Baseline findings of a multicentric ambispective cohort study (2021-2022) among hospitalised mucormycosis patients in India

In India, the incidence of mucormycosis reached high levels during 2021-2022, coinciding with the COVID-19 pandemic. In response to this, we established a multicentric ambispective cohort of patients hospitalised with mucormycosis across India. In this paper, we report their baseline profile, clinical characteristics and outcomes at discharge. Patients hospitalized for mucormycosis during March-July 2021 were included. Mucormycosis was diagnosed based on mycological confirmation on direct microscopy (KOH/Calcofluor white stain), culture, histopathology, or supportive evidence from endoscopy or imaging. After consent, trained data collectors used medical records and telephonic interviews to capture data in a pre-tested structured questionnaire. At baseline, we recruited 686 patients from 26 study hospitals, of whom 72.3% were males, 78% had a prior history of diabetes, 53.2% had a history of corticosteroid treatment, and 80% were associated with COVID-19. Pain, numbness or swelling of the face were the commonest symptoms (73.3%). Liposomal Amphotericin B was the commonest drug formulation used (67.1%), and endoscopic sinus surgery was the most common surgical procedure (73.6%). At discharge, the disease was stable in 43.3%, in regression for 29.9% but 9.6% died during hospitalization. Among survivors, commonly reported disabilities included facial disfigurement (18.4%) and difficulties in chewing/swallowing (17.8%). Though the risk of mortality was only 1 in 10, the disability due to the disease was very high. This cohort study could enhance our understanding of the disease's clinical progression and help frame standard treatment guidelines.

Need Assessment of Existing Mentorship Program Among Undergraduate Medical Students: Experience From a Medical College in Chhattisgarh, India

Introduction While mentoring students during regular medical education has a long-standing tradition in many developed countries' medical schools, it has yet to become a standard practice in the majority of medical institutions, especially in the developing world, such as India. In institutions where mentoring programs are sparsely implemented, there is a lack of data regarding their assessment. Methodology This qualitative study involved two groups of students - nine undergraduate medical students (five male and four female) and 10 undergraduate medical students (six male and four female) who had at least three years of experience in the existing mentorship program at a tertiary care teaching hospital. We conducted two focused group discussions (FGDs) with these two groups of students using a guide, with FGDs lasting 45 and 50 minutes, respectively. We recorded the audio and it was transcripted to text. Thematic analysis of the transcripts from the 2 FGDs was conducted using Atlasti (Version 7.1.8) software to assess perceptions of the mentorship program. Results The content analysis of the discussions revealed two broad themes, namely "Current Functioning of the Programme" and "Suggestions for Improvement." These themes were further divided into multiple domains and subdomains, providing a comprehensive overview of the study's findings. Although there is a consensus among students that the mentorship program is essential, the current operational framework still has limited confidence due to biases, fears, and misinformation among the students. Conclusion The ongoing medical curriculum imparts a vast amount of scientific knowledge within a limited timeframe, with practical application occurring primarily in the last three years of the academic curriculum and minimal emphasis on ethical practice, professionalism, effective communication, handling urgent health situations, and interacting with family members, underscores the genuine need for a structured mentorship curriculum for undergraduate medical students. To enhance the program's effectiveness, the active involvement of undergraduate students must address their specific needs.

Assessment of predictors of diabetic foot ulcers in a tertiary care hospital of Maharashtra, India: A cross-sectional comparative study

BACKGROUND

The chances of nonhealing foot ulcer among the diabetic is 10-20 times more than people without diabetes. Foot ulcer among diabetes population affects more than 40-60 million globally. There is a dearth of quality data on the factor among the diabetes patients, which hastens the progression of diabetic foot. The study aims to assess the risk factors associated with foot ulcer among the diabetics.

MATERIALS AND METHODS

The study was a cross-sectional comparative study in tertiary care hospital in Maharashtra, India. The study population included 200 diabetic foot ulcer patients and 200 of their age and gender matched comparator were patients with diabetes without foot ulcers. The sampling method was stratified random sampling.

RESULTS

The mean age of both the groups of patients was around 54 years. Alcohol consumption, physical activity outside home, low foot care practices, irregularity of diabetic medication, and family history of diabetes among mothers were found to be factors associated with diabetes foot ulcer.

CONCLUSION

There is a need to stratify the diabetes patients in regular care as per risk categories depending on the presence of above risk factors. This will not only prioritization of diabetes care in terms of future risk but also reduce the progression of complications like diabetes foot and resulting amputation through an active preventive intervention.

Comparative assessment of factors affecting anxiety levels among adults attending online meditation sessions during the COVID-19 pandemic: A cross-sectional study

BACKGROUND

The ongoing coronavirus disease 2019 (COVID-19) pandemic induced the governments around the world to impose harsher preventive measures like stay at home order, lock down etc., to contain the spread of infection. This measure increased the stress of the general population through isolation of masses, loss of employment, and loss of recreation. There is a dearth of quality data showing anxiety levels among the population and association of novel nonpharmaceutical measures such as online meditation with it.

MATERIALS AND METHODS

The study is a cross-sectional comparative study based on an online survey. The study population included 74 adult participants, out of which 30, included in the study group were attending structured online meditation sessions and 44 of the participants as a comparison group after matching age, gender, location of residence, and socioeconomic status. The data was collected using self-administered questionnaire. Multiple logistic regression was applied to ascertain factors contributing to the anxiety levels of the participants.

RESULTS

Both the groups of participants were comparable in terms of their demographic characteristics. The mean generalized anxiety disorder (GAD 7) score among the participants of online meditation program was significantly lower as compared to those not attending any online meditation. 6.7% of the participants of online meditation had GAD 7 score more than 10 as compared to 13.6% among the comparison group (P value 0.7).

CONCLUSION

"At home" mental health promotion measures such as structured online meditation can serve an important role in mitigating the mental health impact of COVID-19 pandemic on the community. Further researches are needed to assess the feasibility and effectiveness of such measures.

Discovery of MAP855, an Efficacious and Selective MEK1/2 Inhibitor with an ATP-Competitive Mode of Action

Mutations in MEK1/2 have been described as a resistance mechanism to BRAF/MEK inhibitor treatment. We report the discovery of a novel ATP-competitive MEK1/2 inhibitor with efficacy in wildtype (WT) and mutant MEK12 models. Starting from a HTS hit, we obtained selective, cellularly active compounds that showed equipotent inhibition of WT MEK1/2 and a panel of MEK1/2 mutant cell lines. Using a structure-based approach, the optimization addressed the liabilities by systematic analysis of molecular matched pairs (MMPs) and ligand conformation. Addition of only three heavy atoms to early tool compound 6 removed Cyp3A4 liabilities and increased the cellular potency by 100-fold, while reducing log P by 5 units. Profiling of MAP855, compound 30, in pharmacokinetic-pharmacodynamic and efficacy studies in BRAF-mutant models showed comparable efficacy to clinical MEK1/2 inhibitors. Compound 30 is a novel highly potent and selective MEK1/2 kinase inhibitor with equipotent inhibition of WT and mutant MEK1/2, whose drug-like properties allow further investigation in the mutant MEK setting upon BRAF/MEK therapy.

Covid-19 chemoprophylaxis: Ethics of prevention based on anecdotal evidence

The ongoing pandemic of Covid-19 caused by the SARS-CoV-2 virus has infected more than 6 million all over the world and has caused more than 3.8 lakh fatalities till date(1) Health workers are the frontline responders and are exposed to a plethora of health hazards. Recently, an advisory by the Indian Council of Medical Research for the use of hydroxychloroquine as post-exposure prophylaxis was hailed as an outstanding initiative for the protection of healthcare workers and high risk contacts of patients. But the evidence of effectiveness available is only from in vitro studies and non-randomised control trials of insufficient sample size. Several ongoing large scale clinical trials are focused on the same research questions, the preliminary results of which are still awaited. The present study discusses the ethics of the introduction of therapeutic or preventive interventions based on limited available evidence during the ongoing pandemic of Covid-19.

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MON-309 Prevalence of Silent Corticotroph Adenomas in a Large Cohort of Nonfunctioning Pituitary Adenomas: Plasma Proopiomelanocortin(POMC) Levels and Response to Pasireotide LAR

Silent corticotroph adenomas (SCAs) are tumors of the TPIT anterior pituitary cell lineage that do not lead to biochemical or clinical Cushings syndrome. Thus, they present as clinically nonfunctioning pituitary adenomas (CNFPAs) and are only diagnosed pathologically. Since they are often aggressive tumors, identification of a peripheral blood marker of SCA activity would be useful for diagnosis and monitoring. Some data suggest that aberrant processing of POMC, the precursor of ACTH, underlies the lack of elevated biologically active ACTH and thus cortisol excess in SCAs. We hypothesized that these tumors could secrete POMC, resulting in elevated plasma levels of POMC in patients with SCAs. Therefore, we investigated plasma POMC levels as a potential marker of this tumor type and correlated with tumor ACTH immunoreactivity (IR), which may be detecting unprocessed POMC. We studied 267 patients (134M, 133F, age 56.3±13.6yr) with CNFPAs (Cushings excluded) prior to surgery and at enrollment in a prospective, observational study. We also studied 9 patients with known SCAs with residual macroadenomas after surgery. Peripheral blood was sampled for POMC, ACTH and cortisol levels. POMC was measured by in-house two-site ELISA (detects POMC and 22kD pro-ACTH) and ACTH and cortisol by Immulite(Siemens). POMC levels were compared to the 95%CI of the mean of 70 healthy subjects and considered elevated if ≥ the 97.5 percentile of 39 fmol/mL. Of the CNFPA cohort, 12/267 had elevated POMC levels (range 39-166 fmol/mL) and 4 of the 12 had elevated ACTH levels (> 50 pg/ml)(range 53.6-76 pg/ml). Of the 12 with elevated POMC, 9 underwent surgery and 6 of them had positive ACTH IR in their tumors. An additional 13 patients in the CNFPA cohort had weak ACTH IR tumors, but POMC <39 fmol/mL and normal ACTH. POMC levels were elevated in all 9 known SCA patients (range 40-996 fmol/mL), being highest in those with the most aggressive tumors. ACTH levels were elevated in 6 of them (range 50.6-397 pg/ml). POMC levels were lowered with surgery in 4 of 4 SCA patients followed longitudinally. Two SCAs were treated with monthly pasireotide LAR (40 mg escalated to 60 mg) for 8 months. Plasma POMC levels fell from 104 to 21 fmol/mL in 1 patient, but did not change in the 2^nd, 124 to 112 fmol/mL. Both patients had no change in the size of their macroadenomas during treatment. In summary, patients with elevated plasma POMC levels were correctly identified as SCAs in most surgically treated patients and POMC levels were lowered by tumor removal in all who were tested longitudinally. Although POMC levels were not elevated in some other patients with weakly positive ACTH IR tumors, further characterization of these tumors by lineage specific transcription factors is underway to confirm them to be of corticotroph cell origin. These data suggest that plasma POMC measurements may have clinical utility in the evaluation of SCAs and this warrants further study.

MON-282 Treatment of Hyperprolactinemia with Ropinirole: An Open-Label Dose Escalation Study

Purpose

Treatment of hyperprolactinemia and prolactinomas with ergoline dopamine agonists (DAs) can be complicated by intolerance and resistance. Ropinirole (ROP) is a low cost selective D2/D3 receptor non-ergot DA, approved for treatment of Parkinson’s disease and Restless Leg Syndrome, that has been shown to acutely lower prolactin levels (PRL). This study investigated the efficacy and tolerability of long-term ROP therapy in patients with hyperprolactinemia.

Methods & Results

Ten healthy women (21-45 yrs) with hyperprolactinemia were treated with ROP (0.25-6.0mg/d) for 6 months in an open-label dose escalation study. Clinical and biochemical status was assessed monthly and ROP doses were up-titrated to achieve normal PRL levels, restore menses, and eliminate galactorrhea. Two subjects had macroprolactinomas, 7 had microprolactinomas, and 1 had idiopathic hyperprolactinemia. 8/10 had previously been treated with cabergoline and/or bromocriptine. 5/10 were intolerant and 1/10 was resistant to ergot DAs. Pituitary MRIs were performed at baseline and 6 months.ROP was initiated at 0.25mg QHS in 9/10 subjects. One subject with severe DA intolerance was initiated on 0.125mg QHS. Subjects reaching a total daily dose (TDD) > 2.0mg/d were transitioned to ROP extended release. At study completion, TDDs ranged from 1-6mg/d, with a median TDD of 2mg/d. Baseline PRL levels were 136 ± 49ng/ml (1.9-25ng/ml). Stable PRL normalization was achieved in 50% of subjects. Of the subjects achieving normal PRL, 4 had microadenomas and 1 had idiopathic hyperprolactinemia, and the median effective TDD was 1mg/d (1-4mg/d, range). Among those not achieving PRL normalization, PRL decreased 46 ± 5.4% (Mean ± SEM) from baseline, at a median TDD of 4.0mg/d (2-6mg/d, range). In the subject with documented resistance to ergot DAs, PRL decreased from 529 to 320ng/ml, after 3 months of ROP on the maximum dose studied (6mg/d), but rose to 690ng/ml at 6 months. During ROP treatment, menses normalized in 57%, and galactorrhea resolved in 67% of affected subjects. At study completion, tumor size was unchanged in 7/8 prolactinomas. A 20% decrease in tumor size was observed in one macroadenoma, accompanied by a 30% reduction in PRL levels. There were no changes in BP, HR, weight, renal or kidney function. Mild adverse effects (AEs) were recorded in 80% of subjects. Fatigue (60%), nausea (40%), and headache (20%) were most common. Reported AEs declined after month 1 and ROP was not discontinued due to intolerance.

Conclusion

These data provide support for the efficacy of ROP in the treatment of hyperprolactinemia in patients with microprolactinomas and idiopathic hyperprolactinemia. While further study is needed, ROP treatment for hyperprolactinemia could be considered in patients with ergot DA intolerance or significant cardiac valve disease.

Leprosy-A raging persistent enigma

Leprosy or Hansen's disease despite having achieved the elimination target across the world, the decrease in detection of new cases has almost stagnated for the last 10 years. Southeast Asia is having the highest prevalence of leprosy among all regions in the world. The review focuses on the programmatic laggards’ post-achievement of elimination target in India, the most significant contributors to leprosy caseload in the world, and a way forward.

Achieving excellent microformability in aluminum by engineering a unique ultrafine-grained microstructure

During microforming of conventional materials, specimen and microstructural length-scales are close to each other. This leads to an abnormal deformation behavior of the material and reduces microformability. Engineering ultrafine-grained (UFG) microstructure in the material is a possible solution. However, micro-scale deformation behavior of UFG material is not fully understood. Present work attempts to comprehensively investigate the micro-scale deformation of four distinctly engineered microstructures: UFG with residual dislocations and elongated grains, UFG free of residual dislocation with equiaxed grains, bimodal-grained and coarse-grained. The deformation behavior is captured via micro-scale uniaxial tensile test and micro-deep drawing operation. Micro-cups generated from UFG material with equiaxed grains show excellent surface quality, form-accuracy and minimal process scatter. Postmortem microscopy of the formed micro-cups attributes this improved microformability to the activation of grain boundary-mediated plasticity in the material which results in synergetic grain migration and rotation. Presence of residual dislocations and elongated grains hinders the grain migration and rotation leading to strain localization and thinning. In case of bimodal and coarse-grained material, cross-slip based deformation mode progressively dominates over grain migration and rotation, which results in a reduction in microformability due to the influence of size-effect.

Abstract 1392: Preclinical In vivo evaluation of efficacy, pharmacokinetics and pharmacodynamics of novel PRMT5 inhibitors in multiple tumor models

PRMT5 is a typical type II methyltransferase, transferring two methyl groups to arginine, leading to symmetric dimethylation of the substrate. It can symmetrically methylate histones H2AR3, H3R2, H3R8, and H4R3 and can also methylate many non-histone proteins contributing to tumorigenesis by regulating cell cycle progression, DNA repair, cell growth, apoptosis, and inflammation. Overexpression of PRMT5 is reported in several human malignancies including lymphoma, glioma, melanoma, lung, breast, ovarian, and prostate cancers. Elevated levels correlate with poor prognosis in NSCLC, ovarian cancers, and GBM. Therefore, PRMT5 is considered an attractive target for cancer therapy. We sought to discover and develop PRMT5 inhibitors with the “best-in-class” profile with an emphasis on improved permeability for their potential use in solid tumors. Utilizing structure-guided drug design and SAR-based approaches, we have optimized two chemical series of substrate competitive PRMT5 inhibitors. Determination of co-crystal structures with several de novo designed hits aided in the identification of lead compounds that exhibited potent inhibition of PRMT5. Lead compounds AU-574 and AU-755 were highly active in inhibiting proliferation of a number of cell lines derived from solid tumors that correlated well with cellular H4R3Me2s inhibition, confirming the mechanism. Lead compounds exhibited desirable drug-like properties including solubility, permeability, lack of CYP inhibition, and pharmacokinetic exposure. In xenograft models of Z-138 (lymphoma) and H-358 (lung cancer), treatment with lead compounds resulted in significant tumor growth inhibition while correlating with tumor drug levels and modulation of H4R3Me2s as the pharmacodynamic effect. In summary, we have identified PRMT5 inhibitors with “best-in-class" drug-like properties including optimized permeability and antitumor efficacy. Evaluation of these lead compounds in in vitro selectivity screening and in toxicity studies in higher species is currently under way.

Citation Format: Dinesh Chikkanna, Sunil Kumar Panigrahi, Sujatha Rajagopalan, Srinivasa Raju Sammeta, Darshan Chawla, Pavithra S, Samiulla D.S, Angelene Prasanna, Priyabrata Chand, Kiran Aithal, Sai Sudheer Marri, Naveen Kumar, Srinivasa Rao Ganipisetty, Raju Mutyala, Kasieswara Rao, Thomas Antony, Girish Daginakatte, Anirudha Lakshminarasimhan, Mohan R, Narasihmarao K, Shekar Chelur, Chetan Pandit, Susanta Samajdar, Murali Ramachandra. Preclinical In vivo evaluation of efficacy, pharmacokinetics and pharmacodynamics of novel PRMT5 inhibitors in multiple tumor models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1392.

Abstract A174: Novel inhibitors of protein arginine methyltransferase 5 (PRMT5) for the treatment of solid tumors

PRMT5 is a typical type II methyltransferase, transferring two methyl groups to arginine, leading to symmetric dimethylation of the substrate. It can symmetrically methylate histones H2AR3, H3R2, H3R8, and H4R3 and can also methylate many non-histone proteins contributing to tumorigenesis by regulating cell cycle progression, DNA repair, cell growth, apoptosis, and inflammation. Overexpression of PRMT5 is reported in several human malignancies including lymphoma, glioma, melanoma, lung, breast, ovarian, and prostate cancers. Elevated levels correlate with poor prognosis in NSCLC, ovarian cancers, and GBM. Therefore, PRMT5 is considered an attractive target for cancer therapy. We sought to discover and develop PRMT5 inhibitors with the “best-in-class” profile with an emphasis on improved brain permeability for their potential use in solid tumors including glioblastoma. Utilizing structure-guided drug design and SAR-based approaches, we have optimized two chemical series of substrate competitive PRMT5 inhibitors. Determination of co-crystal structures with several de novo designed hits aided in the identification of lead compounds that exhibited potent inhibition of PRMT5. Lead compounds were highly active in inhibiting proliferation of a number of cell lines derived from solid tumors that correlated well with cellular H4R3Me2s inhibition, confirming the mechanism. Lead compounds exhibited desirable drug-like properties including solubility, permeability, lack of CYP inhibition, and pharmacokinetic exposure. A substantial improvement in brain permeability over reported PRMT5 inhibitors was noted in rodent pharmacokinetic studies. In a xenograft model of lung cancer, treatment with lead compounds resulted in significant tumor growth inhibition while correlating with tumor drug levels and modulation of H4R3Me2s as the pharmacodynamic effect. In summary, we have identified PRMT5 inhibitors with “best-in-class" drug-like properties including optimized brain permeability and antitumor efficacy. Evaluation of the efficacy of these lead compounds in additional xenograft models including glioblastoma is currently under way.

Citation Format: Dinesh Chikkanna, Sunil Kumar Panigrahi, Sujatha Rajagopalan, Srinivasa Raju Sammeta, Anirudha Lakshminarasimhan, Mohan R, Narasihmarao K, Darshan Chawla, Harsha Bhat, Venkateswarlu Kasturi, Samiulla D.S, Angelene Prasanna, Kiran Aithal, Priyabrata Chand Chand, Naveen Kumar, Sai Sudheer Marri, Srinivasa Rao Ganipisetty, Kasieswara Rao N, Raju Mutyala, Nageswara Rao Neerukattu, Nithesh K, Ramya Amin, Priyanka Machhindra Gorade, Thomas Antony, Girish Daginakatte, Shekar Chelur, Chetan Pandit, Susanta Samajdar, Murali Ramachandra. Novel inhibitors of protein arginine methyltransferase 5 (PRMT5) for the treatment of solid tumors [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr A174.

To evaluate and compare the efficacy of combined sucrose and non-nutritive sucking for analgesia in newborns undergoing minor painful procedure: a randomized controlled trial

OBJECTIVE

The objective of this study was to evaluate and compare the efficacy of combined sucrose and non-nutritive sucking (NNS) for analgesia in newborn infants undergoing heel-stick procedures.

STUDY DESIGN

This randomized control trial was conducted in the neonatal intensive care unit of a tertiary care hospital over a period of 1 year. One hundred and eighty full-term neonates with birth weight >2200 g and age >24 h were randomized to one of four interventions administered 2 min before the procedure: 2 ml of 30% sucrose (group I, n=45) or NNS (group II, n=45) or both (group III, n=45) or none (group IV, n=45). Primary outcome was composite score based on Premature Infant Pain Profile (PIPP) score.

RESULT

Baseline variables were comparable among the groups. Median (interquartile range) PIPP score was 3 (2 to 4) in group III as compared with 7 (6.5 to 8) in group I, 9 (7 to 11) in group II and 13 (10.5 to 15) in group IV. Group III had significant decrease in the median PIPP score compared with other groups (P=0.000). Median PIPP score also decreased significantly with any intervention as compared with no intervention (P=0.000).

CONCLUSION

Sucrose and/or NNS are effective in providing analgesia in full-term neonates undergoing heel-stick procedures, with the combined intervention being more effective compared with any single intervention.

Self-circularizing 5'-ETS RNAs accumulate along with unprocessed pre ribosomal RNAs in growth-stressed Entamoeba histolytica

The primary transcript of rRNA genes is a large pre rRNA which is precisely processed to release the mature rRNAs. The 5'-external transcribed spacer (ETS) of rRNA genes contains important sites for pre rRNA processing. Once the processing is accomplished the ETS is rapidly degraded. We show that in growth-stressed cells of the human parasitic protist Entamoeba histolytica the A'-A(0) sub-fragment of the 5'-ETS accumulates to high levels as a family of RNA molecules of size 666 to 912 nt. These etsRNAs are circular in vivo and can spontaneously self-circularize in vitro. The accumulation of etsRNAs is accompanied by accumulation of unprocessed pre rRNA, indicating a possible role of etsRNAs in inhibition of processing during growth stress. Our data shows for the first time that processed etsRNA is not a mere by-product destined for degradation but is stabilized by circularization and could play a regulatory role as noncoding RNA.

Virtual Screening of 4-Anilinoquinazoline Analogues as EGFR Kinase Inhibitors: Importance of Hydrogen Bonds in the Evaluation of Poses and Scoring Functions

Virtual Screening (VS) is a computational technique that allows selection and ranking of possible hits from a library of compounds. We have carried out VS on 128 selected EGFR kinase inhibitors with GOLD and LigandFit. From the experimental crystal structure of the erlotinib-EGFR complex, three key hydrogen bonds were identified as responsible for anchoring the ligand in the active site. These are of the N-H...N, O(w)-H...N, and C-H...O types. Failure to include the hydrogen-bonded water molecule that forms the O(w)-H...N bond leads to incorrect results. Of the three interactions, the C-H...O formed by an activated C-H group is the best conserved. On the basis of the efficacy of these hydrogen bonds, the poses were classified into one of three categories: close, shifted, and misoriented. In the VS context, all three interactions need to be modeled correctly so that correct poses and affinities are obtained, and this happens in ligands of the close variety. Cross scoring wherein the poses from one software are input into another for scoring and consensus scoring wherein the scores from various software packages are weighted are also helpful in obtaining better agreements.