21st century critical care medicine: An overview

Critical care medicine in the 21st century has witnessed remarkable advancements that have significantly improved patient outcomes in intensive care units (ICUs). This abstract provides a concise summary of the latest developments in critical care, highlighting key areas of innovation. Recent advancements in critical care include Precision Medicine: Tailoring treatments based on individual patient characteristics, genomics, and biomarkers to enhance the effectiveness of therapies. The objective is to describe the recent advancements in Critical Care Medicine. Telemedicine: The integration of telehealth technologies for remote patient monitoring and consultation, facilitating timely interventions. Artificial intelligence (AI): AI-driven tools for early disease detection, predictive analytics, and treatment optimization, enhancing clinical decision-making. Organ Support: Advanced life support systems, such as Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy provide better organ support. Infection Control: Innovative infection control measures to combat emerging pathogens and reduce healthcare-associated infections. Ventilation Strategies: Precision ventilation modes and lung-protective strategies to minimize ventilator-induced lung injury. Sepsis Management: Early recognition and aggressive management of sepsis with tailored interventions. Patient-Centered Care: A shift towards patient-centered care focusing on psychological and emotional well-being in addition to medical needs. We conducted a thorough literature search on PubMed, EMBASE, and Scopus using our tailored strategy, incorporating keywords such as critical care, telemedicine, and sepsis management. A total of 125 articles meeting our criteria were included for qualitative synthesis. To ensure reliability, we focused only on articles published in the English language within the last two decades, excluding animal studies, in vitro/molecular studies, and non-original data like editorials, letters, protocols, and conference abstracts. These advancements reflect a dynamic landscape in critical care medicine, where technology, research, and patient-centered approaches converge to improve the quality of care and save lives in ICUs. The future of critical care promises even more innovative solutions to meet the evolving challenges of modern medicine.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Erratum: Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande [Phys. Rev. Lett. 130, 031802 (2023)]

This corrects the article DOI: 10.1103/PhysRevLett.130.031802.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Unpacking the CNS Manifestations of Epstein-Barr Virus: An Imaging Perspective

Epstein-Barr virus is a ubiquitous herpesvirus that may cause both infective (encephalitis, meningitis, and so forth) and postinfection inflammatory (such as Guillain-Barré syndrome, acute disseminated encephalomyelitis) manifestations in the CNS. Diagnosis of Epstein-Barr virus-related CNS pathologies is often complicated due to a nonspecific clinical presentation and overlap with other infectious and noninfectious causes, both clinically and on imaging. The Epstein-Barr virus is also implicated in several lymphoproliferative disorders in both immunocompromised and immunocompetent hosts. MR imaging is preferred for evaluating the extent of involvement and monitoring therapy response, given its high sensitivity and specificity, though imaging findings may be nonspecific. Herein, we review the imaging spectrum of Epstein-Barr virus-associated CNS disorders.

Study Protocol of the Bladder Adjuvant RadioTherapy (BART) Trial: A Randomised Phase III Trial of Adjuvant Radiotherapy Following Cystectomy in Bladder Cancer

AIMS

To assess the efficacy and safety of adjuvant radiotherapy in patients with high-risk muscle-invasive bladder cancer (MIBC) following radical cystectomy (RC) and chemotherapy.

MATERIALS AND METHODS

The BART (Bladder Adjuvant RadioTherapy) trial is an ongoing multicentric, randomised, phase III trial comparing the efficacy and safety of adjuvant radiotherapy versus observation in patients with high-risk MIBC. The key eligibility criteria include ≥pT3, node-positive (pN+), positive margins and/or nodal yield <10, or, neoadjuvant chemotherapy for cT3/T4/N+ disease. In total, 153 patients will be accrued and randomised, in a 1:1 ratio, to either observation (standard arm) or adjuvant radiotherapy (test arm) following surgery and chemotherapy. Stratification parameters include nodal status (N+ versus N0) and chemotherapy (neoadjuvant chemotherapy versus adjuvant chemotherapy versus no chemotherapy). For patients in the test arm, adjuvant radiotherapy to cystectomy bed and pelvic nodes is planned with intensity-modulated radiotherapy to a dose of 50.4 Gy in 28 fractions using daily image guidance. All patients will follow-up with 3-monthly clinical review and urine cytology for 2 years and subsequently 6 monthly until 5 years, with contrast-enhanced computed tomography abdomen pelvis 6 monthly for 2 years and annually until 5 years. Physician-scored toxicity using Common Terminology Criteria for Adverse Events version 5.0 and patient-reported quality of life using the Functional Assessment of Cancer Therapy - Colorectal questionnaire is recorded pre-treatment and at follow-up.

ENDPOINTS AND STATISTICS

The primary endpoint is 2-year locoregional recurrence-free survival. The sample size calculation was based on the estimated improvement in 2-year locoregional recurrence-free survival from 70% in the standard arm to 85% in the test arm (hazard ratio 0.45) using 80% statistical power and a two-sided alpha error of 0.05. Secondary endpoints include disease-free survival, overall survival, acute and late toxicity, patterns of failure and quality of life.

CONCLUSION

The BART trial aims to evaluate whether contemporary radiotherapy after standard-of-care surgery and chemotherapy reduces pelvic recurrences safely and also potentially affects survival in high-risk MIBC.

Plant-based diet and its effect on coronary artery disease: A narrative review

Coronary artery disease (CAD), a primary component of cardiovascular diseases, is one of the top contributors to mortality rates worldwide. In 2021, dietary risk was estimated to be attributed to 6.58 million cardiovascular deaths. Plant-based diets (PBDs), which encourage higher consumption of plant foods and lower intake of animal-based foods, have been shown to reduce the risk of CAD by up to 29% when compared to non-vegetarian diets in a meta-analysis. This article aims to summarize the array of PBDs and compare them with conventional Western diets that include meat. We review the various proposed mechanisms for how the bioactive nutrients of PBDs aid in preventing atherosclerosis and CAD events, as well as other cardiac diseases. We conducted a detailed search of PubMed using our exclusive search strategy using the keywords plant-based diet, vegan diet, phytosterols, CAD, myocardial ischemia, and atherosclerosis. A total of 162 pertinent articles published within the past decade were identified for qualitative synthesis. To ensure the accuracy and reliability of our review, we included a total of 55 full-text, peer-reviewed articles that demonstrated the effects of plant-based diets on CAD and were written in English. We excluded animal studies, in vitro or molecular studies, and non-original data like editorials, letters, protocols, and conference abstracts. In this article, we emphasize the importance of dietary interventions, such as PBDs, to prevent CAD and their benefits on environmental sustainability. Integrating plant foods and whole grains into one's daily eating habits leads to an increase in the intake of nutrient-rich foods while reducing the consumption of processed food could not only prevent millions of premature deaths but also provide prevention against many chronic gastrointestinal and metabolic diseases.

Study of "ALS reversals": LifeTime environmental exposures (StARLiTE)

We previously reported on a series of patients diagnosed with ALS whom had an extraordinary course defined by substantial and sustained improvement in weakness and function. For this study, twenty-five of these "ALS Reversals" completed extensive environmental exposure questionnaires. These responses were then compared to a large database of prior responses from patients with typically progressive ALS (n = 6187). The results demonstrated that the "Reversal" participants have had a diverse number of exposures with substantial heterogeneity. In general, this was similar to the control group; however, there were a few specific differences that could be further explored in future research.

Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande

We report a search for cosmic-ray boosted dark matter with protons using the 0.37  megaton×years data collected at Super-Kamiokande experiment during the 1996-2018 period (SKI-IV phase). We searched for an excess of proton recoils above the atmospheric neutrino background from the vicinity of the Galactic Center. No such excess is observed, and limits are calculated for two reference models of dark matter with either a constant interaction cross section or through a scalar mediator. This is the first experimental search for boosted dark matter with hadrons using directional information. The results present the most stringent limits on cosmic-ray boosted dark matter and exclude the dark matter-nucleon elastic scattering cross section between 10^{-33}cm^{2} and 10^{-27}cm^{2} for dark matter mass from 1  MeV/c^{2} to 300  MeV/c^{2}.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Meta-analyses of the quantitative computed tomography data in dialysis patients show differential impacts of renal failure on the trabecular and cortical bones

Dialysis patients have compromised bone health that increases their fracture risk due to low bone mass and deterioration in bone microarchitecture. Through meta-analyses of published studies, we conclude that dialysis patients suffer from impaired compartmental bone parameters compared with healthy controls.

INTRODUCTION

We performed meta-analyses to determine the effect of chronic kidney disease (CKD) patients under dialysis on the trabecular and cortical parameters of radius and tibia.

METHODS

This is a meta-analysis of cross-sectional and prospective clinical studies. PubMed, Web of Science, Google Scholar, and Scopus were searched using various permutation combinations. Dialysis patients were compared with non-CKD healthy controls using quantitative computed tomography. High-resolution peripheral quantitative computed tomography (HR-pQCT) and pQCT data of dialysis patients were dissected from eligible studies for pooled analysis of each parameter.

RESULTS

Ten studies met the inclusion criteria that included data from 457 dialysis patients and 2134 controls. Pooled analysis showed a significant decrease (a) in total vBMD at distal radius [standard deviation of the mean (SDM) = -0.842, p = 0.000] and tibia (SMD = -0.705, p = 0.000) and (b) in cortical vBMD (SDM = -1.037, p = 0.000) at radius of dialysis patients compared with control. There were strong correlations between total vBMD and microarchitecture parameters at tibia in dialysis patients.

CONCLUSIONS

At radius and tibia, bone mass, microarchitecture, and geometry at trabecular and cortical envelopes displayed impairments in dialysis patients compared with control. Tibial vBMD may have diagnostic value in dialysis. HR-pQCT and pQCT may be used to further understand the compartmental bones response to CKD-induced loss at different stages of CKD.

LB0003 WITHDRAWING METHOTREXATE AFTER BOTH VERSUS ONLY SECOND DOSE OF THE ChAdOx1 nCoV-19 VACCINE IN PATIENTS WITH AUTOIMMUNE INFLAMMATORY ARTHRITIS: TWO INDEPENDENT RANDOMIZED CONTROLLED TRIALS (MIVAC I AND II)

Background

Pausing methotrexate (MTX) for two to four weeks, improved immunogenicity of influenza vaccination in patients with rheumatoid arthritis (RA), albeit a risk of disease flare (1). This guided the framing of guidelines on MTX withdrawal for COVID-19 vaccination (2). However, evidence for MTX withdrawal for COVID-19 vaccination is limited to observational studies only.

Objectives

To compare the efficacy and safety of holding MTX after each (MIVAC 1) and only after the second dose (MIVAC II) of the ChAdOx1 vaccine versus continuation of MTX in two randomized controlled trials (RCTs).

Methods

Two single centre, investigator-blinded, RCTs were conducted in patients with RA or Psoriatic arthritis (PsA) on stable doses of MTX without prior COVID-19 (CTRI reg. no. MIVAC I: CTRI/2021/07/03463 & MIVAC II: CTRI/2021/07/035307). In MIVAC I, unvaccinated patients were randomised (1:1) to hold or continue MTX for two weeks after each dose of the vaccine. MIVAC II included patients who had continued MTX during the first dose of ChAdOx1 and were randomised (1:1) to hold or continue MTX for 2 weeks after the second vaccine dose. The primary outcome for both the trials was the anti-Receptor Binding Domain (RBD) antibody titres measured four weeks after the second vaccine dose (per protocol analysis). Secondary outcome was the flare rate, defined as an increase in disease activity scores (DAS28/cDAPSA) or physician intent to hike DMARDs.

Results

250 patients were randomized for MIVAC 1 and 178 for MIVAC II and after due exclusions, 158 and 157 were eligible for analysis respectively (Figure 1). In MIVAC I, median anti-RBD titres were significantly high in the MTX hold group [2484 (1050-4388) versus 1147(433-2360), p=0.001] but the flare rate was higher in the hold group [20 (25%) versus 6(8%) p=0.005] compared to continue group. In MIVAC II median anti-RBD titres were significantly high for the MTX hold group [2553 (1792-4823) versus 990 (356-2252), p=0.001] when compared to continue group but there was no difference in the flare rate between the groups [9(11.8%) and 4(7.9%), p=0.15] (Table 1). Since both were parallel studies in similar population, MTX hold arms across both the trials were compared for anti-RBD titres and flare. There was no difference in the anti-RBD titres [p=0.2] between the groups. In MIVAC I, 29(36.25%) patients had reported flare (19 in either first or second dose, 10 for both doses) when compared to MIVAC II where only 9(11.84%) patients had reported flare after the second dose (P <0.001).

Table 1.

Baseline demographics and key results

VariableMIVAC IMIVAC IIMTX HoldMTX ContinuePMTX HoldMTX ContinueP valueN=80N=78valueN=76N=81Age†48 (38-53.3)49 (39-59)0.1953 (42.3-59)53(50-62)0.14Female (%) ‡73 (91.3)75 (96.2)0.3365 (85.5)70 (86.4)>0.99RA (%) ‡69(86.3)69 (93.2)70 (85.6)80 (87.7)PsA (%) ‡11(13.8)6 (8.1)0.316 (7.9)1 (1.2)0.057DAS28†2.7 (2.4-3.2)2.6 (2-3.3)0.62.7(2.3-3.4)2.8 (2.1-3.5)0.78cDAPSA †2(3-4.5)2.5(1.3-3.8)0.463(2.8-3)30.15Prednisolone (%) ‡29 (36.3)23(31.1)0.424(31.6)26 (32.1)>0.99MTX mg/week†17.5 (10-25)15 (10-20)0.05715 (9.4-25)17.5(7.5-25)0.92Anti- RBD antibody titres post second dose (IU/mL) †2484 (1050-4388.8)1147.5 (433.5-2360.3)<0.0012553.5 (1792.5-4823.8)990.5 (356.1-2252.5)<0.001Flare (N%) ‡Post first dose20 (25)6 (8)0.005NANAPost second dose19 (23.8)10(13.3)0.19 (11.8)4 (7.9)0.15

All analysis as per protocol population.

†Median (interquartile range): Mann Whitney U test.

‡ N (%): Fisher Exact test

. Bolded if p<0.05.

Conclusion

Holding MTX after both the doses or only after the second dose of ChAdOx1 yields higher anti-RBD antibody titres as compared to continuing MTX. Comparing across the trials, holding MTX only after the second dose appears to be non-inferior to holding MTX after both doses of the vaccine with a lesser risk of flare.

References

[1]Park JK et al. Clin Rheumatol. 2020 Feb; 39(2):375-379.

[2]Curtis JR, et al. Arthritis & Rheumatology. 2021 Oct;73(10): e60-75.

Acknowledgements

Acknowledgments to all participating investigators, patients and their families

Disclosure of Interests

Anu Sreekanth: None declared, Teny Skaria: None declared, Sneha Joseph: None declared, Rashwith Umesh: None declared, Manju Mohanan: None declared, Aby Paul: None declared, Sakir Ahmed Speakers bureau: Sakir Ahmed had received honorarium as speaker from Pfizer, Dr Reddy’s, Cipla, and Novartis unrelated to this Comment, Pankti Mehta: None declared, Seena Oomen: None declared, Janet Benny: None declared, Justin George: None declared, Anagha Paulose: None declared, K Narayanan: None declared, Sanjana Joseph: None declared, Anuroopa Vijayan: None declared, Kaveri Nalianda: None declared, Padmanabha Shenoy: None declared

Corticosteroids reduce vascular ultrasound sensitivity in fast- track pathways (FTP): results from Coventry Multi-Disciplinary FTP for cranial Giant Cell Arteritis

OBJECTIVES

This study aims to assess the feasibility of the Coventry multidisciplinary fast-track cranial giant cell arteritis (FTGCA) pathway, which was set up in 2013 in collaboration with vascular physiology and ophthalmology to enable prompt multidisciplinary assessment, including ultrasound (US). This study also looks at the impact of prior corticosteroid (CS) use on the performance of US in real life.

METHOD

Data were collected retrospectively for patients who attended the Coventry FTGCA pathway between 1 January 2014 and 31 December 2017. Patients were identified from US lists and clinical details were obtained from electronic medical records.

RESULTS

In total, 620 eligible patients were included in this study. US had a sensitivity of 50%, which improved to nearly 56% in CS-naïve patients. The median duration of CS use prior to US was 2 days, and sensitivity was around 46% in this group. The specificity of US was > 96%, and CS use was avoided completely in 345 patients (56%). CSs negatively impacted on the utility of US, with US more likely to be false negative.

CONCLUSIONS

This novel multidisciplinary pathway demonstrates excellent feasibility and minimizes the use of CSs in patients without giant cell arteritis. US was performed promptly, was cost effective- and had reassuring real-life sensitivity and specificity in this cohort, with excellent patient feedback. CS-naïve patients showed higher sensitivity for US despite the short duration of CS use.

Accuracy of commercially available smartphone applications for the detection of melanoma

Artificial intelligence (AI) has shown promise in the analysis of images for detection of melanoma.¹ The number of available dermatology smartphone applications ("apps") is rapidly growing and there is increasing interest in apps that provide diagnosis or triage of skin lesions.^{2, 3} A 2020 systematic review found that nine studies evaluating six apps had poor study design and high risk of bias.³ To date, no studies have evaluated the accuracy of apps using an independent test set of clinical images comparable to those submitted through smartphones .

Protein disulphide isomerase (PDI) is protective against amyotrophic lateral sclerosis (ALS)-related mutant Fused in Sarcoma (FUS) in in vitro models

Mutations in Fused in Sarcoma (FUS) are present in familial and sporadic cases of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). FUS is localised in the nucleus where it has important functions in DNA repair. However, in ALS/FTD, mutant FUS mislocalises from the nucleus to the cytoplasm where it forms inclusions, a key pathological hallmark of neurodegeneration. Mutant FUS also inhibits protein import into the nucleus, resulting in defects in nucleocytoplasmic transport. Fragmentation of the neuronal Golgi apparatus, induction of endoplasmic reticulum (ER) stress, and inhibition of ER-Golgi trafficking are also associated with mutant FUS misfolding in ALS. Protein disulphide isomerase (PDI) is an ER chaperone previously shown to be protective against misfolding associated with mutant superoxide dismutase 1 (SOD1) and TAR DNA-binding protein-43 (TDP-43) in cellular and zebrafish models. However, a protective role against mutant FUS in ALS has not been previously described. In this study, we demonstrate that PDI is protective against mutant FUS. In neuronal cell line and primary cultures, PDI restores defects in nuclear import, prevents the formation of mutant FUS inclusions, inhibits Golgi fragmentation, ER stress, ER-Golgi transport defects, and apoptosis. These findings imply that PDI is a new therapeutic target in FUS-associated ALS.

Robust Protective Effect of COVID-19 Vaccination in India-Results of Survey in the Midst of Pandemic's Second Wave

Introduction  Our objective was to document the incidence of COVID-19 in vaccinated health care professionals and related personnel.

Method  We conducted an online survey to ascertain the incidence of COVID-19 symptoms, reverse transcriptase polymerase chain reaction (RT-PCR) positivity, effect on normal activity, need for anti-COVID-19 medication, hospitalization, and death among individuals who had completed both doses of COVID vaccination at least 2 weeks earlier.

Results  A total of 351 unique valid responses were received. Among the 340 people who had been vaccinated in India, 5% (17/340) had COVID-19 symptoms, 4.7% (16) became COVID-19 RT-PCR positive, 12 (3.5%) had sickness preventing normal daily activity, 2.65% (9) required anti-COVID-19 medication, and 1.18% (4) required hospitalization. Among family members living with the survey responders, the corresponding incidence was even lower. There was one death in this group.

Discussion  Being health care professionals, the responders would be at higher risk of daily exposure to COVID-19. Even in this high risk group, the vaccine efficacy is good. Vulture journalists should stop spreading fake news and misinformation that makes people hesitate taking the vaccine or be afflicted analysis paralysis. Every person who chooses to remain unvaccinated increases the risk for our entire community. We also need to follow universal precautions (wearing mask, physical distancing, handwashing) diligently without letting down our guard.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

A Systematic Review of Clinical Practice Guidelines for Identification and Management of Frailty

OBJECTIVE

This study aims to appraise and summarize consistent recommendations from clinical practice guidelines (CPGs) for identification and management of frailty to maintain and improve functional independence of elderly population.

METHODS

A systematic search of Ovid MEDLINE, Embase, PubMed, PsycINFO, and CINAHL electronic databases using database-specific search terms in two broad areas "guidelines" and "frailty", and a manual search of websites with the key phrase "frailty guideline" was performed. The inclusion criteria included CPGs focusing on identifying and managing frailty in population >65 years old, published in English since January 2010. Three reviewers independently assessed guideline quality using the AGREE II instrument. Data extraction was performed, followed by compilation and comparison of all recommendations to identify the key consistent recommendations.

RESULTS

Six CPGs met the inclusion criteria; however, only three CPGs had high methodological quality in accordance with AGREE II appraisal. The average AGREE II scores of all six CPGs were: 84.5%, 68%, 46.5%, 81.5%, 56.3%, and 60.2% for domains 1-6 (scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, and editorial independence) respectively. A total of 54 recommendations were identified, with 12 key recommendations suggested frequently by the CPGs.

CONCLUSION

The AGREE II instrument identified strengths and weaknesses of the CPGs, but failed to assess clinical implications and feasibility of the guidelines. Further research is needed to improve clinical relevance of CPGs in the identification and management of frailty. The feasibility in implementing these guidelines with regards to cost-effectiveness of frailty screening warrants further investigation.

Sparing the hippocampus and the hypothalamic- pituitary region during whole brain radiotherapy: a volumetric modulated arc therapy planning study

BACKGROUND

Feasibility testing of a simultaneous sparing approach of hippocampus, hypothalamus and pituitary gland in patients undergoing whole-brain radiotherapy (WBRT) with and without a concomitant boost to metastatic sites.

INTRODUCTION

Cognitive impairment and hormonal dysfunction are common side effects of cranial radiotherapy. A reduced dose application to the patho-physiologically involved functional brain areas, i.e. hippocampus, hypothalamus and pituitary gland, could reduce these common side effects. While hippocampal sparing is already a common practice to improve cognitive outcome, technical experience of additional combined sparing of the hypothalamus/pituitary gland (HT-P) is insufficient.

METHODS

Twenty patients were included in the planning study. In 11 patients, a total dose of 36 Gy of WBRT (2 Gy per fraction) plus a simultaneous integrated boost (SIB) of 9 Gy (0.5 Gy per fraction, total dose: 45 Gy) to the brain metastases was applied. In 9 patients, prophylactic cranial irradiation (PCI) was simulated with a total dose of 30 Gy (2 Gy per fraction). In both patient cohorts, a sparing approach of the hippocampus and the HT-P area was simulated during WBRT. For all treatment plans, volumetric modulated arc therapy (VMAT) was used. Quality assurance included assessment of homogeneity, conformality and target coverage.

RESULTS

The mean dose to the hippocampus and HT-P region was limited to less than 50% of the prescribed dose to the planning target volume (PTV) in all treatment plans. Dose homogeneity (HI) of the target volume was satisfying (median HI = 0.16 for WBRT+SIB and 0.1 for PCI) and target coverage (conformation number, CN) was not compromised (median CN = 0.82 for SIB and 0.86 for PCI).

CONCLUSION

Simultaneous dose reduction to the hippocampus and the HT-P area did not compromise the PTV coverage in patients undergoing WBRT+SIB or PCI using VMAT. While the feasibility of the presented approach is promising, prospective neurologic, endocrine outcome and safety studies are required.

FRI0252 HIGH EARLY MORTALITY IN IDIOPATHIC INFLAMMATORY MYOPATHIES: RESULTS FROM INCEPTION COHORT AT A TERTIARY CARE CENTER IN NORTHERN INDIA

Background:

The idiopathic inflammatory myopathies (IIM) lead to significant morbidity and mortality. Understanding short term outcomes is the 1st step towards addressing risk factors for poor prognosis.

Objectives:

To assess the response to therapy, disease and treatment related morbidity and mortality in an inception cohort of IIM and determine the predictors of early mortality.

Methods:

Sixty-nine patients with a physician diagnosis of IIM as per 2017 ACR/EULAR classification criteria were recruited into an inception cohort from Dec 2017 to Nov 2019. Their follow-up data was recorded from June 2019 to December 2019.

Clinical, laboratory and outcome variables were recorded as delineated in Figure 1A. Baseline characteristics were compared between deaths versus survivors, responders versus non-responders and those with and without major infections.

Results are expressed as median (IQR). SPSS, v23, IBM 2010 was used for statistical analysis.

Results:

Of the 69 (54 female and 15 male) patients of median age 40 (23-51) and disease duration 3 (IQR 1-6) months, Dermatomyositis (DM) was the most common subset 26 (37.6%) (Fig, 1B). Myositis Specific and Myositis Associated Antibody (MSA and MAA) were positive in 30 (43.4%) and 11 (17%) respectively (Fig. 1 C).

Forty-eight patients followed-up over 10 (IQR 4.5-13) months accounting for 473 patient years, of which 8 (16.6%) suffered mortality and three PM were reclassified (Fig, 1B). Four (10%) had minimal, 3 (7.5%) had moderate and 33 (82.5%) had a major clinical response (Fig. 2A) with treatment. Eight (20%) of the 40 who survived had a relapse and 13 (32.5%) had steroid related complications. Eleven (27.5%) had at least 1 infection and it correlated with duration of steroid use (p-0.009, RR 0.78, 0.6-0.9) but not the cumulative dose of steroid (p-0.147)

Duration of symptoms prior to treatment, subtype of myositis, MSA or presence of ILD did not predict the short-term response.

6-month survival was 83.3% (Figure 2B). Rapidly progressive ILD was the most common cause of death followed closely by malignancy and infection (n=3, 37.5%)(Table 1). Diagnosis of Cancer associated myositis (OR 6.1), positive anti-MDA5 (OR 5.8) and a negative ANA (OR 5.8) were predictors of early mortality.

Table 1.

Clinical details of the 8 patients who died on follow up.

Case No.Diagn-osisGen-derAge at disease onset (y)Duration of disease in monthsMSAMAACause of deathPlace of death1DMM574Anti-MDA 5Anti- Ro 52RP ILDHospital2DMM5312NegativeNegativeDisseminated TuberculosisHospital3DMF686Anti-TIF 1 yNegativeMalignancyHome4JDMF141NegativeNegativeRP ILDHospital5OMF431NegativeAnti-PM/SclUnclearHome6OMF456Anti-Jo 1Anti- Ro 52LRTIHome7DMM801NegativeAnti- Ro 52MalignancyHome8DMF313Anti-MDA 5NegativeRP ILDHospital

DM- Dermatomyositis, JM- Juvenile Dermatomyositis, OM- Overlap Myositis, M- Male, F- Female, MSA- Myositis Specific Autoantibodies, MAA- Myositis Associated Autoantibodies, RP ILD- Rapidly Progressive Interstitial Lung Disease, LRTI- Lower Respiratory Tract Infection

Conclusion:

Indian patients with IIM suffer high early mortality attributable to RP ILD, cancer and infections.

Positive anti-MDA 5 and a negative ANA predict poor survival.

Acknowledgments:

Muscle Autoantibody testing was funded by APLAR.

Disclosure of Interests:

None declared

SAT0515 COMPLEX HYPERMOBILITY EHLERS-DANLOS SYNDROME (HEDS): MAPPING THE PATIENT’S JOURNEY OVER 40 MONTHS IN A TERTIARY REFERRAL CENTRE

Background:

Ehlers-Danlos Syndromes are heritable connective tissue disorders.They are multisystemic and patients can present with several symptoms such as joint pain and instability, visceral and autonomic dysfunction, as well as significant psychosocial sequela. Managing this cohort of young patients is usually challenging as many patients present late due to delayed diagnosis, often with several complications, problems with mobility and opioid use. Furthermore, there is often a prolonged lack of coordinated healthcare and access to social care services. A recent parliamentary debate in the U.K. highlighted that hEDS services are excluded from specialist Rheumatology commissioning services. In order to ascertain the relevance and utility of specialist services in this population, we conducted this study.

Objectives:

The objective of this study was to map the patient experience following a referral to the specialist clinic in order to assess the need for an integrated, multidisciplinary approach to treating patients with hypermobility EDS.

Methods:

We retrospectively reviewed the records of 50 patients with the diagnosis of hypermobility EDS who were seen in a specialist hypermobility clinic at University College Hospital UCLH between January 2016 and March 2016. Relevant data was collected regarding their medical care in our hospital up to October 2019.

Results:

The median age was 37 (range 21-59). We had 10 males and 40 females. The diagnosis of hypermobility EDS was based on the 1997 criteria as these patients were seen prior to the 2017 classification. Overall, the study yielded 6 key themes: 1. All patients experienced chronic pain, with 36% reporting use of opioids for pain management. 2. Patients were referred to multiple medical specialities within the same hospital trust, (22% patients were referred to ≥5 specialities). 3. Patients required a high number of follow up appointments (28% of patients required ≥20 follow-up visits). 4. Failed discharges were common; patients were often referred back to the Rheumatology Clinic despite being discharged to primary care. 5. Patients had a significant number of comorbidities, reflected by polypharmacy. (36% of patients were prescribed ≥5 medications). 6. Disability was high (20% of patients reported severe mobility problems).

Conclusion:

This study shows that patients with hEDS referred to UCLH have significant levels of disability, opioids use and polypharmacy especially for a relatively young population of patients. They need a complex interdisciplinary approach in a timely manner. In order to minimise delays and allow earlier diagnosis and intervention, we have recently adopted a multidisciplinary team approach, including pain specialists, rheumatologists, psychologists, physiotherapists, nurse specialists, urogynaecologists and neurogastroenterologists. This allows more coordinated and efficient care and incorporates an EDS-specific pain management programme. Specialised services for complex hEDS cases should be established and adequately resourced. Moreover, it would be cost effective to commission a patient-centred “one-stop-shop” service, where patients, who often travel from long distances with severe disabilities, can be seen by multiple specialities in a single visit.

References:

[1]Bennett, S., Walsh, N., Moss, T. and Palmer, S. (2019). Understanding the psychosocial impact of joint hypermobility syndrome and Ehlers–Danlos syndrome hypermobility type: a qualitative interview study. Disability and Rehabilitation, pp.1-10. Healthwatch Calderdale. (2019). Hypermobility Syndromes Project - Healthwatch Calderdale.

[2]Tinkle, B., Castori, M., Berglund, B., Cohen, H., Grahame, R., Kazkaz, H. and Levy, H. (2017). Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 175(1), pp.48-69.

Disclosure of Interests:

None declared

OP0150 WHAT IS THE ROLE OF TEMPORAL ARTERY BIOPSY IN GIANT CELL ARTERITIS FAST-TRACK PATHWAYS WHEN TEMPORAL ARTERY ULTRASOUND IS NEGATIVE?

Background:

A number of centres are now running fast track pathways for diagnosis and management of Giant cell arteritis with ultrasound as the first port of call for diagnosis1. Temporal artery biopsies (TABs) have become the second line of investigation, and it is unclear how useful TAB is in this setting.

Objectives:

This study looked at accuracy of Temporal artery biopsy (TAB) in patients with suspected Giant Cell arteritis (GCA) with negative/inconclusive ultrasound (U/S) and how duration of treatment on steroids prior to these investigations and arterial specimen size affected it.

Methods:

Prospective study of all patients with suspected GCA referred for TAB when U/S was negative or inconclusive, as part of the local fast-track pathway (Coventry). Database included clinical findings, serological work up, U/S and TAB results and treatment. Sensitivity and specificity of U/S and TAB was calculated and compared based on duration of treatment with steroids.

Results:

One hundred and nine patients were referred for TAB via Coventry fast-track-pathway. The sensitivity of U/S in this cohort of patients was 9.08% and specificity was 93.33%. After 3 days of steroid this was 0% and 100% respectively. For TAB when done within 10 days of starting steroids, this was 65% and 87.5% respectively. After 20 days of steroids this was 0 % and 100%. The sensitivity and specificity was 20% and 85% when arterial specimen size was 11-15mm and 47% and 100% when specimen size was 16 mm or more. Sensitivity and specificity of U/S of 644 suspected GCA patients was 48% and 98%.

Conclusion:

Our study demonstrates that TAB plays a relevant role in GCA fast-track-pathways, when U/S is negative/inconclusive. TAB was more sensitive than U/S in this cohort of patients, but overall sensitivity of U/S was higher when calculated for all patients suspected with GCA. Both remain useful tests if performed early. TAB specimen size should ideally be 16mm or more and done within 10 days of starting steroids.

References:

[1]Jonathan Pinnell, Carl Tiivas, Kaushik Chaudhuri, Purnima Mehta, Shirish Dubey, O38 The diagnostic performance of ultrasound Doppler in a fast-track pathway for giant cell arteritis,Rheumatology, Volume 58, Issue Supplement_3, April 2019, kez105.036,https://doi.org/10.1093/rheumatology/kez105.036

Disclosure of Interests:

None declared

OP0200 PATIENTS WITH HYPERMOBILITY RELATED DISORDERS HAVE A SIGNIFICANT NUMBER OF ORTHOPAEDIC INTERVENTIONS ON MULTIPLE SITES AND AT A YOUNG AGE: DATA FROM A TERTIARY REFERRAL CENTRE

Background:

Mechanisms of pain associated with joint hypermobility are poorly understood and include nociceptive pain from structural joint changes along with soft tissue injuries linked to impaired proprioception; central sensitisation associated with chronic pain and muscle weakness alongside deconditioning. Anxiety and depression are also thought to play a role in patients presenting with pain and hypermobility. We have observed an increase in the rate of orthopaedic surgical procedures undertaken in patients attending the hypermobility clinics compared to those attending the general rheumatology and chronic pain clinics. There is limited published data regarding orthopaedic interventions in patients with hypermobility related disorders especially those with confirmed genetic mutations.

Objectives:

We aimed to evaluate the characteristics of patients in our hypermobility cohort focusing on those who had received prior surgical intervention in order to understand the underlying mechanism behind their presentations.

Methods:

A retrospective review of medical records was conducted of patients attending a hypermobility clinic at our tertiary referral centre, University College London Hospital, between January 2018 and December 2018.

Results:

There were 350 patients (300 females, 50 males) with a mean age of 36 years (range 18-71 years). 63% had a diagnosis of Hypermobility Spectrum Disorder or Hypermobility Syndrome and 37% had a type of Ehlers-Danlos Syndromes (EDS) (hypermobile, classical, vascular or other rare type). 46 patients (13%) had documented genetic mutations. 83 patients (24%) had undergone orthopaedic interventions including 9 who had EDS with confirmed genetic mutations. 54% of patients who had surgical intervention were under the age of 40. The total number of surgical procedures in the cohort was 227 (equating to 0.6485 interventions per patient). Of those requiring operative intervention, the average number of interventions per patient was 2.73. One third of patients had surgery on two or more joint groups, including 8 patients (2%) who had surgery in four or more joint groups. Knees (24%) and hips (23%) were the most common sites for operative intervention with 9% having surgery on their shoulders. 29% of pts had significant hypermobility with a Beighton score of 7 and above but there was no correlation between Beighton score and number of surgical procedures. Only 2% of cases were referred from an orthopaedic team thereby excluding a referral bias.

Conclusion:

Patients with hypermobility related disorders have a significant number of orthopaedic surgical procedures on multiple sites and at a young age, with indication of mechanical pathology playing an important role in their symptoms. The Beighton score does not appear to be a reliable predictor of surgical intervention. This is not surprising given that the score only covers 5 joint areas and excludes common surgical sites such as the hips and shoulders. Early diagnosis and a holistic non-operative approach combining physiotherapy and chronic pain management is essential to reduce the need for multiple surgical procedures.

References:

[1]Chopra P, Tinkle B, Hamonet C, Brock I, Gompel A, Bulbena A, et al. Pain management in the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet [Internet]. 2017 [cited 2020 Jan 27];175(1):212–9. Available from:http://www.ncbi.nlm.nih.gov/pubmed/28186390

[2]Shirley ED, Demaio M, Bodurtha J. Ehlers-danlos syndrome in orthopaedics: etiology, diagnosis, and treatment implications. Sports Health [Internet]. 2012 Sep [cited 2019 Jan 30];4(5):394–403. Available from:http://www.ncbi.nlm.nih.gov/pubmed/23016112

Disclosure of Interests:

None declared

Are hypothalamic- pituitary (HP) axis deficiencies after whole brain radiotherapy (WBRT) of relevance for adult cancer patients? - a systematic review of the literature

Background

Cranial radiotherapy (cRT) can induce hormonal deficiencies as a consequence of significant doses to the hypothalamic-pituitary (HP) axis. In contrast to profound endocrinological follow-up data from survivors of childhood cancer treated with cRT, little knowledge exists for adult cancer patients.

Methods

A systematic search of the literature was conducted using the PubMed database and the Cochrane library offering the basis for our debate of the relevance of HP axis impairment after cRT in adult cancer patients. Against the background of potential relevance for patients receiving whole brain radiotherapy (WBRT), a particular focus was set on the temporal onset of hypopituitarism and the radiation dose to the HP axis.

Results

Twenty-eight original papers with a total of 1728 patients met the inclusion criteria. Radiation doses to the HP area ranged from 4 to 97 Gray (Gy). Hypopituitarism incidences ranged from 20 to 93% for adult patients with nasopharyngeal cancer or non-pituitary brain tumors. No study focused particularly on hypopituitarism after WBRT. The onset of hypopituitarism occurred as early as within the first year following cRT (range: 3 months to 25.6 years). However, since most studies started follow-up evaluation only several years after cRT, early onset of hypopituitarism might have gone unnoticed.

Conclusion

Hypopituitarism occurs frequently after cRT in adult cancer patients. Despite the general conception that it develops only after several years, onset of endocrine sequelae can occur within the first year after cRT without a clear threshold. This finding is worth debating particularly in respect of treatment options for patients with brain metastases and favorable survival prognoses.

Transdermal Microneedles-A Materials Perspective

Transdermal drug delivery is an emerging field in the pharmaceutical remit compared with conventional methods (oral and parenteral). Microneedle (MN)-based devices have gained significant interest as a strategy to overcome the skin's formidable barrier: the stratum corneum. This approach provides a less invasive, more efficient, patient friendly method of drug delivery with the ability to incorporate various therapeutic agents including macromolecules (proteins and peptides), anti-cancer agents and other hydrophilic and hydrophobic compounds. This short review attempts to assess the various materials involved in the fabrication of MNs as well as incorporation of other excipients to improve drug delivery for novel medical devices. The focus will be on polymers, metals and other inorganic materials utilised for MN drug delivery, as well as their application, limitations and future work to be carried out.

Successful transplantation of transfected enriched buffalo (Bubalus bubalis) spermatogonial stem cells to homologous recipients

Genetic modification of spermatogonial stem cells (SSCs) is an alternative method to pronuclear microinjection and somatic cell nuclear transfer for transgenesis in large animals. In the present study, we optimized the process of homologous SSC transplantation in the water buffalo (Bubalus bubalis) using transfected enriched SSCs generated by a non-viral transfection approach. Firstly, the SSC enrichment efficiencies of extracellular matrix components viz. collagen, gelatin, and Datura stramonium agglutinin (DSA) lectin were determined either individually or in combination with Percoll density gradient centrifugation. The highest enrichment was achieved after differential plating with DSA lectin followed by Percoll density gradient centrifugation. Nucleofection showed greater transfection efficiency (68.55 ± 4.56%, P < 0.05) for enriched SSCs in comparison to fugene HD (6.7 ± 0.25%) and lipofectamine 3000 (15.57 ± 0.74%). The transfected enriched SSCs were transplanted into buffalo males under the ultrasound guidance and testis was removed by castration after 7-8 weeks of transplantation. Persistence and localization of donor cells within recipient seminiferous tubules was confirmed using fluorescent microscopy. Further confirmation was done by flow cytometric evaluation of GFP expressing cells among those isolated from two-step enzymatic digestion of recipient testicular parenchyma. In conclusion, we demonstrated for the first time, generation of buffalo transfected enriched SSCs and their successful homologous transplantation in buffaloes. This study represents the first step towards genetic modifications in buffaloes using SSC transplantation technique.

Comparative analysis of buffalo (Bubalus bubalis) non-transgenic and transgenic embryos containing human insulin gene, produced by SCNT

Somatic cell nuclear transfer (SCNT), using transgenic donor cells, is a highly efficient method for producing transgenic embryos. We compared the developmental competence, quality and gene expression of transgenic embryos produced by Hand-made cloning from buffalo fetal fibroblasts (BFFs) containing human insulin gene, with non-transgenic embryos produced from BFFs (Controls). The expression vector (pAcISUBC), constructed by inserting human insulin gene between DNA fragments containing mammary gland-specific buffalo β-lactoglobulin (buBLG) promoter and terminator buBLG 3'UTR regions into pAcGFP-N1 vector, was used for obtaining the 11 kb insert for transfection of BFFs by nucleofection. Presence of the transgene in embryos was confirmed by examining GFP expression by RT-PCR and immunofluorescence. The blastocyst rate was lower (P < 0.05) for transgenic embryos than for controls (35.7 ± 1.8% vs 48.7 ± 2.4%). The apoptotic index was higher (P < 0.05) for transgenic than for control blastocysts which, in turn, was higher (P < 0.05) than for IVF counterparts (6.9 ± 0.9, 3.8 ± 0.5 and 1.8 ± 0.3, respectively). The total cell number was similar for transgenic and non-transgenic blastocysts (143.2 ± 17.0 and 137.2 ± 7.6, respectively). The expression level of pro-apoptotic genes BAX and BID but not that of CASP3 and CASP9, and cell cycle check point control-related gene P53 was higher (P < 0.05), and that of development- (IGF-1R and G6PD) and pluripotency-related gene NANOG was lower (P < 0.05) in transgenic than in control embryos. The expression level of epigenetic-related genes DNMT1, DNMT3a and HDAC1 and pluripotency-related gene OCT4 was similar in the two groups. The expression level of BAX, BID, CASP9, P53, DNMT1 and DNMT3a was higher (P < 0.05) and that of OCT4, NANOG IGF-1R and G6PD was lower (P < 0.05) in cloned transgenic than in IVF blastocysts whereas, that of CASP3 and HDAC1 was similar between the two groups. In conclusion, these results suggest that transgenic embryos produced by SCNT have lower developmental competence and quality, and altered gene expression compared to non-transgenic embryos.

Practical consensus recommendation on when to do BRCA testing

BRCA-mutation associated breast cancer and to future cancer risks and sensitivity to systemic therapies. Now that rapid genetic testing for BRCA1 and BRCA2 mutations is available, BRCA mutation status can be considered when making treatment and prevention decisions for BRCA testing, BRCA mutation carriers with breast cancer. Expert group used data from published literature, practical experience, and opinion of a large group of academic oncologists, to arrive at practical consensus recommendations for use by the community oncologists.

Xpert(®) MTB/RIF for improved case detection of extra-pulmonary TB in a tertiary care setting in urban India

SETTING

Department of microbiology at a tertiary care hospital, Mumbai, India.

OBJECTIVE

To determine 1) the sensitivity and specificity of the Xpert(®) MTB/RIF assay in comparison with microscopy and culture in extra-pulmonary tuberculosis (EPTB), and 2) the number of additional cases of EPTB and rifampicin (RMP) resistance detected using this assay.

DESIGN

The study was conducted from July 2013 to April 2015. All consecutive patients with clinically suspected EPTB referred for microscopic examination to the Department of Microbiology that were sufficient in specimen volume were included in the study.

RESULTS

Of the 728 specimens included in the study, respectively 5.5%, 23.5% and 20.9% were positive on smear, culture and Xpert. Compared to culture, Xpert had a sensitivity of 84.2% (95%CI 81.4-86.6) and specificity of 98.2% (95%CI 90-104). All specimens with high and medium load on assay were positive on culture; 28 (18.4%) specimens were RMP-resistant and 124 (81.6%) were Xpert-susceptible. No additional RMP-resistant cases were detected using Xpert as compared to phenotypic drug susceptibility testing.

CONCLUSION

The ability of the Xpert assay to rapidly detect a significantly greater number of bacteriologically confirmed EPTB cases, including RMP-resistant cases, makes it an important diagnostic tool in a TB-endemic country.

209 PRODUCTION OF BUFFALO (BUBALUS BUBALIS) EMBRYOS CONTAINING HUMAN LYSOZYME GENE

Lysozyme is a ubiquitous enzyme found in all major taxa of living organisms with a diverse role in human and animal health. It plays an important role as a nonspecific immune factor and anti-inflammatory factor and is a part of the innate immune system. Research on the expression of recombinant human lysozyme is, thus, potentially valuable to the dairy industry. Therefore, the present study was carried out to observe the developmental competence and quality of cloned embryos containing the human lysozyme gene. Primary fetal fibroblast cells were obtained from a slaughterhouse-derived fetus. The initial passage cells were transfected with pAchLYZ vector containing human lysozyme gene and green fluorescence protein (GFP) via nucleofection, lipofectamine, and FuGene (Roche Diagnostics, Indianapolis, IN, USA). Transfected cells were selected by adding G418 (400–800 µg µL−1), which selectively killed the nontransfected cells in culture. The presence of hLYZ gene in transfected cells was confirmed by PCR amplification of this gene. For cloned embryo production, reconstructs were formed with 2 enucleated demi oocyte fused with 1 donor cell of hLYZ transfected cells or nontransfected fibroblast cells. Gene expression in the resulting embryos was assessed for apoptosis (BID, BAX, and BCL-XL) and development- (G6PD, IGF1R, and FGF) and pluripotency-related (OCT4, SOX2, and NANOG) genes. The transfection efficiency of the cells by nucleofection methods was the highest and toxicity to the cells was minimum as compared with chemical methods. Transfected cells expressed GFP within 48 to 72 h of transfection. When these cells were passaged the intensity of GFP expression was reduced and the reduced level was maintained in subsequent passages. A total of 114 and 60 reconstructed embryos were produced using transfected and nontransfected cells, respectively. When transfected cells were used, the cleavage, 4 cell, 8 to 16 cell, morula, and blastocyst rate was 62.01 ± 4.78, 43.54 ± 3.93, 27.69 ± 4.44, 24.55 ± 5.12, and 22.87 ± 5.39%, respectively, whereas rates were 73.34 ± 2.36, 68.34 ± 4.82, 59.89 ± 2.39, 46.44 ± 2.64, and 36.36 ± 2.53% for nontransfected cells, respectively. The cleavage rate had no significant (P < 0.05, Student’s t-test) difference in both type of donor cells but all other stages [i.e. 4 cell, 8 to 16 cell, morula, and blastocyst rate was significantly (P < 0.05) lower with transfected cells]. Most of the transgenic cloned embryos expressed GFP and integrated with hLYZ gene. We found that proapoptotic gene (BID and BAX) expression did not differ, whereas BCL-XL expression was significantly low (P < 0.05) in transgenic embryos. The development- (G6PD, IGF1R, and FGF) and pluripotency-related (OCT4, SOX2, and NANOG) gene expression was significantly (P < 0.05) lower in transgenic embryos. In conclusion, transgenic cloned embryo successfully developed up to the blastocyst stage in the preliminary study for producing genetically modified animal with human milk components having antimicrobial activity, which would be potentially valuable for human as well as animal health.

208 PRODUCTION OF TRANSGENIC CLONED BUFFALO (BUBALUS BUBALIS) EMBRYOS CONTAINING HUMAN INSULIN GENE THROUGH HAND-GUIDED CLONING

Diabetes is a growing disease worldwide and has emerged as a major healthcare problem in India. Insulin is an essential medicine for the treatment of diabetes. Large dairy animals, such as buffaloes and cows, may be used as bioreactors for cost-effective production of human insulin. The present study was aimed to produce transgenic buffalo embryos containing the human insulin gene through hand-guided cloning for production of transgenic animals. Buffalo female fetal fibroblast cells at passage number 3 were transfected using mammary gland- specific expression vector containing the human insulin gene under buffalo β-lactoglobulin promoter by nucleofection method and cultured with G418 drug for 3 weeks to obtain positive transgenic cell clones. Transgene integration into buffalo female fetal fibroblast genome was confirmed by PCR and Southern blotting. Nontransfected and transgene integrated cells were used as nuclear donors to produce embryos by the hand-guided cloning technique. The developmental competence and quality of embryos as judged by total cell number and TUNEL assay were compared among transgenic and nontransgenic (control) embryos. The blastocyst rate was lower (P < 0.05) for transgenic embryos than that of nontransgenic cloned embryos (35.97 ± 2.16 v. 45.80 ± 4.11, respectively). The apoptotic index was found to be lower (P < 0.05) for control blastocysts than that for transgenic blastocysts. However, the total cell number was similar (P < 0.05) among transgenic and control cloned blastocysts. Thus, transgenic cells, and subsequently transgenic embryos containing the human insulin gene, were successfully produced and transferred in recipients. In the future, these may be used for production of transgenic buffalo expressing human insulin in its milk and thus can be further utilised in large-scale production of human insulin.