a close relation of JefA protein with drug efflux pumps of other clinically relevant bacteria. In homology derived structure prepared from nearest available model, it was observed that amino acids forming TMH 1, 8 and 11 participated in ethambutol specificity and those forming TMH 2, 7 and 10 participated in isoniazid specificity in JefA.

INTERPRETATION & CONCLUSION

The increased transcription of jefA leads to increased resistance to ethambutol and isoniazid in M. tuberculosis via efflux pump like mechanism and contributes in the development of resistance to these drugs. JefA amino acid sequence is well conserved among clinically important bacterial genera, which further provides evidence of being a potent drug efflux pump. The involvement in drug resistance and very little homology with any of the human proteins makes JefA important to be included in the list of potential drug targets.

In vitro effect of fluoroquinolones against Mycobacterium tuberculosis isolates from Agra & Kanpur region of north India

BACKGROUND & OBJECTIVE

Fluoroquinolones (FQs) are important drugs used for treatment of drug resistant tuberculosis and are also now being considered as first line drugs to shorten the duration of treatment of tuberculosis (TB). In order to find out useful FQs for treatment of tuberculosis, the comparative efficacy of five FQs, namely, ofloxacin (OFL), ciprofloxacin (CIP), sparfloxacin (SPX), gatifloxacin (GAT) and levofloxacin (LEVX) was studied against Mycobacterium tuberculosis (MTB) isolates obtained from both treated and untreated patients from Agra and Kanpur regions of north India.

METHODS

A total of 162 MTB isolates [including 110 MTB isolates obtained from untreated patients (Cat-I) and 52 isolates from treated patients (Cat-II)] were tested for their susceptibilities to FQs using standard minimum inhibitory concentration (MIC) method on Löwenstein-Jensen medium.

RESULTS

Keeping in view the therapeutically achievable drug levels, it was found that in Cat-I 97.2 per cent (107/110) isolates were sensitive to GAT, 89 per cent (98/110) to LEVX at 1 microg/ml whereas 92.7 per cent (102/110) isolates were inhibited by OFL at 2 microg/ml and 73.6 per cent (81/110) to SPX at 0.5 microg/ml. Only 63.6 per cent (70/110) isolates were found to be sensitive to CIP at 2 microg/ml which increased to 89 per cent (98/110) at 4 microg/ml (higher than achievable peak serum level). On the other hand, among 52 isolates for Cat-II, 37 (71.2%) were found to be sensitive to GAT and 33 (63.5%) to LEVX at 1 microg/ml concentration, 28 (53.8%) to SPX at 0.5 microg/ml whereas 33 (63.5%) and 24 (46.2%) isolates were found to be sensitive to OFL and CIP at 2 microg/ml, respectively.

INTERPRETATION & CONCLUSION

It appears that GAT has higher activity against MTB isolates followed by OFL, LEVX and SPX whereas CIP showed the lowest activity. GAT was also found to be the most effective FQ against multi-drug resistant (MDR) isolates both from Cat-I and Cat-II patients. Thus, except CIP, other FQs showed potential to be included in the treatment regimens of tuberculosis including MDR-TB.

Conformational studies on cyclic dipeptides

An analysis of 11 crystal structures of cyclic dipeptides so far reported in the literature is made, with main reference to the internal parameters of these molecules. Preferred conformations of the side chains of cyclic dipeptides with different alpha-amino acid residues have been studied by classical energy calculations. The possible conformations of the DKP ring are also studied. The significance of the non-bonded interaction in deciding the pathway for conformational change has also been investigated. The agreement between theoretical results and experimental observations is quite good, both with respect to the conformation of these molecules as well as the enthalpy difference as estimated from n.m.r. studies between different conformers.