Hydroclimatic changes on multiple timescales since 7800 y BP in the winter precipitation-dominated Central Asia

Central Asia (CA) is one of the world's most significant arid regions, which is markedly impacted by global warming. A better understanding of the dynamical processes governing its Holocene climate variability is critical for a better understanding of possible future impacts of climate change in the region. To date, most of the existing CA paleoclimate records are from the summer precipitation-dominated eastern CA (ECA), with few records from the winter precipitation-dominated western CA (WCA). Here, we present a precisely dated (~6‰) and highly resolved (<4-y) record of hydroclimatic variations from the WCA covering the period between 7,774 and 656 y BP. Utilizing multiple proxies (δ18O, δ13C, and Sr/Ca) derived from a stalagmite from the Fergana Valley, Kyrgyzstan, we reveal a long-term drying trend in WCA, which is in contrast with the wetting trend in ECA. We propose that different responses of winter and summer westerly jets to seasonal solar insolation over the past 8,000 y may have resulted in an antiphased precipitation relationship between the WCA and ECA. Our data contain dominant quasiperiodicities of 1,400, 50 to 70, and 20 to 30 y, indicating close connections between the WCA climate and the North Atlantic. We further identified a series of droughts and pluvials on centennial-to-decadal timescales, which may have influenced regional societies and trans-Eurasian culture exchanges during historical and prehistorical times.

DermSynth3D: Synthesis of in-the-wild annotated dermatology images

In recent years, deep learning (DL) has shown great potential in the field of dermatological image analysis. However, existing datasets in this domain have significant limitations, including a small number of image samples, limited disease conditions, insufficient annotations, and non-standardized image acquisitions. To address these shortcomings, we propose a novel framework called DermSynth3D. DermSynth3D blends skin disease patterns onto 3D textured meshes of human subjects using a differentiable renderer and generates 2D images from various camera viewpoints under chosen lighting conditions in diverse background scenes. Our method adheres to top-down rules that constrain the blending and rendering process to create 2D images with skin conditions that mimic in-the-wild acquisitions, ensuring more meaningful results. The framework generates photo-realistic 2D dermatological images and the corresponding dense annotations for semantic segmentation of the skin, skin conditions, body parts, bounding boxes around lesions, depth maps, and other 3D scene parameters, such as camera position and lighting conditions. DermSynth3D allows for the creation of custom datasets for various dermatology tasks. We demonstrate the effectiveness of data generated using DermSynth3D by training DL models on synthetic data and evaluating them on various dermatology tasks using real 2D dermatological images. We make our code publicly available at https://github.com/sfu-mial/DermSynth3D.

Comparison of laparoscopic cholecystectomy in children at paediatric centres and adult centres: a systematic review and meta-analysis

INTRODUCTION

Paediatric laparoscopic cholecystectomy (LC) is performed by both paediatric and adult surgeons. The aim of this review was to compare outcomes at paediatric centres (PCs) and adult centres (ACs).

METHODS

A literature search was conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, for papers published between January 2000 and December 2020. Statistical analysis was performed using Stata® version 16 (StataCorp, College Station, TX, US).

RESULTS

A total of 92 studies involving 74,852 paediatric LCs met the inclusion criteria. Over half (59%) of the LCs were performed at ACs. No significant differences were noted in the male-to-female ratio, mean age or mean body mass index between PCs and ACs. The main indications were cholelithiasis (34.1% vs 34.4% respectively, p=0.83) and biliary dyskinesia (17.0% vs 23.5% respectively, p<0.01). There was no significant difference in the median inpatient stay (2.52 vs 2.44 days respectively, p=0.89). Bile duct injury was a major complication (0.80% vs 0.37% respectively, p<0.01). Reoperation rates (2.37% vs 0.74% respectively, p<0.01) and conversion to open surgery (1.97% vs 4.74% respectively, p<0.01) were also significantly different. Meta-analysis showed no significant difference in overall complications (p=0.92).

CONCLUSIONS

The number of LCs performed, intraoperative cholangiography use and conversion rates were higher at ACs whereas bile duct injury and reoperation rates were higher at PCs. Despite a higher incidence of bile duct injury at PCs, the incidence at both PCs and ACs was <1%. In complex cases, a joint operation by both paediatric and adult surgeons might be a better approach to further improve outcomes. Overall, LC was found to be a safe operation with comparable outcomes at PCs and ACs.

NCCP-ICS joint consensus-based clinical practice guidelines on medical thoracoscopy

ABSTRACT

Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.

Landscaping tuberculosis multimorbidity: findings from a cross-sectional study in India

BACKGROUND

Multimorbidity, the concurrent presence of two or more chronic conditions is an emerging public health challenge. Till date, most of the research have focused on the presence and interaction of selected co-morbidities in tuberculosis (TB). There exist a critical knowledge gap on the magnitude of multimorbidity among TB patients and its impact on health outcomes.

METHODS

We undertook a cross-sectional study to assess the prevalence and patterns of multimorbidity among newly diagnosed TB patients in two states of India. A total of 323 patients were interviewed using a structured multimorbidity assessment questionnaire for primary care (MAQ-PC). MAQ-PC is already validated for Indian population and elicits 22 chronic conditions. We defined TB multimorbidity as the co-existence of TB with one or more chronic conditions and identified commonly occurring dyads (TB + single condition) and triads (TB + two conditions).

RESULTS

More than half (52%) of TB patients reported multimorbidity. Among dyads, depression, diabetes mellitus (DM), acid peptic disease (APD), hypertension, chronic alcoholism, arthritis and chronic back ache (CBA) were the most common co-occurring conditions while 'DM + arthritis', 'depression + APD', 'depression + DM' were the most commonly occurring triads among TB patients. Factors such as increasing age, low levels of education, alcohol abusers, drug-resistant TB and having health insurance were significantly associated with multimorbidity among TB patients.

CONCLUSIONS

Our findings suggest high prevalence of multimorbidity among newly diagnosed TB patients in India. The presence of concordant and discordant conditions with TB may increase the health complexity, thus necessitating appropriate care protocols. Given, the current situation, wherein TB and non-communicable diseases (NCD) services are delivered through collaborative framework between programmes, there is a need for addressing multimorbidity at the healthcare delivery level.

Treatment of Complex Desmoid Tumors in Familial Adenomatous Polyposis Syndrome by Intestinal Transplantation

Background

Desmoid tumors are fibroblastic lesions which often have an unpredictable and variable clinical course. In the context of familial adenomatous polyposis (FAP), these frequently occur intra-abdominally, especially in the small-bowel mesentery resulting in sepsis, fistulation, and invasion of the abdominal wall and retroperitoneum. In selected cases where other modalities have failed, the most radical option is to perform a total enterectomy and intestinal transplantation (ITx). In this study, we present our center's experience of ITx for desmoid in patients with FAP.

Methods

We performed a retrospective review of our prospectively collected database between 2007 and 2022. All patients undergoing ITx for FAP-related desmoid were included.

Results

Between October 2007 and September 2023, 144 ITx were performed on 130 patients at our center. Of these, 15 patients (9%) were for desmoid associated with FAP (7 modified multivisceral transplants, 6 isolated ITx, and 2 liver-containing grafts). The median follow-up was 57 mo (8-119); 5-y patient survival was 82%, all with functioning grafts without local desmoid recurrence. These patients presented us with several complex surgical issues, such as loss of abdominal domain, retroperitoneal/abdominal wall involvement, ileoanal pouch-related issues, and the need for foregut resection because of adenomatous disease.

Conclusions

ITx is a viable treatment in selected patients with FAP and extensive desmoid disease. The decision to refer for ITx can be challenging, particularly the timing and sequence of treatment (simultaneous versus sequential exenteration). Delays can result in additional disease burden, such as secondary liver disease or invasion of adjacent structures.

Review of management practices of sinogenic intracranial abscesses in children

OBJECTIVE

This study aimed to evaluate the management practices and outcomes in children with sinogenic intracranial suppuration.

METHOD

This was a retrospective cohort study in a single paediatric tertiary unit that included patients younger than 18 years with radiologically confirmed intracranial abscess, including subdural empyema and epidural or intraparenchymal abscess secondary to sinusitis. Main outcomes studied were rate of return to the operating theatre, length of hospital stay, death in less than 90 days and neurological disability at 6 months.

RESULTS

A cohort of 39 consecutive patients presenting between 2000 and 2020 were eligible for inclusion. Subdural empyema was the most common intracranial complication followed by extradural abscess and intraparenchymal abscess. Mean length of hospital stay was 42 days. Sixteen patients were managed with combined ENT and neurosurgical interventions, 15 patients underwent ENT procedures alone and 4 patients had only neurosurgical drainage. Four patients initially underwent non-operative management. The rates of return to the operating theatre, neurological deficits and 90-day mortality were 19, 9 and 3, respectively, and were comparable across the 4 treatment arms. In the univariate logistic regression, only the size of an intracranial abscess was found be associated with an increased likelihood of return to the operating theatre, whereas combined ENT and neurosurgical intervention did not result in improved outcomes.

CONCLUSION

Sinogenic intracranial abscesses are associated with significant morbidity and mortality. The size of an intracranial abscess has a strong association with a need for a revision surgery.

Household drug-resistant TB contact tracing in Tajikistan

BACKGROUND: Tajikistan has a high burden of rifampicin-resistant TB (RR-TB), with 2,700 new cases estimated for 2021 (28/100,000 population). TB is spread among household members through close interaction and children exposed through household contact progress to disease rapidly and frequently.METHODS: We retrospectively analysed programmatic data from household contact tracing in Dushanbe over 50 months. We calculated person-years of follow-up, contact tracing yield, number needed to screen (NNS) and number needed to test (NNT) to find one new case, and time to diagnosis.RESULTS: We screened 6,654 household contacts of 830 RR-TB index cases; 47 new RR-TB cases were detected, 43 in Year 1 and 4 in Years 2 or 3. Ten were aged <5 years; 46/47 had TB symptoms, 34/45 had chest radiographs consistent with TB, 11/35 were Xpert Ultra-positive, 29/32 were tuberculin skin test-positive and 28/47 had positive TB culture and phenotypic drug susceptibility results. The NNS to find one RR-TB case was 141.57 and the NNT was 34.49. The yields for different types of contacts were as follows: 0.7% for screened contacts, 2.9% for tested contacts, 17.0% for symptomatic contacts and 12.1% for symptomatic contacts aged below 5 years.CONCLUSION: RR-TB household contact tracing was feasible and productive in Tajikistan, a low middle-income country with an inefficient healthcare delivery system.

Molecular surveillance detects high prevalence of the neglected parasite Mansonella ozzardi in the Colombian Amazon

Mansonellosis is an undermapped insect-transmitted disease caused by filarial nematodes that are estimated to infect hundreds of millions of people globally. Despite their prevalence, there are many outstanding questions regarding the general biology and health impacts of the responsible parasites. Historical reports suggest that the Colombian Amazon is endemic for mansonellosis and may serve as an ideal location to pursue these questions in the backdrop of other endemic and emerging pathogens. We deployed molecular and classical diagnostic approaches to survey Mansonella prevalence among adults belonging to indigenous communities along the Amazon River and its tributaries near Leticia, Colombia. Deployment of a loop-mediated isothermal amplification (LAMP) assay on blood samples revealed an infection prevalence of ∼40% for Mansonella ozzardi . This assay identified significantly more infections than blood smear microscopy or LAMP assays performed using plasma, likely reflecting greater sensitivity and the ability to detect low microfilaremias or occult infections. Mansonella infection rates increased with age and were higher among males compared to females. Genomic analysis confirmed the presence of M. ozzardi that clusters closely with strains sequenced in neighboring countries. We successfully cryopreserved and revitalized M. ozzardi microfilariae, advancing the prospects of rearing infective larvae in controlled settings. These data suggest an underestimation of true mansonellosis prevalence, and we expect that these methods will help facilitate the study of mansonellosis in endemic and laboratory settings.

Primary bedaquiline resistance in Karakalpakstan, Uzbekistan

BACKGROUND: Bedaquiline (BDQ) is widely used in the treatment of rifampicin-resistant TB (RR-TB). However, resistance to BDQ is now emerging. There are no standardised regimens for BDQ-resistant TB. This study aims to share experience in managing primary BDQ-resistant TB.METHODS: We performed a retrospective study of patients treated for RR-TB in Karakalpakstan, Uzbekistan, from January 2017 to March 2022. We identified patients with resistance to BDQ with no history of BDQ exposure. We describe baseline characteristics, treatment and follow-up of these patients.RESULTS: Twelve of the 1,930 patients (0.6%) had baseline samples resistant to BDQ with no history of BDQ exposure, 75% (9/12) of whom had been previously treated for TB. Ten (83.3%) were resistant to fluoroquinolones; respectively 66% and 50% had culture conversion by Month 3 and Month 6. The interim treatment outcomes were as follows: unfavourable treatment outcomes (3/12, 25%), favourable outcomes (2/12, 17%); the remaining seven (58%) were continuing treatment.CONCLUSIONS: A large proportion of the cases had previously been treated for TB and had TB resistant to quinolone. Both patients who had not experienced culture conversion by Month 3 had an unfavourable treatment outcome. Therefore, we recommend monthly monitoring of culture status for patients on treatment regimens for BDQ resistance.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Coupled atmosphere-ice-ocean dynamics during Heinrich Stadial 2

Our understanding of climate dynamics during millennial-scale events is incomplete, partially due to the lack of their precise phase analyses under various boundary conditions. Here we present nine speleothem oxygen-isotope records from mid-to-low-latitude monsoon regimes with sub-centennial age precision and multi-annual resolution, spanning the Heinrich Stadial 2 (HS2) - a millennial-scale event that occurred at the Last Glacial Maximum. Our data suggests that the Greenland and Antarctic ice-core chronologies require +320- and +400-year adjustments, respectively, supported by extant volcanic evidence and radiocarbon ages. Our chronological framework shows a synchronous HS2 onset globally. Our records precisely characterize a centennial-scale abrupt "tropical atmospheric seesaw" superimposed on the conventional "bipolar seesaw" at the beginning of HS2, implying a unique response/feedback from low-latitude hydroclimate. Together with our observation of an early South American monsoon shift at the HS2 termination, we suggest a more active role of low-latitude hydroclimate dynamics underlying millennial events than previously thought.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Acquired bedaquiline resistance in Karakalpakstan, Uzbekistan

BACKGROUND: The WHO recommends the use of bedaquiline (BDQ) in longer, as well as shorter, multidrug-resistant TB (MDR-TB) treatment regimens. However, resistance to this new drug is now emerging. We aimed to describe the characteristics of patients in Karakalpakstan, Uzbekistan, who were treated for MDR-TB and acquired BDQ resistance during treatment.METHODS: We performed a retrospective study of routinely collected data for patients treated for MDR-TB in Karakalpakstan between January 2015 and December 2020. We included patients on BDQ-containing regimens with baseline susceptibility to BDQ who developed BDQ resistance at any point after treatment initiation. Patients resistant to BDQ at baseline or with no confirmed susceptibility to BDQ at baseline were excluded.RESULTS: Of the 523 patients who received BDQ-containing regimens during the study period, BDQ resistance was detected in 31 patients (5.9%); 20 patients were excluded-16 with no prior confirmation of BDQ susceptibility and 4 who were resistant at baseline. Eleven patients with acquired BDQ resistance were identified. We discuss demographic variables, resistance profiles, treatment-related variables and risk factors for unfavourable outcomes for these patients.CONCLUSION: Our programmatic data demonstrated the acquisition of BDQ resistance during or subsequent to receiving a BDQ-containing regimen in a patient cohort from Uzbekistan. We highlight the need for individualised treatment regimens with optimised clinical and laboratory follow up to prevent resistance acquisition.

Beware of spurious tracheo-bronchial stents

OBJECTIVE

To present a case of accidental sheath removal of tracheo-bronchial self-expandable metallic airway stent in a patient with endotracheal tumour.

METHODS

Design: Case Report; Setting: Tertiary care hospital; Patient: One.

RESULTS

A 65 years male, follow up case of endotracheal tumor with tracheo-bronchial self-expandable metallic stenting done presented with dry cough and difficulty in breathing since 8-10 days and suddenly coughed out thin whitish paper-like material 2 days back (which later proved as sheath of metallic stent). Direct laryngoscopy with flexible videobronchoscopy was done which showed tracheal stent well placed and intact, coughed out sheath couldn't be replaced back. Procedure was uneventful and patient was discharged in satisfactory condition and is doing well on regular follow up.

CONCLUSION

Self-expandable metallic airway stents (SEMAS) represents a standard method of airways stenting especially when employed for the management of malignant central airway obstruction. Despite the obvious stenting advantages, it may be complicated with stent migration and accidental removal or coughing out of stent especially in high tracheal stenosis. In our case, as a peculiar complication there was accidental removal of the tracheal stent sheath which couldn't be replaced back whereas stent was well in place and intact. We need to be beware of such spurious tracheo-bronchial stents.

Time-resolved hadronic particle acceleration in the recurrent nova RS Ophiuchi

Recurrent novae are repeating thermonuclear explosions in the outer layers of white dwarfs, due to the accretion of fresh material from a binary companion. The shock generated when ejected material slams into the companion star's wind can accelerate particles. We report very-high-energy (VHE, [Formula: see text]) gamma rays from the recurrent nova RS Ophiuchi, up to a month after its 2021 outburst, observed using the High Energy Stereoscopic System. The VHE emission has a similar temporal profile to lower-energy GeV emission, indicating a common origin, with a two-day delay in peak flux. These observations constrain models of time-dependent particle energization, favoring a hadronic emission scenario over the leptonic alternative. Shocks in dense winds provide favorable environments for efficient acceleration of cosmic-rays to very high energies.

Trajectory of Serum Bilirubin Predicts Spontaneous Recovery in a Real-World Cohort of Patients With Alcoholic Hepatitis

BACKGROUND AND AIMS

Alcoholic hepatitis (AH) is a severe condition with poor short-term prognosis. Specific treatment with corticosteroids slightly improves short-term survival but is associated with infection and is not used in many centers. A reliable method to identify patients who will recover spontaneously will minimise the numbers of patients who experience side effects of available treatments.

METHODS

We analysed the trajectory of serum bilirubin concentration over the course of hospital admissions in patients with AH to predict spontaneous survival and the need for treatment.

RESULTS

data from 426 patients were analysed. Based on bilirubin trajectory, patients were categorized into three groups: 'fast fallers' (bilirubin <0.8 x admission value at day 7), 'static' (bilirubin of >0.9 - <1.2 x admission value) and 'rapid risers' (bilirubin of ≥1.2 x admission bilirubin). Fast fallers had significantly better 90-day survival compared to other groups (log rank p < .001), and showed no benefit of corticosteroid therapy (OR for survival at 28 days of treatment, 0.94, 95% CI 0.06 - 8.41). These findings remained even amongst patients with severe disease based on initial DF, GAHS or MELD scores.

CONCLUSIONS

We present an intuitive method of classifying patients with AH based on the trajectory of bilirubin over the first week of admission. It is complimentary to existing scores that identify candidates for corticosteroid treatment or assess response to treatment. This method identifies a group of patients with AH who recover spontaneously and can avoid corticosteroid therapy.

Introducing Clinical Pathology Course to Fourth Year Medical Students as a Bridge between Pre-clinical and Clinical Medical Sciences

There isn't any vertical integration of pre-clinical and clinical sciences subjects in the existing Kathmandu University MBBS curriculum. Many of the graduates are not able to correlate the clinico-pathological aspects of various diseases as a result the rational use of investigations for diagnosing various diseases is compromised. There are few published examples of implementation of pathology instruction courses during the clinical years of medical training but it is not universally practiced. This lack of exposure to pathology may lead to poor understanding of laboratory testing and the role of pathologists in patient care. To set and implement an exemplary vertical integration of pre-clinical science with clinical science. A 12 credit hours clinical pathology education course comprising clinical hematology, cytopathology and histopathology was developed. Students belonging from the ongoing fourth year MBBS course of Birat Medical College were enrolled in the course. All of the interactive lecture sessions were delivered via an e-learning interface, using the Zoom platform as the main teaching methods. Evaluation of students' achievement of learning objectives was conducted through distributing pre and post-test online multiple-choice questionnaires. Chi-square tests were used to compare the variables between pre-test and post-test questionnaire responses. Results suggested that the designed clinical pathology course is valuable. The pretest and post-test questionnaire responses revealed the positive impact regarding the importance of introducing clinical pathology courses within the clinical year of MBBS undergraduate curriculum. Response rate to the online session was 100%. The point of agreement between the pre-test and post-test questionnaire responses were highly achieved after intervention of the clinical pathology course. A statistically significant result (p < 0.05) between all of the pre-test and post-test questionnaire responses was noted. There was a strong positive recommendation for incorporating clinical laboratory medicine courses within the MBBS clinical science curriculum. The improvement observed among fourth-year MBBS students on learning the importance of clinical pathology courses was encouraging. This experience thus contributed to set and implement an exemplary vertical integration of pre-clinical science with clinical science.

ADRENAL HISTOPLASMOSIS: AN EASTERN INDIAN PERSPECTIVE

CONTEXT

The clinical presentation of histoplasmosis is varied. Due to its propensity for adrenal involvement, histoplasmosis is an important differential diagnosis in any patient presenting with adrenal mass, bilateral in particular.

OBJECTIVE

Data on clinical presentation, pattern of adrenal involvement, radiological appearance and long-term follow-up of adrenal histoplasmosis are relatively sparse; hence we looked at it.

DESIGN

This record based single-centre retrospective study was conducted in one of the tertiary care hospitals, situated in eastern India catering the Gangetic delta.

SUBJECTS AND METHODS

Data on demographic characters, presenting manifestations, biochemical & hormonal parameters and radiological appearance of confirmed adrenal histoplasmosis cases (n=9), admitted between 2015-2019 have been retrieved. The treatment outcome and condition of patients after 1-4 years of follow-up has also been discussed.

RESULTS

Four out of the nine (44.4%) patients had predisposing immunocompromised conditions in the form of diabetes and/or chronic alcoholism while rest were immunocompetent. Seven out of nine patients (77.8 %) had signs and symptoms suggestive of adrenal insufficiency, while two (22.2%) presented with only pyrexia of unknown origin. All of them had bilateral adrenal mass, though the radiologically appearances were different. All patients received anti-fungal agents with/without hydrocortisone and/or fludrocortisone. One patient died (11.1%), while majority responded favourably to treatment. Adrenocortical function did not recover completely.

CONCLUSIONS

The possibility of adrenal histoplasmosis should always be considered in patients presenting with bilateral adrenal mass, irrespective of adrenal morphology. Treatment is effective, but many of them require supplemental hydrocortisone for quite a long period, if not lifelong. Mineralocorticoid deficiency, however, is not permanent.

Collapse of the Liangzhu and other Neolithic cultures in the lower Yangtze region in response to climate change

The Liangzhu culture in the Yangtze River Delta (YRD) was among the world’s most advanced Neolithic cultures. Archeological evidence suggests that the Liangzhu ancient city was abandoned, and the culture collapsed at ~4300 years ago. Here, we present speleothem records from southeastern China in conjunction with other paleoclimatic and archeological data to show that the Liangzhu culture collapsed within a short and anomalously wet period between 4345 ± 32 and 4324 ± 30 years ago, supporting the hypothesis that the city was abandoned after large-scale flooding and inundation. We further show that the demise of Neolithic cultures in the YRD occurred within an extended period of aridity that started at ~4000 ± 45 years ago. We suggest that the major hydroclimatic changes between 4300 and 3000 years ago may have resulted from an increasing frequency of the El Niño–Southern Oscillation in the context of weakened Northern Hemisphere summer insolation.

198 Immediate Post-Operative PDE5i Therapy Improves Early Erectile Function Outcomes after Robot-Assisted Radical Prostatectomy (RARP)

Aim

To assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function, continence, or safety outcomes.

Method

Data was prospectively collected from a single surgeon in one tertiary centre and retrospectively evaluated. 158 patients were treated with PDE5i therapy post RARP over a two-year period.

Results

There were no significant differences in pre-operative characteristics between the therapy groups. Patients that had bilateral nerve sparing had a mean drop in Erectile Function (EF) score by 5.4 compared to 8.8 in the unilateral group. Additionally, 34.9% of bilateral nerve sparing patients returned to baseline compared to 12.1% of unilateral. Drop in EF scores and percentage return to baseline for unilateral nerve sparing was respectively 9 and 11.1% of immediate (day 1-2), 7 and 14.8% of early (day 3-14) and 9.7 and 9.5% of late (day &gt;14) therapy (p = 0.9 and p = 0.6). For bilateral nerve sparing this was respectively 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p = 0.017 and p = 0.045). Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication, or readmission outcomes.

Conclusions

Immediate PDE5i therapy should be considered in patients following nerve sparing RARP in order to maximise functional outcomes, especially in those undergoing bilateral nerve spare.

81 VIRTUAL: Virtual Interactive Surgical Skills Classroom – An Ongoing Randomized Controlled Trial

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention, and Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed.

Results

Data collection will be completed in January 2021. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusions

To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the virtual classroom’s suitability as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

Malaria, COVID-19 and angiotensin-converting enzyme 2: what does the available population data say?

The etiopathogenesis of COVID-19 and its differential geographic spread suggest some populations are apparently 'less affected' through many host-related factors that involve angiotensin-converting enzyme 2 (ACE2) protein, which is also the entry receptor for SARS-CoV-2. The role of ACE2 has been well studied in COVID-19 but not in the context of malaria and COVID-19. We have previously suggested how malaria might intersect with COVID-19 through ACE2 mutation and here we evaluate the currently available data that could provide a link between the two diseases. Based on the existing global and Indian data on malaria, COVID-19 and the suggested ACE2 mutation, the association could not be examined robustly, neither accepting nor refuting the suggested hypothesis. We strongly recommend targeted evaluation of this hypothesis through carefully designed robust molecular epidemiological studies.

O43 Virtual: virtual interactive surgical skills classroom: a randomized controlled trial (protocol)

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on surgical skills experience and confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention. Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts.

Result

Change in confidence, time to completion and a novel granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusion

This will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and beyond.

Take-home Message

This is the first RCT assessing virtual basic surgical skill classroom training and serves as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

Revealing x-ray and gamma ray temporal and spectral similarities in the GRB 190829A afterglow

Gamma-ray bursts (GRBs), which are bright flashes of gamma rays from extragalactic sources followed by fading afterglow emission, are associated with stellar core collapse events. We report the detection of very-high-energy (VHE) gamma rays from the afterglow of GRB 190829A, between 4 and 56 hours after the trigger, using the High Energy Stereoscopic System (H.E.S.S.). The low luminosity and redshift of GRB 190829A reduce both internal and external absorption, allowing determination of its intrinsic energy spectrum. Between energies of 0.18 and 3.3 tera-electron volts, this spectrum is described by a power law with photon index of 2.07 ± 0.09, similar to the x-ray spectrum. The x-ray and VHE gamma-ray light curves also show similar decay profiles. These similar characteristics in the x-ray and gamma-ray bands challenge GRB afterglow emission scenarios.

The significance of urgent ultrasound scan for shoulder dislocation in patients above the age of 40: A prospective British Elbow and Shoulder Society pathway implementation study

BACKGROUND

The highlight of the British Elbow and Shoulder Society pathway for the management of traumatic anterior shoulder instability is early imaging in patients aged over 40 years to assess rotator cuff integrity and early repair, if indicated to optimise function. The senior author set up a protocol in our institute to streamline the diagnostic process for this cohort of patients. This was a retrospective analysis from a prospectively collected database to highlight the importance of early specialist imaging.

METHODS

Our protocol is to perform urgent ultrasound scans for all suitable patients above 40 years after first-time traumatic shoulder dislocation. Demographics, associated injuries, ultrasound scan results, operations and functional outcomes were collated.

RESULTS

One year following the introduction of our protocol, 40 patients with a mean age of 67 (range, 42-89; SD = 13.1) had ultrasound. The incidence of full-thickness rotator cuff tears was 57.5% (n = 23). Eleven patients with confirmed full-thickness rotator cuff tears underwent surgery. The mean age of surgical patients was significantly younger than the non-surgical group (p = 0.004).

DISCUSSION

The use of early diagnostic imaging demonstrated a high incidence of full-thickness rotator cuff tears in this cohort of patients. This allowed early surgical repair to optimise function.

31 Immediate Post-Operative Phosphodiesterase-5 Inhibitors (PDE5i) Therapy Improves Early Erectile Function Outcomes After Robot Assisted Radical Prostatectomy (RARP)

Introduction

To assess whether the timing of post-RARP PDE5i therapy affects early erectile function, continence, or safety outcomes.

Method

Data from 158 patients treated with PDE5is post-RARP was prospectively collected over two years from a single surgeon at one tertiary centre and retrospectively evaluated. Therapy was started: immediately (day 1-2) in 29%, early (day 3-14) in 37% and late (after day 14) post-op in 34%. EPIC-26 Erectile Function (EF) scores were collected pre-op and post-op after a median 43-day follow-up interval.

Results

Drop in EF scores and percentage return to baseline post unilateral nerve sparing (UNS) compared to bilateral nerve sparing (BNS) RARP was respectively 9 and 11.1% versus 3.5 and 42.9% of immediate therapy, 7 and 14.8% versus 5.5 and 35.5% of early and 9.7 and 9.5% versus 7.3 and 25% of late. Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early and 26% and 54% for late.

Conclusions

Immediate post RARP PDE5i therapy may protect EF and should be considered clinically, with more benefits for BNS than UNS patients. Immediate or early, rather than late, PDE5i therapy improved early continence in BNS patients.

Consensus statement from the international consensus meeting on post-traumatic cranioplasty

Background

Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach.

Methods

The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP.

Results

The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations.

Conclusions

This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.

Multi-Scale Self-Guided Attention for Medical Image Segmentation

Even though convolutional neural networks (CNNs) are driving progress in medical image segmentation, standard models still have some drawbacks. First, the use of multi-scale approaches, i.e., encoder-decoder architectures, leads to a redundant use of information, where similar low-level features are extracted multiple times at multiple scales. Second, long-range feature dependencies are not efficiently modeled, resulting in non-optimal discriminative feature representations associated with each semantic class. In this paper we attempt to overcome these limitations with the proposed architecture, by capturing richer contextual dependencies based on the use of guided self-attention mechanisms. This approach is able to integrate local features with their corresponding global dependencies, as well as highlight interdependent channel maps in an adaptive manner. Further, the additional loss between different modules guides the attention mechanisms to neglect irrelevant information and focus on more discriminant regions of the image by emphasizing relevant feature associations. We evaluate the proposed model in the context of semantic segmentation on three different datasets: abdominal organs, cardiovascular structures and brain tumors. A series of ablation experiments support the importance of these attention modules in the proposed architecture. In addition, compared to other state-of-the-art segmentation networks our model yields better segmentation performance, increasing the accuracy of the predictions while reducing the standard deviation. This demonstrates the efficiency of our approach to generate precise and reliable automatic segmentations of medical images. Our code is made publicly available at: https://github.com/sinAshish/Multi-Scale-Attention.

Integrated ozonation assisted electrocoagulation process for the removal of cyanide from steel industry wastewater

This work focuses on the removal of cyanide, chemical oxygen demand (COD), biological oxygen demand (BOD), and chloride from biological oxidation treated (BOT) effluent of the steel industry by integrated ozonation assisted electrocoagulation method. The removal efficiency of the pollutants was found to be inefficient when the electrocoagulation or ozonation process was performed separately. However, a combination of ozonation and electrocoagulation gives a highly satisfactory result. Such an integrated approach for the treatment of BOT effluent has not been previously investigated. The effects of operating variables viz. ozone generation rate, current density, and analysis time on pollutant removal were primarily analyzed for the hybrid process. The experimental operating condition was optimized and was seen that ozone generation rate of 1.33 mg s^-1, ozonation time of 40 min, a current density of 100 A m^-2, and electrolysis time of 30 min were sufficient for reducing the pollutant concentration below its permissible limits. The removal efficiencies of the combined process at optimum conditions were 99.8%, 94.7%, 95%, and 46.5% for cyanide, COD, BOD, and chloride ions, respectively. A kinetic study was performed for the degradation of the pollutants during ozonation. The pseudo-first-order kinetic model was found to be best suited for the analysis with the highest R² value of 0.99 for cyanide, COD, BOD, and chloride, respectively. The mass transfer study conducted further showed that the volumetric mass transfer coefficient, K_la, was increased with that of the ozone generation rate. Cost estimation of the hybrid process was done and compared with that of the other reported integrated process.

Starting Residency with COVID-19

Introduction By Dr. Ashish Sinha, MD, PhD, DABA, MBA, FASA As a Program Director of a just established anesthesia program, one faces enough challenges. A curve ball that I was not expecting was one of my residents to inform me on July 3rd that he was feeling feverish with chills, had myalgia and a headache. First response in my mind, that I didn't verbalize was, "Anosmia too?" I arranged COVID testing ASAP in a drive-by setting, which we could avail immediately. My resident had driven from New Orleans, LA to Riverside, CA, making a few stops along the way, (food, gas, rest) utilizing the best safety he could practice. To no one's surprise the test came back positive. My resident needed to not feel abandoned by program, co-residents or institution. To keep him involved, while quarantined, I asked him to join us in all academic activities by Zoom and further gave him this introspective assignment. He took on this task with enthusiasm and provided a great piece, or at least I think so!

A multimillennial climatic context for the megafaunal extinctions in Madagascar and Mascarene Islands

Madagascar and the Mascarene Islands of Mauritius and Rodrigues underwent catastrophic ecological and landscape transformations, which virtually eliminated their entire endemic vertebrate megafauna during the past millennium. These ecosystem changes have been alternately attributed to either human activities, climate change, or both, but parsing their relative importance, particularly in the case of Madagascar, has proven difficult. Here, we present a multimillennial (approximately the past 8000 years) reconstruction of the southwest Indian Ocean hydroclimate variability using speleothems from the island of Rodrigues, located ∼1600 km east of Madagascar. The record shows a recurring pattern of hydroclimate variability characterized by submillennial-scale drying trends, which were punctuated by decadal-to-multidecadal megadroughts, including during the late Holocene. Our data imply that the megafauna of the Mascarenes and Madagascar were resilient, enduring repeated past episodes of severe climate stress, but collapsed when a major increase in human activity occurred in the context of a prominent drying trend.

The weekend effect - How can it be mitigated? Introduction of a consultant-delivered emergency general surgical service

Background

Poorer patient outcomes for emergency general surgery have been observed in patients admitted to hospital over the weekend. This paper reports the outcomes of a Consultant-delivered service model for weekend admissions and its impact for patients undergoing emergency laparotomy.

Methods

Operative data was analysed from a prospectively collected database over 5-years. Primary outcome measures were 30-day all-cause mortality and Clavien-Dindo class ≥2 morbidity. Secondary outcomes included time from admission to diagnostic imaging and time to surgery, post-operative length of stay and requirement for Intensive Care Unit admission.

Results

263 patients underwent an emergency laparotomy. Overall 30-day mortality was 4.6% and all-cause morbidity was 55.9%. The most common indications for laparotomy were mechanical small bowel obstruction (32.7%) and hollow viscus perforation (30.4%) of the 263 emergency laparotomies, 92 patients in the cohort were weekend admissions (Saturday or Sunday). There was no significant difference amongst patients admitted during the weekend in ASA grade, age, gender, or proportion of patients receiving a pre-operative computed tomography scan, when compared to those during the week. Compared to weekdays, weekend admission was not associated with a significant difference in mortality (5.3% and 3.3%, respectively p = 0.458), all-cause morbidity (p = 0.509), post-operative length of stay (p = 0.681), or Intensive Care Unit admission (p = 0.761).

Conclusion

A Consultant Surgeon delivered emergency service can avoid the poor patient outcomes associated with weekend admissions and the ‘weekend effect’.

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Poorer patient outcomes have been observed in patients admitted during the weekend.

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A Consultant Surgeon delivered model of service delivery ensures peri- and intra-operative Consultant presence for all emergency surgery.

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Under this model, there was no weekend effect observed.

Assessing continuum of trauma care for road accident victim in Jodhpur, Rajasthan

Background

Road traffic injuries (RTIs) are a major public health problem, requiring concerted efforts both for their prevention and a reduction of their consequences. The present study was designed to assess the existing process of pre-hospital trauma care administered to road accident victims in a fast urbanizing city of Jodhpur, Rajasthan

Methods

A cross-sectional study was designed from 1st November 2018 to 30th June 2019. All cases who were admitted to tertiary level trauma care facility in the study period were reviewed and were analyzed for type of injuries suffered, prehospital care services availed and the time duration that elapsed before patient arrived at tertiary health facility. Geographic information system was used to identify clustering of accident hot spots in the Jodhpur district.

Results

A total of 137 patients or their caregivers were interviewed during the study period. A large proportion of patients 57(41.6%) were unconscious in post-crash phase. Private taxis contributed to maximum patient transfer (75.9%) and only 12.4% were transported through ambulance. Almost three fourth (78.1%) of patients received some form of pre-hospital care within 30 minutes of accident. About one third patients (35.7%) reached the trauma facility directly after the accident while majority (64.9%) were referred from other health facilities

Conclusions

Pre-hospital trauma care for road traffic accident victims is available in golden hour for majority of victims in Jodhpur district. Victims from rural area and tourists form a sizeable proportion of accident victims brought to trauma care facility. The primary health care facilities play a pivotal role in managing victims as first point of care. Future research is thus warranted to explicitly examine the role of health professionals at primary health care facilities in administering pre-hospital trauma care.

Key messages

The primary health care facilities play a pivotal role in managing victims as first point of care. In areas with evolving trauma systems, pre-hospital trauma care strengthening requires capacity building of all level of health professionals.