Chronic pain, chronic stress and substance use: overlapping mechanisms and implications

Chronic pain is among the most common reasons adults in the U.S. seek medical care. Despite chronic pain's substantial impact on individuals' physical, emotional, and financial wellness, the biologic underpinnings of chronic pain remain incompletely understood. Such deleterious impact on an individuals' wellness is also manifested in the substantial co-occurrence of chronic stress with chronic pain. However, whether chronic stress and adversity and related alcohol and substance misuse increases risk of developing chronic pain, and, if so, what the overlapping psychobiological processes are, is not well understood. Individuals suffering with chronic pain find alleviation through prescription opioids as well as non-prescribed cannabis, alcohol, and other drugs to control pain, and use of these substances have grown significantly. Substance misuse also increases experience of chronic stress. Thus, given the evidence showing a strong correlation between chronic stress and chronic pain, we aim to review and identify overlapping factors and processes. We first explore the predisposing factors and psychologic features common to both conditions. This is followed by examining the overlapping neural circuitry of pain and stress in order to trace a common pathophysiologic processes for the development of chronic pain and its link to substance use. Based on the previous literature and our own findings, we propose a critical role for ventromedial prefrontal cortex dysfunction, an overlapping brain area associated with the regulation of both pain and stress that is also affected by substance use, as key in the risk of developing chronic pain. Finally, we identify the need for future research in exploring the role of medial prefrontal circuits in chronic pain pathology. Critically, in order to alleviate the enormous burden of chronic pain without exacerbating the co-occurring substance misuse crisis, we emphasize the need to find better approaches to treat and prevent chronic pain.

Inhibition and eradication of Pseudomonas aeruginosa biofilms by secondary metabolites of Nocardiopsis lucentensis EMB25

Millions of people worldwide have been impacted by biofilm-associated disorders, which are impregnable owing to frequent changes in surface antigens and gene expression. Globally, about 11% of nosocomial infections, including cystic fibrosis, chronic wound infections, and post-surgical infections, are caused by Pseudomonas aeruginosa, the most prevalent Gram-negative bacterial species. Moreover, biofilms are highly resistant to the host's immune system, and exhibit increased tolerance to stress factors such as starvation, dehydration, and antimicrobials. Here, we have isolated a rare halophilic actinobacteria, Nocardiopsis lucentensis EMB25, and utilized the secondary metabolites for inhibition and eradication of P. aeruginosa biofilm. For the first time, N. lucentensis EMB25 bacteria was explored to study the anti-effect of secondary metabolites on pre-established biofilm. The secondary metabolites targeted the quorum sensing pathway and were found to bind to LasR and RhlR, as confirmed via molecular docking. Also, the reduction in virulence factors, rhamnolipids and pyocyanin further supported the study as these two are regulated by LasR and RhlR. In addition, the downregulation of various QS system genes lasA, lasB, rhlA, rhlB, and pqsA confirmed that the secondary metabolites act on two main regulators of the quorum sensing pathway, LasR, and RhlR. The findings of this study support the bioprospecting of previously unknown and extreme-condition actinobacteria as a rich source of novel bioactives against infections caused by bacterial biofilms.

P11.24.A The anisotropic component of the decomposed diffusion tensor predicts overall survival in patients with glioblastoma

Background

The diffusion tensor can be decomposed into isotropic (DTI-p) and anisotropic (DTI-q) components (Peña et al., 2006). Regions of DTI-q abnormality have a high tumour burden and increased surgical resection of abnormal DTI-q positively correlates with overall survival (OS) (Yan et al., 2017). We aimed to establish if median voxel DTI-q (MVQ) or a distribution measure of DTI-q (DMQ) could act as a neuro-imaging biomarker, to predict OS in patients with glioblastoma.

Material and Methods

Diffusion tensor decomposition was used to create DTI-p and DTI-q maps, using FSL software (FMRIB Software Library, Oxford). MVQ and DMQ (the 95th centile minus the 5th centile of the DTI-q distribution, divided by the MVQ) were calculated from the preoperative whole brain (WB), contrast-enhancing (CE), and non-contrast-enhancing (NCE) hemisphere DTI-q maps, using fslstats, for 33 patients with glioblastoma. Using R Studio, multiple linear regression (MLR) models were computed to establish if MVQ or DMQ of the WB, CE and NCE hemispheres or age, significantly predicts OS. The Breusch-Pagan Test, on package “lmtest” in R, was calculated for all MLR models, to determine if heteroscedasticity was present and, if so, bootstrapped multiple regression (BMR) models were computed using package “boot” in R.

Results

Evidence for heteroscedasticity was present in MLRs that modelled the relationship between DMQ of WB, age, and OS (BP = 6.032, p = 0.014) and DMQ of CE hemisphere, age, and OS (BP = 7.163, p = 0.028). In the BMR of WB DMQ, age, and OS, the 95% bias-corrected accelerated confidence intervals (BCa-CI) for the WB DMQ regression coefficient was 133.5 - 1851.4 and included the WB DMQ estimated coefficient of 803.9. The BMR of CE hemisphere DMQ, age, and OS, computed a 95% BCa-CI for the CE hemisphere DMQ coefficient of 101.8 - 1579.6, containing the CE hemisphere DMQ coefficient estimate of 612.414. For both BMRs, the 95% BCa-CI for age coefficients crossed a value of 0. From computed MLR models, WB MVQ (t = -2.569, p = 0.015), CE hemisphere MVQ (t = -2.143, p = 0.040), NCE hemisphere MVQ (t = -2.567, p = 0.015) and NCE hemisphere DMQ (t = 2.39, p = 0.024) were significant predictors of OS. Age did not significantly predict OS in any models and was not significantly related to WB, CE and NCE hemisphere MVQ or DMQ.

Conclusion

WB, CE and NCE hemisphere MVQ and DMQ predict OS in our tested subgroup of patients with glioblastoma. Age is not a significant predictor of OS and does not significantly correlate with MVQ or DMQ. The median value and distribution spread of DTI-q may act as a prognostic biomarker in glioblastoma, facilitating patient stratification.

P15.07.A Predicting sites of local tumour progression - what should be our imaging biomarker?

Background

Glioblastoma is the most aggressive primary brain tumour diagnosed in adults. Despite intensive treatment of maximal safe resection and chemoradiotherapy, the prognosis remains grim due to invasive tumour cells. Current treatment and standard imaging methods are highly limited in terms of managing these invasive cells as they are often located outside the area of surgical resection and are generally resistant to chemoradiation. DTI appears to be a promising tool for imaging tumour cell invasion and predicting the site of recurrence especially when decomposed into its anisotropic (q) and isotropic (p) components. The aim of this study is to investigate the sensitivity of imaging biomarkers as predictors of recurrence.

Material and Methods

All pre-op and recurrence sequences were co-registered to the pre-op post-contrast T1-weighted images as reference. Co-registration of images was performed using FSL and ANTs. The ROIs for 49 patients with a primary diagnosis of GBM were segmented using 3DSlicer. Each voxel was assigned to one of four status: true negative, false negative, true positive and false positive. Sensitivity and specificity between the pre-op ROIs and the progression region were calculated using FSL. The significance of the differences in sensitivity and specificity between the ROIs was computed in MATLAB.

Results

The sensitivity for the contrast enhancing region was 48.77 ± 26.13 (Mean ± SD) and 62.40 ± 23.07 (Mean ± SD). The abnormal q alone has a significantly greater sensitivity than the contrast enhancing region (t = -2.7327, df = 96, p-value = 0.0075). The sensitivity for the ROI of combined contrast enhancement and abnormal q was 65.86 ± 23.29 (Mean ± SD). There is an even more significant increase in sensitivity when the contrast enhancing ROI is combined with abnormal q region (t = -3.4133, df = 96, p-value = 9.4123e-04) compared to when it is alone. There was no statistical difference in the specificities of the different ROIs.

Conclusion

Current surgical and radiation volumes focus solely on pre-op contrast enhancement. However, these results suggest that combining the abnormal q with the standard contrast enhancing region is a more sensitive predictor of tumour recurrence than contrast enhancement alone, while still retaining high specificity. The higher sensitivity is an indicator of correct identification of tumour recurrence while the high specificity correctly identifies normal brain, or non-recurrent regions. These results are currently being prospectively assessed in a multi-centre study (PRaM-GBM).

POS0339 POINTS TO CONSIDER AT THE EARLIEST STAGES OF THE DIAGNOSIS AND MANAGEMENT OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS/MACROPHAGE ACTIVATION SYNDROME (HLH/MAS)

Background

Hemophagocytic Lymphohistiocytosis (HLH) and Macrophage Activation Syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that occur in many contexts and are often called by many names. They nevertheless can progress rapidly, and early identification and management are critical for preventing organ failure and mortality.

Objectives

The purpose of this effort was to develop a series of ‘points to consider’ to assist clinicians at the earliest stages of evaluation and diagnosis, management, and monitoring of patients with HLH/MAS in order to improve patient outcomes.

Methods

A working group of adult and pediatric rheumatologists (14), hematologist/oncologists (4), immunologists (2), infectious disease specialists (2), intensivists (3), allied health care professionals (1), and patients/parents (2) formulated relevant research questions for a systematic literature review (SLR). We then used the SLR results, Delphi questionnaires, and consensus methodology to devise and refine overarching and specific ‘points to consider’ statements.

Results

The group arrived at six overarching statements and 24 specific points-to-consider relevant to early decision-making in diagnostics, initial management, and monitoring of HLH/MAS. Major themes included the a) need for prompt recognition, evaluation, and management of underlying triggers and conditions, b) multi-disciplinary/expert input, and c) early, tailored intervention with the goals of halting disease progression and preventing life- and organ-threatening immunopathology

Conclusion

These 2022 EULAR/ACR Points to Consider provide guidance on the initial evaluation, management, and monitoring of patients during the initial consideration of HLH/MAS.

Disclosure of Interests

Bita Shakoory: None declared, Ashley Geerlinks: None declared, Marta Wilejto: None declared, Kate Kernan: None declared, Erkan Demirkaya: None declared, Angelo Ravelli: None declared, Rashmi Sinha: None declared, Raphaela goldbach-mansky Grant/research support from: SOBI, Novartis, Regneneron, IFM, Lilly, Pfizer, Fabrizio De Benedetti Consultant of: abbvie, sobi, novimmune, novartis, roche, sanofi, Grant/research support from: sobi novimmune novartis roche sanofi, Rebecca Marsh: None declared, Scott Canna Consultant of: Simcha Therapeutics, Grant/research support from: Immvention therapeutics, AB2Bio Ltd, Novartis

Alcohol withdrawal symptoms predict corticostriatal dysfunction that is reversed by prazosin treatment in alcohol use disorder

Chronic alcohol use increases risk of alcohol withdrawal symptoms (AW) and disrupts stress biology and resilient coping, thereby promoting excessive alcohol intake. Chronic alcohol intake and multiple alcohol detoxifications are known to impair brain medial prefrontal cortex (mPFC) and striatal functioning, regions involved in regulating stress, craving and alcohol intake. In two related studies, we examined whether AW predicts this functional brain pathology and whether Prazosin versus Placebo treatment may reverse these effects. In Study 1, patients with Alcohol Use Disorder (AUD) (N = 45) with varying AW levels at treatment entry were assessed to examine AW effects on corticostriatal responses to stress, alcohol cue and neutral visual images with functional magnetic resonance imaging (fMRI). In Study 2, 23 AUD patients entering a 12-week randomised controlled trial (RCT) of Prazosin, an alpha1 adrenergic antagonist that decreased withdrawal-related alcohol intake in laboratory animals, participated in two fMRI sessions at pretreatment and also at week 9-10 of chronic treatment (Placebo: N = 13; Prazosin: N = 10) to assess Prazosin treatment effects on alcohol-related cortico-striatal dysfunction. Study 1 results indicated that higher AW predicted greater disruption in brain mPFC and striatal response to stress and alcohol cues (p < 0.001, family-wise error [FWE] correction) and also subsequently greater heavy drinking days (HDD) in early treatment (p < 0.01). In Study 2, Prazosin versus Placebo treatment reversed mPFC-striatal dysfunction (p < 0.001, FWE), which in turn predicted fewer drinking days (p < 0.01) during the 12-week treatment period. These results indicate that AW is a significant predictor of alcohol-related prefrontal-striatal dysfunction, and Prazosin treatment reversed these effects that in turn contributed to improved alcohol treatment outcomes.

Assessment of the Teaching on Alcohol Use and Management in Current Health Professional Curricula in India

Alcohol consumption is globally a serious public health challenge, and it is rampant across all parts of India. The COVID-19 pandemic has added to the overall burden of alcoholism due to long working hours, increased mental stress, depression, and so on. Primary care physicians have an important role in assessing risk and providing counselling, intervention and treatment of alcohol misuse. Studies have demonstrated primary health care facilities to be ideally suited for alcohol prevention and cessation interventions as most patients with alcohol use disorders (AUDs) seek treatment from facilities in the primary care setting in India. Thus, the training of healthcare professionals is vital in addressing AUDs in India. The Indian government is setting up Health and Wellness Centres across the country intended to address long-term care and holistic health promotion. At the same time, healthcare providers have expressed their limited competence in cessation and counselling practices related to AUDs. One of the attributing factors for these limitations is the paucity of exposure during the formative years. With this background, a review was undertaken of the current prescribed undergraduate professional curricula (medical, nursing, dentistry and physiotherapy) in India to assess its current status and preparedness in addressing alcohol misuse. The study findings emphasise the need to bolster the continuing education of health professionals aimed at health promotion and preventive strategies by hands-on training, brief workshops, supervised clinical experience by extramural faculty such as addiction psychiatrists, use of standardised patients, role play, and other similar methods.

Profile of comorbidity and multimorbidity among women attending antenatal clinics: An exploratory cross-sectional study from Odisha, India

Background:

Multimorbidity is being recognized as a crucial maternal health challenge in India. However, pregnancy remains an exclusion criterion in most multimorbidity estimation studies resulting in a deficient understanding of the problem in this population. The present study aims to estimate the prevalence of multimorbidity, identify its correlates, and assess healthcare utilization and expenditure outcomes among women availing of antenatal care clinics

Methods:

An exploratory cross-sectional study was conducted among 127 pregnant women attending three antenatal clinics of Bhubaneswar, Odisha, from February to July 2016. Data were collected using a “multimorbidity assessment questionnaire for primary care,” contextualized for antenatal settings. The prevalence and correlates were determined using descriptive analysis, and the outcomes were measured by the number of healthcare visits, medications, and healthcare expenditure. About 15% of antenatal women were multimorbid

Result:

Anemia (52.6%), hypertension (31.6%), acid-peptic diseases (26.3%), and thyroid (26.3%) were the leading chronic conditions. Statistically, significant association was found between multimorbidity and medical consultation, the medicines consumed, and functional limitation. The healthcare expenditure was significantly higher among the multimorbidity groups

Conclusion:

Our findings suggest the inclusion of comprehensive multimorbidity assessment in routine antenatal screening. Preconception care should establish linkages between maternal and reproductive health with chronic disease prevention, and identify ways to reduce healthcare utilization and expenditure. Longitudinal studies to assess the trajectory and impact of multimorbidity on maternal and infant health are warranted.

Lesion Border Detection of Skin Cancer Images Using Deep Fully Convolutional Neural Network with Customized Weights

Deep learning techniques have been widely employed in semantic segmentation problems, especially in medical image analysis, for understanding image patterns. Skin cancer is a life-threatening problem, whereas timely detection can prevent and reduce the mortality rate. The aim is to segment the lesion area from the skin cancer image to help experts in the process of deeply understanding tissues and cancer cells' formation. Thus, we proposed an improved fully convolutional neural network (FCNN) architecture for lesion segmentation in dermoscopic skin cancer images. The FCNN network consists of multiple feature extraction layers forming a deep framework to obtain a larger vision for generating pixel labels. The novelty of the network lies in the way layers are stacked and the generation of customized weights in each convolutional layer to produce a full resolution feature map. The proposed model was compared with the top four winners of the International Skin Imaging Collaboration (ISIC) challenge using evaluation metrics such as accuracy, Jaccard index, and dice co-efficient. It outperformed the given state-of-the-art methods with higher values of the accuracy and Jaccard index.

Profile of multimorbidity in outpatients attending public healthcare settings: A descriptive cross-sectional study from Odisha, India

Background

Multimorbidity, the co-occurrence of two or more long-term conditions (LTC) in individuals, is associated with greater healthcare utilization, expenditure, and premature mortality, thus positing a challenge for patients and healthcare providers. Given its sparsely available epidemiological evidence, we aimed to describe the profile of multimorbidity in a representative sample of public healthcare outpatients in India.

Methods

A facility-based cross-sectional study was conducted from 1^st July to 31^st December 2015 in Odisha, India. Fifteen public healthcare facilities were selected by stratified random sampling. Data was collected from 1,870 adult outpatients attending these settings using Multimorbidity Assessment Questionnaire for Primary Care (MAQ-PC) tool.

Result

Nearly 3/4^th of both women and men outpatients were either obese or overweight. >1/2 had multimorbidity (≥2 LTC) while 1/3^rd had ≥3 LTC. Most prevalent condition was hypertension (63%), followed by chronic backache and arthritis. Cancer and psychiatric illness were least reported. Multimorbidity increased with age group, socioeconomic status, and education level. Females across all age groups had higher reported multimorbidity than males. Diabetes--hypertension was frequently occurring dyad. Both physical and mental component of quality of life was reduced in multimorbidity.

Conclusion

Multimorbidity is becoming a norm in healthcare practice with high prevalence in females and older adults. Health services for non-communicable diseases need to include commonly occurring dyads along with health promotion. Higher prevalence in females reinforces the need to incorporate gender differences while studying multimorbidity. Analysis of multimorbidity epidemiology through an equity lens could illuminate the underpinning complexities and heterogeneities of this phenomenon.

OS14.4.A The Neuroplastic Potential of the Human Brain before and After Glioma Surgery: Towards “Interventional Neurorehabilitation

INTRODUCTION

The human brain is a highly neuroplastic ‘complex’ network: it self-organises without a hard blueprint, adapts to evolving circumstances, and can withstand insults. However, similar to other naturally occurring networks, brain networks can only endure a finite amount of damage before cognitive processes are affected. In this study, we first sought to establish the brain networks governing domain-general cognition (DGC) in healthy individuals across the lifespan. We then sought to map, track, and potentially rehabilitate networks governing DGC through connectomics and non-invasive brain stimulation (NIBS) when damaged by low-grade gliomas (LGG) and surgical oncology.

METHODS

Using MRI and cognitive data from n=629 individuals (aged 18–88, Female= 51%), we assessed the structural, functional, and topological relevance of the spatially-distributed multiple-demand (MD) system for DGC. Next, in n=17 patients undergoing glioma surgery, we longitudinally acquired connectomic and cognitive data at multiple time points: pre-surgery and post-surgery Day 1, Month 3, Month 12. In an independent cohort of n=34 patients, we sought to establish the safety profile for “interventional neurorehabilitation”: connectome-driven NIBS in the acute post-operative period to accelerate cognitive recovery.

RESULTS

In healthy individuals, the MD system across multiple scales of biological organisation was positively associated with higher-order cognition (Catell’s fluid intelligence). In our patients, pre-operative LGG infiltration into the structural MD system was negatively associated with the number of long-term cognitive deficits, suggesting a functional reorganisation. Mixed-effects modelling demonstrated the resilience of the functional MD system to infiltration and resection, while the early post-operative period was critical for effective neurorehabilitation. Graph analyses revealed increased perioperative modularity can distinguish patients with long-term cognitive improvements at one-year follow-up. Finally, NIBS within two weeks post-craniotomy had a 90% (n=31/34) recruitment rate into the trial. There were no seizures or serious complications due to NIBS in this patient population. Transient headaches and tingling were reported in a minority of patients.

CONCLUSION

For the first time, we elucidate long-term cognitive and network trajectories following LGG surgery while establishing a positive safety-profile for NIBS in the acute post-operative period. We argue that “mesoscale” brain mapping serves as a robust biomarker for intervention-related plasticity for future clinical trials. While we performed these experiments in the context of neurosurgery, connectomics and NIBS could be adopted across diverse neuro-oncological care pathways (i.e. chemotherapy/radiation).

Direct visualization and correlation of liver stereotactic body radiation therapy treatment delivery accuracy with interfractional motion

This study used the visualization of hypo‐intense regions on liver‐specific MRI to directly quantify stereotactic body radiation therapy (SBRT) spatial delivery accuracy. Additionally, the interfractional motion of the liver region was determined and compared with the MRI‐based evaluation of liver SBRT spatial treatment delivery accuracy. Primovist^®‐enhanced MRI scans were acquired from 17 patients, 8–12 weeks following the completion of liver SBRT treatment. Direct visualization of radiation‐induced focal liver reaction in the form of hypo‐intensity was determined. The auto‐delineation approach was used to localize these regions, and center‐of‐mass (COM) discrepancy was quantified between the MRI hypo‐intensity and the CT‐based treatment plan. To assess the interfractional motion of the liver region, a planning CT was registered to a Cone Beam CT obtained before each treatment fraction. The interfractional motion assessed from this approach was then compared against the localized hypo‐intense MRI regions. The mean ± SD COM discrepancy was 1.4 ± 1.3 mm in the left‐right direction, 2.6 ± 1.8 mm in an anteroposterior direction, and 1.9 ± 2.6 mm in the craniocaudal direction. A high correlation was observed between interfractional motion of visualized hypo‐intensity and interfractional motion of planning treatment volume (PTV); the quantified Pearson correlation coefficient was 0.96. The lack of correlation was observed between Primovist^® MRI‐based spatial accuracy and interfractional motion of the liver, where Pearson correlation coefficients ranged from −0.01 to −0.26. The highest random and systematic errors quantified from interfractional motion were in the craniocaudal direction. This work demonstrates a novel framework for the direct evaluation of liver SBRT spatial delivery accuracy.

Antimicrobial resistance in biofilms: Exploring marine actinobacteria as a potential source of antibiotics and biofilm inhibitors

Antimicrobial resistance (AMR) is one of the serious global public health threats that require immediate action. With the emergence of new resistance mechanisms in infection-causing microorganisms such as bacteria, fungi, and viruses, AMR threatens the effective prevention and treatment of diseases caused by them. This has resulted in prolonged illness, disability, and death. It has been predicted that AMR will lead to over ten million deaths by 2050. The rapid spread of multidrug-resistant bacteria is also causing old antibiotics to become ineffective. Among the diverse factors contributing to AMR, intrinsic biofilm development has been highlighted as an essential contributing facet. Moreover, biofilm-derived antibiotic tolerance leads to serious recurrent chronic infections. Therefore, the discovery of novel bioactive molecules is a potential solution that can help combat AMR. To achieve this, sustained mining of novel antimicrobial leads from actinobacteria, particularly marine actinobacteria, can be a promising strategy. Given their vast diversity and different habitats, the extraordinary capacity of actinobacteria can be tapped to synthesize new antibiotics or bioactive molecules for biofilm inhibition. Advanced screening strategies and novel approaches in the field of modern biochemical and molecular biology can be used to detect such new compounds. In view of this, the present review focuses on understanding some of the recent strategies to inhibit biofilm formation and explores the potential role of marine actinobacteria as sources of novel antibiotics and biofilm inhibitor molecules.

Effects of Momordica Charantia (Karela/bitterguord) in Type 2 Diabetic Patients Taking Allopathic Drugs: A pilot study

Background Momordica charantia is evoloving as supplementary therapy in type 2 diabetes mellitus. Animal studies reveal its anti-diabetic and lipid lowering property. However, clinical studies with human subjects are very few. Objective To find out the effects of Momordica charantia supplements on glycemic and lipid profile among type 2 diabetes mellitus patients taking allopathic drugs. Method A comparative study was conducted in internal medicine department of B P Koirala Institute of Health Sciences, Dharan from July 2015 to May 2016 after ethical clearance. Twenty two uncomplicated type-2 diabetes mellitus patients were enrolled. Group A patients were supplemented with allopathic drug (oral anti-diabetic agents) only and Group B with add on treatment of 200 ml juice of Momordica charantia along with allopathic drug daily for ninety days. Fasting, post prandial blood sugar and lipid profile levels were compared between baseline and ninety days post supplementation. Data was collected and entry was done in Statistical Packages for Social Services version 20.0, using independent t test with p < 0.05. Result Add on treatment with 200 ml of Momordica charantia along with anti-diabetic drug daily significantly reduced fasting (p= < 0.0001) and post prandial blood sugar (p < 0.0001). Treatment with anti-diabetic drugs only reduced fasting (p = 0.0008) and post-prandial blood sugar but the reduction was not significant ((p =0.0001). There was improvement in lipid profile by both anti-diabetic drugs alone and Momordica charantia along with anti-diabetic drug, but it was not significant. Conclusion Add on treatment with 200 ml/day juice of Momordica charantia is effective in glycaemic control in type-2 diabetes mellitus patients as compared to the allopathic treatment alone.

Critical Role of 3D ultrasound in the diagnosis and management of Robert's uterus: a single-centre case series and a review

A septate uterus with a non-communicating hemicavity was first described by Robert in 1969/70 as a specific malformation of the uterus. The condition is commonly associated with a blind uterine hemicavity, unilateral haematometra, a contralateral unicornuate uterine cavity and a normal external uterine fundus. The main symptoms are repetitive attacks of pain at four-weekly intervals around menarche, repeated dysmenorrhea, recurrent pregnancy loss and infertility. In this report, we review the disease, its diagnosis and treatment, and describe five cases of Robert's uterus. Three dimensional (3D) ultrasound (US) imaging was performed by the transvaginal route in four cases. In the fifth case of a 13-year-old girl, we avoided the vaginal route and magnetic resonance imaging (MRI) and 3D transrectal US yielded the correct diagnosis. The following treatment procedures were undertaken: laparoscopic endometrectomy, hysteroscopic septum resection, laparoscopic uterine hemicavity resection and total laparoscopic hysterectomy (TLH). The diagnosis and optimum treatment of Robert's uterus remains difficult for clinicians because of its rarity. A detailed and careful assessment by 3D US should be performed, followed by hysteroscopy in combination with laparoscopy, to confirm the diagnosis.

Artificial intelligence and synthetic biology approaches for human gut microbiome

The gut microbiome comprises a variety of microorganisms whose genes encode proteins to carry out crucial metabolic functions that are responsible for the majority of health-related issues in human beings. The advent of the technological revolution in artificial intelligence (AI) assisted synthetic biology (SB) approaches will play a vital role in the modulating the therapeutic and nutritive potential of probiotics. This can turn human gut as a reservoir of beneficial bacterial colonies having an immense role in immunity, digestion, brain function, and other health benefits. Hence, in the present review, we have discussed the role of several gene editing tools and approaches in synthetic biology that have equipped us with novel tools like Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR-Cas) systems to precisely engineer probiotics for diagnostic, therapeutic and nutritive value. A brief discussion over the AI techniques to understand the metagenomic data from the healthy and diseased gut microbiome is also presented. Further, the role of AI in potentially impacting the pace of developments in SB and its current challenges is also discussed. The review also describes the health benefits conferred by engineered microbes through the production of biochemicals, nutraceuticals, drugs or biotherapeutics molecules etc. Finally, the review concludes with the challenges and regulatory concerns in adopting synthetic biology engineered microbes for clinical applications. Thus, the review presents a synergistic approach of AI and SB toward human gut microbiome for better health which will provide interesting clues to researchers working in the area of rapidly evolving food and nutrition science.

Optical fiber sensors for monitoring in critical care

Monitoring of key physiological and pharmacological parameters is an important part of a closed loop control system in critical care. Optical fiber sensors provide a versatile platform technology that can be easily incorporated into existing in-dwelling catheters or face masks. With appropriate functional coatings they can be used to monitor a range of relevant parameters and two different examples are presented: (i) respiration monitoring; (ii) drug level monitoring. Respiration monitoring involves monitoring of temperature and humidity in inhaled and exhaled breath. The optical fiber sensor consists of a fiber Bragg grating to measure temperature and a tip coating whose refractive index changes with humidity. The sensor is demonstrated to be able to track breath to breath changes when incorporated into a mask. Drug level monitoring is demonstrated in vitro using a long period grating coated with molecularly imprinted polymer nanoparticles that are sensitive to fentanyl. The sensor has a limit of detection of 50ng/ml.

Protein Engineering for Improved Health: Technological Perspectives

Protein engineering has enabled development of novel proteins aimed at disease diagnosis, alleviation and improved health attributes. The present article provides an overview of recent approaches and techniques used to modify proteins at diverse levels, which find therapeutically relevant applications. There is immense interest among researchers to discover new and increasingly valuable solutions for various health related issues and protein engineering could be a possible venue to sort out such problems. In this mini review we have tried to decipher some of the novel aspects of protein engineering in terms of protein-based therapeutics and diagnostics, in-silico tools and related approaches. A special emphasis has been given for some innovative aspects of protein-nanoparticle conjugates; use of artificial intelligence (AI)- based tools and post-translational modifications. Utilization of such approaches in protein engineering might be ground breaking in future research endeavor of researchers across the world.

The impact of ultrasound in an integrated one-stop sarcoma clinic

AIM

To evaluate the utilisation of ultrasound within a one-stop clinic model in a regional bone and soft-tissue sarcoma centre in the UK, assess its contribution to patient management, and compare diagnostic outcomes to general musculoskeletal "lumps and bumps" clinics.

MATERIALS AND METHODS

This study was a retrospective evaluation of 1,918 referrals between October 2016 and September 2018. All ultrasound examinations and biopsies were performed by one of two musculoskeletal sarcoma radiologists. Ultrasound criteria for suspicion of malignancy were agreed. Study parameters included patient demographics, imaging modality, imaging findings, biopsy results, and time intervals. Correlation has been made between imaging findings and biopsy results.

RESULTS

Five hundred and twenty-four patients (27%) underwent diagnostic ultrasound within the one-stop clinic, out of which 244 (46.5%) underwent an ultrasound-guided biopsy within the same appointment. From this cohort, 412 (78.6%) were given a likely benign diagnosis, either based on imaging alone or in combination with an ultrasound-guided biopsy and a histologically malignant diagnosis was made in the remaining 112 (21.4%). Diagnostic ultrasound within the one-stop sarcoma clinic has a positive predictive value of 86%, negative predictive value of 97%, and sensitivity of 89%.

CONCLUSION

Integration of ultrasound within a one-stop sarcoma clinic provides rapid diagnostic imaging input within the outpatient setting and facilitates early effective triaging of patients into appropriate management plans. It reduces waiting times, unnecessary outpatient appointments and short-term patient anxiety. Clinical and communications skills of the sarcoma radiologist are of paramount importance to improving overall efficiency and patient experience.

Current Trends in Protein Engineering: Updates and Progress

Proteins are one of the most important and resourceful biomolecules that find applications in health, industry, medicine, research, and biotechnology. Given its tremendous relevance, protein engineering has emerged as significant biotechnological intervention in this area. Strategic utilization of protein engineering methods and approaches has enabled better enzymatic properties, better stability, increased catalytic activity and most importantly, interesting and wide range applicability of proteins. In fact, the commercialization of engineered proteins have manifested in economically beneficial and viable solutions for industry and healthcare sector. Protein engineering has also evolved to become a powerful tool contributing significantly to the developments in both synthetic biology and metabolic engineering. The present review revisits the current trends in protein engineering approaches such as rational design, directed evolution, de novo design, computational approaches etc. and encompasses the recent progresses made in this field over the last few years. The review also throws light on advanced or futuristic protein engineering aspects, which are being explored for design and development of novel proteins with improved properties or advanced applications.

Non-communicable Disease Risk Reduction Teaching in India: A Curricular Landscape

Non-communicable diseases (NCDs) have today become a growing epidemic, surpassing infectious diseases and adversely impacting national health systems, policies, and socio-economic developments. Management of NCD and its risk factors such as tobacco use, poor diet, physical inactivity, and obesity has garnered paramount importance under the Sustainable Development Goals (SDGs). However, the educational settings for healthcare professionals to prepare them for delivery of preventive interventions w.r.t. to NCD risk factors require a stronger foundation. In the present work, a landscaping exercise of the teaching of NCD risk factors in the extant Bachelor of Medicine and Bachelor of Surgery (MBBS) curricula of healthcare professionals from select medical colleges in India has been undertaken. Our assessment indicates that in the present MBBS curriculum, effort is largely directed upon teaching only specific aspects of NCDs, such as hypertension, diabetes, mental illness, blindness, and cancer with greater inclination toward clinical aspects. With regard to NCD risk factors, there is inadequate focus on the healthcare promotion aspects. The overall syllabus also does not address long-term health implications of tobacco smoking, lack of proper diet or physical activity, excessive alcohol consumption etc. It also does not reflect any practical trainings or sessions related to health promotion or behavior change activities. As a way forward, we suggest that NCD risk reduction aspects be incorporated extensively into existing health professional education through the development of a curricular framework and an intervention plan contextualized to India. Findings from this study are expected to help provide critical inputs for the design and development of a curricular plan with thrust on tobacco cessation, physical activity, healthy diet, and restricted alcohol consumption, leading to creation of a health competent workforce engaged in NCD prevention and health promotion.

Proteomic profiling of Sporotrichum thermophile under the effect of ionic liquids: manifestation of an oxidative stress response

Sporotrichum thermophile, a known producer of industrial enzymes exhibited stability in the presence of ionic liquids (ILs).The study reports, for the first time, the stress response of S. thermophile upon exposure to ILs. In vitro assay showed increased anti-oxidative enzyme levels indicating ROS-mediated oxidative stress by ILs. The proteomic profile and identification of differential proteins confirmed the fungal adaptations by (i) increased expression of glycolytic enzymes and ATP synthases (ii) downregulation of TCA cycle and protein synthesis machinery components (iii) expression of HSP70 and catalase/peroxidase. These changes are indicative of metabolic regulation of many important pathways and how ILs can be used to manipulate protein behavior.

Meeting report from the joint IARC-NCI international cancer seminar series: a focus on colorectal cancer

Despite significant progress in our understanding of the etiology, biology and genetics of colorectal cancer, as well as important clinical advances, it remains the third most frequently diagnosed cancer worldwide and is the second leading cause of cancer death. Based on demographic projections, the global burden of colorectal cancer would be expected to rise by 72% from 1.8 million new cases in 2018 to over 3 million in 2040 with substantial increases anticipated in low- and middle-income countries. In this meeting report, we summarize the content of a joint workshop led by the National Cancer Institute and the International Agency for Research on Cancer, which was held to summarize the important achievements that have been made in our understanding of colorectal cancer etiology, genetics, early detection and treatment and to identify key research questions that remain to be addressed.