Surgical Technique for Lateral Patellofemoral Ligament Reconstruction Using Bone Tunnels: A New Method

Medial patellar instability (lateral patellofemoral ligament tear) is a rare condition which is commonly associated with lateral release for lateral patellar instability. LPFL is a lateral stabilizer of the patellofemoral joint. Reconstruction of LPFL is necessary to provide stability to the patella-femoral joint in patients with instability. We describe a novel technique of trans-osseous reconstruction of LPFL to gain stability and have better graft incorporation. A doubled peroneus longus graft is inserted into the patellar tunnel and secured with an endo button on the anteromedial aspect of the patella; the other end is then inserted into the insertional point on the femur and secured with an interference screw. This is an easy, novel, and reproducible technique which can be used to reconstruct LPFL.

Leveraging Lymphatic System Targeting in Systemic Lupus Erythematosus for Improved Clinical Outcomes

The role of advanced drug delivery strategies in drug repositioning and minimizing drug attrition rates, when applied early in drug discovery, is poised to increase the translational impact of various therapeutic strategies in disease prevention and treatment. In this context, drug delivery to the lymphatic system is gaining prominence not only to improve the systemic bioavailability of various pharmaceutical drugs but also to target certain specific diseases associated with the lymphatic system. Although the role of the lymphatic system in lupus is known, very little is done to target drugs to yield improved clinical benefits. In this review, we discuss recent advances in drug delivery strategies to treat lupus, the various routes of drug administration leading to improved lymph node bioavailability, and the available technologies applied in other areas that can be adapted to lupus treatment. Moreover, this review also presents some recent findings that demonstrate the promise of lymphatic targeting in a preclinical setting, offering renewed hope for certain pharmaceutical drugs that are limited by efficacy in their conventional dosage forms. These findings underscore the potential and feasibility of such lymphatic drug-targeting approaches to enhance therapeutic efficacy in lupus and minimize off-target effects of the pharmaceutical drugs. SIGNIFICANCE STATEMENT: The World Health Organization estimates that there are currently 5 million humans living with some form of lupus. With limited success in lupus drug discovery, turning to effective delivery strategies with existing drug molecules, as well as those in the early stage of discovery, could lead to better clinical outcomes. After all, effective delivery strategies have been proven to improve treatment outcomes.

There is a Minimal Difference in Ankle Functional Outcomes After Peroneus Longus Harvest: Systematic Review and Meta-analysis

Importance

Recently, peroneus longus (PL) autograft as a graft choice for ligament surgeries have attracted interest due to studies showing good clinical outcomes and minimal donor site morbidity. There remain concerns related to these grafts, especially the potential impact on ankle functions.

Aims/Objective

The purpose of this review and meta-analysis is to summarize the available evidence for ankle functional outcomes after PL harvest. This will provide objective clinical evidence for surgical decision making.

Evidence Review

Cochrane, Embase, Medline, and Google Scholar were all searched for articles published between January 2001 and May 2021. For the aim of a systematic review, certain inclusion and exclusion criteria were adopted in accordance with PRISMA recommendations. The primary outcome measure was the assessment of ankle functional outcomes using validated instruments (such as AOFAS score, FADI score etc.).

Findings

A total of twelve studies representing pooled patient populations of 537 patients were included in this review. The average follow-up duration was 17 months (range; 6-32 months) across all studies. All twelve studies assessed AOFAS score and six studies also additionally assessed FADI score. The pooled mean outcomes measured showed a slight decrease in post-operative as compared to pre-operative AOFAS and FADI score (mean difference of AOFAS 1.92, 95% CI 1.021-3.123, p value < 0.05 and mean difference for FADI 1.50, 95% CI 0.561-2.445, p value < 0.05). Though statistically significant the magnitude of variance implies minimal clinical impact.

Conclusion and Relevance

This review and meta-analysis found that PL autograft harvest leads to statistically significant but minimal impact on ankle functional outcomes. This, in conjunction with various studies on ankle parameters after PL harvest, shows that PL harvest leads to minimal impact on ankle outcomes and function.

Level of Evidence

Systematic review Level III.

Prenatal Pb exposure is associated with reduced abundance of beneficial gut microbial cliques in late childhood: an investigation using Microbial Co-occurrence Analysis (MiCA)

Background

Many analytical methods used in gut microbiome research focus on either single bacterial taxa or the whole microbiome, ignoring multi-bacteria relationships (microbial cliques). We present a novel analytical approach to identify multiple bacterial taxa within the gut microbiome of children at 9-11 years associated with prenatal Pb exposure.

Methods

Data came from a subset of participants (n=123) in the Programming Research in Obesity, Growth, Environment and Social Stressors (PROGRESS) cohort. Pb concentrations were measured in maternal whole blood from the second and third trimesters of pregnancy. Stool samples collected at 9-11 years old underwent metagenomic sequencing to assess the gut microbiome. Using a novel analytical approach, Microbial Co-occurrence Analysis (MiCA), we paired a machine-learning algorithm with randomization-based inference to first identify microbial cliques that were predictive of prenatal Pb exposure and then estimate the association between prenatal Pb exposure and microbial clique abundance.

Results

With second-trimester Pb exposure, we identified a 2-taxa microbial clique that included Bifidobacterium adolescentis and Ruminococcus callidus, and a 3-taxa clique that added Prevotella clara. Increasing second-trimester Pb exposure was associated with significantly increased odds of having the 2-taxa microbial clique below the 50th percentile relative abundance (OR=1.03,95%CI[1.01-1.05]). In an analysis of Pb concentration at or above vs. below the United States and Mexico guidelines for child Pb exposure, odds of the 2-taxa clique in low abundance were 3.36(95%CI[1.32-8.51]) and 6.11(95%CI[1.87-19.93]), respectively. Trends were similar with the 3-taxa clique but not statistically significant.

Discussion

Using a novel combination of machine-learning and causal-inference, MiCA identified a significant association between second-trimester Pb exposure and reduced abundance of a probiotic microbial clique within the gut microbiome in late childhood. Pb exposure levels at the guidelines for child Pb poisoning in the United States, and Mexico are not sufficient to protect against the potential loss of probiotic benefits.

Systemic Anti-Inflammatory Therapy Aided by Curcumin-Laden Double-Headed Nanoparticles Combined with Injectable Long-Acting Insulin in a Rodent Model of Diabetes Eye Disease

Therapeutic interventions that counter emerging targets in diabetes eye diseases are lacking. We hypothesize that a combination therapy targeting inflammation and hyperglycemia can prevent diabetic eye diseases. Here, we report a multipronged approach to prevent diabetic cataracts and retinopathy by combining orally bioavailable curcumin-laden double-headed (two molecules of gambogic acid conjugated to terminal carboxyl groups of poly(d,l-lactide-co-glycolide)) nanoparticles and injectable basal insulin. The combination treatment led to a significant delay in the progression of diabetic cataracts and retinopathy, improving liver function and peripheral glucose homeostasis. We found a concurrent reduction in lens aggregate protein, AGEs, and increased mitochondrial ATP production. Importantly, inhibition of Piezo1 protected against hyperglycemia-induced retinal vascular damage suggesting possible involvement of Piezo1 in the regulation of retinal phototransduction. Histologic evaluation of murine small intestines revealed that chronic administration of curcumin-laden double-headed nanoparticles was well tolerated, circumventing the fear of nanoparticle toxicity. These findings establish the potential of anti-inflammatory and anti-hyperglycemic combination therapy for the prevention of diabetic cataracts and retinopathy.

Bone mineral density, vertebral fractures and trabecular bone score in primary ovarian insufficiency

PURPOSE

Bone health in primary ovarian insufficiency (POI) is under-investigated. We assessed patients with spontaneous POI for vertebral fractures (VFs) and related parameters of bone health.

METHODS

70 cases with spontaneous POI (age 32.5 ± 7.0 years) and an equal number of controls were assessed for BMD, TBS, and VFs. BMD at the lumbar-spine (L1-L4), left hip, non-dominant forearm, and TBS (iNsight software) were measured on a dual-energy X-ray absorptiometry (DXA) machine. VFs were assessed by Genant's classification. Serum FSH, LH, estradiol, T4, TSH, iPTH, serum 25(OH)D, total calcium, and inorganic phosphorus were measured.

RESULTS

BMD at the lumbar-spine, hip and forearm was reduced by 11.5%, 11.4% and 9.1% in POI as compared to controls (P < 0.001). Degraded or partially degraded microarchitecture on TBS was observed in 66.7% of patients and 38.2% of controls (P = 0.001). 15.7% of the POI patients had VFs, compared to 4.3% of controls (P = 0.045). Age, duration of amenorrhea and duration of HRT use were the significant predictors of TBS (P < 0.01). Serum 25(OH)D was the significant determinant of VFs. TBS abnormalities were higher in patients with POI and VFs. BMD was not significantly different in patients with and without VFs.

CONCLUSION

Thus, lumbar-spine osteoporosis, impaired TBS and VFs were present in 35.7%, 66.7% and 15.7% of patients with spontaneous POI in their early third decade. This indicates need for rigorous investigations for impaired bone health in these young patients and management with HRT, vitamin-D, and possible need for bisphosphonate therapy.

Genetic evidence for association of NOTCH4 variant rs2071287 with schizophrenia susceptibility in the North Indian population

Background

Neurogenic locus notch homolog 4 (NOTCH4) regulates signaling pathways associated with neuronal maturation, a process involved in the development and patterning of the central nervous system. The NOTCH4 gene has also been identified as a possible susceptibility gene for schizophrenia (SCZ).

Aim

The study aimed to determine the association of NOTCH4 polymorphisms with the risk of SCZ in the North Indian population of the Jammu region.

Methods

The single nucleotide polymorphism genotyping for NOTCH4 variant rs2071287 was done by Sanger's sequencing method, and the other variant rs3131296 was done by TaqMan assay method for 207 SCZ cases and 304 healthy controls of North Indian origin.

Results

This association study suggested that the rs2071287 was found to be significantly associated with SCZ. Moreover, the GG genotype of rs2071287 was observed to be associated with a higher risk for SCZ (P-value = 6.45 × 10 - 5; OR = 1.71; 95% CI, 1.31-2.24).

Conclusion

To establish the potential biomarker role of this variant, large-scale association analyses in other populations is required.

Barriers and Facilitators to Healthcare Service Access among Persons with Spinal Cord Injury (SCI)

Background

Despite having a high healthcare need, persons with complex conditions are less likely to receive comprehensive care. Individuals with SCI experience difficulties accessing services 2-4 times more than the general population. There is little agreement concerning the factors that influence these access restrictions. Few studies focus on health system impact on characteristics on access.

Objective

To outline barriers and facilitators to service access among persons with SCI across 22 countries in terms of health system characteristics

Methods

InSCI(2017): 1st community survey on experience of persons with SCI, 12591 participants, 22 countries (Australia, Brazil, China, France, Germany, Greece, Indonesia, Italy, Japan, Lithuania, Malaysia, Morocco, the Netherlands, Norway, Poland, Romania, South Africa, South Korea, Spain, Switzerland, Thailand, USA).

Data analysis

1. Hierarchical cluster analysis based on Gower distance (to group systems by access restrictions: Acceptability, Approachability, Availability, Affordability, Appropriateness).

2. Generalized linear mixed-effects decision tree (to explore the association of system characteristics and access, including WHO and OECD system indicators (e.g. UHC index, expenditure, human resources). Missing values were imputed with missforest.

Results

12% of persons with SCI reported having an access restriction, most of them (7%) with Availability. By country, the highest unmet needs were reported in Poland (25%), Germany, Lithuania, and Romania (13).

1. Cluster analysis: 7 health systems clusters (groups) were identified.

2. By June 2022, we will have the results of the second analysis: the association of system characteristics with access and how it is modified by socio-demographic and medical factors.

Expected conclusions

The study identifies factors a country could modify in order to improve access and strengthen the system for persons with SCI/disability, that might be relevant to general population as well.

Key messages

• Persons with SCI often experience similar access restrictions across countries, incl. those with high-performing health systems. System strengthening in this area is further required in all countries.

• Health systems are fragmented, e.g. healthcare quality and access inside a country differs by region, urban/rural setting etc., hence, the systems are challenging to classify.

Signaling pathways and their potential therapeutic utility in esophageal squamous cell carcinoma

Esophageal cancer is a complex gastrointestinal malignancy with an extremely poor outcome. Approximately 80% of cases of this malignancy in Asian countries including India are of squamous cell origin, termed Esophageal Squamous Cell Carcinoma (ESCC).The five-year survival rate in ESCC patients is less than 20%. Neo-adjuvant chemo-radiotherapy (NACRT) followed by surgical resection remains the major therapeutic strategy for patients with operable ESCC. However, resistance to NACRT and local recurrence after initial treatment are the leading cause of dismal outcomes in these patients. Therefore, an alternative strategy to promote response to the therapy and reduce the post-operative disease recurrence is highly needed. At the molecular level, wide variations have been observed in tumor characteristics among different populations, nevertheless, several common molecular features have been identified which orchestrate disease progression and clinical outcome in the malignancy. Therefore, determination of candidate molecular pathways for targeted therapy remains the mainstream idea of focus in ESCC research. In this review, we have discussed the key signaling pathways associated with ESCC, i.e., Notch, Wnt, and Nrf2 pathways, and their crosstalk during disease progression. We further discuss the recent developments of novel agents to target these pathways in the context of targeted cancer therapy. In-depth research of the signaling pathways, gene signatures, and a combinatorial approach may help in discovering targeted therapy for ESCC.

COVID-19 and tobacco cessation: lessons from India

OBJECTIVES

The Government of India prohibited the sale of tobacco products during the COVID-19 lockdown to prevent the spread of the SARS-CoV-2 virus. This study assessed the tobacco cessation behaviour and its predictors among adult tobacco users during the initial COVID-19 lockdown period in India.

METHODS

A cross-sectional study was conducted with 801 adult tobacco users (both smoking and smokeless tobacco) in two urban metropolitan cities of India over a 2-month period (July to August 2020). The study assessed complete tobacco cessation and quit attempts during the lockdown period. Logistic and negative binomial regression models were used to study the correlates of tobacco cessation and quit attempts, respectively.

RESULTS

In total, 90 (11.3%) tobacco users reported that they had quit using tobacco after the COVID-19 lockdown period. Overall, a median of two quit attempts (interquartile range 0-6) was made by tobacco users. Participants with good knowledge on the harmful effects of tobacco use and COVID-19 were significantly more likely to quit tobacco use (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.2-4.0) and reported more quit attempts (incidence risk ratio 5.7; 95% CI 2.8-11.8) compared to those with poor knowledge. Participants who had access to tobacco products were less likely to quit tobacco use compared to those who had no access (OR 0.3; 95% CI 0.2-0.5].

CONCLUSIONS

Access restrictions and correct knowledge on the harmful effects of tobacco use and COVID-19 can play an important role in creating a conducive environment for tobacco cessation among users.

Improvement in quality of life of postmenopausal women with depression with commonly used antidepressants (Escitalopram vs. Desvenlafaxine): A randomized controlled trial in a tertiary care teaching hospital of North India

Introduction:

The postmenopausal symptoms affect the quality of life (QoL) of women. Depression and anxiety too have been associated with diminished QoL. It is known that antidepressants escitalopram and desvenlafaxine are effective in the treatment of depression and anxiety. However, to the best of our knowledge, their comparative effect on the QoL of postmenopausal women with depression and anxiety has not been studied in the Indian setup.

Materials and Methods:

The present study was a randomized, intention to treat, open-label trial undertaken in North India's a tertiary care teaching hospital. Postmenopausal women attending the psychiatry outpatient department and newly diagnosed with depression and anxiety were randomized in two groups to receive Tab. Escitalopram 10–20 mg and Tab. Desvenlafaxine 50–100 mg. Their QoL was assessed using the WHOQOL BREF scale at baseline, 3 weeks and 6 weeks.

Results:

Escitalopram was observed to be statistically better than desvenlafaxine in improving the overall QoL score of the WHOQOL-BREF scale. Individually, escitalopram significantly improved the scores of the physical health domain, psychological and environmental domains except for the social relationship domain. Desvenlafaxine significantly improved scores of all four domains.

Conclusion:

Escitalopram was observed to be significantly better than desvenlafaxine in improving the overall QoL scores. Both the drugs were well tolerated.

The potential applications of artificial intelligence in drug discovery and development

Development of a new dug is a very lengthy and highly expensive process since only preclinical, pharmacokinetic, pharmacodynamic and toxicological studies include a multiple of in silico, in vitro, in vivo experimentations that traditionally last several years. In the present review, we briefly report some examples that demonstrate the power of the computer-assisted drug discovery process with some examples that are published and revealing the successful applications of artificial intelligence (AI) technology on this vivid area. Besides, we address the situation of drug repositioning (repurposing) in clinical applications. Yet few success stories in this regard that provide us with a clear evidence that AI will reveal its great potential in accelerating effective new drug finding. AI accelerates drug repurposing and AI approaches are altogether necessary and inevitable tools in new medicine development. In spite of the fact that AI in drug development is still in its infancy, the advancements in AI and machine-learning (ML) algorithms have an unprecedented potential. The AI/ML solutions driven by pharmaceutical scientists, computer scientists, statisticians, physicians and others are increasingly working together in the processes of drug development and are adopting AI-based technologies for the rapid discovery of medicines. AI approaches, coupled with big data, are expected to substantially improve the effectiveness of drug repurposing and finding new drugs for various complex human diseases.

The potential applications of artificial intelligence in drug discovery and development

Development of a new dug is a very lengthy and highly expensive process since only preclinical, pharmacokinetic, pharmacodynamic and toxicological studies include a multiple of in silico, in vitro, in vivo experimentations that traditionally last several years. In the present review, we briefly report some examples that demonstrate the power of the computer-assisted drug discovery process with some examples that are published and revealing the successful applications of artificial intelligence (AI) technology on this vivid area. Besides, we address the situation of drug repositioning (repurposing) in clinical applications. Yet few success stories in this regard that provide us with a clear evidence that AI will reveal its great potential in accelerating effective new drug finding. AI accelerates drug repurposing and AI approaches are altogether necessary and inevitable tools in new medicine development. In spite of the fact that AI in drug development is still in its infancy, the advancements in AI and machine-learning (ML) algorithms have an unprecedented potential. The AI/ML solutions driven by pharmaceutical scientists, computer scientists, statisticians, physicians and others are increasingly working together in the processes of drug development and are adopting AI-based technologies for the rapid discovery of medicines. AI approaches, coupled with big data, are expected to substantially improve the effectiveness of drug repurposing and finding new drugs for various complex human diseases.

In silico guided designing of 4-(1H-benzo[d]imidazol-2-yl)phenol-based mutual-prodrugs of NSAIDs: synthesis and biological evaluation

The free COOH group of conventional NSAIDs is a structural feature for non-selective cyclooxygenase (COX) inhibition and the molecular cause of their gastrointestinal (GI) toxicity. In this context, an in house database of synthesizable ester prodrugs of some well-known NSAIDs was developed by combining their -COOH group with -OH of a newly identified antioxidant 4-(1H-benzo[d]imidazol-2-yl)phenol (BZ). The antioxidant potential of BZ was unveiled through in silico PASS prediction and in vitro/in vivo evaluation. The in house database of NSAIDs-BZ prodrugs was first subjected to screening with our previously reported pharmacophore models of hCES1 (AAHRR.430) and hCES2 (AHHR.21) for determining hydrolytic susceptibility. Biotransformation behaviour of screened prodrugs was then assessed by using QM/MM and sterimol parameterization, followed by ADMET calculations to predict the drug likeness. On the basis of in silico results, five prodrugs were duly synthesized and the best three were subject to the in vivo evaluation for their anti-inflammatory, analgesic, antioxidant activities, and ulcerogenic index. Among these prodrugs, BN₂ and BN₅ displayed better anti-inflammatory and analgesics potential in comparison to their parent drugs. All the prodrugs were found to be gastro sparing in the rat model and significantly improved the levels of oxidative stress biomarkers in both blood plasma as well as gastric homogenate.

Systemic anti-inflammatory therapy aided by double-headed nanoparticles in a canine model of acute intraocular inflammation

Novel approaches circumventing blood-ocular barriers in systemic drug delivery are lacking. We hypothesize receptor-mediated delivery of curcumin (CUR) across intestinal and ocular barriers leads to decreased inflammation in a model of lens-induced uveitis. CUR was encapsulated in double-headed polyester nanoparticles using gambogic acid (GA)-coupled polylactide-co-glycolide (PLGA). Orally administered PLGA-GA₂-CUR led to notable aqueous humor CUR levels and was dosed (10 mg/kg twice daily) to adult male beagles (n = 8 eyes) with induced ocular inflammation. Eyes were evaluated using a semiquantitative preclinical ocular toxicology scoring (SPOTS) and compared to commercial anti-inflammatory treatment (oral carprofen 2.2 mg/kg twice daily) (n = 8) and untreated controls (n = 8). PLGA-GA₂-CUR offered improved protection compared with untreated controls and similar protection compared with carprofen, with reduced aqueous flare, miosis, and chemosis in the acute phase (<4 hours). This study highlights the potential of PLGA-GA₂ nanoparticles for systemic drug delivery across ocular barriers.

Meningocele and ankyloblepharon following in utero exposure to olanzapine

Although atypical antipsychotics are widely used during pregnancy, their safety is not well established. This case highlights the possible teratogenic effect of olanzapine, in which the baby was born with meningocele and ankyloblepharon. It is suggested that olanzapine may interfere with embryonic development at different stages of pregnancy.

Efficacy and Safety of Asenapine Versus Olanzapine in Combination With Divalproex for Acute Mania: A Randomized Controlled Trial

BACKGROUND

Atypical antipsychotics are used for the treatment of acute mania, either as monotherapy or in combination with lithium or divalproex, which have a better tolerability profile as compared with typical antipsychotics. Asenapine, a newer atypical antipsychotic, has been found to be effective for the treatment of mania, with efficacy similar to olanzapine. The objective of the study was to compare the efficacy and safety of asenapine and olanzapine when used in combination with divalproex in patients with acute mania.

METHODS

One hundred twenty patients aged 18 to 55 years, diagnosed with manic episode, were randomized to receive either flexible dose of sublingual asenapine (10-20 mg/d) or tablet olanzapine (10-20 mg/d), in combination with valproate 20 mg/kg per day for a period of 6 weeks. Efficacy was measured as change in Young Mania Rating Scale and Clinical Global Impression-Bipolar using intention-to-treat analysis with last observation carried forward, and safety was measured using Udvalg for Kliniske Undersøgelser scale and Modified Simpson-Angus Extrapyramidal Side Effects Scale.

RESULTS

There was a significant reduction in Young Mania Rating Scale and Clinical Global Impression-Bipolar scores over time in both groups, with a significantly higher reduction in the olanzapine group as shown by the group × time interaction effect. Higher weight gain, increased sleep and appetite, and tremors were seen in the olanzapine-treated patients as compared with asenapine-treated patients; however, tongue hypesthesia was seen in the asenapine group only.

CONCLUSIONS

This study found that asenapine was an effective and well-tolerated atypical antipsychotic alternative to olanzapine in combination with divalproex for the short-term management of acute mania.

Prevalence and correlates of depression in a rural adult population in Northwest India

BACKGROUND

Mental disorders are showing a discerning upward trend globally and it is projected that by 2030, depression would be the leading cause of disease burden globally. Depression has not only confined the developed world but is increasingly seen as a major public health problem in the developing world too.

METHODS

A stratified two-stage design was used to conduct a house-to-house survey in selected villages among consenting eligible members of the family. A three-part questionnaire, with the first part eliciting sociodemographic information was used. Patient Health Questionnaire (PHQ-9), the second part of the questionnaire was used to screen those positive for depression and Beck's Depression Inventory (BDI-II). The third part was used for rating the depression. Data thus collected was analyzed and Chi-square test was used as test of significance.

RESULTS

The prevalence of depression was found to be 8.94% (73/816). Beck's Depression Inventory (BDI- II) for rating the depression revealed that mild depression was present in nearly half of the cases (47.95%), while 39.7% and 9.5% of the cases had moderate and severe depression, respectively. Among the various variables, literacy level, marital status, alcohol intake, chronic illness, and socioeconomic status were significantly associated with the depression.

CONCLUSIONS

Prevalence of depression to the tune of 8.94% in rural adults seems to be a cause of concern for the health planners. Prevention and treatment of depression must be taken on priority and as a challenge by the health professionals.

Comparative Efficacy and Safety of Escitalopram versus Desvenlafaxine in Postmenopausal Women with Depression and Anxiety: A Randomized, Open-Label, Comparative Trial

Aims and Objectives:

The aim was to evaluate the comparative efficacy and safety of escitalopram versus desvenlafaxine in postmenopausal women with depression and anxiety in our study cohort.

Materials and Methods:

A randomized, open-label, intention-to-treat, comparative study was conducted over a period of 1 year. Group 1 (n = 20) patients received tablet escitalopram 10 mg once daily orally which was increased to 20 mg/day when needed at the first follow-up. Group 2 (n = 20) patients received tablet desvenlafaxine 50 mg once daily orally which was increased to 100 mg/day when needed at the first follow-up. Patients were followed at 3 and 6 weeks. Primary endpoints were change in baseline scores (recorded as mean ± standard deviation) of Hamilton Depression Rating Scale (HAM-D) and Hamilton Anxiety Rating Scale (HAM-A), and safety was also assessed and compared.

Results:

Forty patients completed the study. Escitalopram was statistically better than desvenlafaxine in reducing depression after 6 weeks of treatment (P < 0.05). Both the drugs were found to be equally effective in treating anxiety. Furthermore, they showed comparable safety and tolerability.

Conclusion:

Escitalopram appears to be more effective on short-term basis in treating depression, and both the drugs appear equally effective in combating anxiety. Furthermore, they appear to be equally safe and well tolerated in postmenopausal women with depression and anxiety.

Oral Drug Delivery Technologies-A Decade of Developments

Advanced drug delivery technologies, in general, enable drug reformulation and administration routes, together contributing to life-cycle management and allowing the innovator to maintain the product monopoly. Over the years, there has been a steady shift from mere life-cycle management to drug repurposing-applying delivery technologies to tackle solubility and permeability issues in early stages or safety and efficacy issues in the late stages of drug discovery processes. While the drug and the disease in question primarily drive the choice of route of administration, the oral route, for its compliance and safety attributes, is the most preferred route, particularly when it comes to chronic conditions, including pain, which is not considered a disease but a symptom of a primary cause. Therefore, the attempt of this review is to take a stock of the advances in oral delivery technologies that are applicable for injectable to oral transformation, improve risk-benefit profiles of existing orals, and apply them in the early discovery program to minimize the drug attrition rates.

Next-Generation Noncompetitive Nanosystems Based on Gambogic Acid: In silico Identification of Transferrin Receptor Binding Sites, Regulatory Shelf Stability, and Their Preliminary Safety in Healthy Rodents

A major challenge in drug delivery is to enhance the transport of drugs across biological barriers, such as the small intestine, the blood-brain barrier, and the blood-retinal/ocular barrier, and to effectively reach the site of action while minimizing the systemic impact. In recent years, piggybacking cell surface receptors have been considered a viable strategy for active drug delivery across the biological barriers. However, the ligands used to target drugs to plasma membrane receptors often have to compete against endogenous ligands, thereby limiting their binding to the cell surface and their transport across barriers. To address this problem, gambogic acid (GA) was identified as a noncompetitive ligand specific to the transferrin receptor (TfR), a receptor present on various barriers. However, the binding sites of the GA on TfR remain unknown, an essential step toward establishing structure-activity relationships. In silico binding site prediction tools, blind docking, and molecular docking simulation confirm that the GA binding site on the TfR is independent of the transferrin-bound iron binding sites. The GA-conjugated polyesters were processed into nanoparticles suitable for drug delivery applications that possess excellent storage stability under regulatory conditions. Traditionally, GA has been used as an anticancer compound that warrants safety assessment. The preliminary studies in healthy rodents on 10-repeated oral doses show no adverse effects. This work will generate paradigm shifting, new knowledge in the field of nanomedicines using unique noncompetitive nanosystems that do not compete with endogenous transferrin.

Significance of third trimester ultrasound in detecting congenital abnormalities of kidney and urinary tract-a prospective study

INTRODUCTION

Antenatal hydronephrosis is defined as dilatation of the renal pelvis with or without dilatation of calyces in the developing fetus. Although second trimester scan is more sensitive in detecting congenital abnormalities of kidney and urinary tract (CAKUT), it has been suggested that the third trimester scan is more predictive of postnatal outcome.

OBJECTIVES

This study aims to determine the incidence of antenatal hydronephrosis at our institution and the significance of third trimester scan in detecting CAKUT postnatally.

STUDY DESIGN

It is a prospective observational study. During the 3-year study period from June 2013 to May 2016, all cases of antenatal hydronephrosis, defined as renal pelvic diameter (RPD) ≥4 mm in the second trimester and ≥7 mm in the third trimester scan, diagnosed in the fetal medicine unit of our hospital, were included and were followed up postnatally for 6 months.

RESULTS

In the fetal medicine unit, 32,443 women were screened for anomalies, and hydronephrosis was detected in 269 cases. Incidence of antenatal hydronephrosis was observed to be 0.83% in our institution. In second trimester scan, of 80 cases with the left hydronephrosis, only 22 (27.5%) had postnatal CAKUT and of 70 cases with the right hydronephrosis, 18 (25.7%) had CAKUT. In the third trimester scan, it was observed that with RPD >10 mm, on the left side hydronephrosis, 87% had CAKUT on postnatal scan, and 85% with the right hydronephrosis had CAKUT.

CONCLUSION

Sixty percent cases of hydronephrosis detected in the second trimester scan resolve in utero. In the third trimester scan with RPD <10 mm, the possibility of postnatal CAKUT is 23%, whereas if RPD is > 10 mm, then the possibility of postnatal CAKUT is 86%.

Double-headed nanosystems for oral drug delivery

We demonstrate a novel strategy to engineer double-headed nanosystems by chemical modification of the carboxyl terminal polyester with a linker that offers tripodal arrangement of ligands on the particle surfaces. The in vivo results suggest that the bioavailability of encapsulated curcumin is proportional to the ligand density rendered by double-headed nanosystems.

Polyester Nanoparticle Encapsulation Mitigates Paclitaxel-Induced Peripheral Neuropathy

Chemotherapy utilizing cytotoxic drugs, such as paclitaxel (PTX), is still a commonly used therapeutic approach to treat both localized and metastasized cancers. Unlike traditional regimens in which PTX is administered at the maximum tolerated dose, alternative regimens like metronomic dosing are beneficial by administering PTX more frequently and in much lower doses exploiting antiangiogenic and immunomodulatory effects. However, PTX-induced peripheral neuropathy and lack of patient compliant dosage forms of PTX are major roadblocks for the successful implementation of metronomic regimens. Because of the success of polyester nanoparticle drug delivery, we explored the potential of nanoparticle-encapsulated paclitaxel (nPTX) in alleviating peripheral neuropathy using a rat model. Rats were injected intraperitoneally with 2 mg/kg body weight of PTX or nPTX on four alternate days, and neuropathic pain and neuronal damage were characterized using behavioral assessments, histology, and immunohistochemistry. The reduction in tactile and nociceptive pressure thresholds was significantly less in nPTX-treated rats than in PTX-treated rats over a 16-day study period. Histological analysis showed that the degree of dorsal root ganglion (DRG) degeneration and reduction in motor neurons in the spinal cord was significantly lower in the nPTX group than the PTX group. Further, immunofluorescence data reveals that nPTX-treated rats had an increased density of a neuronal marker, β-tubulin-III, reduced TUNEL positive cells, and increased high molecular weight neurofilament in the spinal cord, DRG, and sciatic nerves compared with PTX-treated rats. Therefore, this work has important implications in improving risk-benefit profile of PTX, paving the way for metronomic regimens.

P86 Surgical management of spinal cavernous malformations

Objectives

Evaluation of the presentation, demographics, pathology and outcomes associated with the surgical management of spinal cavernous malformations [sCM].

Design

A retrospective single-centre case series of surgically managed cavernous malformations over a 3 year period.

Subjects

Ten patients were identified to have a diagnosis of sCM.

Methods

Cases were identified from electronic and theatre records at a single centre. All patients underwent pre-operative assessment and radiographic evaluation.

Results

10 patients with a mean age of 52.6 years [SD ±14.1] and a male to female ratio of 1:1 with a mean follow-up of 14.1 months [SD ±7.9] were identified. Spinal CM spanned two vertebral levels in 9 out 10 cases with 3 cervical, 1 cervico-thoracic and 6 within the thoracic region. Duration of the symptoms prior to surgical intervention was 17 months [SD ±24], with three cases presenting with an acute [<2 week] history. Of those that underwent surgery [n=7] pain [85%, n=6], sensory/motor changes [85% n=6] and sphincteric disturbance [43%, n=3] were the commonest presenting signs and symptoms. Acute haemorrhage was a presenting factor in 3 cases. Post-operatively motor and sensory scores improved in 4 patients, 2 patients remained unchanged and 1 patient was worse. Recent haemorrhage was associated with increased likelihood in improvement in motor scores following resection.

Conclusions

In selected cases surgical management of sCM is associated with improvement in motor and sensory function postoperatively.

Abstract P6-19-03: The role of lumpectomy and radiation therapy in men 70 years of age and older with early breast cancer on hormone therapy: A NCDB analysis

Background: Current consensus guidelines for the treatment of male breast cancer are driven by female-only clinical trials despite data suggesting distinct biologic, clinicopathologic, and prognostic differences between male and female breast cancer patients. This includes a recent retrospective multicenter analysis showing greater overall survival among male breast cancer patients who underwent lumpectomy with radiation therapy (RT), compared to total mastectomy or lumpectomy alone. In light of these findings and the CALGB 9343 trial performed in women, we sought to evaluate if survival was also equivalent in men ≥70 years old with early stage breast cancer treated with hormone therapy and lumpectomy with or without radiation therapy (RT), as shown in women.

Methods: We performed a retrospective analysis of 752 stage I (T1N0M0), estrogen receptor (ER) positive male breast cancer patients ≥70 years of age who were treated with hormone therapy and underwent lumpectomy with or without RT or total mastectomy (without RT) from the National Cancer Database (NCDB) between the years 2004 to 2014. Chi-squared, Kruskal-Wallis, and analysis of variance tests were used to compare demographic and clinicopathologic differences between groups. Multivariable Cox proportional hazards regression analysis was used to compare overall survival between treatment groups, controlling for demographic and clinicopathologic differences.

Results: Most patients underwent total mastectomy (67.4%), with only 32.6% treated with lumpectomy. Of those who underwent lumpectomy, 72.6% (n=178) underwent adjuvant RT. There were significant differences in age, tumor size, histology, grade, surgical margins, nodal surgery, and chemotherapy between patients who underwent lumpectomy without RT, lumpectomy with RT, and total mastectomy (p&lt;0.05). Lumpectomy without RT patients were older (78.9 vs. 76.0 & 76.9 years, p&lt;0.01), more frequently presented with invasive ductal carcinoma (77.6% vs. 71.3% & 85.4%, p&lt;0.0001), and less frequently underwent axillary nodal surgery including sentinel lymph node biopsy (71.7% vs. 91.6% & 94.9%, p&lt;0.0001) compared to lumpectomy with RT and total mastectomy patients. In multivariate analysis, there were no significant differences in overall survival for lumpectomy without RT, lumpectomy with RT (HR 0.71, 95%CI 0.39-1.27, p=0.25), and total mastectomy alone (HR 0.92, 95%CI 0.55-1.56, p=0.76). Older age, higher Charlson-Deyo comorbidity scores, and poorly differentiated tumors were associated with poorer overall survival, while treatment at an academic/research center was associated with improved overall survival (p&lt;0.05).

Conclusion: In this national sample of elderly ER positive male breast cancer patients with early disease on hormone therapy, lumpectomy alone was associated with equivalent survival compared to lumpectomy with RT and total mastectomy alone. These results suggest that breast conserving surgery without radiation therapy is appropriate for this subset of male breast cancer patients and greater adoption by breast surgeons should be considered.

Citation Format: Bateni SB, Arora M, Daly ME, Bold RJ, Canter RJ, Sauder CA. The role of lumpectomy and radiation therapy in men 70 years of age and older with early breast cancer on hormone therapy: A NCDB analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-19-03.

A comparison of measured and predicted diffusion coefficients applied to sand and silt sized acid mine drainage materials

Determining the rate at which Acid Mine Drainage (AMD) sulfide oxidation occurs in mining waste products is a central requirement for safe and sustainable long term design of storages, including tails storage facilities, ore stockpiles and waste rock dumps. Inappropriate design can result in AMD acidification, mobilisation of heavy metals and pollution of ground and surface waters. The use of soil gas (oxygen) transport modelling to model AMD based sulfide oxidation and potential acidity loads is widespread, but diffusion coefficients used for modelling are based on existing diffusion coefficient models derived for natural and agricultural soils. Mining wastes are often well sorted due to mineral processing, and differences in soil structure and porosity can impact on diffusion coefficient behaviour compared to natural soils. This study compares a variety of approaches to estimate the diffusion coefficient and compare these results to measured values for comparison and analysis. A diffusion column apparatus is used to compare diffusion coefficient models from the literature with test results from the laboratory in several mining derived AMD materials. The results of the comparison indicate that laboratory testing of diffusion provides more accurate estimation of soil gas diffusion coefficients in mine materials. The use of diffusion coefficient safety factor approaches are explored as possible alternatives, if measurement of mine material matrix soil gas diffusion coefficient is not possible.

Socioeconomic differences in prevalence of biochemical, physiological, and metabolic risk factors for non-communicable diseases among urban youth in Delhi, India

This study examined whether the distribution of biochemical, physiological, and metabolic risk factors for non-communicable diseases (NCDs) among children and youth in urban India vary by socioeconomic status (SES). Data were derived from a cross-sectional survey of students enrolled in the 2nd and 11th grades in 19 randomly selected schools in Delhi (N = 1329) in 2014-15. Mixed-effect regression models were used to determine the prevalence of risk factors for NCDs among private (higher SES) and government (lower SES) school students. After adjusting for age, gender, and grade we found the percentage of overweight (13.16% vs. 3.1%, p value < 0.01) and obese (8.7% vs. 0.3%, p value < 0.01) students was significantly higher among private relative to government school students. Similarly, significantly higher percentage of private school students had higher waist circumference values (7.72% vs. 0.58%, p value < 0.01) than government school students. Furthermore, similar trend was observed across schools in the distribution of other NCD risk factors: raised blood pressure, raised total cholesterol, and low-density lipoprotein. Surprisingly, despite a higher prevalence of all risk factors, significantly higher percentage of private school students had adequate/ideal levels of high-density lipoprotein. Overall, the risk profile of private school students suggests they are more vulnerable to future NCDs.

Challenges in comprehensive management of spinal cord injury in India and in the Asian Spinal Cord network region: findings of a survey of experts, patients and consumers

STUDY DESIGN

Online survey.

OBJECTIVES

To understand the prevailing scenario of the comprehensive management of spinal cord injuries (SCI) in India and in the Asian Spinal Cord Network (ASCoN) region, especially with a view to document the challenges faced and its impact.

SETTING

Indian Spinal Injuries Centre.

METHODS

A questionnaire was designed which covered various aspects of SCI management. Patients, consumers (spinal injured patients discharged since at least 1 year) and experts in SCI management from different parts of India and the ASCoN region were approached to complete the survey.

RESULTS

Sixty patients, 66 consumers and 34 experts completed the survey. Difference of opinion was noticed among the three groups. Disposable Nelaton catheters were used by 57% consumers and 47% patients. For reusable catheter, 31% experts recommended processing with soap and running water and 45% recommended clean cotton cloth bag for storage. Pre-hospital care and community inclusion pose the biggest challenges in management of SCI. More than 75% of SCI faced problems of access and mobility in the community. Awareness about SCI, illiteracy and inadequate patient education are the most important factors hindering pre- and in-hospital care. Inadequate physical as well as vocational rehabilitation and financial barriers are thought to be the major factors hindering integration of spinal injured into mainstream society. Strong family support helped in rehabilitation.

CONCLUSIONS

Our study brought out that SCI in India and ASCoN region face numerous challenges that affect access to almost all aspects of comprehensive management of SCI.

Evolving concepts in prognostic scoring of chronic GvHD

Chronic GvHD (cGvHD) remains one of the most complex and challenging complications after allogeneic hematopoietic cell transplantation. Emerging knowledge about the clinical manifestations and associated organ involvement of cGvHD has led to the establishment of prognostic parameters for post-transplant survival among affected allograft recipients. Studies employing the pre-National Institutes of Health (NIH) consensus data on cGvHD incidence and its risks have led to development of the CIBMTR's cGvHD risk stratification, which serves as the most refined and validated prognostic tool for estimating survival of patients with cGvHD. However, cGvHD global severity scoring has recently evolved as a powerful prognostic tool for patient survival in the post-NIH consensus era. Current use of the substantially redefined NIH criteria of cGvHD diagnosis and measurements of its severity makes it challenging to interpret prognostic scoring systems generated in the pre-NIH era. Some of the pre-NIH prognostic parameters, however, appear to retain their significance in predicting survival independently from the NIH global severity score. Thus, future analyses of prospective cohorts of patients with cGvHD defined by NIH consensus criteria will be critical in reconciling and integrating various prognostic scoring systems of cGvHD.

Probiotics, prebiotics, and microencapsulation: A review

The development of a suitable technology for the production of probiotics is a key research for industrial production, which should take into account the viability and the stability of the organisms involved. Microbial criteria, stress tolerance during processing, and storage of the product constitute the basis for the production of probiotics. Generally, the bacteria belonging to the genera Lactobacillus and Bifidobacterium have been used as probiotics. Based on their positive qualities, probiotic bacteria are widely used in the production of food. Interest in the incorporation of the probiotic bacteria into other products apart from dairy products has been increasing and represents a great challenge. The recognition of dose delivery systems for probiotic bacteria has also resulted in research efforts aimed at developing probiotic food outside the dairy sector. Producing probiotic juices has been considered more in the recent years, due to an increased concern in personal health of consumers. This review focuses on probiotics, prebiotics, and the microencapsulation of living cells.

An experimental and theoretical study on a novel donor-π-acceptor bridge type 2, 4, 5-trimethoxy-4'-chlorochalcone for optoelectronic applications: A dual approach

In this article the authors aim is to investigate and analyze the various key parameters of an organic D-π-A type novel nonlinear optical material 2, 4, 5-trimethoxy-4'-chlorochalcone (2,4,5TMCC) through experimental and quantum chemical studies. The Claisen-Schmidt condensation reaction mechanism was applied to synthesize the 2,4,5TMCC compound and its single crystal was grown by a slow evaporation solution growth (low cost) technique. The crystal structure was confirmed by powder X-ray diffraction analysis. The robust vibrational study has been done using FT-IR and FT-Raman spectra and its NLO activity was discussed. The factor group analysis was also performed. The optical absorption spectrum was recorded and the band gap was calculated to be 2.8eV. In photoluminescence spectrum, an intense emission band at ~540nm has been observed which shows that the grown crystals can be used in green organic light emitting diodes and laser applications. To achieve the stable ground state molecular geometry of 2,4,5TMCC, the computational techniques were applied at different levels of theory using 6-31G* basis set. The calculated geometrical parameters and vibrational spectra are found to be in good agreement with the experimental results. To probe the optical properties of the title compound the time dependent density functional theory was applied. The excitation wavelength was observed at ~398.63nm calculated at B3LYP/6-31G* level of theory and found close to experimental value (i.e. 396nm). The static first hyperpolarizability value is found to be 136 times higher than prototype urea molecule. Additionally, the molecular level approach was attained as HOMO-LUMO gap and electrostatic potential maps. The DSC study reveals that the titled material is stable up to 149°C. The photophysical and nonlinear optical properties suggest that the titled material could be a better choice for the fabrication of optoelectronic devices.

Necrotizing Enterocolitis with Perforation in an Extreme Preterm, Extremely Low Birth Weight Neonate

Necrotizing enterocolitis (NEC) remains the most common and serious surgical condition among preterm, very low birth weight neonates with a mortality of 40% to 50% in those requiring surgery. We report perforation secondary to NEC in an extreme preterm, extremely low birth weight neonate with a good outcome due to aggressive surgical management and intensive care.J Nepal Paediatr Soc 2016;36(2):201-203.

Poly(lactic acid) blends in biomedical applications

Poly(lactic acid) (PLA) has become a "material of choice" in biomedical applications for its ability to fulfill complex needs that typically include properties such as biocompatibility, biodegradability, mechanical strength, and processability. Despite the advantages of pure PLA in a wider spectrum of applications, it is limited by its hydrophobicity, low impact toughness, and slow degradation rate. Blending PLA with other polymers offers a convenient option to enhance its properties or generate novel properties for target applications without the need to develop new materials. PLA blends with different natural and synthetic polymers have been developed by solvent and melt blending techniques and further processed based on end-use applications. A variety of PLA blends has been explored for biomedical applications such as drug delivery, implants, sutures, and tissue engineering. This review discusses the opportunities for PLA blends in the biomedical arena, including the overview of blending and postblend processing techniques and the applications of PLA blends currently in use and under development.

GvHD after umbilical cord blood transplantation for acute leukemia: an analysis of risk factors and effect on outcomes

Using the Center for International Blood and Marrow Transplant Research (CIBMTR) registry, we analyzed 1,404 UCBT patients [single (< 18 years) = 810, double (≥ 18 years) = 594] with acute leukemia to define the incidence of acute and chronic graft-vs.-host disease (GVHD), analyze clinical risk factors and investigate outcomes. After single UCBT, 100-day incidence of grades II–IV aGVHD was 39% (95% CI, 36–43%), grades III–IV aGVHD was 18% (95% CI, 15–20%), and 1-year cGVHD was 27% (95% CI, 24–30%). After double UCBT, 100-day incidence of grades II–IV aGVHD was 45% (95% CI, 41%–49%), grades III–IV aGVHD was 22% (95% CI, 19–26%), and 1-year cGVHD was 26% (95% CI, 22–29%). For single UCBT, multivariate analysis showed that absence of anti-thymocyte globulin (ATG) was associated with aGVHD, whereas prior aGVHD was associated with cGVHD. For double UCBT, absence of ATG and myeloablative conditioning were associated with aGVHD, while prior aGVHD predicted for cGVHD. Grades III–IV aGVHD led to worse survival whereas cGVHD had no significant effect on disease-free or overall survival. GVHD is prevalent after UCBT with severe aGVHD leading to higher mortality. Future research in UCBT should prioritize prevention of GVHD.

Clozapine Effective in Olanzapine-Induced Pisa Syndrome

Objective:

To report a case of olanzapine-induced Pisa syndrome that improved after treatment with clozapine.

Case Summary:

A 22-year-old male with paranoid schizophrenia presented with insidious onset tonic truncal flexion with axial rotation and difficulty in walking after exposure to olanzapine in doses up to 15 mg/day for 9 months. An objective causality assessment suggested that Pisa syndrome was probably related to olanzapine. There was improvement in his symptoms after 6 weeks of treatment with clozapine in doses gradually titrated to 350 mg/day.

Discussion:

Pisa syndrome is a type of dystonia that has been associated with both typical and atypical antipsychotics. Both acute and insidious onset cases have been described in the literature, which have different course and treatment response. Clozapine was found to be effective in reducing the severity of olanzapine-induced Pisa syndrome.

Conclusion:

Clozapine may be a useful treatment option for Pisa syndrome that has been caused by olanzapine.

Paroxetine Useful for Palmar–Plantar Hyperhidrosis

Objective:

To report a case of palmar–plantar hyperhidrosis (PPH) In which paroxetine was found to be helpful.

Case Summary:

A 32-year-old man with a history of excessive sweating of the palms and soles since childhood was diagnosed with PPH and was prescribed paroxetine 10 mg/day, which was increased to 20 mg/day. After one month, he experienced a marked reduction in sweating and improvement in socio-occupational functioning, which were sustained during follow-up at 6 months without any emergent adverse effects.

Discussion:

Paroxetine's anticholinergic action may be responsible for its beneficial effect in PPH, as it may override the adrenergic mechanism, which has a minor effect on sweating from eccrine glands. Alternatively, paroxetine's beneficial effect in PPH may be secondary to its antianxiety effect, through central mechanisms.

Conclusions:

Paroxetine may be a useful option in the treatment of PPH.

The reliability of measuring wound undermining in people with spinal cord injury

OBJECTIVE

The objective of this study was to determine the reliability of measuring wound undermining in people with spinal cord injury (SCI).

STUDY DESIGN

A psychometric study.

SETTING

The study was conducted at the Indian Spinal Injuries Centre, New Delhi, India.

PARTICIPANTS

Thirty people with a complete or incomplete SCI and a pressure ulcer with wound undermining were recruited.

METHODS

Wound undermining was measured using the four cardinal points from a clock face (with 12 O'clock defined as towards the head). Inter-rater reliability was tested by comparing the wound undermining scores from two different assessors. Intra-rater reliability was tested by comparing the wound undermining scores from the same assessor on two different days.

RESULTS

The intraclass correlation coefficients (95% confidence interval) for inter-rater and intra-rater reliability were 0.996 (0.992-0.999) and 0.998 (0.996-0.999), respectively. Repeat measurements by the same and different assessor were within 0.3 cm of each other, 80% and 83% of the time, respectively.

CONCLUSION

Measurements of wound undermining have excellent reliability.