Technological Aspects of Nanoemulsions for Post-harvest Preservation of Fruits and Vegetables

Recent times have witnessed a growing demand for sustainable technology for food preservation that can retain its freshness, promises lower contents of additives and preservatives, safe consumption, eco-friendly milder processing technologies and eco-friendlier packaging solutions. Application of Biopolymers has served as the most sustainable and viable option to its synthetic counterparts. These biopolymers have been incorporated to develop biodegradable packaging like edible films and coatings owing to their biological origin. Nanoemulsion technology offers a leap forward to upgrade the features of conventional biodegradable packaging items. The present review discusses various trends and perspectives of nanoemulsion technology in post-harvest preservation for enhancing the shelf life of fresh fruits and vegetables. It investigates the interconnectedness between food preservation techniques, biodegradable packaging materials made from biopolymers, and nanoemulsions. It further addresses the preservation challenges post-harvest and underscores the limitations of conventional preservation methods, advocating for eco-friendly alternatives with a specific focus on the potential of nanoemulsions in enhancing food safety and quality. This review elaborates on the composition, formulation techniques, nanoemulsion products and role of nanoemulsions in the management of foodborne pathogens. Furthermore, it examines the potential health hazards linked to the use of nanoemulsions and stresses the significance of a regulatory framework for food safety. In conclusion, this review offers insights into the promising prospects of using nanoemulsions in food preservation.

A census of general surgery consultants in England and Wales: implications for the current and future surgical workforce

INTRODUCTION

This study aimed to describe the composition of the current general surgical consultant body in England and Wales and quantify levels of inequality within it as well as describe future workforce challenges.

METHODS

This is an observational study of all general surgical departments in England and Wales. Consultant general surgeons were identified and data regarding their gender, country of undergraduate medical education, subspecialty and private practice were recorded.

RESULTS

Of the 2,682 consultant general surgeons in England and Wales identified for this study, just 17% are women, with gender inequality most marked in university teaching hospitals and among certain subspecialties. Almost 40% of consultants did not obtain their primary undergraduate degree in the United Kingdom and there are considerably fewer surgeons who studied abroad in university teaching hospitals. Over 40% of current general surgical consultants have been qualified for more than three decades and there is no equivalent sized group of younger consultants.

CONCLUSIONS

There remains considerable gender and racial inequality in the consultant general surgical workforce, with pockets of a lack of diversity within university or teaching hospital surgical departments and some subspecialties. The proportion of surgeons in their fourth decade of clinical practice represents the largest group of current practising consultants, which points towards an impending workforce crisis should senior clinicians seek to reduce activity or consider taking early retirement.

[90Y]Yttria Alumino Silicate Glass Microspheres: A Biosimilar Formulation to "TheraSphere" for Cost-Effective Treatment of Liver Cancer

Background: Selective internal radiation therapy (SIRT) using a suitable β--emitting radionuclide is a promising treatment modality for unresectable liver carcinoma. Yttrium-90 (90Y) [T1/2 = 64.2 h, Eβ(max) = 2.28 MeV, no detectable γ-photon] is the most preferred radioisotope for SIRT owing to its favorable decay characteristics. Objective: The present study describes indigenous development and evaluation of intrinsically radiolabeled [90Y]yttria alumino silicate ([90Y]YAS) glass microsphere, a formulation biosimilar to "TheraSphere" (commercially available, U.S. FDA-approved formulation), for SIRT of unresectable liver carcinoma in human patients. Methods: YAS glass microspheres of composition 40Y2O3-20Al2O3-40SiO2 (w/w) and diameter ranging between 20 and 36 μm were synthesized with almost 100% conversion efficiency and >99% sphericity. Intrinsically labeled [90Y]YAS glass microspheres were produced by thermal neutron irradiation of cold YAS glass microspheres in a research reactor. Subsequent to in vitro evaluations and in vivo studies in healthy Wistar rats, customized doses of [90Y]YAS glass microspheres were administered in human patients. Results: [90Y]YAS glass microspheres were produced with 137.7 ± 8.6 MBq/mg YAS glass (∼6800 Bq per microsphere) specific activity and 99.94% ± 0.02% radionuclidic purity at the end of irradiation. The formulation exhibited excellent in vitro stability in human serum and showed >97% retention in the liver up to 7 d post-administration when biodistribution studies were carried out in healthy Wistar rats. Yttrium-90 positron emission tomography scans recorded at different time points post-administration of customized dose of [90Y]YAS glass microspheres in human patients showed near-quantitative retention of the formulation in the injected lobe. Conclusions: The study confirmed the suitability of indigenously prepared [90Y]YAS glass microspheres for clinical use in the treatment of unresectable hepatocellular carcinoma.

Comparing the performance of a deep learning-based lung gross tumour volume segmentation algorithm before and after transfer learning in a new hospital

Objectives

Radiation therapy for lung cancer requires a gross tumour volume (GTV) to be carefully outlined by a skilled radiation oncologist (RO) to accurately pinpoint high radiation dose to a malignant mass while simultaneously minimizing radiation damage to adjacent normal tissues. This is manually intensive and tedious however, it is feasible to train a deep learning (DL) neural network that could assist ROs to delineate the GTV. However, DL trained on large openly accessible data sets might not perform well when applied to a superficially similar task but in a different clinical setting. In this work, we tested the performance of DL automatic lung GTV segmentation model trained on open-access Dutch data when used on Indian patients from a large public tertiary hospital, and hypothesized that generic DL performance could be improved for a specific local clinical context, by means of modest transfer-learning on a small representative local subset.

Methods

X-ray computed tomography (CT) series in a public data set called "NSCLC-Radiomics" from The Cancer Imaging Archive was first used to train a DL-based lung GTV segmentation model (Model 1). Its performance was assessed using a different open access data set (Interobserver1) of Dutch subjects plus a private Indian data set from a local tertiary hospital (Test Set 2). Another Indian data set (Retrain Set 1) was used to fine-tune the former DL model using a transfer learning method. The Indian data sets were taken from CT of a hybrid scanner based in nuclear medicine, but the GTV was drawn by skilled Indian ROs. The final (after fine-tuning) model (Model 2) was then re-evaluated in "Interobserver1" and "Test Set 2." Dice similarity coefficient (DSC), precision, and recall were used as geometric segmentation performance metrics.

Results

Model 1 trained exclusively on Dutch scans showed a significant fall in performance when tested on "Test Set 2." However, the DSC of Model 2 recovered by 14 percentage points when evaluated in the same test set. Precision and recall showed a similar rebound of performance after transfer learning, in spite of using a comparatively small sample size. The performance of both models, before and after the fine-tuning, did not significantly change the segmentation performance in "Interobserver1."

Conclusions

A large public open-access data set was used to train a generic DL model for lung GTV segmentation, but this did not perform well initially in the Indian clinical context. Using transfer learning methods, it was feasible to efficiently and easily fine-tune the generic model using only a small number of local examples from the Indian hospital. This led to a recovery of some of the geometric segmentation performance, but the tuning did not appear to affect the performance of the model in another open-access data set.

Advances in knowledge

Caution is needed when using models trained on large volumes of international data in a local clinical setting, even when that training data set is of good quality. Minor differences in scan acquisition and clinician delineation preferences may result in an apparent drop in performance. However, DL models have the advantage of being efficiently "adapted" from a generic to a locally specific context, with only a small amount of fine-tuning by means of transfer learning on a small local institutional data set.

Cross-cultural adaptation of Nepalese literacy and stigma of suicide scales (LOSS-SF-Nep and SOSS-SF-Nep) among Nepalese medical and nursing students

INTRODUCTION

Nepal is a country in South-east Asia with high suicide. There is ongoing trend of emerging research on suicide from Nepal but there is lack of validated scale in measuring literacy or stigma. In the view of poor media reporting and large treatment gap, this study was conducted. All previous validation studies were done in non-Hindu populations.

METHODS

A cross-sectional study was planned where the short forms of Nepalese literacy of suicide scale (LOSS-SF-Nep) and Stigma of Suicide Scale (SOSS-SF-Nep) were validated using standard procedure at a medical college in southern Nepal. Medical and nursing students of all batches were approached offline after successful pretesting. The psychometric properties of the scales were tested, and the statuses of literacy and stigma were assessed. Patient Health Questionnaire-9 and General Anxiety Disorder Scale-7 were used for revealing depression and generalized anxiety.

RESULTS

Three hundred and nineteen Nepalese students participated and most of them were males, belonged to nuclear family, upper-middle socioeconomic status and represented 46 out of 77 districts of Nepal. The mean score of LOSS-SF-Nep was 6.36 ± 1.92 and literacy ranged from 37.9% to 89.7%. The deeper exposure to suicidal patients was associated with better literacy. Factor analysis of SOSS-SF-Nep revealed three subscales: stigmatization, isolation/depression, and normalization/glorification and had acceptable psychometric properties. Gender, occupation of head of the family, region and years of education, using mental health services, and depression were associated with variable literacy or stigma.

CONCLUSION

Literacy and stigma scales were validated in Nepali, and SOSS factor structures were revealed with modified descriptors. The literacy and stigma levels in medical students were calculated for the first time in Nepal and Hindu majority population.

AN EVALUATION OF ANTIBIOTIC PRESCRIPTION PRACTICES: PERSPECTIVES OF VETERINARY TRAINEES AND PRACTICING VETERINARIANS

Antibiotic resistance is a major worldwide problem that has an impact on the well-being of humans as well as animals. Antibiotic resistance is caused by the misuse and excessive use of antibiotics. The key to reducing this issue lies in educating veterinary medical learners on the proper and accountable utilization of antibiotics for the care of animals. Objective - using awareness-raising and instruction as the foundation, this research of Indian veterinary learners can help resolve the issue of antibiotic resistance throughout the care of animals. The questionnaire survey was taken between June and July 2022 and it was aimed at learners registered in veterinary medical studies at academic and research institutions in India. The study included 500 pupils overall. The purpose of the survey was to gather information about students' knowledge of antibiotics, including antibiotic resistance, as well as their feelings on the consequences of antibiotic resistance on the globe at large and their acquaintance with the one health ideology. According to this study's findings, 83.3 percent of respondents thought antibiotic resistance was a serious problem. 57.92 percent of respondents understood the issue's worldwide consequences and its one health ideology. The study emphasizes the significance of expanding the veterinary educational program to include thorough instruction on prudent antibiotic usage and the concepts of one health.

Development of a Radiomic Signature from Pre-Treatment FDG-PET for Recurrence Prediction in Cervical Cancer

PURPOSE/OBJECTIVE(S)

As many as 30-50% of patients with locally advanced cervical cancer (LACC) experience recurrence after standard-of-care chemoradiation therapy (CRT), creating a critical need to identify pre-treatment biomarkers of treatment failure. The purpose of this study is to identify whether radiomic features derived from pre-treatment FDG-PET imaging can be used to construct a predictive signature useful for assessing risk of recurrence during treatment planning.

MATERIALS/METHODS

Standardized uptake values (SUV) were obtained from within the physician-defined metabolic tumor volumes (MTV) delineated on FDG-PET scans acquired for 90 LACC patients at our institution prior to standard of care curative-intent CRT. Clinical outcome data of these patients has a median follow-up time of 85 months. The clinical endpoint was local recurrence within 3 years of treatment. 851 quantitative radiomic features describing intensity, shape, texture and high and low frequency spatial filters of the MTV were extracted for each patient. Low information features, defined by pairwise correlation > 0.85 with another feature or a maximum deviation within 20% of the mean, were discarded, leaving 146 features. Predictive signatures were constructed from features using multiple techniques, including multivariate Cox modelling, a set of machine learning models (random forest (RF), support vector classifier (SVC), ridge regression, LASSO regression, and elastic net regression), and a deep neural network (DNN) classifier.

RESULTS

The DNN classifier had the best overall performance, predicting a patient's recurrence group with an F1 score of 0.917 ± 0.028 under 5-fold cross-validation. By contrast, the Cox model classifier yielded an F1 score of 0.604 ± 0.085 and the best performing of the alternative machine learning models, elastic net, yielded F1 score of 0.868 ± 0.018. A set of textural features contributed the most to the output of the DNN classifier, including Large Area Low Gray Level Emphasis of the gray level size zone matrix (GLSZM) and coarseness and busyness of the neighboring gray tone difference matrix (NGTDM), reflecting the important role patterns of tumor heterogeneity play in post-treatment recurrence.

CONCLUSION

In this pilot study, we investigated multiple techniques to construct predictive radiomic signatures for local recurrence in LACC, determining that a DNN classifier is most capable of stratifying patients by risk of early recurrence. Future work will seek to validate this result on additional PET imaging data sets and to integrate radiomic features with gene expression data from matched tumor samples to establish radiogenomic biomarkers for recurrence.

CT Based Tumor Radiomics with Machine Learning Classifiers for Molecular Subtyping of Diffuse Large B Cell Lymphoma

PURPOSE/OBJECTIVE(S)

Diffuse large B-cell lymphoma (DLBL) has been classified into two distinct molecular subtypes based on their cell of origin- namely germinal center B-cell-like (GCB) and activated B-cell-subtype (ABC) based on Han's algorithm. These two entities are also prognostically distinct. We assessed CT based tumor radiomic features using machine learning classifiers to distinguish the two molecular subtypes.

MATERIALS/METHODS

One hundred one patients were accrued in the study after institutional ethics committee approval. GCB subtype was diagnosed in 59 while 42 patients were ABC subtype. Lesion with maximum SUV was delineated using a semi-automated segmentation tool (3D slicer) and radiomic features were extracted using Pyradiomics. A total of 1030 features were extracted including Shape features, first, second, third, higher order and wavelet-based features. Recursive feature elimination was used for feature selection and optimal 10 features were selected. Five machine learning (ML) tools were used to build a model to sub- classify the two molecular subtypes. (Table -1) Model performance was assessed using Accuracy, Precision, Recall, F1 score and Area under curve of receiver operating characteristic curve. The models were constructed by two methods.1) A 5-fold internal cross validation strategy & 2) splitting the data into training (70%) and validation set (30%).

RESULTS

Recursive feature elimination using a random forest algorithm method was used to select 7 radiomic features. These 7 features were then used to build the model using the 5 ML classifiers. Of the five classifiers, Random Forest Classifier (RFC) using a 70:30 training: test strategy was the best performer among all the ML models, with the highest accuracy of 80%, AUC of 0.87, recall(sensitivity), f1score(specificity) & precision (Positive Predictive value; PPV) or precision of 82% respectively. When an internal 5-fold cross validation strategy was used, RFC again performed better than other ML classifiers with an accuracy of 75%, AUC of 0.80, recall of 79%, PPV of 77% and specificity of 79%.

CONCLUSION

The machine-learning based Radiomics features extracted from pre-treatment CT images can provide a simple and non-invasive method for the prediction of DLBL molecular subtypes with favorable predictive accuracy. The Random Forest Classifier was the most accurate in distinguishing GCB subtype from the ABC subtype.

Analgesic Efficacy of Fascia Iliaca Compartment Block for Positioning During Spinal Anesthesia in Patients with Femur Fractures

Background Positioning patients with femur fractures for spinal anesthesia is associated with excruciating pain. Fascia iliaca compartment block has the potential to block all nerves supplying the femur and therefore may provide effective analgesia during positioning these patients for spinal anesthesia. Objective To assess the analgesic efficacy of Fascia iliaca compartment block, during positioning patients with femur fracture for spinal anesthesia. We also assessed the duration of analgesia and the requirement for rescue analgesics in the postoperative period. Method Seventy adult patients with fracture femurs were randomly divided into two equal groups (A and B). Patients in both groups received fentanyl one mcg/kg intravenously, 20 minutes before positioning them for spinal anesthesia. Patients of group B additionally, received ultrasound-guided Fascia iliaca compartment block with 40 ml of 0.25% Ropivacaine, immediately after intravenous fentanyl. Numerical rating score (0-10) was used for the assessment of pain at five, 10, and 20 minutes after the block and immediately after positioning patients for spinal anesthesia. Result Immediately after positioning patients for spinal anesthesia, the numerical rating score of pain was 5.06±1.5 in group A and 2.49±1.2 in group B (p<0.001). The duration of analgesia was 799.7±62.1 minutes in group B and 314.65±118.9 minutes in group A (p<0.001). One (2.8%) patient of group B and 18(51.4%) patients of group A required rescue analgesics within four to twelve hours in the postoperative period (p=0.001). In group A, seven patients were satisfied with the analgesia technique while in group B, 17 were satisfied and eight patients were strongly satisfied (p<0.001). Conclusion Ultrasound-guided Fascia iliaca compartment block is effective in reducing pain during positioning patients with femur fractures for spinal anesthesia. Patients receiving this block had a prolonged duration of analgesia, required lesser analgesics, and were more satisfied in the postoperative period as compared to patients not receiving the block.

Cyber Attacker Profiling for Risk Analysis Based on Machine Learning

The notion of the attacker profile is often used in risk analysis tasks such as cyber attack forecasting, security incident investigations and security decision support. The attacker profile is a set of attributes characterising an attacker and their behaviour. This paper analyzes the research in the area of attacker modelling and presents the analysis results as a classification of attacker models, attributes and risk analysis techniques that are used to construct the attacker models. The authors introduce a formal two-level attacker model that consists of high-level attributes calculated using low-level attributes that are in turn calculated on the basis of the raw security data. To specify the low-level attributes, the authors performed a series of experiments with datasets of attacks. Firstly, the requirements of the datasets for the experiments were specified in order to select the appropriate datasets, and, afterwards, the applicability of the attributes formed on the basis of such nominal parameters as bash commands and event logs to calculate high-level attributes was evaluated. The results allow us to conclude that attack team profiles can be differentiated using nominal parameters such as bash history logs. At the same time, accurate attacker profiling requires the extension of the low-level attributes list.

Tumour radiomics as imaging biomarker of tumour response to chemo-radiotherapy in patients with adenocarcinoma of rectum

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Background: We aimed to study whether texture (Radiomic) features obtained from T2W MRI of patients with rectal cancer can be used as a surrogate imaging biomarker to predict response to NACTRT. We explored various machine learning tools to develop the best model to predict response to NACTRT. Methods: One hundred patients with stage II/III who underwent MRI before and after NACTRT and surgical treatment were enrolled. Patients were classified into complete response (pCR, n = 21) and partial and nonresponse (pPR + pNR, n = 53) on the basis of histopathological report (74 patients who underwent surgery) and clinico-radiological response (26 patients who did not undergo surgery). Tumor volumes (Region of interest) were manually selected in each tumour segment. There were sixty four first-order and higher-order radiomic features. Recursive feature elimination method was used for feature selection and 5 prediction models were tested using 10-fold cross validation for predicting tumour response to NACTRT. Results: Using prediction model assessment matrix (RFC, SVC, GBC, NBC, ABC), the best results for prediction response were obtained using the random forest model with AUC of 0.79 ± 0.15 (Mean ± Standard deviation) accuracy of 0.72 ±0.12, precision of 0.77 ± 0.10, sensitivity of 0.87 ± 0.07, f1 score- 0.81 ±0.07. By using random forest model, Texrad features obtained from pre and post NACTRT MRI could accurately predict pCR. To the best of our knowledge, apart for the added values of RF model to Texrad features, is the first study to demonstrate and compare RF, SVC, GBC, NBC, Adaboost models to the same cohort of patient with 10-fold validation. Conclusions: Our study shows that RFM was most accurate and stable for predicting tumour response. MRI based Radiomic features can be used as surrogate image biomarker to accurately predict the treatment response to NACTRT in patients with locally advanced rectal cancer. The prediction model can be used as a complementary non-invasive tool to identify patients eligible for organ preservation. [Table: see text]

956 AN AUDIT CONDUCTED LOOKING INTO THE USE OF IV IRON TO TREAT IRON DEFICIENCY ANAEMIA ON THE ELDERLY CARE WARDS

Aims

To assess whether patients on the elderly care wards at NUH (Nottingham University Hospitals) were appropriately given IV (intravenous) iron for Iron deficiency anaemia (IDA). To improve our practice in the investigation and follow up of patients with IDA.

Method

Data was obtained of patients who had IV iron dispensed from June—September 2019. This totalled 146 patients. Digital medical records and Notis results. Server were reviewed and a spread sheet database compiled with patient demographics, presentation, blood results. Co-morbidities, medication, investigations and follow up.

Results

The average age of the patients receiving IV iron on the elderly care wards was 86 (range 74–106). 89 were female and 57 male. The top presenting complaints were; fall (38%), abdominal symptoms of pain, diarrhoea or vomiting (15%), SOB (12%). 30% of patient were on anti-coagulation and 27% were on an anti-platelet with 2% of patient on both. Mean female Hb was 89 (41–129) and male Hb was 91 (49–117). The data showed that 8 out of 81 female patients were given IV iron despite not being anaemic. In 7.5% of cases ferritin, TSAT, iron and transferrin had not been checked. Ferritin was not checked 16%. 82% of patients had no documentation with regards to the rationale for choosing not to proceed with invasive investigation.

Conclusion

Improvement is needed in the way we manage patients with IDA. This audit highlighted the need for continued review of medications—particularly anti-platelets and anti-coagulants. If there is a weak indication consider the risks and benefits. It is important we discuss and document the consideration or unsuitability of invasive investigations and follow up. A proforma is being written to guide clinicians with regards to the appropriate prescribing of IV iron and to guide investigation and follow up.

Evaluation of Dual Marker Approach Using Heart-Type Fatty Acid Binding Protein and High Sensitivity Troponin-I as an Alternative to Serial Sampling for Diagnosis of Acute Myocardial Infarction

Objective

An early rule in (high specificity and high PPV) and early rule out (high sensitivity and high NPV) is essential for diagnosing acute myocardial infarction (AMI) to provide better utilization of resources, cost-effectiveness, and to reduce mortality.

Methods

Consecutive chest pain patients (n=80) with symptoms indicative of coronary artery disease reported to the emergency room within 6 hours after onset of symptoms. An alternate Dual Marker Approach (DMA; both Heart-type Fatty Acid Binding Protein (H-FABP) and High sensitive Troponin-I (hsTnI) at 0 h) was compared to the Double Sampling approach (DSA; hsTnI at 0 h and 3 h (ESC guidelines)).

Results

If both biomarkers were increased (n=17; 77.5%: 11 STEMI and 6 NSTEMI) above their respective cut-off value (HFABP 6.3 ng/mL and hsTnI 20.24 ng/L) at presentation, AMI ensued (100% PPV). Also, if both the markers were below their respective cut-offs at presentation, AMI was safely ruled out (n=41; with only 1 false negative). However, among the patients with either of these markers above their respective cut-off at presentation (n=22), DSA was required to find remaining AMI cases (n=4). Overall, DMA stands best for rule out (sensitivity 95.5%, NPV 97.6%) while DSA is superior for rule in (98.2% specificity, 95.2% PPV).

Conclusion

With the use of the proposed DMA, 58/80 (72.5%) patients with acute chest pain were reliably ruled in/ruled out for AMI at the presentation itself, while the remaining patients still required serial monitoring (DSA) for confirmation.

Nevus Lipomatosus Cutaneous Superficialis of Hoffmann and Zurhelle: a rare cutaneous hamartoma

Nevus lipomatosus cutaneous superficialis (NLCS) is a rare idiopathic cutaneous hamartoma characterized by ectopic clusters of mature adipose tissues in dermis. It is classified into two types. Classical type presenting as multiple lesions with onset at birth or within third decade of life and solitary type with onset between third to sixth decade of life. Here we present a case of 45 years female with adult onset, asymptomatic, grouped, skin colored, soft sessile growth in zosteriform pattern on left buttock. We here intend to report rare case of classical Nevus Lipomatosus Cutaneous Superficialis.

Atypical presentations of cutaneous tuberculosis: Series of 10 cases

Cutaneous tuberculosis classically presents as Lupus vulgaris, scrofuloderma, tuberculosis verrucose cutis and tubercular abscess. Hypersensitivity reaction to the bacilli leads to Lichen scrofulosorum and papulonecrotic tuberculids. At the same time, it can have myriad of clinical presentations, many of which are still undescribed. It is important to regularly update ourselves with these unusual manifestations so as to ensure early treatment and reduction of overall morbidity. In this case series tuberculosis manifesting as rapidly progressing diffuse facial granulomas, sporotrichoid tuberculosis, tuberculosis mimicking squamous cell carcinoma, scrofuloderma as tubercular ulcer, lupus vulgaris with nasal septal perforation, lupus vulgaris resembling furuncle, psoriasis, dermatitis and BT Hansen are described in immunocompetent individuals. These cases highlight the importance of recognition of atypical forms of cutaneous tuberculosis to minimize scarring and dissemination of bacilli.

Knowledge, attitude, and practice of stroke and thrombolysis among students preparing for undergraduate medical entrance examination in Kathmandu, Nepal

BACKGROUND

Stroke is a major disabling disease, especially for low and middle-income countries like Nepal. The aim of our study is to assess knowledge, attitude, and practice (KAP) among the students preparing for undergraduate medical entrance examination regarding risk factors, warning signs and symptoms, and management of stroke.

METHODS

A cross-sectional, single staged study using self-structured questionnaire intended to assess KAP about stroke and thrombolysis was conducted.

RESULTS

A total of 378 students participated in our study (53% male; mean age = 18.12 ± 0.97). Majority of the participants (88.4%) had heard about stroke. The more common risk factors identified by them were hypertension (86.2%), oily food (48%), alcohol (37.8%), and smoking (32.8%). Limb weakness, slurring of speech and facial weakness as symptoms and signs of stroke were indicated by 43.4%, 30.2%, and 18.8% of the participants, respectively. Only 23.8% of the participants had heard about thrombolysis and 10% of all could rightly mention the window period of thrombolysis. Male participants had better knowledge about smoking [86 (43.0) vs 38 (21.3); P < .001] and oily food [108 (54.0) vs 73 (41.0); P = .012] being risk factors and facial weakness [50 (37.6) vs 21 (11.8); P = .001] being symptom of stroke compared with females. Similarly, male participants had heard more about thrombolysis than females [68 (34.0) vs 22 (12.4); P < .001].

CONCLUSION

Knowledge regarding risk factors and signs and symptoms of stroke was adequate among the students preparing for undergraduate medical entrance examination. However, knowledge about thrombolysis was poor. Male participants had better knowledge about risk factors, warning signs and symptoms of stroke, and thrombolysis compared with female.

Comparison of Superior Vena Cava and Inferior Vena Cava Diameter Changes by Echocardiography in Predicting Fluid Responsiveness in Mechanically Ventilated Patients

Context:

Resuscitation of critically ill patients requires an accurate assessment of the patient's intravascular volume status. Passive leg raise cause auto transfusion of fluid to the thoracic cavity.

Aims:

This study aims to assess and compare the efficacy of superior vena cava (SVC) and inferior vena cava (IVC) diameter changes in response to passive leg raise (PLR) in predicting fluid responsiveness in mechanically ventilated hemodynamically unstable critically ill patients.

Methods:

We enrolled 30 patients. Predictive indices were obtained by transesophageal and transthoracic echocardiography and were calculated as follows: (Dmax − Dmin)/Dmax for collapsibility index of SVC (cSVC) and (Dmax − Dmin)/Dmin for distensibility index of IVC (dIVC), where Dmax and Dmin are the maximal and minimal diameters of SVC and IVC. Measurements were performed at baseline and 1 min after PLR. Patients were divided into responders (increase in cardiac index (CI) ≥10%) and nonresponders (NR) (increase in CI <10% or no increase in CI).

Results:

Among those included, 24 (80%) patients were R and six were NR. There was significant rise in mean arterial pressure, decrease in heart rate, and decrease in mean cSVC from baseline to 1 min after PLR among responders. The best threshold values for discriminating R from NR was 35% for cSVC, with sensitivity and specificity of being 100%, and 25% for dIVC, with 54% sensitivity and 86.7% specificity. The areas under the receiver operating characteristic curves for cSVC and dIVC regarding the assessment of fluid responsiveness were 1.00 and 0.66, respectively.

Conclusions:

cSVC had better sensitivity and specificity than dIVC in predicting fluid responsiveness.

Anal cancer survival: a socioeconomic analysis

INTRODUCTION

Squamous cell carcinoma is the most common variant of anal malignancy. Certain disease-related factors have been established in determining survival. These include tumour size, differentiation and nodal involvement. Other factors such as HIV status, human papillomavirus infection, smoking and socioeconomic disparity may have important roles, however few data are available on the UK population. We aim to correlate social deprivation and survival of anal cancer patients at a tertiary centre.

MATERIALS AND METHODS

All consecutive cases diagnosed with anal squamous cell carcinoma and treated as per local protocol between July 2010 and April 2017 were included. The pathological and demographical details were collected from a prospectively maintained database. Socioeconomic deprivation was defined for each postcode using the Index of Multiple Deprivation decile compiled by local governments in England. Survival was estimated using Kaplan-Meier analysis and Cox regression was used to investigate the effect of different factors on overall survival.

RESULTS

A total of 129 patients with anal squamous cell carcinoma over a median follow-up of 43 months were included. Overall survival for the entire patient cohort was 87.7% (95% confidence interval, CI, 82.0-93.7%), 75.5% (95% CI 67.5-84.5%) and 68.9% (95% CI 59.7-79.6%) at one year, three years and five years, respectively. On multivariate analysis, Index of Multiple Deprivation and income do not significantly influence overall survival (p = 0.79, hazard ratio, HR, 1.07; 95% CI 0.61-1.63), (p = 0.99, HR=1.00; 95% CI 0.61-1.63), respectively. Increased risk of death was observed for male sex (p = 0.02, HR=2.80; 95% CI 1.02-5.50) and larger tumour size (p = 0.01, HR=1.64; 95% CI 1.12-2.41).

CONCLUSION

In contrast to US studies, there is little difference in survival between the least deprived and most deprived groups. We attribute this to equal access to intensity-modulated radiation therapy-based chemoradiotherapy. Thus, a highly effective treatment made available to all mitigates any survival difference between socioeconomic groups.

Politics of disease control in Africa and the critical role of global health diplomacy: A systematic review

Background: Africa is facing the triple burden of communicable diseases, non-communicable diseases (NCDs), and nutritional disorders. Multilateral institutions, bilateral arrangements, and philanthropies have historically privileged economic development over health concerns. That focus has resulted in weak health systems and inadequate preparedness when there are outbreaks of diseases. This review aims to understand the politics of disease control in Africa and global health diplomacy’s (GHD’s) critical role.

Methods: A literature review was done in Medline/PubMed, Web of Science, Scopus, Embase, and Google scholar search engines. Keywords included MeSH and common terms related to the topics: "Politics," "disease control," "epidemics/ endemics," and "global health diplomacy" in the "African" context. The resources also included reports of World Health Organization, United Nations and resolutions of the World Health Assembly (WHA).

Results: African countries continue to struggle in their attempts to build health systems for disease control that are robust enough to tackle the frequent epidemics that plague the continent. The politics of disease control requires the crafting of cooperative partnerships to accommodate the divergent interests of multiple actors. Recent outbreaks of COVID-19 and Ebola had a significant impact on African economies. It is extremely important to prioritize health in the African development agendas. The African Union (AU) should leverage the momentum of the rise of GHD to (i) navigate the politics of global health governance in an interconnected world(ii) develop robust preparedness and disease response strategies to tackle emerging and reemerging disease epidemics in the region (iii) address the linkages between health and broader human security issues driven by climate change-induced food, water, and other insecurities (iv) mobilize resources and capacities to train health officials in the craft of diplomacy.

Conclusion: The AU, Regional Economic Communities (RECs), and African Centres for Disease Control should harmonize their plans and strategies and align them towards a common goal that integrates health in African development agendas. The AU must innovatively harness the practice and tools of GHD towards developing the necessary partnerships with relevant actors in the global health arena to achieve the health targets of the Sustainable Development Goals.

Comparison of Outcome of Borderline and Normal Amniotic Fluid Index in Term Pregnancy

Background Determination of Amniotic Fluid Index (AFI) is an important component of antepartum assessment of all normal pregnancies. Objective To compare the obstetric interventions and neonatal outcomes in term pregnancies with borderline Amniotic Fluid Index versus normal Amniotic Fluid Index. Method This hospital based prospective study was conducted at Tribhuwan University Teaching Hospital over 1 year between 2017 and 2018 in 128 women having uncomplicated term pregnancy admitted in labor ward. Of the 128 women, 64 women had borderline Amniotic Fluid Index (5.1-8 cm) and 64 normal AFI (8.1 - 24 cm). Parameters studied were induction of labor, cesarean section, instrumental delivery, intrapartum abnormal fetal heart rate, meconium staining of liquor, APGAR score at 5 and 7 minutes, birth weight, neonatal intensive care unit (NICU) admission and neonatal death. Data was analyzed using software OpenEpi. Result Statistically significant difference in result was obtained in the two groups in terms of rate of induction of labor (73.4% vs 35.9%, p = 0.0001, OR = 4.9), rate of cesarean section (42.1% vs 28 .1%, p = 0.04, OR = 1.8), tachypnea (50% vs 11.1%, p = 0.01) and low birth weight (9.1% vs 4.5%, p = 0.04). No statistical significance was found in meconium staining of liquor (33% vs 38.3%, p = 0.3) and APGAR score of <7 at 5 minutes (3.1% vs 1.5%, p = 0.06). There were no neonatal intensive care unit admissions and neonatal mortality in any of the babies. Conclusion Detection of amniotic fluid volume at term is important for timely maternal interventions to improve the overall fetal outcome.

Cost-effectiveness of cancer drugs: Comparative analysis of the United States and England

BACKGROUND

England's National Institute for Health and Care Excellence (NICE) and the US' Institute for Clinical and Economic Review (ICER) both conduct cost-effectiveness evaluations for new cancer drugs to help payers make drug coverage decisions. However, NICE and ICER assessments have been noted to reach different conclusions. We aim to better understand the degree to which their recommendations diverge and what drives these apparent differences.

METHODS

We compared the methods and results of publicly available cost-effectiveness evaluations performed by ICER and NICE of similarly assessed cancer drugs. Assessments were compared based on incremental cost-effectiveness ratio, comparator treatment, price, recommendation, and the design of the economic evaluation.

FINDINGS

Among 11 commonly assessed cancer drugs, ICER and NICE were in concordance for 7 evaluations and in discordance on the cost-effectiveness and coverage decisions for 4 drugs. Most new cancer drugs were not cost-effective in either the US (7/11) or England (7/11). Furthermore, NICE's capacity to negotiate price discounts and access schemes result in much lower cost per QALY valuations and more favourable recommendations than those of ICER for similarly assessed cancer drugs.

INTERPRETATIONS

NICE and ICER employ similar health technology assessment (HTA) methodologies and were aligned with most recommendations, finding that many new and expensive cancer drugs are cost ineffective. Growing use of ICER assessments will continue to send stronger price signals to manufacturers that cancer drugs with low value for money will be viewed less favourably by private insurers. NICE provides an important reminder of how much lower other countries pay for drugs when comparative effectiveness and value-based pricing are integrated into public drug coverage decisions.

Outcomes, resource utilization and predictors of thirty day readmission in patients with heart failure with preserved ejection fraction (HFpEF): insights from the Nationwide Readmissions Database 2017

Background and aims

Nearly half of all heart failure patients have heart failure with preserved ejection fraction (HFpEF). Due to differences in pathophysiology of heart failure with preserved and reduced ejection fraction, as well as a paucity of studies, the treatment of hHFpEF remains a challenge.

We aimed to determine the rate of hospital readmission within 30 days of acute or acute on chronic HFpEF and its impact on mortality and health care utilization in the United States. We also focused on patient demographics as well as independent variables affecting readmission.

Methods

We performed a retrospective study using the Agency for Health-care Research and Quality's Health-care Cost and Utilization Project (HCUP), Nationwide Readmission Database (NRD) for the year of 2017 (data on approximately 18 million hospital stays at 2,454 hospitals in the United States). We collected data on hospital readmissions of 60,514 adults who were hospitalized for acute or acute on chronic diastolic heart failure and discharged. The primary outcome was the rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, and resource use (length of stay, total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis.

Results

The 30-day rate of readmission was 21%. Only 1,175 (9.17%) of readmissions were associated with an admitting diagnosis of acute on chronic diastolic heart failure. The most common readmission diagnosis was hypertensive chronic kidney disease with heart failure (1,245; 9.7%). Readmission cases were associated with increased in-hospital mortality compared to index admission (7.9% vs 2.9%, p=0.000). Readmission was associated with a total of 81,997 hospital days. Total health care in-hospital economic burden was $206 million (in costs) and $779 million (in charges). Significant predictors of increased thirty-day readmission were Medicaid insurance (1.15, 1.05–1.27, p=0.004), higher Charlson co-morbidity score (1.08, 1.06–1.09, p=0.000), patient admitted to teaching hospital (1.09, 1.04–1.15, p=0.001) and longer stays in the hospital (1.01, 1.01–1.02, p=0.000). Residence in a small metropolitan (0.91, 0.86–0.97, p=0.003) or micropolitan area (0.83, 0.77–0.90, p=0.000), older age (0.99, 0.993–0.997, p=0.000), female sex (0.91, 0.86–0.95, p=0.000), private (0.85, 0.77–0.93, p=0.000) or no insurance (0.70, 0.53–0.93, p=0.015) were associated with lower odds of readmission. Interestingly discharges to rehabilitation had no effect on re-admission (0.67, 0.28–1.6, p=0.381).

Conclusions

In conclusion patients hospitalized for acute or acute on chronic HFpEF, we found that 21% of patients were readmitted to the hospital within 30 days of discharge. Readmissions were associated with higher mortality and resource utilization. Most readmissions were due to cardiorenal syndrome.

Funding Acknowledgement

Type of funding source: None

Pharmacophore-based identification and in vitro validation of apoptosis inducers as anticancer agents

Ligand-based pharmacophore modelling and virtual screening along with in vitro screening were performed as a rational strategy for the identification of novel compounds as apoptosis inducers and anticancer agents from the chemical database. Known apoptosis inducers were selected from the literature for generation of pharmacophore models, which were subjected to validation using Receiver operating characteristic (ROC) and Günere-Henry (GH) scoring methods. Based on highest fitness score of 4680.61, ROC value of 0.872 and GH score of 0.758, pharmacophore model-2 was selected as the best model. Model-2 as 3D search query was searched against the IBS database to find novel compounds as hits. Three hits were selected with a Q_FIT value more than 82 for in vitro screening as apoptosis inducers and anticancer agents. In vitro anticancer activity was performed using resazurin cell variability assay, and apoptosis inducing activity was determined using caspase-3 activation and annexin-FITC assays. One of the retrieved hit, STOCK5S-44056 demonstrated IC₅₀ value of 23.56 µM in cell variability assay, and had EC₅₀ value of 26.95 µM in caspase-3 activation assay. STOCK5S-44056 also indicated late stage induction of apoptosis in annexin assay. The results of in vitro activity revealed that STOCK5S-44056 has a potential to become anticancer agents.

Demographic history of the fragmented yellowthroated bulbul (Pycnonotus xantholaemus) population in the Deccan Peninsula, India

The yellow-throated bulbul (YTB) is an endemic passerine restricted to scrub forests along hill slopes with exposed rocky outcrops in the Deccan Peninsula, India. It is found in small, discontinuous populations and is vulnerable to extinction due to ongoing habitat loss and subsequent population decline. To assess the genetic connectivity and past demography, we sequenced 1050 nucleotide base pairs of the mitochondrial control region of 60 individuals that represent distinct populations in the geographic range of the species. We recovered 39 haplotypes defined by 81 variable sites. Haplotype diversity was high with low nucleotide diversity, suggesting rapid population growth from a founder population with a small effective population size. The negative values of Tajima’sDand Fu’sFsand small positive value of Ramos-Onsins and Rozas’R2suggest deviation from neutrality and population expansion. The haplotype network and demographic expansion parameters further suggest historical population expansion. Mismatch analysis statistics and Bayesian skyline plots estimate population expansion during the late Pleistocene. Although the species presently occurs in small, disconnected we found no structuring of the population. Dispersal events are the most likely explanation for the absence of genetic structuring in the YTB population. These results represent important data for the design of a conservation plan for this endemic and globally threatened species.

Tentorial Venous Anatomy: Variation in the Healthy Population

BACKGROUND AND PURPOSE

A new transtentorial venous system consisting of medial, intermediate, and lateral tentorial veins, connecting infra- and supratentorial compartments, was recently shown in 2 cadaver dissections and 2 patient scans. We sought to characterize the venous patterns within the tentorium and their relation to measures of skull development in a cohort of healthy adults.

MATERIALS AND METHODS

We retrospectively reviewed tentorial venous anatomy of the head using CTA/CTV performed for routine care or research purposes in 238 patients. Included studies had adequate contrast opacification of venous structures and a section thickness of ≤2 mm; we excluded cases with space-occupying lesions and vascular pathologies. Tentorial angle, dural sinus configurations, and measures of skull base development were assessed as predictors of tentorial venous anatomy variation via Cramér V association, the binary encoded Pearson correlation, and nearest-point algorithm with the Euclidean distance metric for clustering.

RESULTS

Tentorial vein development was related to the ringed configuration of the tentorial sinuses (P < .005). There were 3 configurations. Groups 1A and 1B (n = 50/238) had ringed configuration, while group 2 did not (n = 188/238). Group 1A (n = 38/50) had a medialized ringed configuration, and group 1B had a lateralized ringed configuration (n = 12/50). Measurements of skull base development were predictive of these groups. The ringed configuration of group 1 was related to the presence of a split confluens, which correlated with a decreased internal auditory canal-petroclival fissure angle. Configuration 1A was related to the degree of petrous apex pneumatization (P value = .010).

CONCLUSIONS

Variations in the transtentorial venous system directly correlate with cranial development.

Recurrent Pneumonias and Bronchiectasis - Is it an Immunodeficiency Disorder? - A Case Report

Common Variable Immunodeficiency (CVID) is a form of primary immunodeficiency disorder characterised by hypogammaglobulinemia and recurrent sino-pulmonary infections. Its diagnosis is based on the presence of low serum IgG (< 2 SD below normal for age) with or without low IgA/ IgM levels and presentation beyond two years of age. These children also have disorders of autoimmunity with majority of them presenting as autoimmune cytopenias, predominantly thrombocytopenia and some having anaemia and neutropenias. Here we report a nine years old boy with past history of recurrent pneumonia, presenting this episode with fungal pneumonia, thrombocytopenia and anaemia eventually diagnosed as CVID.

Comparison of Health Care Spending by Age in 8 High-Income Countries

This cross-sectional study compares health care spending by age in the US with spending in 8 other high-income countries.

Sonographic Quantification of Ovarian Volume in Adults Attending General Health Checkup and General Out Patient Department in Tribhuvan University Teaching Hospital

Background Ultrasonography is the easily available, cheap and reliable method for evaluation of ovaries. Ovarian volume is the major factor in the diagnosis of various ovarian pathologies and confusing discrepancies are found in the literature. Objective To determine the ovarian volume among individuals attending outpatient department in tertiary level hospital. Method Descriptive cross sectional study design was used; 305 patients of 16-60 years attending general outpatient department in the Tribhuvan University Teaching Hospital, Kathmandu, Nepal were included. Ovarian volume was calculated by using transabdominal ultrasonography. Data was collected in the predesigned proforma and analyzed using statistical package for the social sciences software. Result The study showed mean total ovarian volume 5.95 ± 2.44 cc (centimeter cube) with mean right ovarian volume 5.94 ± 2.70 cc and mean left ovarian volume 6.05 ± 2.79 cc. Significant decrease in ovarian volume with age was observed. Height and weight did not show significant correlation with ovarian volumes and no significant variation seen in the volumes of right and left ovaries. Periovulatory ovaries show significantly higher volumes on right side than luteal phase. Similarly, significantly higher volume of left ovary seen in mixed ethnic group than mongoloid group. Conclusion Measurement of ovarian volume is important for evaluation and management of ovarian disorders. Ultrasonography which is readily available, simple and cost effective is better suited for our environment than other imaging modality. Values of ovarian volume from this study may provide a baseline of normal ovarian volume in our community.

The quality of malaria care in 25 low-income and middle-income countries

Introduction

Even with accessible and effective diagnostic tests and treatment, malaria remains a leading cause of death among children under five. Malaria case management requires prompt diagnosis and correct treatment but the degree to which this happens in low-income and middle-income countries (LMICs) remains largely unknown.

Methods

Cross-sectional study of 132 566 children under five, of which 25% reported fever in the last 2 weeks from 2006 to 2017 using the latest Malaria Indicators Survey data across 25 malaria-endemic countries. We calculated the per cent of patient encounters of febrile children under five that received poor quality of care (no blood testing, less or more than two antimalarial drugs and delayed treatment provision) across each treatment cascade and region.

Results

Across the study countries, 48 316 (58%) of patient encounters of febrile children under five received poor quality of care for suspected malaria. When comparing by treatment cascade, 62% of cases were not blood tested despite reporting fever in the last 2 weeks, 82% did not receive any antimalarial drug, 17% received one drug and 72% received treatment more than 24 hours after onset of fever. Of the four countries where we had more detailed malaria testing data, we found that 35% of patients were incorrectly managed (26% were undertreated, while 9% were overtreated). Poor malaria care quality varies widely within and between countries.

Conclusion

Quality of malaria care remains poor and varies widely in endemic LMICs. Treatments are often prescribed regardless of malaria test results, suggesting that presumptive diagnosis is still commonly practiced among cases of suspected malaria, rather than the WHO recommendation of 'test and treat'. To reach the 2030 global malaria goal of reducing mortality rates by at least 90%, focussing on improving the quality of malaria care is needed.

Antibacterial properties and regenerative potential of Sr2+ and Ce3+ doped fluorapatites; a potential solution for peri-implantitis

Scaffolds and implants in orthopaedics and regenerative dentistry usually fail because of bacterial infections. A promising solution would be the development of biomaterials with both significant regenerative potential and enhanced antibacterial activity. Working towards this direction, fluorapatite was synthesised and doped with Sr2+ and Ce3+ ions in order to tailor its properties. After experiments with four common bacteria (i.e. E. Coli, S. Aureus, B. Subtilis, B. Cereus), it was found that the undoped and the Ce3+ doped fluorapatites present better antibacterial response than the Sr2+ doped material. The synthesised minerals were incorporated into chitosan scaffolds and tested with Dental Pulp Stem Cells (DPSCs) to check their regenerative potential. As was expected, the scaffolds containing Sr2+-doped fluorapatite, presented high osteoconductivity leading to the differentiation of the DPSCs into osteoblasts. Similar results were obtained for the Ce3+-doped material, since both the concentration of osteocalcin and the RUNX2 gene expression were considerably higher than that for the un-doped mineral. Overall, it was shown that doping with Ce3+ retains the good antibacterial profile of fluorapatite and enhances its regenerative potential, which makes it a promising option for dealing with conditions where healing of hard tissues is compromised by bacterial contamination.