Single parent adoption in India: Mental health and legal perspectives and the way forward

Single parent adoption (SPA) is a relatively new construct worldwide and in India. The Ministry of Women and Child Development, Government of India, has laid down criteria for adoption in general and SPA in particular, in conjunction with the Juvenile Justice Act (Care and Protection of Children), 2015. There is scant literature on this topic of SPA, more so in India, that looks into the various psychological nuances of SPA from a mental health professional's (MHP) perspective. This review paper aims to assess SPA from the perspective of a MHP that will focus on its various legal nuances as well as the psychological connotations attached to it. For this, a search strategy was employed that included a thorough literature search from two databases (PubMed and Google Scholar) with relevant keywords related to the topic. The various legal issues pertaining to SPA in the current scenario, the psychological issues and challenges faced by single parents, the behavioral outcomes of adoptees who are adopted by single parents, and ways to deal with the various obstacles of SPA are discussed.

Understanding Organisms Using Ecological Observatory Networks

Human activities are rapidly changing ecosystems around the world. These changes have widespread implications for the preservation of biodiversity, agricultural productivity, prevalence of zoonotic diseases, and sociopolitical conflict. To understand and improve the predictive capacity for these and other biological phenomena, some scientists are now relying on observatory networks, which are often composed of systems of sensors, teams of field researchers, and databases of abiotic and biotic measurements across multiple temporal and spatial scales. One well-known example is NEON, the US-based National Ecological Observatory Network. Although NEON and similar networks have informed studies of population, community, and ecosystem ecology for years, they have been minimally used by organismal biologists. NEON provides organismal biologists, in particular those interested in NEON's focal taxa, with an unprecedented opportunity to study phenomena such as range expansions, disease epidemics, invasive species colonization, macrophysiology, and other biological processes that fundamentally involve organismal variation. Here, we use NEON as an exemplar of the promise of observatory networks for understanding the causes and consequences of morphological, behavioral, molecular, and physiological variation among individual organisms.

Energetic Electron Precipitation Driven by Electromagnetic Ion Cyclotron Waves from ELFIN's Low Altitude Perspective

We review comprehensive observations of electromagnetic ion cyclotron (EMIC) wave-driven energetic electron precipitation using data collected by the energetic electron detector on the Electron Losses and Fields InvestigatioN (ELFIN) mission, two polar-orbiting low-altitude spinning CubeSats, measuring 50-5000 keV electrons with good pitch-angle and energy resolution. EMIC wave-driven precipitation exhibits a distinct signature in energy-spectrograms of the precipitating-to-trapped flux ratio: peaks at >0.5 MeV which are abrupt (bursty) (lasting ∼17 s, or Δ L ∼ 0.56 ) with significant substructure (occasionally down to sub-second timescale). We attribute the bursty nature of the precipitation to the spatial extent and structuredness of the wave field at the equator. Multiple ELFIN passes over the same MLT sector allow us to study the spatial and temporal evolution of the EMIC wave - electron interaction region. Case studies employing conjugate ground-based or equatorial observations of the EMIC waves reveal that the energy of moderate and strong precipitation at ELFIN approximately agrees with theoretical expectations for cyclotron resonant interactions in a cold plasma. Using multiple years of ELFIN data uniformly distributed in local time, we assemble a statistical database of ∼50 events of strong EMIC wave-driven precipitation. Most reside at L ∼ 5 - 7 at dusk, while a smaller subset exists at L ∼ 8 - 12 at post-midnight. The energies of the peak-precipitation ratio and of the half-peak precipitation ratio (our proxy for the minimum resonance energy) exhibit an L -shell dependence in good agreement with theoretical estimates based on prior statistical observations of EMIC wave power spectra. The precipitation ratio's spectral shape for the most intense events has an exponential falloff away from the peak (i.e., on either side of ∼ 1.45 MeV). It too agrees well with quasi-linear diffusion theory based on prior statistics of wave spectra. It should be noted though that this diffusive treatment likely includes effects from nonlinear resonant interactions (especially at high energies) and nonresonant effects from sharp wave packet edges (at low energies). Sub-MeV electron precipitation observed concurrently with strong EMIC wave-driven >1 MeV precipitation has a spectral shape that is consistent with efficient pitch-angle scattering down to ∼ 200-300 keV by much less intense higher frequency EMIC waves at dusk (where such waves are most frequent). At ∼100 keV, whistler-mode chorus may be implicated in concurrent precipitation. These results confirm the critical role of EMIC waves in driving relativistic electron losses. Nonlinear effects may abound and require further investigation.

Early changes in myocardial stunning and biomarkers after ST-elevation myocardial infarction compared to the takotsubo syndrome

Background

Takotsubo syndrome (TS) and ST-elevation myocardial infarction (STEMI) are both characterized by sudden cessation of myocardial contractions (myocardial stunning) as well as elevation of cardiac troponins and B-type natriuretic peptides (BNP). Whereas STEMI results in variable degrees of necrosis and persistent cardiac dysfunction, TS results in little to any necrosis and full recovery of cardiac function. No “head-to-head” comparison of the temporal resolution of myocardial stunning and serum biomarkers in STEMI versus takotsubo has been done.

Purpose

To compare the time course of the recovery of cardiac function and serum biomarkers over the acute and subacute phases of takotsubo and STEMI, with patients with STEMI further subdivided into anterior and non-anterior STEMI.

Method

The Stunning In Takotsubo and Acute Myocardial Infarction (STAMI) study is a prospective, multi-center study that enrolls patients with TS or STEMI without known pre-existing cardiac dysfunction. Echocardiography, laboratory testing (including troponins and NT-proBNP), and ECG are acquired within 4 hours after acute coronary angiography and at 24±6, 48±12, 72±12 hours and 7±1, 14±2, and 30±2 days. The primary endpoint is the proportion of reversible myocardial akinesia resolved after 72 hours (Figure 1), as determined by echocardiography. Secondary endpoints include troponin-I, troponin-T, and NT-proBNP.

Results

Preliminary results from 155 patients with STEMI (78 anterior STEMI and 77 non-anterior STEMI) and 32 patients with TS are presented in Figure 1. Mean (SD) age was similar for patients with takotsubo (67±14), anterior STEMI (68±11), and non-anterior STEMI (68±10). All 3 groups showed substantial recovery of cardiac function over the course of the study, with the most pronounced recovery of cardiac function in TS. Compared to both STEMI groups, the TS group also had lower troponin-I to troponin-T ratio, and higher NT-proBNP (Figure 2). The proportion of reversible akinesia that had recovered at 72 hours was similar in patients with TS, anterior STEMI and non-anterior STEMI (p=0.8414).

Conclusion

The STAMI study will provide the comprehensive assessment of cardiac function and serum biomarker profile of patients with takotsubo and STEMI over the early course of the disease. Preliminary data from the study suggest that early myocardial functional recovery is more substantial but follows a similar time-course in takotsubo and STEMI. The differences in the magnitude of troponin elevation after takotsubo versus STEMI were more pronounced for troponin-I than T.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ERC - European Research Council

Proper understanding of recurrent stress urinary incontinence treatment in women (PURSUIT): a randomised controlled trial of endoscopic and surgical treatment

BACKGROUND

Women with stress urinary incontinence (SUI) experience urine leakage with physical activity. Currently, the interventional treatments for SUI are surgical, or endoscopic bulking injection(s). However, these procedures are not always successful, and symptoms can persist or come back after treatment, categorised as recurrent SUI. There are longstanding symptoms and distress associated with a failed primary treatment, and currently, there is no consensus on how best to treat women with recurrent, or persistent, SUI.

METHODS

A two-arm trial, set in at least 20 National Health Service (NHS) urology and urogynaecology referral units in the UK, randomising 250 adult women with recurrent or persistent SUI 1:1 to receive either an endoscopic intervention (endoscopic bulking injections) or a standard NHS surgical intervention, currently colposuspension, autologous fascial sling or artificial urinary sphincter. The aim of the trial is to determine whether surgical treatment is superior to endoscopic bulking injections in terms of symptom severity at 1 year after randomisation. This primary outcome will be measured using the patient-reported International Consultation on Incontinence Questionnaire - Urinary Incontinence - Short Form (ICIQ-UI-SF). Secondary outcomes include assessment of longer-term clinical impact, improvement of symptoms, safety, operative assessments, sexual function, cost-effectiveness and an evaluation of patients' and clinicians' views and experiences of the interventions.

DISCUSSION

There is a lack of high-quality, randomised, scientific evidence for which treatment is best for women presenting with recurrent SUI. The PURSUIT study will benefit healthcare professionals and patients and provide robust evidence to guide further treatment and improve symptoms and quality of life for women with this condition.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Number (ISRCTN) registry ISRCTN12201059. Registered on 09 January 2020.

Associations of weekend versus weekday admission on transesophageal echocardiogram utilization and outcomes in infective endocarditis hospitalizations

Background

Infective endocarditis (IE) occurs worldwide and is associated with high mortality. Diagnosis and management of IE requires timely transesophageal echocardiography (TEE), which may not be consistently available in many institutions, especially on weekends. Hence, we wanted to evaluate the effect of weekend admission on IE in-hospital outcomes.

Purpose

To evaluate the differences in mortality and TEE utilization between weekend and weekday admissions in IE hospitalizations.

Methods

In this retrospective cohort study, we queried the 2017 and 2018 National Inpatient Sample (NIS) database to identify primary diagnosis of IE using appropriate ICD-10 CM codes. The variable for weekend admission which is available in the dataset was used to categorize hospitalizations into weekend and weekday admission groups. TEE procedures were identified using appropriate ICD-10 PCS codes. We used the Chi-square test to evaluate the difference between binary variables, and Student's t- test for differences between continuous variables. Multivariate logistic regression analysis was used to adjust for potential hospital and patient level confounders (age, sex, race, diabetes, hypertension, obesity, acute renal failure, diabetes, and Elixhauser comorbidity index score). Stata SE 16.1 was used to perform all statistical analyses.

Results

Among the identified 27,735 weighted adult IE hospitalizations, 6,145 (22.1%) were admitted on weekends. Weekend IE admissions were similar to weekday in all measured aspects except for elective admissions (Table 1). There were more elective admissions on the weekday compared to the weekend (11.3% for weekday vs. 4.9% for weekend; p<0.01). The mean age was 51 years for both hospitalizations. There were more TEEs in the first 24 hrs in weekday compared to weekend hospitalizations (7.8% vs. 3.4%; p<0.01). After adjusting for potential patient and hospital level confounders, there was no difference in mortality [Adjusted Odds ratio (aOR): 0.91 (0.62–1.33); p=0.63)], valve replacement procedures [aOR: 0.91 (0.62–1.33); p=0.63)] or incidence of atrioventricular (AV) blocks [aOR: 0.91 (0.62–1.33); p=0.63)] comparing weekend versus weekday IE hospitalizations. Additionally, we did not observe any mean difference in length of stay and total hospitalization charges between weekend and weekday hospitalizations.

Conclusion

In patients with IE, weekend admissions did not have a clinically significant difference in mortality, length of stay, incidence of AV blocks or valve replacements compared to weekday admissions. TEEs were performed equally in IE hospitalizations regardless of day of admission; however, early TEEs (within 24 hours of admission) were more commonly associated with weekday admission. Despite this, there was no clinically significant difference in the mortality between early TEEs and TEEs done after 24 hours of admission.

Funding Acknowledgement

Type of funding sources: None.

Impact of a mid-urethral synthetic mesh sling on long-term risk of systemic conditions in women with stress urinary incontinence: a national cohort study

Objective

To compare the incidence of systemic conditions between women who had surgical treatment for stress incontinence with mesh and without mesh.

Design

National cohort study.

Setting

English National Health Service.

Population

Women with no previous record of systemic disease who had first‐time urinary incontinence surgery between 1 January 2006 and 31 December 2013, followed up to the earliest of 10 years or 31 March 2019.

Methods

Competing‐risks regression was used to estimate hazard ratios (HR), adjusted for patient characteristics, with HR > 1 indicating increased incidence following mesh surgery.

Main outcome measures

First postoperative admission with a record of autoimmune disease, fibromyalgia or myalgic encephalomyelitis up to 10 years following the first incontinence procedure.

Results

The cohort included 88 947 women who had mesh surgery and 3389 women who had non‐mesh surgery. Both treatment groups were similar with respect to age, socio‐economic deprivation, comorbidity and ethnicity. The 10‐year cumulative incidence of autoimmune disease, fibromyalgia or myalgic encephalomyelitis was 8.1% (95% CI 7.9–8.3%) in the mesh group and 9.0% (95% CI 8.0–10.1%) in the non‐mesh group (adjusted HR 0.89, 95% CI 0.79–1.01; P = 0.07). A sensitivity analysis including only autoimmune diseases as an outcome returned a similar result.

Conclusions

These findings do not support claims that synthetic mesh slings cause systemic disease.

Tweetable abstract

No evidence of increased risk of systemic conditions after stress incontinence treatment with a mesh sling.

No evidence of increased risk of systemic conditions after stress incontinence treatment with a mesh sling.

The ELFIN Mission

The Electron Loss and Fields Investigation with a Spatio-Temporal Ambiguity-Resolving option (ELFIN-STAR, or heretoforth simply: ELFIN) mission comprises two identical 3-Unit (3U) CubeSats on a polar (∼93^∘ inclination), nearly circular, low-Earth (∼450 km altitude) orbit. Launched on September 15, 2018, ELFIN is expected to have a >2.5 year lifetime. Its primary science objective is to resolve the mechanism of storm-time relativistic electron precipitation, for which electromagnetic ion cyclotron (EMIC) waves are a prime candidate. From its ionospheric vantage point, ELFIN uses its unique pitch-angle-resolving capability to determine whether measured relativistic electron pitch-angle and energy spectra within the loss cone bear the characteristic signatures of scattering by EMIC waves or whether such scattering may be due to other processes. Pairing identical ELFIN satellites with slowly-variable along-track separation allows disambiguation of spatial and temporal evolution of the precipitation over minutes-to-tens-of-minutes timescales, faster than the orbit period of a single low-altitude satellite (T_orbit ∼ 90 min). Each satellite carries an energetic particle detector for electrons (EPDE) that measures 50 keV to 5 MeV electrons with Δ E/E < 40% and a fluxgate magnetometer (FGM) on a ∼72 cm boom that measures magnetic field waves (e.g., EMIC waves) in the range from DC to 5 Hz Nyquist (nominally) with <0.3 nT/sqrt(Hz) noise at 1 Hz. The spinning satellites (T_spin ∼ 3 s) are equipped with magnetorquers (air coils) that permit spin-up or -down and reorientation maneuvers. Using those, the spin axis is placed normal to the orbit plane (nominally), allowing full pitch-angle resolution twice per spin. An energetic particle detector for ions (EPDI) measures 250 keV - 5 MeV ions, addressing secondary science. Funded initially by CalSpace and the University Nanosat Program, ELFIN was selected for flight with joint support from NSF and NASA between 2014 and 2018 and launched by the ELaNa XVIII program on a Delta II rocket (with IceSatII as the primary). Mission operations are currently funded by NASA. Working under experienced UCLA mentors, with advice from The Aerospace Corporation and NASA personnel, more than 250 undergraduates have matured the ELFIN implementation strategy; developed the instruments, satellite, and ground systems and operate the two satellites. ELFIN's already high potential for cutting-edge science return is compounded by concurrent equatorial Heliophysics missions (THEMIS, Arase, Van Allen Probes, MMS) and ground stations. ELFIN's integrated data analysis approach, rapid dissemination strategies via the SPace Environment Data Analysis System (SPEDAS), and data coordination with the Heliophysics/Geospace System Observatory (H/GSO) optimize science yield, enabling the widest community benefits. Several storm-time events have already been captured and are presented herein to demonstrate ELFIN's data analysis methods and potential. These form the basis of on-going studies to resolve the primary mission science objective. Broad energy precipitation events, precipitation bands, and microbursts, clearly seen both at dawn and dusk, extend from tens of keV to >1 MeV. This broad energy range of precipitation indicates that multiple waves are providing scattering concurrently. Many observed events show significant backscattered fluxes, which in the past were hard to resolve by equatorial spacecraft or non-pitch-angle-resolving ionospheric missions. These observations suggest that the ionosphere plays a significant role in modifying magnetospheric electron fluxes and wave-particle interactions. Routine data captures starting in February 2020 and lasting for at least another year, approximately the remainder of the mission lifetime, are expected to provide a very rich dataset to address questions even beyond the primary mission science objective.

AB0395 SYSTEMIC LUPUS ASSOCIATED MACROPHAGE ACTIVATION SYNDROME – A SINGLE CENTRE EXPERIENCE FROM INDIA

Background:

Macrophage activation syndrome (MAS) is a potentially fatal complication of systemic lupus erythematosus (SLE).(1) Overlapping clinical features of SLE activity with MA makes it a clinical diagnosis. There is limited data from developing countries like India.

Objectives:

To study the clinical features, treatment, and outcomes in SLE-MAS.

Methods:

This single-centre, retrospective study included patients fulfilling SLICC 2011 criteria for SLE, admitted from January 2017 to November 2019, and diagnosed as MAS by a team of attending physicians. Their demographic and clinical data, treatment, and outcomes were recorded. H score and SLEDAI were calculated. Patients were assessed for HLH classification criteria (2004) and preliminary diagnostic criteria for MAS in childhood SLE (cSLE).

Results:

Sixteen patients (median age – 26 years, 15 females) were included. Twelve patients (75%) had MAS as the initial presentation of SLE. The common clinical features were fever (100%) and cytopenias (100%). The mean duration of symptoms was 60 days. The most frequent biochemical abnormalities were high ferritin (>500 ng/ml, 100%) and elevated transaminases (100%, aspartate transaminase > alanine transaminase). Common complications were renal (43.8%), neurological (43.8%), and coagulopathy (43.8%). Seven and 16 patients fulfilled the HLH 2004 and cSLE – MAS preliminary criteria, respectively. The median H score was 222, giving a cumulative probability of 96%. All the patients received high-dose steroids. Cyclophosphamide pulse and cyclosporine were administered to 8 (50%) and 6 (37.5%) patients respectively. There were four (25%) in-hospital mortalities.

CharacteristicN=16Age (years)26 (19.5 – 30)Duration of symptoms (days)60 (18.7 – 90)Fever16 (100)Pancreatitis1 (6.3)Renal7 (43.8)Neurological7 (43.8)Myocarditis6 (37.5)Hepatomegaly7 (43.8)Splenomegaly3 (18.8)Lymphadenopathy12 (75)Anaemia16 (100)Leukopenia13 (82)Thrombocytopenia14 (88.2)Coagulopathy7 (43.8)Concomitant infection3 (18.8)H score222 (193 – 254)cSLE-MAS diagnostic criteria16 (100%)HLH 2004 (≥5)7 (43.8)Corticosteroids16 (100%)Cyclophosphamide8 (50%)Intravenous immunoglobulin2 (12.5%)Cyclosporine6 (37.5%)Death4 (25%)

All data presented as n (%) and median (IQR)

cSLE-MAS – Childhood systemic lupus erythematosus – Macrophage activation syndrome, HLH – Hemophagocytic lymphohistiocytosis

ParameterN = 16Haemoglobin (g/dL)6.9 (5.7 – 7.8)Total leucocyte count (cells/mm3)1400 (1025 -3175)<10003 (18.8)1000 – 25009 (56.3)2500 - 40001 (6.3)Platelet (cells/mm3)57500 (23500 – 95250)<200003 (18.8)20000 – 500003 (18.8)50000 – 1 lac8 (50)Serum ferritin > 500 ng/ml16 (100%)Fibrinogen2.48 (1.6 – 4)Triglycerides (mg/dL)375 (294 -470)AST/ALT (U/L)153 (113 – 234) / 90 (68 – 170)Procalcitonin (pg/mL)0.8 (0.3 – 1.4)Lactate dehydrogenase (U/L)1674 (1081 – 2184)Erythrocyte sedimentation rate (mm in 1sthour)61 (44 – 69)C- reactive protein (mg/L)36 (6.3 – 52)Bone marrow examination14 (87.5)Increased histiocytes with hemophagocytosis5 (32.5)

All data presented as n (%) and median (IQR)

ALT – Alanine transaminase, AST – Aspartate transaminase

Conclusion:

Fever, cytopenia, high ferritin, and elevation of transaminases were the commonest features in this series of SLE-MAS. SLE-MAS carried a high mortality (25%) despite aggressive treatment.

References:

[1]Gavand P-E, Serio I, Arnaud L, Costedoat-Chalumeau N, Carvelli J, Dossier A, et al. Clinical spectrum and therapeutic management of systemic lupus erythematosus-associated macrophage activation syndrome: A study of 103 episodes in 89 adult patients. Autoimmun Rev. 2017;16(7):743–9.

Acknowledgments:

NONE

Disclosure of Interests:

None declared

AB0570 MIXED CONNECTIVE TISSUE DISEASE: NOT THAT UNCOMMON, A SINGLE-CENTER EXPERIENCE FROM INDIA

Background:

Mixed connective tissue disease (MCTD) is considered to be uncommon; specifically there is sparse data on MCTD from developing countries like India.

Objectives:

This study examines the clinical and serological features of these patients in a single center in North-India.

Methods:

This was a retrospective single-center study of patients diagnosed as MCTD in last 20 years. The patients included fulfilled at least one of the diagnostic criteria namely Alarcón-Segovia, Kasukawa, and Kahns. Demographic details, clinical signs and symptoms, laboratory parameters, treatment and outcome were extracted from medical records and clinic files in a pre-designed proforma.

Results:

This study included 41 MCTD patients. There was a marked female preponderance (F: M=40:1), and mean age of disease onset and diagnosis was 33.8 ± 10.7 and 39.3 ± 10.2 years. 39 (92%) of the patients fulfilled both Kahn and Kasukawa criteria, while 31 (76%) fulfilled Alarcon-Segovia criteria. Initially patients had been (mis)diagnosed as rheumatoid arthritis, systemic lupus erythematosus (or UCTD) (in five patients each), overlap syndromes or myositis (in 4 patients). ANA was commonly high-titer and specked, U1RNP was positive in all. (Table 1) Other autoantibodies on immunoblot included SSA and Ro52 in half the patients. Raynaud’s was seen in three-fourth at presentation and all the patients over time. Digital gangrene and puffy fingers were seen in 8 (20%) and 18 (46%) patients. Other clinical features included arthritis in 33 (81%), sclerodactyly in 23 (56%) and proximal weakness in 20 patients (49%). Interstitial lung disease and pulmonary arterial hypertension were seen in 20 (57%) and 15 (44%) patients. All patients (except one) received prednisolone, and it was currently used in almost 90%. Intravenous cyclophosphamide was used in one-third, commonly for ILD.

Table 1.

Laboratory features of patients with MCTD

Labs n (%)Leucopenia9 (22)Thrombocytopenia10 (24)Raised globulinsb22 (69)Mean globulins, mean (SD)a5±3.4Elevated CPKb10 (31)CPK Levels U/L, median (IQR)256 (57.5-1036)ANA Speckled Pattern N (%)31d(82)U1RNP N (%)b32 (100%)U1RNP Blot Intensity1+8 (25%)2+1 (3.2%)3+7 (21.8%)4+16 (50%)U1RNP EIA, mean(SD), n=19141.3 ± 82.4Raised RF Titersh10 (35.7%)Low C3 mg/dlf8 (40%)Low C4 mg/dlf3 (15%)FVC, mean (SD) n=2082.4 ± 18.9 ILD on HRCTg20 (57) Dilated PA on CTf10 (50)PAHeon ECHO15 (44.1%)RA/RV Dilated5 (18)

SD-standard deviation, IQR- Interquartile range, CPK- Creatinine phosphokinase,, ILD- Interstitial lung disease, PAH- Pulmonary arterial hypertension, ANA- Anti nuclear antibody, IIF- Indirect Immunofluorescence, PA- pulmonary artery, RA/RV- Right atrium/Right Ventricle,a34b32d38e34f20g34h28

Conclusion:

MCTD was not uncommon in the single-center in North India. Kahn and Kasukawa criteria were found to be the most sensitive for its diagnosis. Digital gangrene was relatively common and sometimes the presenting feature; whereas puffy fingers was present in only half the patients.

Disclosure of Interests:

None declared

Point-of-care lung ultrasound in intensive care during the COVID-19 pandemic

Coronavirus disease 2019 has spread to every inhabited continent in the world. So far, plain radiography and computed tomography have been the mainstay of imaging methods used. The present analytical paper on the role of point-of-care lung ultrasound in this pandemic examines its diagnostic accuracy, clinical utility, and physical practicality in the intensive care unit.

•

POCUS has a high sensitivity for pulmonary manifestations of COVID-19.

•

POCUS minimises nosocomial spread.

•

POCUS can prognosticate and assess response to therapy.

•

Healthcare providers with skills in POCUS are encouraged to help provide this service.

Harmine Acts as an Indirect Inhibitor of Intracellular Protein Aggregation

Protein aggregation and oxidative stress are two pathological hallmarks of a number of protein misfolding diseases, including Huntington's disease (HD). Whether protein aggregation precedes elevation of oxidative stress or follows it remains ambiguous. We have investigated the role of harmine, a beta-carboline alkaloid, in aggregation of a mutant huntingtin fragment (103Q-htt) in a yeast model of HD. We observed that harmine was able to decrease intracellular aggregation of 103Q-htt, and this reduction was higher than that observed with trehalose, a conventional protein stabilizer. The presence of harmine also decreased prion formation. Decreased protein aggregation was accompanied by reduction in oxidative stress. However, harmine had no effect on aggregation of the mutant huntingtin fragment in vitro. Thus, based on experimental data, we conclude that the antioxidant harmine lowers aggregation-induced elevation in oxidative stress, which slows down intracellular protein aggregation.

P759Electrocardiographic predictors of adverse in-hospital outcomes in the Takotsubo syndrome

Background

The takotsubo syndrome is a life-threatening acute cardiac condition. However, little is known about risk factors associated with worse outcomes in TS, and no high-risk electrocardiographic criteria have been defined for patients with TS. We sought to identify high-risk admission ECG findings among patients with TS.

Methods

Using the Swedish Angiography and Angioplasty Registry (SCAAR) we identified all cases of TS who were treated at our university hospital between 2008 and 2017. We reviewed all cases and included patients who met the revised Gothenburg diagnostic criteria. We conducted an in-depth review of all presenting electrocardiograms, using a pre-defined case report form (CRF), including the following variables: heart rate; rhythm; PR-interval; QRS axis; QTc-interval; T-wave inversion.; presence of Q-wave; T-wave axis; and the magnitude of ST-segment deviation in each individual lead. The primary endpoint was the occurrence of in-hospital major adverse cardiac event (MACE), defined as the composite of death, ventricular tachycardia or fibrillation (VT/VF), atrioventricular block ≥2 or asystole >10 seconds.

Results

We identified 161 patients with TS, of whom 151 (93.8%) were women. The mean age was 69±13 years. MACE occurred in 19 patients (11.8%), and VT/VF occurred in 14 patients (8.7%). No clinical variables were significantly different between patients with and without MACE. Patients with MACE were less likely than those without MACE to have sinus rhythm (79.0% versus 95.8%, p=0.02) or T-wave inversion (15.8% versus 52.8%, p=0.02). T-wave inversion was less common among patients with than without VT/VF (14.3% versus 51.7%, p=0.01). After adjustment for age and sex T-wave inversion was independently associated with lower risk of MACE (Odds ratio 0.13, 95% confidence interval 0.04 to 0.48, p>0.001).

Conclusions

T-wave inversion is common in TS and is associated with lower risk of adverse events, driven by a lower risk of VT/VF.

Progress in ITER ECE Diagnostic Design and Integration

The ITER Electron Cyclotron Emission (ECE) diagnostic is progressing towards its Preliminary Design Review (PDR). In parallel, the diagnostic integration in the Equatorial Port is ongoing. Port Integration has to address the structural integrity to withstand various loads, maintenance and the safety aspects of ECE diagnostic. The ITER ECE system includes radial and oblique lines-of-sight. Recently, a successful peer-review of the in-port plug Hot Calibration Source has taken place and its performance and integration feasibility has been demonstrated. Four 45-meter long low-loss transmission lines are designed to transmit mm-wave power in the frequency range of 70- 1000 GHz in both X- and O-mode polarization from the port plug to the ECE instrumentation room in the diagnostic building. Prototype transmission lines are being tested [1]. A prototype polarizing Martin-Puplett type Fourier Transform Spectrometer (FTS) operating in the frequency range 70-1000 GHz, has a fast scanning mechanism and a cryo-cooled dual-channel THz detector system. Its performance has been tested as per ITER requirements. Assessment of the instrumentation and control requirements, functional and non-functional requirements, operation procedures, plant automation are ongoing for the PDR. The current status of the diagnostic, together with integration activities, is presented.

Maintaining sexual function after pelvic floor surgery

Sexual dysfunction in women with prolapse and incontinence is well documented in the literature, but the impact of treatment, particularly surgical correction, remains very limited and confusing. Age, on the other hand, has been shown to be an independent risk factor for deteriorating sexual function, with all aspects of the sexual function (i.e. desire, arousal, penetration, and orgasm) being affected. When combined with surgical correction of prolapse or incontinence there is potential for further worsening of sexual function, and hence this should be assessed before any pelvic floor surgery and patient expectations established. In this article the current evidence will be reviewed looking at the impact of pelvic floor dysfunction on sexual function and the effect of commonly performed surgery for these problems. Ways and means of preserving sexual function in women undergoing corrective surgery will also be investigated.

Experiences in running a complex electronic data capture system using mobile phones in a large-scale population trial in southern Nepal

The increasing availability and capabilities of mobile phones make them a feasible means of data collection. Electronic Data Capture (EDC) systems have been used widely for public health monitoring and surveillance activities, but documentation of their use in complicated research studies requiring multiple systems is limited. This paper shares our experiences of designing and implementing a complex multi-component EDC system for a community-based four-armed cluster-Randomised Controlled Trial in the rural plains of Nepal, to help other researchers planning to use EDC for complex studies in low-income settings. We designed and implemented three interrelated mobile phone data collection systems to enrol and follow-up pregnant women (trial participants), and to support the implementation of trial interventions (women's groups, food and cash transfers). 720 field staff used basic phones to send simple coded text messages, 539 women's group facilitators used Android smartphones with Open Data Kit Collect, and 112 Interviewers, Coordinators and Supervisors used smartphones with CommCare. Barcoded photo ID cards encoded with participant information were generated for each enrolled woman. Automated systems were developed to download, recode and merge data for nearly real-time access by researchers. The systems were successfully rolled out and used by 1371 staff. A total of 25,089 pregnant women were enrolled, and 17,839 follow-up forms completed. Women's group facilitators recorded 5717 women's groups and the distribution of 14,647 food and 13,482 cash transfers. Using EDC sped up data collection and processing, although time needed for programming and set-up delayed the study inception. EDC using three interlinked mobile data management systems (FrontlineSMS, ODK and CommCare) was a feasible and effective method of data capture in a complex large-scale trial in the plains of Nepal. Despite challenges including prolonged set-up times, the systems met multiple data collection needs for users with varying levels of literacy and experience.

Participatory Women's Groups with Cash Transfers Can Increase Dietary Diversity and Micronutrient Adequacy during Pregnancy, whereas Women's Groups with Food Transfers Can Increase Equity in Intrahousehold Energy Allocation

Background

There is scarce evidence on the impacts of food transfers, cash transfers, or women's groups on food sharing, dietary intakes, or nutrition during pregnancy, when nutritional needs are elevated.

Objective

This study measured the effects of 3 pregnancy-focused nutrition interventions on intrahousehold food allocation, dietary adequacy, and maternal nutritional status in Nepal.

Methods

Interventions tested in a cluster-randomized controlled trial (ISRCTN 75964374) were "Participatory Learning and Action" (PLA) monthly women's groups, PLA with transfers of 10 kg fortified flour ("Super Cereal"), and PLA plus transfers of 750 Nepalese rupees (∼US$7.5) to pregnant women. Control clusters received usual government services. Primary outcomes were Relative Dietary Energy Adequacy Ratios (RDEARs) between pregnant women and male household heads and pregnant women and their mothers-in-law. Diets were measured by repeated 24-h dietary recalls.

Results

Relative to control, RDEARs between pregnant women and their mothers-in-law were 12% higher in the PLA plus food arm (log-RDEAR coefficient = 0.12; 95% CI: 0.02, 0.21; P = 0.014), but 10% lower in the PLA-only arm between pregnant women and male household heads (-0.11; 95% CI: -0.19, -0.02; P = 0.020). In all interventions, pregnant women's energy intakes did not improve, but odds of pregnant women consuming iron-folate supplements were 2.5-4.6 times higher, odds of pregnant women consuming more animal-source foods than the household head were 1.7-2.4 times higher, and midupper arm circumference was higher relative to control. Dietary diversity was 0.4 food groups higher in the PLA plus cash arm than in the control arm.

Conclusions

All interventions improved maternal diets and nutritional status in pregnancy. PLA women's groups with food transfers increased equity in energy allocation, whereas PLA with cash improved dietary diversity. PLA alone improved diets, but effects were mixed. Scale-up of these interventions in marginalized populations is a policy option, but researchers should find ways to increase adherence to interventions. This trial was registered at www.controlled-trials.com as ISRCTN 75964374.

Impact on birth weight and child growth of Participatory Learning and Action women's groups with and without transfers of food or cash during pregnancy: Findings of the low birth weight South Asia cluster-randomised controlled trial (LBWSAT) in Nepal

BACKGROUND

Undernutrition during pregnancy leads to low birthweight, poor growth and inter-generational undernutrition. We did a non-blinded cluster-randomised controlled trial in the plains districts of Dhanusha and Mahottari, Nepal to assess the impact on birthweight and weight-for-age z-scores among children aged 0-16 months of community-based participatory learning and action (PLA) women's groups, with and without food or cash transfers to pregnant women.

METHODS

We randomly allocated 20 clusters per arm to four arms (average population/cluster = 6150). All consenting married women aged 10-49 years, who had not had tubal ligation and whose husbands had not had vasectomy, were monitored for missed menses. Between 29 Dec 2013 and 28 Feb 2015 we recruited 25,092 pregnant women to surveillance and interventions: PLA alone (n = 5626); PLA plus food (10 kg/month of fortified wheat-soya 'Super Cereal', n = 6884); PLA plus cash (NPR750≈US$7.5/month, n = 7272); control (existing government programmes, n = 5310). 539 PLA groups discussed and implemented strategies to improve low birthweight, nutrition in pregnancy and hand washing. Primary outcomes were birthweight within 72 hours of delivery and weight-for-age z-scores at endline (age 0-16 months). Only children born to permanent residents between 4 June 2014 and 20 June 2015 were eligible for intention to treat analyses (n = 10936), while in-migrating women and children born before interventions had been running for 16 weeks were excluded. Trial status: completed.

RESULTS

In PLA plus food/cash arms, 94-97% of pregnant women attended groups and received a mean of four transfers over their pregnancies. In the PLA only arm, 49% of pregnant women attended groups. Due to unrest, the response rate for birthweight was low at 22% (n = 2087), but response rate for endline nutritional and dietary measures exceeded 83% (n = 9242). Compared to the control arm (n = 464), mean birthweight was significantly higher in the PLA plus food arm by 78·0 g (95% CI 13·9, 142·0; n = 626) and not significantly higher in PLA only and PLA plus cash arms by 28·9 g (95% CI -37·7, 95·4; n = 488) and 50·5 g (95% CI -15·0, 116·1; n = 509) respectively. Mean weight-for-age z-scores of children aged 0-16 months (average age 9 months) sampled cross-sectionally at endpoint, were not significantly different from those in the control arm (n = 2091). Differences in weight for-age z-score were as follows: PLA only -0·026 (95% CI -0·117, 0·065; n = 2095); PLA plus cash -0·045 (95% CI -0·133, 0·044; n = 2545); PLA plus food -0·033 (95% CI -0·121, 0·056; n = 2507). Amongst many secondary outcomes tested, compared with control, more institutional deliveries (OR: 1.46 95% CI 1.03, 2.06; n = 2651) and less colostrum discarding (OR:0.71 95% CI 0.54, 0.93; n = 2548) were found in the PLA plus food arm but not in PLA alone or in PLA plus cash arms.

INTERPRETATION

Food supplements in pregnancy with PLA women's groups increased birthweight more than PLA plus cash or PLA alone but differences were not sustained. Nutrition interventions throughout the thousand-day period are recommended.

TRIAL REGISTRATION

ISRCTN75964374.

Overdiagnosis in imaging

Overdiagnosis, more than an error regarding the diagnosis, is an error regarding the prognosis. We cannot know what consequences some lesions that we detect by imaging would have on our patients' lives if they were left untreated. As long as it is not possible for imaging techniques to differentiate between lesions that will have an indolent course from those that will have an aggressive course, there will be overdiagnosis. Advanced imaging techniques, radiomics, and radiogenomics, together with artificial intelligence, promise advances in this sense. In the meantime, it is important that radiologists be careful to ensure that only strictly necessary imaging tests are done. Moreover, we need to participate, together with patients, in making multidisciplinary decisions about diagnosis and clinical management. Finally, of course, we need to continue to contribute to the technological and scientific advance of our profession, so that we can continue to improve the diagnosis and early detection of abnormalities, especially those that require treatment.

Nonmetric analysis of caroticoclinoid foramen in foothills of Himalayas: Its clinicoanatomic perspective

OBJECTIVE OF THE STUDY

Study was conducted to evaluate the incidence of caroticoclinoid foramen in north Indian population. Authors have also endeavoured to discuss its clinical and embryological implications.

MATERIALS AND METHODS

Study was conducted on 108 dry human skulls in department of anatomy SGRR medical college, Dehradun. Incidence of caroticoclinoid foramen was evaluated in accordance with side.

RESULTS

A percentage of 22.22 skulls presented with the caroticoclinoid foramen with maximum incidence of unilateral and incomplete type. Incidence revealed no bias towards side.

CONCLUSION

Anatomical knowledge about CCF may be helpful to radiologists and neurosurgeons in providing an additional insight into the diagnosis and management of various pathologies around sellar region.

Development of a Valid and Reliable Questionnaire to Identify Professional Opinion Regarding Organ Transplantation System

BACKGROUND

Currently, the Nepalese law permits organ donation by an individual who falls into the category of a "close relative" of the recipient. There is a need for expansion of the live organ donor pool beside close relatives. Different systems of organ transplantation are followed by several countries and the professional opinions that underpin these systems need to be studied.

OBJECTIVE

To generate a questionnaire related to different organ transplant systems and validate it so that it can be used to collect mass professional opinions.

METHODS

Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire. The final version of the questionnaire was reviewed by experts for its content validity and then was used twice for participants at a 20-day interval to calculate Cronbach's alpha for testing its internal consistency and Intra-class correlation for testing its test and retest reliability.

RESULTS

The questionnaire was found to be valid and reliable with an overall Cronbach's alpha of 0.701. Intra-class correlation scores for each question in both test and retest were correlated.

CONCLUSION

A valid and reliable questionnaire was developed that can be used to collect mass professional opinions to assist policy makers to establish a better organ transplant system.

Normal and Delayed Fracture Healing: Symphony and Cacophony

The incidence of any fracture in the US is estimated to be 2 704 fractures per 100,000 person-years. Approximately 10 percent of these fractures develop complications of healing. The processes that occur during fracture healing mimic the processes that take place in the growth plate during development. The study of fracture healing represents a window to enhance our understanding of the processes of growth and development of bones and its reparative biology. This review is aimed for clinicians evaluating non-unions as an overview of different factors that inhibit fracture healing.

Three-dimensional printing and patient-specific pre-contoured plate: future of acetabulum fracture fixation?

PURPOSE

Due to the complexity of acetabulum, achieving anatomical contouring intra-operatively is difficult for surgeon. A 3D (dimensional) real model can facilitate us both in contouring the plate pre-operatively and in better pre-operative planning. Patient-specific pre-contoured plate in acetabular fracture has been studied by few researchers but randomized case-control study was lacking. Hence, we conducted a case-control study to evaluate the accuracy of patient-specific pre-contoured plate.

MATERIALS AND METHODS

Prospective randomized case control study was conducted. 21 patients were included. 10 patients were distributed in "case" group and remaining 11 in "control" group.

INCLUSION CRITERIA

Displaced acetabulum fractures with displacement of ≥3 mm in adults who reported within 3 weeks of injury. Exclusion criteria were: Open fractures, associated Morel-Lavallée lesion and patients with >3 weeks old fracture. In case group, patient-specific real 3D model of fractured acetabulum was generated using rapid prototyping technology and plates were contoured pre-operatively. Control group was treated using intra-operative contoured plates. Both the groups were compared using parameters: Blood loss, Surgery time, post-operative reduction on X-ray, post-surgical residual displacement and reduction achieved as evaluated by CT scan.

RESULTS

Reduced blood loss (100 ml less in case group) and surgical time (12 min less in case group) and better post-operative reduction were observed in case than control. In control group, 4 patients even had step of 2-3 mm, which was not seen in case group. All the pre-contoured plates fitted well to the pelvis intra-operatively. Reduction achieved as evaluated by CT was more in "case" group with statistically significant outcomes (p < 0.05).

CONCLUSION

Patient-specific pre-contoured plate made using 3D model is a better implant than intra-operatively contoured plate. Real-time 3D pelvis model is an accurate technique for pre-operative planning in acetabular fractures.

Three-dimensional printing and patient-specific pre-contoured plate: future of acetabulum fracture fixation?

PURPOSE

Due to the complexity of acetabulum, achieving anatomical contouring intra-operatively is difficult for surgeon. A 3D (dimensional) real model can facilitate us both in contouring the plate pre-operatively and in better pre-operative planning. Patient-specific pre-contoured plate in acetabular fracture has been studied by few researchers but randomized case-control study was lacking. Hence, we conducted a case-control study to evaluate the accuracy of patient-specific pre-contoured plate.

MATERIALS AND METHODS

Prospective randomized case control study was conducted. 21 patients were included. 10 patients were distributed in "case" group and remaining 11 in "control" group.

INCLUSION CRITERIA

Displaced acetabulum fractures with displacement of ≥3 mm in adults who reported within 3 weeks of injury. Exclusion criteria were: Open fractures, associated Morel-Lavallée lesion and patients with >3 weeks old fracture. In case group, patient-specific real 3D model of fractured acetabulum was generated using rapid prototyping technology and plates were contoured pre-operatively. Control group was treated using intra-operative contoured plates. Both the groups were compared using parameters: Blood loss, Surgery time, post-operative reduction on X-ray, post-surgical residual displacement and reduction achieved as evaluated by CT scan.

RESULTS

Reduced blood loss (100 ml less in case group) and surgical time (12 min less in case group) and better post-operative reduction were observed in case than control. In control group, 4 patients even had step of 2-3 mm, which was not seen in case group. All the pre-contoured plates fitted well to the pelvis intra-operatively. Reduction achieved as evaluated by CT was more in "case" group with statistically significant outcomes (p < 0.05).

CONCLUSION

Patient-specific pre-contoured plate made using 3D model is a better implant than intra-operatively contoured plate. Real-time 3D pelvis model is an accurate technique for pre-operative planning in acetabular fractures.

Protocol of the Low Birth Weight South Asia Trial (LBWSAT), a cluster-randomised controlled trial testing impact on birth weight and infant nutrition of Participatory Learning and Action through women's groups, with and without unconditional transfers of fortified food or cash during pregnancy in Nepal

Background

Low birth weight (LBW, < 2500 g) affects one third of newborn infants in rural south Asia and compromises child survival, infant growth, educational performance and economic prospects. We aimed to assess the impact on birth weight and weight-for-age Z-score in children aged 0–16 months of a nutrition Participatory Learning and Action behaviour change strategy (PLA) for pregnant women through women’s groups, with or without unconditional transfers of food or cash to pregnant women in two districts of southern Nepal.

Methods

The study is a cluster randomised controlled trial (non-blinded). PLA comprises women’s groups that discuss, and form strategies about, nutrition in pregnancy, low birth weight and hygiene. Women receive up to 7 monthly transfers per pregnancy: cash is NPR 750 (~US$7) and food is 10 kg of fortified sweetened wheat-soya Super Cereal per month. The unit of randomisation is a rural village development committee (VDC) cluster (population 4000–9200, mean 6150) in southern Dhanusha or Mahottari districts. 80 VDCs are randomised to four arms using a participatory ‘tombola’ method. Twenty clusters each receive: PLA; PLA plus food; PLA plus cash; and standard care (control). Participants are (mostly Maithili-speaking) pregnant women identified from 8 weeks’ gestation onwards, and their infants (target sample size 8880 birth weights). After pregnancy verification, mothers may be followed up in early and late pregnancy, within 72 h, after 42 days and within 22 months of birth. Outcomes pertain to the individual level. Primary outcomes include birth weight within 72 h of birth and infant weight-for-age Z-score measured cross-sectionally on children born of the study. Secondary outcomes include prevalence of LBW, eating behaviour and weight during pregnancy, maternal and newborn illness, preterm delivery, miscarriage, stillbirth or neonatal mortality, infant Z-scores for length-for-age and weight-for-length, head circumference, and postnatal maternal BMI and mid-upper arm circumference. Exposure to women’s groups, food or cash transfers, home visits, and group interventions are measured.

Discussion

Determining the relative importance to birth weight and early childhood nutrition of adding food or cash transfers to PLA women’s groups will inform design of nutrition interventions in pregnancy.

Trial registration

ISRCTN75964374, 12 Jul 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1102-x) contains supplementary material, which is available to authorized users.

Effect of carboxymethylation on physicochemical, micromeritics and release characteristics of Kyllinga nemoralis starch

Lesser usages of native starch has attracted attention in the modification of starch to incorporate its benefits for pharmaceutical application. A work has been carried out to study the influence of carboxymethylation on the morphological, physico-chemical, powder, spectroscopical and drug discharge characteristics of native starch. Various amount of monochloroacetic acid was used to study the influence of degree of substitution (DS) on the diverse characteristics of modified starch. Amylose content was found to be reduced with the increase in degree of substitution. An enhanced degree of structure deformation was observed with the increment in the DS by the help of scanning electron micrographs. The FT-IR spectra established the polysaccharide nature and the carboxymethylation of the chemically modified starch molecules through the new bands at 1602cm^-1, and 1418.69cm^-1. The stability of carboxymethyl starches pertaining to the temperature has been revealed by thermogravimetric analysis. Micromeritics of carboxymethylated starches shows their effectiveness as excipients in tablet formulation. The delayed % release of the drug, with the rise in degree of substitution from the tablets prepared marks that the carboxymethyl derivatives of Kyllinga nemoralis rhizomes starch may be used as a suitable source of excipient for sustained release formulations.

Suicide by self-inflicted stab wound to the heart: a rare case of suicide from Nepal

Suicide, or the deliberate act of killing oneself, accounts for a substantial number of unnatural deaths each year in many countries. Though death by self-stabbing is quite uncommon, the left part of the chest represents one of the elected sites of self-inflicted wounds because of the knowledge of the situation of the heart and that the injuries to the heart are severe. We present a case of suicidal stab to the left thoracic region involving the heart.DOI: http://dx.doi.org/10.3126/jcmsn.v10i2.12952 Journal of College of Medical Sciences-Nepal, 2014, Vol.10(2); 33-35

A case report of Traumatic Asphyxia

Traumatic asphyxia is a condition presenting with cervicofacial cyanosis and edema, subconjunctival hemorrhage, and petechial hemorrhages of the face, neck, and upper chest that occurs due to a compressive force to the thoracoabdominal region.In this case report a 52 years old lady who was brought to the mortuary because of death due to traumatic asphyxia as a result of being stampeded by her own cows upon her chest was discussed. Congestion on both the conjunctiva, cyanosis on chin and adjacent upper left side of neck found with a well demarcated area observed between the cyanosed area over face and the normal area of neck. Hematoma was present in the chin and the adjacent neck region.Apart from quickly eliminating organ pathologies and initiation of supportive therapy in a case of traumatic asphyxia, possibility of formation of hematoma in neck after few hours of getting injured should also be considered, as this type of hematoma may contribute to the cause of death.Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3, 51-55