Semaglutide vs Endoscopic Sleeve Gastroplasty for Weight Loss

Importance

Obesity is a disease with a large socioeconomic burden. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric procedure with wide global adoption. More recently, new weight-loss medications, such as glucagon-like peptide-1 receptor agonists (eg, semaglutide), have attracted increased attention due to their efficacy. However, their cost-effectiveness over an extended period compared with ESG is a critical gap that needs to be better explored for informed health care decision-making.

Objective

To assess the cost-effectiveness of semaglutide compared with ESG over 5 years for individuals with class II obesity.

Design, Setting, and Participants

This economic evaluation study, conducted from September 1, 2022, to May 31, 2023, used a Markov cohort model to compare ESG and semaglutide, with a no-treatment baseline strategy. The study comprised adult patients in the US health care system with class II obesity (body mass index [BMI] of 35-39.9). The base case was a 45-year-old patient with class II obesity (BMI of 37). Patients undergoing ESG were subjected to risks of perioperative mortality and adverse events with resultant costs and decrement in quality of life.

Interventions

Strategies included treatment with semaglutide and ESG.

Main Outcomes and Measures

Costs (2022 US dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100 000/QALY. A 5-year time horizon with a cycle length of 1 month with a 3% discount rate was used. Probabilities, costs, and quality-of-life estimates of the model were derived from published literature. One-way, 2-way, and probabilistic sensitivity analyses were also performed.

Results

The model found that ESG was more cost-effective than semaglutide over a 5-year time horizon, with an ICER of -$595 532/QALY. Endoscopic sleeve gastroplasty added 0.06 QALYs and reduced total cost by $33 583 relative to semaglutide. The results remained robust on 1-way and probabilistic sensitivity analyses. Endoscopic sleeve gastroplasty sustained greater weight loss over 5 years vs semaglutide (BMI of 31.7 vs 33.0). To achieve nondominance, the annual price of semaglutide, currently $13 618, would need to be $3591.

Conclusions and Relevance

This study suggests that ESG is cost saving compared with semaglutide in the treatment of class II obesity. On price threshold analyses, a 3-fold decrease in the price of semaglutide is needed to achieve nondominance.

Artificial intelligence-enhanced electrocardiography for accurate diagnosis and management of cardiovascular diseases

Electrocardiography (ECG), improved by artificial intelligence (AI), has become a potential technique for the precise diagnosis and treatment of cardiovascular disorders. The conventional ECG is a frequently used, inexpensive, and easily accessible test that offers important information about the physiological and anatomical state of the heart. However, the ECG can be interpreted differently by humans depending on the interpreter's level of training and experience, which could make diagnosis more difficult. Using AI, especially deep learning convolutional neural networks (CNNs), to look at single, continuous, and intermittent ECG leads that has led to fully automated AI models that can interpret the ECG like a human, possibly more accurately and consistently. These AI algorithms are effective non-invasive biomarkers for cardiovascular illnesses because they can identify subtle patterns and signals in the ECG that may not be readily apparent to human interpreters. The use of AI in ECG analysis has several benefits, including the quick and precise detection of problems like arrhythmias, silent cardiac illnesses, and left ventricular failure. It has the potential to help doctors with interpretation, diagnosis, risk assessment, and illness management. Aside from that, AI-enhanced ECGs have been demonstrated to boost the identification of heart failure and other cardiovascular disorders, particularly in emergency department settings, allowing for quicker and more precise treatment options. The use of AI in cardiology, however, has several limitations and obstacles, despite its potential. The effective implementation of AI-powered ECG analysis is limited by issues such as systematic bias. Biases based on age, gender, and race result from unbalanced datasets. A model's performance is impacted when diverse demographics are inadequately represented. Potentially disregarded age-related ECG variations may result from skewed age data in training sets. ECG patterns are affected by physiological differences between the sexes; a dataset that is inclined toward one sex may compromise the accuracy of the others. Genetic variations influence ECG readings, so racial diversity in datasets is significant. Furthermore, issues such as inadequate generalization, regulatory barriers, and interpretability concerns contribute to deployment difficulties. The lack of robustness in models when applied to disparate populations frequently hinders their practical applicability. The exhaustive validation required by regulatory requirements causes a delay in deployment. Difficult models that are not interpretable erode the confidence of clinicians. Diverse dataset curation, bias mitigation strategies, continuous validation across populations, and collaborative efforts for regulatory approval are essential for the successful deployment of AI ECG in clinical settings and must be undertaken to address these issues. To guarantee a safe and successful deployment in clinical practice, the use of AI in cardiology must be done with a thorough understanding of the algorithms and their limits. In summary, AI-enhanced electrocardiography has enormous potential to improve the management of cardiovascular illness by delivering precise and timely diagnostic insights, aiding clinicians, and enhancing patient outcomes. Further study and development are required to fully realize AI's promise for improving cardiology practices and patient care as technology continues to advance.

Adjuvant Radiofrequency Ablation Along With Stenting Versus Stenting Alone for Biliary Tree Drainage in Patients With Malignant Biliary Strictures: A Systemic Review and Meta-analysis

OBJECTIVE

This metanalysis aims to assess the efficacy and safety of biliary stenting along with radiofrequency ablation compared with stents alone to treat malignant biliary obstruction (MBO) due to extrahepatic biliary strictures secondary to cholangiocarcinoma, pancreatic cancer, and metastatic cancer.

METHODS

A systemic search of major databases through April 2022 was done. All original studies were included comparing radiofrequency ablation with stenting versus stenting alone for treating malignant biliary strictures. The primary outcomes of interest were the difference in the mean stent patency and overall survival (OS) days between the 2 groups. The secondary outcome was to compare the adverse events of the 2 groups. The mean difference in the stent patency and OS days was pooled by using a random-effect model. We calculated the odds ratio to compare the adverse events between the 2 groups.

RESULTS

A total of 13 studies with 1339 patients were identified. The pooled weighted mean difference in stent patency was 43.50 days (95% CI, 25.60-61.41), favoring the RFA plus stenting. Moreover, the pooled weighted mean difference in OS was 90.53 days (95% CI, 49.00-132.07), showing improved survival in the RFA group. Our analysis showed no statistically significant difference in adverse events between the 2 groups OR 1.13 (95% CI, 0.90-1.42).

CONCLUSION

Our analysis showed that RFA, along with stent, is safe and is associated with improved stent patency and overall patient survival in malignant biliary strictures. More robust prospective studies should assess this association further.

Safety and adverse events of EUS-guided gallbladder drainage using lumen-apposing metal stents and percutaneous cholecystostomy tubes: a systematic review and meta-analysis

BACKGROUND AND AIMS

EUS-guided gallbladder drainage using lumen-apposing metal stents (EUS-GBD-LAMSs) and percutaneous cholecystostomy for gallbladder drainage (PTGBD) are the alternative treatment modalities in high-risk surgical patients with acute cholecystitis (AC). The aim of this study was to compare the safety of these procedures for AC in surgically suboptimal candidates.

METHODS

Six studies compared the 2 groups' early, delayed, and overall adverse events; they also compared length of hospital stay, re-interventions, and re-admissions rate. A random effect model calculated odds ratios (ORs) with a 95% confidence interval (CI).

RESULTS

The 2 groups had similar early adverse events; however, EUS-GBD-LAMS was associated with a lower rate of delayed (OR, .21; 95% CI, .07-.61; P ≤ .01) and overall (OR, .43; 95% CI, .30-.61; P ≤ .01) adverse events. Patients with EUS-GBD-LAMSs had a shorter hospital stay than PTGBD.

CONCLUSIONS

EUS-GBD-LAMS is a safer option than PTGBD and is associated with a shorter hospital stay in nonsurgical candidates with AC.

A versatile dataset for intrinsic plagiarism detection, text reuse analysis, and author clustering in Urdu

Plagiarism detection (PD) is a process of identifying instances where someone has presented another person's work or ideas as their own. Plagiarism detection is categorized into two types (i) Intrinsic plagiarism detection primarily concerns the assessment of authorship consistency within a single document, aiming to identify instances where portions of the text may have been copied or paraphrased from elsewhere within the same document. Author clustering, closely related to intrinsic plagiarism detection, involves grouping documents based on their stylistic and linguistic characteristics to identify common authors or sources within a given dataset. On the other hand, (ii) extrinsic plagiarism detection delves into the comparative analysis of a suspicious document against a set of external source documents, seeking instances of shared phrases, sentences, or paragraphs between them, which is often referred to as text reuse or verbatim copying. Detection of plagiarism from documents is a long-established task in the area of NLP with remarkable contributions in multiple applications. A lot of research has already been conducted in the English and other foreign languages but Urdu language needs a lot of attention especially in intrinsic plagiarism detection domain. The major reason is that Urdu is a low resource language and unfortunately there is no high-quality benchmark corpus available for intrinsic plagiarism detection in Urdu language. This study presents a high-quality benchmark Corpus comprising 10,872 documents. The corpus is structured into two granularity levels: sentence level and paragraph level. This dataset serves multifaceted purposes, facilitating intrinsic plagiarism detection, verbatim text reuse identification, and author clustering in the Urdu language. Also, it holds significance for natural language processing researchers and practitioners as it facilitates the development of specialized plagiarism detection models tailored to the Urdu language. These models can play a vital role in education and publishing by improving the accuracy of plagiarism detection, effectively addressing a gap and enhancing the overall ability to identify copied content in Urdu writing.

Mobilisation and analyses of publicly available SARS-CoV-2 data for pandemic responses

The COVID-19 pandemic has seen large-scale pathogen genomic sequencing efforts, becoming part of the toolbox for surveillance and epidemic research. This resulted in an unprecedented level of data sharing to open repositories, which has actively supported the identification of SARS-CoV-2 structure, molecular interactions, mutations and variants, and facilitated vaccine development and drug reuse studies and design. The European COVID-19 Data Platform was launched to support this data sharing, and has resulted in the deposition of several million SARS-CoV-2 raw reads. In this paper we describe (1) open data sharing, (2) tools for submission, analysis, visualisation and data claiming (e.g. ORCiD), (3) the systematic analysis of these datasets, at scale via the SARS-CoV-2 Data Hubs as well as (4) lessons learnt. This paper describes a component of the Platform, the SARS-CoV-2 Data Hubs, which enable the extension and set up of infrastructure that we intend to use more widely in the future for pathogen surveillance and pandemic preparedness.

The European Nucleotide Archive in 2023

The European Nucleotide Archive (ENA; https://www.ebi.ac.uk/ena) is maintained by the European Molecular Biology Laboratory's European Bioinformatics Institute (EMBL-EBI). The ENA is one of the three members of the International Nucleotide Sequence Database Collaboration (INSDC). It serves the bioinformatics community worldwide via the submission, processing, archiving and dissemination of sequence data. The ENA supports data types ranging from raw reads, through alignments and assemblies to functional annotation. The data is enriched with contextual information relating to samples and experimental configurations. In this article, we describe recent progress and improvements to ENA services. In particular, we focus upon three areas of work in 2023: FAIRness of ENA data, pandemic preparedness and foundational technology. For FAIRness, we have introduced minimal requirements for spatiotemporal annotation, created a metadata-based classification system, incorporated third party metadata curations with archived records, and developed a new rapid visualisation platform, the ENA Notebooks. For foundational enhancements, we have improved the INSDC data exchange and synchronisation pipelines, and invested in site reliability engineering for ENA infrastructure. In order to support genomic surveillance efforts, we have continued to provide ENA services in support of SARS-CoV-2 data mobilisation and have adapted these for broader pathogen surveillance efforts.

Spatial soil loss prediction impacted by long-term land use/land cover change: a case study of Swat District

Soil erosion is a destructive consequence of land degradation caused by deforestation, improper farming practices, overgrazing, and urbanization. This irreversible effect negatively impacts the limited renewable soil resource, causing soil truncation, reduced fertility, and unstable slopes. To address the anticipation of erosion modulus resulting from long-term land use and land cover (LULC) changes, a study was conducted in the Swat District of Khyber Pakhtunkhwa (Kpk), Pakistan. The study aimed to predict and evaluate soil erosion concerning these changes using remote sensing (RS), geographic information systems (GIS), and the Revised Universal Soil Loss Equation (RUSLE) model. We also evaluated the impact of the Billion Tree Tsunami Project (BTTP) on soil erosion in the region. Model inputs, such as rainfall erosivity factor, topography factor, land cover and management factor, and erodibility factor, were used to calculate soil erosion. The results revealed that significant soil loss occurred under 2001, 2011, and 2021 LULC conditions, accounting for 67.26%, 61.78%, and 65.32%, falling within the category of low erosion potential. The vulnerable topographical features of the area indicated higher erosion modulus. The maximum soil loss rates observed in 2001, 2011, and 2021 were 80 t/ha-1/year-1, 120 t/ha-1/year-1, and 96 t/ha-1/year-1, respectively. However, the observed reduction in soil loss in 2021 as compared to 2001 and 2011 suggests a positive influence of the BTTP on soil conservation efforts. This study underscores the potential of afforestation initiatives like the BTTP in mitigating soil erosion and highlights the significance of environmental conservation programs in regions with vulnerable topography.

PLGA-Encapsulated Haemonchus contortus Antigen ES-15 Augments Immune Responses in a Murine Model

Haemonchus contortus is a gastrointestinal parasite that adversely impacts small ruminants, resulting in a notable reduction in animal productivity. In the current investigation, we developed a nanovaccine by encapsulating the recombinant protein rHcES-15, sourced from the excretory/secretory products of H. contortus, within biodegradable poly (D, L-lactide-co-glycolide) (PLGA) nanoparticles (NPs). The development of this nanovaccine involved the formulation of PLGA NPs using a modified double emulsion solvent evaporation technique. Scanning electron microscopy (SEM)verified the successful encapsulation of rHcES-15 within PLGA NPs, exhibiting a size range of 350-400 nm. The encapsulation efficiency (EE) of the antigen in the nanovaccine was determined to be 72%. A total of forty experimental mice were allocated into five groups, with the nanovaccine administered on day 0 and the mice euthanized at the end of the 14-day trial. The stimulation index (SI) from the mice subjected to the nanovaccine indicated heightened lymphocyte proliferation (*** p < 0.001) and a noteworthy increase in anti-inflammatory cytokines (IL-4, IL-10, and IL-17). Additionally, the percentages of T-cells (CD4+, CD8+) and dendritic cell phenotypes (CD83+, CD86+) were significantly elevated (** p < 0.01, *** p < 0.001) in mice inoculated with the nanovaccine compared to control groups and the rHcES-15 group. Correspondingly, higher levels of antigen-specific serum immunoglobulins (IgG1, IgG2a, IgM) were observed in response to the nanovaccine in comparison to both the antigenic (rHcES-15) and control groups (* p < 0.05, ** p < 0.01). In conclusion, the data strongly supports the proposal that the encapsulation of rHcES-15 within PLGA NPs effectively triggers immune cells in vivo, ultimately enhancing the antigen-specific adaptive immune responses against H. contortus. This finding underscores the promising potential of the nanovaccine, justifying further investigations to definitively ascertain its efficacy.

GPU-acceleration of the distributed-memory database peptide search of mass spectrometry data

Database peptide search is the primary computational technique for identifying peptides from the mass spectrometry (MS) data. Graphical Processing Units (GPU) computing is now ubiquitous in the current-generation of high-performance computing (HPC) systems, yet its application in the database peptide search domain remains limited. Part of the reason is the use of sub-optimal algorithms in the existing GPU-accelerated methods resulting in significantly inefficient hardware utilization. In this paper, we design and implement a new-age CPU-GPU HPC framework, called GiCOPS, for efficient and complete GPU-acceleration of the modern database peptide search algorithms on supercomputers. Our experimentation shows that the GiCOPS exhibits between 1.2 to 5[Formula: see text] speed improvement over its CPU-only predecessor, HiCOPS, and over 10[Formula: see text] improvement over several existing GPU-based database search algorithms for sufficiently large experiment sizes. We further assess and optimize the performance of our framework using the Roofline Model and report near-optimal results for several metrics including computations per second, occupancy rate, memory workload, branch efficiency and shared memory performance. Finally, the CPU-GPU methods and optimizations proposed in our work for complex integer- and memory-bounded algorithmic pipelines can also be extended to accelerate the existing and future peptide identification algorithms. GiCOPS is now integrated with our umbrella HPC framework HiCOPS and is available at: https://github.com/pcdslab/gicops .

Malignant Middle Cerebral Artery Infarct Caused by Eagle's Syndrome

Eagle's syndrome is characterised by elongation of the styloid process. The elongated styloid process can cause symptoms like dysphagia, facial or neck pain, syncope, visual changes, etc. In severe cases, it may cause a rupture or dissection of the carotid artery, which can lead to intracranial thrombo-embolism and ischemic stroke. We report a case of a 57-year-old male presenting with dysarthria and mild left-sided body weakness. An initial non-contrast computed tomography (CT) scan showed a possible right internal carotid artery thrombus. He developed worsening left-sided weakness and gaze palsy one day after the admission. Repeated CT brain and intracranial angiography were arranged, which showed significant oedema with mass effect and right internal carotid artery dissection with thrombus. He underwent decompressive craniectomy. An enlarged styloid process measuring 4.53 cm in close proximity to the cervical vasculature was also noted. He was not deemed an appropriate candidate for styloidectomy. Due to residual left-sided weakness, he had to take early retirement. He underwent extensive rehabilitation and was able to mobilize with the help of a quad stick after a period of nine months. At the five-year follow-up, there were no characteristic symptoms of Eagle's syndrome and he was mobilizing without support.

The Standard Operating Procedures in COVID-19 Pandemic for Periodontal Aerosol-Generating Procedures: A Process Audit

OBJECTIVE

 This study aims to audit the process of patient management with aerosol-generating procedure (ultrasonic scaling) while adherence to the guidelines for health care workers (HCWs) during the coronavirus disease 2019 (COVID-19).

MATERIALS AND METHODS

 Audits records at the Department of Periodontology at University College of Medicine and Dentistry Hospital, Lahore, Pakistan were collected (prospectively) over the period of October 1 to November 30, 2020 (1st cycle) and December 14, 2020 to February 12, 2021 (2nd cycle). The audit was divided into three components based on the guidelines: (1) physical environment, (2) patients/appointments, and (3) COVID standard operating procedures related to HCWs.

RESULTS

 The recommended physical layout and procedural factors, as suggested by the guidelines for dental clinics, were observed during the first cycle of audit, and discrepancy of ventilation system was fixed after the first cycle. Audit team reported the observance of fallow time three times daily, which revealed 83.3% observance of fallow time.Later in the second cycle when the extraoral high-volume air evacuator was installed, the fallow time was reduced to 15 minutes and not only five procedural slots per day were created but fallow time was also observed 100% of the time.

CONCLUSION

 Following the standard guidelines resulted in more efficient working environment and lesser risk for HCWs while performing aerosol-generating procedures.

Type 1 Autoimmune Pancreatitis Masquerading as Pancreatic Head Carcinoma

Obstructive jaundice is a joint clinical presentation with many etiologies, including pancreatic cancer and autoimmune pancreatitis (AIP). Differentiating between these two conditions is pivotal due to the divergent management approaches and prognoses. In this case report, we present a case of a 49-year-old female patient who presented with weight loss, intermittent chronic abdominal pain, and jaundice. She was initially suspected of having pancreatic cancer because of clinical presentation and imaging findings. However, she was ultimately diagnosed with Type 1 AIP due to histopathology findings and elevated immunoglobulin G4. This case highlights the complexities in diagnosis, the role of advanced imaging techniques and tissue sampling, and the lessons learned regarding managing this challenging clinical scenario.

Endoscopic therapy for gastroesophageal reflux disease: where are we, where are we going?

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) is the most common chronic condition with increasing prevalence in the Western world. Despite medical therapy, a considerable proportion of patients continue to experience symptoms, thus fueling the demand for minimally invasive GERD treatment options. This review will assess the currently available endoscopic approaches by analyzing their outcomes data, indication for use and limitations.

RECENT FINDINGS

With increasing evidence of the safety and efficacy of endoscopic therapies, recent guidelines and consensus society documents have updated their recommendations for the endoscopic treatment of GERD. In this review, we have comprehensively assessed the current landscape of endoscopic approaches for the treatment of GERD and provided insight into future directions.

SUMMARY

Endoscopic therapies for GERD show promise as new treatments emerge and existing therapies evolve into safer and more reproducible options. They are well positioned to cater to a large subset of the population suffering from chronic condition of GERD.

Acute Pancreatitis, Hypertriglyceridemia, and Diabetic Ketoacidosis: A Life-Threatening Triad

Hypertriglyceridemia (HTG)-induced pancreatitis is a known complication of uncontrolled diabetes mellitus (DM). However, the coexistence of diabetic ketoacidosis (DKA) and acute pancreatitis in the presence of HTG is rare and presents diagnostic and therapeutic challenges. We present the case of a 42-year-old female with poorly controlled type 2 DM who developed severe HTG-induced pancreatitis complicated by DKA. She initially presented with abdominal pain, metabolic acidosis, and marked hyperglycemia. Subsequent investigations revealed significantly elevated serum triglyceride and lipase levels and characteristic findings of acute pancreatitis on imaging. This case report highlights the complex interplay of metabolic disturbances in diabetes and the importance of timely recognition and tailored management to achieve a successful outcome.

P176S Mutation Rewires Electrostatic Interactions That Alter Maspin Functionality

Maspin is known to regress tumors by inhibiting angiogenesis; however, its roles have been reported to be context- and sequence-dependent. Various proteins and cofactors bind to maspin, possibly explaining its conflicting roles. Moreover, polymorphic forms of maspin have also been linked to tumor regression and survival; for instance, maspin with Ser at 176 (maspin-S176) promotes tumors, while maspin with Pro at 176 (maspin-P176) has opposing roles in cancer pathogenesis. With the help of long molecular dynamics simulations, a possible link between polymorphic forms and tumor progression has been established. First, maspin is dynamically stable with either amino acid at the 176 position. Second, differential contacts have been observed among various regions; third, these contacts have significantly altered the electrostatic energetics of various residues; finally, these altered electrostatics of maspin-S176 and maspin-P176 rewire the polar contacts that abolished the allosteric control of the protein. By combining these factors, the altered electrostatics substantially affect the localization and preference of maspin-binding partners, thus culminating in a different maspin-protein(cofactor)-interaction landscape that may have been manifested in previous conflicting reports. Here, the underlying reason has been highlighted and discussed, which may be helpful for better therapeutic manipulation.

Malignant Perivascular Epithelioid Cell Neoplasm of Left Kidney Treated With Targeted Therapy: A Rare Case Report

Perivascular epithelioid cell neoplasm (PEComa) is one of the rare entities which is challenging to diagnose clinically. These tumors occur due to tuberous sclerosis complex gene mutations leading to upregulation and overexpression of the mammalian target of rapamycin (mTOR). Malignant PEComas are rare, and we report a peculiar case of PEComa treated with mTOR inhibitors. A 43-year-old woman presented with complaints of back pain, intermittent fever, dysuria, and cough with expectoration for one month. Abdominal computed tomography (CT) revealed heterogeneously enhancing exophytic mass of the left kidney. A positron emission tomography CT whole body showed a primary malignancy in the left kidney, sclerotic lesions in the bony skeleton, and lymphangitis carcinomatosis in both lungs. A biopsy of the left renal mass revealed PEComa, focally positive for melanocytic and muscle markers. She was commenced on treatment with intravenous temsirolimus, and there was a complete tumor regression by the end of the completion of six cycles.

Cardiac Angiosarcoma With Pulmonary Metastasis: A Rare and Challenging Case

Cardiac angiosarcoma is a rare and aggressive malignant tumor arising from the endothelial cells of the heart. It accounts for only a small fraction of all cardiac neoplasms and has a poor prognosis. We present a challenging case of a 20-year-old student who presented exertional dyspnea, palpitation, and occasional chest discomfort. Her clinical picture, radiological and pathological investigations confirm the diagnosis of cardiac angiosarcoma with pulmonary metastasis. This case highlights the importance of early diagnosis and multidisciplinary management for improved patient outcomes.

Quantifying irrigation water demand and supply gap using remote sensing and GIS in Multan, Pakistan

Human interventions and rapid changes in land use adversely affect the adequate distribution of water resources. A research study was conducted to quantify the gap between demand and supply for irrigation water in Multan, Pakistan, which may lead to sustainable water management. Two remotely sensed images (Landsat 8 OLI and Landsat 5 TM) were downloaded for the years 2010 and 2020, and supervised classification method was performed for the selected land use land cover (LULC) classes and basic framework. During the evaluation, the kappa coefficient was found in the ranges of 0.83-0.85, and overall accuracy was found to be more than 80% which indicated a substantial agreement between the classified maps and the ground truth data for both years and seasons. The LULC maps showed that urbanization has increased by 49% during the last decade (2010-2020). Reduction in planting areas for wheat (9%), cotton (24%), and orchards (46%) was observed. An increase in planting areas for rice (92%) and sugarcane (63%) was observed. The changing LULC pattern may be related to variation in water demand and supply for irrigation. The irrigation water demand has decreased by 370.2 Mm3 from 2010 to 2020, due to the reduction in agricultural land and an increase in urbanization. Available irrigation water supply (canals/rainfall) was estimated as 2432 Mm3 for the year 2020 which was 26% less than that of total irrigation water demand (3281 Mm3). The findings also provide the database for sustainable water management and equitable distribution of water in the region.

Atrial Myxoma: An Unusual Etiology of Ischemic Stroke in an Adult Patient

Atrial myxoma is the most frequent primary cardiac tumor; however, it is a rare, substantial cause of cardiogenic emboli causing a stroke, especially in young adults. A cardiac myxoma has no specific clinical presentation, ranging from constitutional symptoms to non-cardiac symptoms and emboli, which leads to a diagnostic challenge in the clinical process. We report a case of a left atrial myxoma in an adult female who presented with sudden onset of right-sided weakness, headache, and numbness. Imaging confirmed cardiogenic emboli from the cardiac myxoma, which was reflected in an ischemic stroke.

Takotsubo Cardiomyopathy: A Possible Rare Complication of Guillain-Barré Syndrome

Dysautonomia is a common and severe complication of Guillain-Barré syndrome (GBS), which may manifest as cardiac arrhythmias, labile blood pressure, diaphoresis, and changes in gastrointestinal motility. Takotsubo cardiomyopathy (TCM) is a life-threatening manifestation of dysautonomia in patients with GBS, which is not widely underlined in the literature. The association between GBS and TCM has been well-documented in previous studies; however, there are few reported cases with GBS who developed TCM following their diagnosis with GBS. In this case report, we will discuss our experience treating a 59-year-old female patient who became hemodynamically unstable while recovering from an acute GBS infection. She was diagnosed with TCM after undergoing an echocardiogram and coronary angiogram ruling out thrombotic or obstructive coronary disease and myocarditis.

Do demographic factors affect the environment? Empirical evidence from the Middle East and North African countries

Every country intends to enhance national production by achieving sustainable development. The purpose of this study is to examine whether there exists any long-run association among environmental deterioration measured by territorial emissions in CO₂, demographic factors (total population, population density, and urban population) and some other variables, namely, energy use, per capita income, energy intensity, and industrial value added for the 16 countries from the Middle East and North African (MENA) over 1990-2018. We implemented the generalized method of moments (GMM), fully modified ordinary least square (FMOLS), robust least square estimators, and panel Granger causality techniques for estimation. The empirical estimates reveal that there exists a long run cointegration among the series. Results also exhibit that energy use, per capita income, energy intensity, industrial value added, population density, total population, and urban population have positive effects on CO₂ emissions. Furthermore, in each panel, there is bi-directional causality between population density and CO₂ emissions, total population and CO₂ emissions, and urban population and CO₂ emissions. These findings suggest that the policymakers need not exclusively to focus on the transformation of rural labor from an agricultural-based model to urban regions with powerful, dominant industry and services sectors but also related to the changing of rural establishments into urban spaces is required. These changes in demographics involve changes in the demand for additional transportation services, food, shelter, clothing, and other necessities.

Short-term outcomes after peroral endoscopic myotomy, Heller myotomy, and pneumatic dilation in patients with achalasia: a nationwide analysis

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LHM), and pneumatic dilation (PD) are the most common modalities for management of achalasia. Our study aimed to directly compare their short-term outcomes and safety profile in a hospitalized cohort in the United States.

METHODS

The National Readmission Database (2016-2019) was queried using International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify a cohort of inpatient admissions who underwent POEM, LHM, or PD. Baseline demographic variables, resource utilization, periprocedural outcomes, and 30-day readmissions were analyzed. A univariate and multivariate logistic regression model was used to compare odds of readmission with POEM as a reference.

RESULTS

LHM was the most performed procedure (n = 9710) as compared with PD (n = 2453) and POEM (n = 1911). Patients undergoing PD were older with a higher Charlson Comorbidity Index. The 30-day readmission rate was 4.3%, 3.9%, and 12.6% for POEM, LHM, and PD, respectively. Compared with POEM, the adjusted odds of readmission for PD was 2.42 (95% confidence interval, 1.56-3.75). There was no statistically significant difference in odds of readmission for LHM (.91; 95% confidence interval, .62-1.33) compared with POEM. Within the 30-day readmitted population, 13.1% of PD and 3.4% of LHM patients required achalasia-related procedural intervention. The rate of bleeding (4.3%), blood transfusion (2.3%), and mortality were higher (1.1%) in PD as compared with POEM and LHM.

CONCLUSIONS

In the United States, the risk of readmission and resource utilization are higher in patients with achalasia undergoing PD. The outcomes are comparable between POEM and LHM, but there is a significant difference between the utilization of these myotomy procedures.

P-17 An innovative technique for practising peeling of donor descemet's membrane for descemet's membrane endothelial keratoplasty

*Correspondence, Shakeel Ahmad: drshakeel333@gmail.com PURPOSE: To evaluate the feasibility of residual corneoscleral buttons after primary surgery for practising the donor tissue preparation for Descemet's membrane endothelial keratoplasty (DMEK) by trainees and fellows.

METHODS

Fellows with zero experience in DMEK used 5 residual corneoscleral buttons after DSAEK surgery (central 8 mm graft was punched during the primary surgery), to practice donor Descemet's membrane peeling. A 9.5 mm donor punch was used for partial cutting of the residual button after staining it with brilliant blue G for 1 minute. 360° stripping of Descemet's was practised under a balanced salt solution.

RESULT

Fellow successfully peeled 360° Descemet's membrane in 3 out of 5 residual corneoscleral buttons.

CONCLUSION

Residual corneoscleral button is an excellent source to practice donor Descemet's membrane peeling for DMEK. This technique can provide cost-effective and easily available platform to the trainees and fellows for gaining skills and practising graft preparation without the fear of financial loss or surgery deferment in case of tissue loss or damage.

Autoimmune Neuroinflammatory Diseases: Role of Interleukins

Autoimmune neuroinflammatory diseases are a group of disorders resulting from abnormal immune responses in the nervous system, causing inflammation and tissue damage. The interleukin (IL) family of cytokines, especially IL-1, IL-6, and IL-17, plays a critical role in the pathogenesis of these diseases. IL-1 is involved in the activation of immune cells, production of pro-inflammatory cytokines, and promotion of blood-brain barrier breakdown. IL-6 is essential for the differentiation of T cells into Th17 cells and has been implicated in the initiation and progression of neuroinflammation. IL-17 is a potent pro-inflammatory cytokine produced by Th17 cells that plays a crucial role in recruiting immune cells to sites of inflammation. This review summarizes the current understanding of the roles of different interleukins in autoimmune neuroinflammatory diseases, including multiple sclerosis, amyotrophic lateral sclerosis, Alzheimer's disease, neuromyelitis optica, and autoimmune encephalitis, and discusses the potential of targeting ILs as a therapeutic strategy against these diseases. We also highlight the need for further research to better understand the roles of ILs in autoimmune neuroinflammatory diseases and to identify new targets for treating these debilitating diseases.

Acute Pancreatitis Simulating Myocardial Infarction: A Challenging Case

Acute pancreatitis is an inflammatory condition with varying local and systemic complications and variable severity. Although rare, cardiovascular complications induced by acute pancreatitis are rarely described in the literature. Epigastric pain with acute pancreatitis often simulates electrocardiographic changes in the absence of coronary artery abnormalities, resulting in a diagnostic dilemma for optimal treatment and management. We underline a case of acute pancreatitis complicated by acute coronary syndrome in a patient who presented with chest heaviness, dyspnea, nausea, and worsening epigastric pain associated with vomiting. Clinical and laboratory evaluations and using imaging modalities were suggestive of acute pancreatitis mimicking myocardial infarction (MI) in the absence of coronary artery abnormalities.

Heavily Ossified Soft Tissue Chondroma of Plantar Foot and the Significance of Radiological Imaging: A Case Report

Soft tissue chondroma is a relatively rare, slowly growing, benign cartilaginous tumor. This solitary mass can imitate chondrosarcomas in radiologic and histological characteristics. The diagnosis is hard to establish on clinical presentation and relies on careful radiological examination. The lesion is equally prevalent in both genders and primarily affects people in their forties and sixties. They may occur in any part of the body; however, they are most commonly observed in hand and foot. We report the case of a 61-year-old female who presented with heavily ossified soft tissue chondroma within the plantar fascia of her left foot. A conclusive diagnosis was established via histopathological examination. The chondroma was marginally excised, and the postoperative period was uneventful.

In Silico Analysis of SARS-CoV-2 Spike Proteins of Different Field Variants

Coronaviruses belong to the group of RNA family of viruses that trigger diseases in birds, humans, and mammals, which can cause respiratory tract infections. The COVID-19 pandemic has badly affected every part of the world. Our study aimed to explore the genome of SARS-CoV-2, followed by in silico analysis of its proteins. Different nucleotide and protein variants of SARS-CoV-2 were retrieved from NCBI. Contigs and consensus sequences were developed to identify these variants using SnapGene. Data of the variants that significantly differed from each other was run through Predict Protein software to understand the changes produced in the protein structure. The SOPMA web server was used to predict the secondary structure of the proteins. Tertiary structure details of the selected proteins were analyzed using the web server SWISS-MODEL. Sequencing results showed numerous single nucleotide polymorphisms in the surface glycoprotein, nucleocapsid, ORF1a, and ORF1ab polyprotein while the envelope, membrane, ORF3a, ORF6, ORF7a, ORF8, and ORF10 genes had no or few SNPs. Contigs were used to identify variations in the Alpha and Delta variants of SARS-CoV-2 with the reference strain (Wuhan). Some of the secondary structures of the SARS-CoV-2 proteins were predicted by using Sopma software and were further compared with reference strains of SARS-CoV-2 (Wuhan) proteins. The tertiary structure details of only spike proteins were analyzed through the SWISS-MODEL and Ramachandran plots. Through the Swiss-model, a comparison of the tertiary structure model of the SARS-CoV-2 spike protein of the Alpha and Delta variants was made with the reference strain (Wuhan). Alpha and Delta variants of the SARS-CoV-2 isolates submitted in GISAID from Pakistan with changes in structural and nonstructural proteins were compared with the reference strain, and 3D structure mapping of the spike glycoprotein and mutations in the amino acids were seen. The surprisingly increased rate of SARS-CoV-2 transmission has forced numerous countries to impose a total lockdown due to an unusual occurrence. In this research, we employed in silico computational tools to analyze the SARS-CoV-2 genomes worldwide to detect vital variations in structural proteins and dynamic changes in all SARS-CoV-2 proteins, mainly spike proteins, produced due to many mutations. Our analysis revealed substantial differences in the functionality, immunological, physicochemical, and structural variations in the SARS-CoV-2 isolates. However, the real impact of these SNPs can only be determined further by experiments. Our results can aid in vivo and in vitro experiments in the future.

Non-ST-Segment Elevation Myocardial Infarction As Initial Thrombotic Event of Thrombotic Thrombocytopenic Purpura: A Rare Challenging Case

Thrombotic thrombocytopenic purpura (TTP) is a rare autoimmune and devastating blood disorder that results in micro-clots throughout the body, leading to tissue damage and organ dysfunction resulting in widespread microangiopathic hemolytic anemia, thrombocytopenia, fever, and neurological symptoms. TTP patients commonly manifest renal and neurological symptoms; however, cardiovascular involvement is not widely reported in the literature. We report a case of non-ST-segment elevation myocardial infarction (NSTEMI) as an initial manifestation of TTP. Although rare, TTP complications must be considered among other possible causes of unexpected thrombocytopenia during acute phase treatment of acute coronary syndrome because of high morbidity and mortality.

Impact of second-generation transoral incisionless fundoplication on atypical GERD symptoms: a systematic review and meta-analysis

BACKGROUND AND AIMS

Transoral incisionless fundoplication (TIF) using the EsophyX device (EndoGastric Solutions, Inc, Redmond, Wash, USA) is a minimally invasive endoscopic fundoplication technique. Our study aimed to assess the efficacy of TIF for atypical GERD symptoms in patients with chronic or refractory GERD.

METHODS

A systematic search of 4 major databases was performed. All original studies assessing atypical GERD using a validated symptom questionnaire (the reflux symptom index [RSI]) were included. The RSI score was assessed before and after TIF at a 6- and 12-month follow-up. Data on technical success rate, adverse events, proton pump inhibitor (PPI) use, and patient satisfaction were also collected. Only TIF procedures currently in practice using the EsophyX device (ie, TIF 2.0) and TIF with concomitant hiatal hernia repair were included in the review.

RESULTS

Ten studies (564 patients) were included. At the 6- and 12- month follow-up, there was a mean reduction of 15.72 (95% confidence interval, 12.15-19.29) and 14.73 (95% confidence interval, 11.74-17.72) points, respectively, in the RSI score post-TIF, with a technical success rate of 99.5% and a pooled adverse event rate of 1%. At both time intervals, more than two-thirds of the patients were satisfied with their health condition and roughly three-fourths of the patients were off daily PPIs.

CONCLUSIONS

Our study shows that TIF using the EsophyX device is safe and effective in reducing atypical GERD symptoms at 6 and 12 months of follow-up. It improves patient-centered outcomes and can be a minimally invasive therapeutic option for patients suffering from atypical GERD symptoms on chronic medical therapy.

Estimating the Cost of Production of Two Pentatomids and One Braconid for the Biocontrol of Spodoptera frugiperda (Lepidoptera: Noctuidae) in Maize Fields in Florida

The fall armyworm is a polyphagous lepidopteran pest that primarily feeds on valuable global crops like maize. Insecticides and transgenic crops have long been a primary option for fall armyworm control, despite growing concerns about transgenic crop resistance inheritance and the rate of insecticide resistance development. Global dissemination of the pest species has highlighted the need for more sustainable approaches to managing overwhelming populations both in their native range and newly introduced regions. As such, integrated pest management programs require more information on natural enemies of the species to make informed planning choices. In this study, we present a cost analysis of the production of three biocontrol agents of the fall armyworm over a year. This model is malleable and aimed towards small-scale growers who might benefit more from an augmentative release of natural enemies than a repetitive use of insecticides, especially since, though the benefits of using either are similar, the biological control option has a lower development cost and is more environmentally sustainable.

Investment Trade-Off between Mating Behavior and Tonic Immobility in the Sweetpotato Weevil Cylas formicarius (Coleoptera: Brentidae)

Numerous studies have confirmed that the trade-off between anti-predator behavior and mating behavior occurs in certain insect species. This suggests that insects invest more in anti-predator behavior, and fewer resources or time can be used in mating behavior. However, few studies focus on tonic immobility, an important anti-predator behavior in nature, and different stages in mating behavior. Tonic immobility (TI) is considered to be an important anti-predator behavior. Herein, we investigated the relationship between TI and mating behavior in the sweetpotato weevil (SPW), Cylas formicarius. As the first step, we artificially selected SPWs for the longer duration of TI (L-strain) and the shorter duration of TI (S-strain). The effect of courtship and copulation on the duration of TI in two artificial selection strains was tested. Furthermore, we compared the frequency and duration of two mating behaviors in four kinds of pairs (LF×LM, LF×SM, SF×LM, and SF×SM: LM-L-strain male; SM-S-strain male; LF-L-strain female; SF-S-strain female). Finally, we tested insemination success in four kinds of pairs (male and female SPWs from the L-strain or the S-strain). The courtship and copulation significantly reduced the duration of TI. Pairs with males from the L-strain showed lower frequency and longer duration of courtship than pairs with males from the S-strain. Similarly, males from L-strain pairs showed a longer period of copulation than pairs with males from the S-strain. However, there is no significant difference in the frequency of copulation and the success of insemination. These results support that there was a significant trade-off between TI and courtship as well as copulation in the SPW.

pH-Responsive, Hemocompatible, and Non-Toxic Polysaccharide-Based Hydrogel from Seeds of Salvia spinosa L. for Sustained Release of Febuxostat

Herein, a polysaccharide-based hydrogel from seeds of Salvia spinosa (SSH) was evaluated as a pH-responsive, superporous, hemocompatible, non-toxic, and sustained release material. The SSH-based tablets showed pH-dependent swelling (pH 7.4 > 6.8 > 4.5 > 1.2) as well as swelling and de-swelling behavior at pH 7.4 and 1.2, respectively. Sustained release of febuxostat was achieved by mimicking the gastrointestinal tract conditions for 14 h and following the zero-order kinetics and super case-II transport mechanism. Scanning electron microscopy revealed the porous nature of SSH even after compression. SSH was found to be hemocompatible with antioxidant properties. Acute toxicity studies ensured the safety of SSH at a maximum dose level of 2.0 g kg-1 body weight of the animals. SSH was also found as non-irritant to the eye. The histopathology of vital organs did not show any lesions or inflammation. Conclusively, SSH can be considered a safe ingredient for oral, dermal, and ophthalmic formulations.

Immune Thrombocytopenia and Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Case Report

Mass vaccination against coronavirus disease 2019 (COVID-19) has been safe and effective. The ongoing emergence of vaccine-induced complications has challenged the public trust in vaccination programs and, though uncommon, can lead to significant morbidity and mortality. Vaccine-induced immune thrombocytopenia and thrombosis (VITT) is a rare and fatal complication of the COVID-19 vaccine. We present a rare case of VITT in a young female who presented with worsening headache, body rash with deteriorating neurological deficit after 12 days of the second dose of the ChAdOx1 COVID-19 vaccine. Initial blood tests showed thrombocytopenia with deranged clotting time and D-dimer levels. Her computed tomography venogram showed thrombosis in the left transverse sinus, and she was diagnosed with a provisional diagnosis of VITT. She initially managed with dexamethasone, intravenous immunoglobulins, and apixaban to reverse the autoimmune process. Our case highlights the clinical course, diagnosis, and management of VITT, which will assist physicians in the timely recognition and adequate management of VITT.

The European Nucleotide Archive in 2022

The European Nucleotide Archive (ENA; https://www.ebi.ac.uk/ena), maintained by the European Molecular Biology Laboratory's European Bioinformatics Institute (EMBL-EBI), offers those producing data an open and supported platform for the management, archiving, publication, and dissemination of data; and to the scientific community as a whole, it offers a globally comprehensive data set through a host of data discovery and retrieval tools. Here, we describe recent updates to the ENA's submission and retrieval services as well as focused efforts to improve connectivity, reusability, and interoperability of ENA data and metadata.

Schwannoma of the Ascending Colon in a 22-Year-Old Male: A Case Report

Schwannoma of the ascending colon is an extremely rare neoplasm that is often discovered incidentally in the asymptomatic older population on surveillance colonoscopy. We present the case of a symptomatic 22-year-old male presenting with one month of discomfort in the right lower abdominal quadrant, abdominal bloating, and hematochezia. A sessile polyp measuring 0.5 cm was identified in the ascending colon on the colonoscopy. The polyp was completely resected using cold snare polypectomy. Histological examination of the resected polyp with hematoxylin-eosin staining revealed small nodules of bland spindle cells with focal nuclear condensation. The lesional cells tested positive for S-100 and SOX-10 on immunohistochemical analysis, establishing the diagnosis of benign schwannoma. Since this lesion was submucosal, its diagnosis required an endoscopic biopsy that could only be performed on the mucosa. It was difficult to distinguish it from other mesenchymal tumors (gastrointestinal stromal tumor or leiomyoma), and this makes the differential diagnosis exceedingly challenging. If the immunohistochemistry is positive for S-100 and negative for C-KIT, CD-34, actin, and desmin, it aids in diagnosis. These tumors have non-specific radiological features and are asymptomatic.

ANCA-Negative EGPA With Pulmonary, Cutaneous, and Neurological Manifestations in a 25-Year-Old Male: A Case Report

Eosinophilic granulomatosis with polyangiitis is a systemic vasculitis characterized by the presence of asthma, hyper-eosinophilia, and necrotizing vasculitis with extravascular eosinophilic granulomas. We report the case of a 25-year-old male who presented to the outpatient department complaining of joint aches and numbness in the hands and legs. Physical examination revealed erythematous blanchable macular rashes on palms and soles. Raynaud's phenomenon was also observed. Lab workup revealed elevated WBC count and peripheral blood eosinophilia. Antibody tests were positive only for anti-nuclear antibodies. A diagnosis of eosinophilic granulomatosis with polyangiitis including peripheral neuropathy, arthralgia, rash, and pulmonary manifestations was established. The patient was started on a therapeutic regimen of corticosteroids and immunosuppressants, which halted the progression of the disease. Peripheral neuropathy and arthralgia also improved.

Effects of Three Cultural Practices on Drosophila suzukii (Diptera: Drosophilidae) in Open Blueberry Fields in Florida

The spotted-wing Drosophila (SWD), Drosophila suzukii, is native species in Southeast Asia. For over a decade, this invasive pest has been globally expanding. The economic losses to soft fruits and stoned fruits in the United States are increasing every year. Presently, the only viable tool to reduce the SWD population is the continued use of broad-spectrum insecticides. Pesticide resistance is appearing in the populations for the SWD. Organic farmers have limited options to control this pest in open fields. The major goal of this study was to develop cost-effective pest management strategies to manage the SWD using three types of mulches (two plant-based and one fabric-based) to reduce fly population and damage in open blueberry fields in north Florida. The study was conducted in two fruiting seasons (2017 and 2018). The study results demonstrated that the fly trap catches in 2017 shortleaf pine needle mulch had much higher populations (about 2.5-fold) of the SWD than all other treatments. In 2018, the numbers were about 1.7-fold more on shortleaf pine needle mulch than on other treatments. The fine texture of the mulch (pine needles) can easily facilitate the emergence of the SWD if the mulch is not thick enough. Although the pine needles covered the soil surface, it may have been too thin and thus allowed the SWD adults to emerge from the soil without much hindrance. In 2018, a higher population of the SWD was recorded from all the mulching practices. However, there were no significant differences in trap catches between all treatments. In general, the fly population is reduced with the use of pine bark and black weed fabric mulches. This is the first study that reports the effects of three mulches in controlling the SWD populations, which could benefit conventional and organic blueberry growers.

Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Renal Vasculitis Following COVID-19 Vaccination: A Case Report and Literature Review

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is an immune-mediated disorder of small and medium-sized vessels, characterized by the production of autoantibodies that target the neutrophilic antigens leading to mononuclear cell infiltration and destruction of blood vessels in lungs, skin, and kidneys. Although rare, the coronavirus disease 2019 (COVID-19) vaccine may trigger autoimmune vasculitis. We report a rare case of ANCA-associated renal vasculitis following COVID-19 vaccination in a 59-year-old male who presented with flu-like symptoms and deranged renal function tests. He received his second dose of the Pfizer COVID-19 vaccine 17 days ago. His clinical picture, serological testing, and radiological imaging were concerned with glomerular disease. His serum was positive for ANCAs, and the renal biopsy specimen revealed pauci-immune glomerulonephritis. He was diagnosed with AAV-associated renal vasculitis following COVID-19 vaccination because no other etiology was identified. His clinical improvement after starting rituximab and steroids reinforced the diagnosis.

Dermoid Cyst Spillage Resulting in Chemical Peritonitis: A Case Report and Literature Review

A dermoid cyst, also called a mature teratoma, is a benign tumor of the ovary derived from pluripotent germ cells. It is often asymptomatic; however, it can be expressed by several complications, including infection, adnexal torsion, and rupture. Rarely ovarian dermoid cysts can also transform into malignant degeneration. A ruptured teratoma is a rare and life-threatening complication and may arise spontaneously. However, cystic rupture is often secondary to surgical procedures such as ovarian cystectomy, leading to acute peritonitis and surgical emergency. Herein, we report a case of acute peritonitis in a female resulting from ovarian dermoid cyst spillage. Her clinical picture and radiological imaging were consistent with a ruptured ovarian cyst leading to chemical peritonitis, and a histopathological examination confirmed an ovarian dermoid cyst.

Toll-like Receptor Mediation in SARS-CoV-2: A Therapeutic Approach

The innate immune system facilitates defense mechanisms against pathogen invasion and cell damage. Toll-like receptors (TLRs) assist in the activation of the innate immune system by binding to pathogenic ligands. This leads to the generation of intracellular signaling cascades including the biosynthesis of molecular mediators. TLRs on cell membranes are adept at recognizing viral components. Viruses can modulate the innate immune response with the help of proteins and RNAs that downregulate or upregulate the expression of various TLRs. In the case of COVID-19, molecular modulators such as type 1 interferons interfere with signaling pathways in the host cells, leading to an inflammatory response. Coronaviruses are responsible for an enhanced immune signature of inflammatory chemokines and cytokines. TLRs have been employed as therapeutic agents in viral infections as numerous antiviral Food and Drug Administration-approved drugs are TLR agonists. This review highlights the therapeutic approaches associated with SARS-CoV-2 and the TLRs involved in COVID-19 infection.

Intraguild Interactions of Three Biological Control Agents of the Fall Armyworm Spodoptera frugiperda (JE Smith) in Florida

The fall armyworm, Spodoptera frugiperda (J.E. Smith) (Lepidoptera: Noctuidae), is a maize pest worldwide. Its host range comprises more than 350 reported plant species, and it is the primary insect pest attacking maize in Florida. Global trade has not only assisted but accelerated its invasion into the Eastern Hemisphere. Regular pesticide use promotes resistance in the species; therefore, there is an urgent need for alternative pest management strategies. This study evaluated the interactions of biological control agents within a similar guild. Some of the reported interactions could potentially lead to the integration of these agents within the same niche to increase biological control efficiency against the fall armyworm. We evaluated three biocontrol agents that are natural enemies of Lepidopteran pests, the true bugs Podisus maculiventris and Euthyrhynchus floridanus (Hemiptera: Pentatomidae) and a parasitoid, Cotesia marginiventris (Hymenoptera: Braconidae). Depending on their intraguild interactions, these agents could potentially be useful for biological control of the fall armyworm. The study investigated these three biocontrol agents and concluded that integrating these agents to control the fall armyworm is a possibility; however, only under certain conditions. Investigations were focused on evaluating the predator-parasitoid and devised pairing interactions. Predator response to prey in a choice or no-choice scenario and choices based on olfaction or other bodily cues were studied under experimental laboratory conditions.

An Unusual Bacterial Etiology of Fournier’s Gangrene in an Immunocompetent Patient

Fournier's gangrene (FG) is necrotizing fasciitis that affects the penis, scrotum, or perineum. Males are more likely to get affected by this disease. The most common predisposing risk factors are diabetes, alcoholism, hypertension, smoking, and immunosuppressive disorders. FG is a polymicrobial infection caused by both aerobic and anaerobic bacteria. The most common aerobic organisms are Escherichia coli, Klebsiella, Proteus, Staphylococcus, and Streptococcus. The most common anaerobic organisms are Bacteroides, Clostridium, and Peptostreptococcus. The disease carries high mortality and morbidity, so timely diagnosis and treatment are of utmost importance.

Here, we report a case of a 61-year-old male with a medical history significant for benign prostatic hyperplasia (BPH), who presented to our hospital with fever, watery diarrhea, and painful swelling of the scrotum and penis. The patient was started on piperacillin-tazobactam, vancomycin, and clindamycin. A computed tomography scan of the pelvis showed prostatic enlargement, edema of the penis and scrotum, and air collection within the corpus cavernosum. The patient underwent multiple surgical debridements of the glans penis. Patient wound cultures were positive for Streptococcus anginosus, Actinomyces turicensis, and Peptoniphilus harei. As mentioned earlier, FG is common in diabetic and immunocompromised patients, and infection is usually polymicrobial. Our patient was immunocompetent and his cultures grew atypical organisms.