Patient, family caregiver, and economic outcomes of an integrated screening and novel stepped collaborative care intervention in the oncology setting in the USA (CARES): a randomised, parallel, phase 3 trial

BACKGROUND

The current standard of care of screening and referring patients for treatment for symptoms, such as depression, pain, and fatigue, is not effective. This trial aimed to test the efficacy of an integrated screening and novel stepped collaborative care intervention versus standard of care for patients with cancer and at least one of the following symptoms: depression, pain, or fatigue.

METHODS

This randomised, parallel, phase 3 trial was conducted in 29 oncology outpatient clinics associated with the UPMC Hillman Cancer Center in the USA. Patients (aged ≥21 years) with any cancer type and clinical levels of depression, pain, or fatigue (or all of these) were eligible. Eligible family caregivers were aged 21 years or older and providing care to a patient diagnosed with cancer who consented for this study. Patients were randomly assigned (1:1) to stepped collaborative care or standard of care using a central, permuted block design (sizes of 2, 4, and 6) stratified by sex and prognostic status. The biostatistician, oncologists, and outcome assessors were masked to treatment assignment. Stepped collaborative care was once-weekly cognitive behavioural therapy for 50-60 min from a care coordinator via telemedicine (eg, telephone or videoconferencing). Pharmacotherapy for symptoms might be initiated or changed if recommended by the treatment team or preferred by the patient. Standard of care was screening and referral to a health-care provider for treatment of symptoms. The primary outcome was health-related quality of life in patients at 6 months. Maintenance of the treatment benefits was assessed at 12 months. Participants included in the primary analysis were per intention to treat, which included patients missing one or both follow-up assessments. This trial was registered with ClinicalTrials.gov (NCT02939755).

FINDINGS

Between Dec 5, 2016, and April 8, 2021, 459 patients and 190 family caregivers were enrolled. 222 patients were assigned to standard of care and 237 to stepped collaborative care. Of 459 patients, 201 (44%) were male and 258 (56%) were female. Patients in the stepped collaborative care group had a greater 0-6-month improvement in health-related quality of life than patients in the standard-of-care group (p=0·013, effect size 0·09). Health-related quality of life was maintained for the stepped collaborative care group (p=0·74, effect size 0·01). Patients in the stepped collaborative care group had greater 0-6-month improvements than the standard-of-care group in emotional (p=0·012), functional (p=0·042), and physical (p=0·033) wellbeing. No adverse events were reported by patients in either group and deaths were considered unrelated to the study.

INTERPRETATION

An integrated screening and novel stepped collaborative care intervention, compared with the current standard of care, is recommended to improve health-related quality of life. The findings of this study will advance the implementation of guideline concordant care (screening and treatment) and has the potential to shift the practice of screening and treatment paradigm nationwide, improving outcomes for patients diagnosed with cancer.

FUNDING

US National Cancer Institute.

Free Energy Surface and Molecular Mechanism of Slow Structural Transitions in Lipid Bilayers

Lipid membrane remodeling, crucial for many cellular processes, is governed by the coupling of membrane structure and shape fluctuations. Given the importance of the ∼ nm length scale, details of the transition intermediates for conformational change are not fully captured by a continuum-mechanical description. Slow dynamics and the lack of knowledge of reaction coordinates (RCs) for biasing methods pose a challenge for all-atom (AA) simulations. Here, we map system dynamics on Langevin dynamics in a normal mode space determined from an elastic network model representation for the lipid-water Hamiltonian. AA molecular dynamics (MD) simulations are used to determine model parameters, and Langevin dynamics predictions for bilayer structural, mechanical, and dynamic properties are validated against MD simulations and experiments. Transferability to describe the dynamics of a larger lipid bilayer and a heterogeneous membrane-protein system is assessed. A set of generic RCs for pore formation in two tensionless bilayers is obtained by coupling Langevin dynamics to the underlying energy landscape for membrane deformations. Structure evolution is carried out by AA MD, wherein the generic RCs are used in a path metadynamics or an umbrella sampling simulation to determine the thermodynamics of pore formation and its molecular determinants, such as the role of distinct bilayer motions, lipid solvation, and lipid packing.

Bispidine as a promising scaffold for designing molecular machines

The development of artificial molecular machines is a challenging endeavor. Herein, we have synthesized a series of bispidine diamides D1-D6 that exhibit rotation reminiscent of a motor motion. Dynamic NMR, X-ray diffraction, quantum mechanical calculations, and molecular dynamics simulations provided insights into their rotational dynamics. All the diamides D1-D6 exhibited mutually independent rotation around the two bispidine arms. However, the rate of rotation and the presence or absence of directionality in amide bond rotation were found to depend on the solvent, temperature, and nature of substitution on the amide carbonyl. These engineered systems may aid in the development of biologically relevant synthetic molecular motors. Studies on homochiral and heterochiral bispidine-peptides revealed that the direction of rotation can be controlled by chirality and the nature of the amino acid.

Hematopoietic stem-cell transplantation in a zoo of multidrug-resistant organisms: Data from a cancer center in eastern India

BACKGROUND

Infections by multidrug-resistant organisms (MDRO) are a major hurdle in hematopoietic stem-cell transplants (HSCTs). Conditioning regimens lead to mucosal barrier injury, which in-turn leads to transmigration of gut bacteria and sepsis. Pre-transplant stool and throat surveillance cultures can guide empirical antibiotic policy during the neutropenic period. In this paper, we document colonization with MDRO in pre-transplant surveillance cultures and the correlation with bloodstream infections in HSCT patients and analyze transplant outcomes with respect to these infections.

METHODS

A single-center, retrospective study on HSCT was performed between January 2021 and December 2021. The incidence of bacterial infections, percentage of MDROs, correlation with pre-transplant stool/throat surveillance cultures, and their impact on overall 100-day and post-100-day to 6-month post-transplant survival were analyzed.

RESULTS

Sixty-four patients were included in the study. Pre-transplant stool surveillance cultures were positive for MDRO in 85.9% of patients. Almost half (48.5%) of the isolates were positive for carbapenemase-producing genes (mainly New Delhi metallo-beta-lactamase-1 [NDM-1] and oxacillinase-48 [OXA-48]). Eighteen patients (18/64, 28%) had a positive blood culture for MDRO in the peri-engraftment neutropenic period. Correlation between surveillance and blood cultures was seen in 61% (11/18) of patients. All-cause mortality was 14.1% (9/64) and 25% (16/64) in patients at 100 days and 6 months post-HSCT, respectively. The 100-day and post-100-day all-cause mortality rates were higher in patients with Gram-negative MDRO bloodstream infections (p < .012 and <.008, respectively).

CONCLUSION

MDRO infections can adversely affect HSCT outcomes. Pre-transplant stool and throat surveillance cultures may guide empirical antibiotic policy and lead to favorable transplant outcomes.

Factors affecting clinical outcome in COVID-associated rhino-orbito-cerebral mucormycosis (CAROM) patients-An ambispective, single-arm, observational study

BACKGROUND

COVID-associated Rhino-Orbito-Cerebral Mucormycosis (CAROM) appeared as an epidemic in India during the second wave of the COVID-19 pandemic during the months of March to May 2021. Though many reports have highlighted cross sectional and short-term attributes related to CAROM, long term follow up data is sparse.

OBJECTIVE

This report aims to analyze the follow-up outcomes in consecutive patients presenting to us during the epidemic.

PATIENTS AND METHODS

This was an ambispective observational analytical study, recruiting the consecutive patients admitted to our tertiary care centre during the period of the CAROM epidemic. The mortality rate during the follow-up and various factors affecting survival were studied using univariable and multivariable statistics with the Stata 14.0 software.

RESULTS

Of the 189 patients studied, eight were lost to follow-up. The outcome analysis was performed for the 181 patients. 93.6 % (162/173) of the patients had diabetes. The All-cause mortality was 45 % (81/181), while the ROCM-specific mortality was found to be 24 % (46/181) at a median follow-up of 176 days (IQR: 21-217 days). With univariable analysis, increasing age, higher serum IL-6 levels, presence of additional comorbidities (in addition to Diabetes and hypertension), bilateral disease, skin necrosis, palatal involvement, infratemporal fossa involvement, and impaired vision/ocular movements were found to be associated with increased mortality. However, on multivariable analysis, only 1) increasing age, 2) raised serum IL-6 levels, and 3) bilateral disease were predictive of increased mortality. Surgical debridement (endoscopic, palatal removal, orbital exenteration, neurosurgical intervention) was associated with significantly reduced mortality on both univariable and multivariable analysis.

CONCLUSION

Our intermediate-term follow-up data showed advanced age at presentation, raised IL-6 levels, and bilateral sinonasal involvement to be predictive of increased mortality, while surgical debridement is significantly protective from mortality in CAROM patients.

An efficient computational protocol for template-based design of peptides that inhibit interactions involving SARS-CoV-2 proteins

The RNA-dependent RNA polymerase (RdRp) complex of SARS-CoV-2 lies at the core of its replication and transcription processes. The interfaces between holo-RdRp subunits are highly conserved, facilitating the design of inhibitors with high affinity for the interaction interface hotspots. We, therefore, take this as a model protein complex for the application of a structural bioinformatics protocol to design peptides that inhibit RdRp complexation by preferential binding at the interface of its core subunit nonstructural protein, nsp12, with accessory factor nsp7. Here, the interaction hotspots of the nsp7-nsp12 subunit of RdRp, determined from a long molecular dynamics trajectory, are used as a template. A large library of peptide sequences constructed from multiple hotspot motifs of nsp12 is screened in-silico to determine sequences with high geometric complementarity and interaction specificity for the binding interface of nsp7 (target) in the complex. Two lead designed peptides are extensively characterized using orthogonal bioanalytical methods to determine their suitability for inhibition of RdRp complexation. Binding affinity of these peptides to accessory factor nsp7, determined using a surface plasmon resonance (SPR) assay, is slightly better than that of nsp12: dissociation constant of 133nM and 167nM, respectively, compared to 473nM for nsp12. A competitive ELISA is used to quantify inhibition of nsp7-nsp12 complexation, with one of the lead peptides giving an IC50 of 25μM . Cell penetrability and cytotoxicity are characterized using a cargo delivery assay and MTT cytotoxicity assay, respectively. Overall, this work presents a proof-of-concept of an approach for rational discovery of peptide inhibitors of SARS-CoV-2 protein-protein interactions.

People's perceptions on COVID-19 vaccination: an analysis of twitter discourse from four countries

More than six and half million people have died as a result of the COVID-19 pandemic till Dec 2022. Vaccination is the most effective means to prevent mortality and infection attributed to COVID-19. Identifying public attitudes and perceptions on COVID-19 vaccination is essential to strengthening the vaccination programmes. This study aims to identify attitudes and perceptions of twitter users towards COVID-19 vaccinations in four different countries. A sentiment analysis of 663,377 tweets from October 2020 to September 2022 from four different countries (i.e., India, South Africa, UK, and Australia) was conducted. Text mining using roBERTA (Robustly Optimized Bert Pretraining approach) python library was used to identify the polarity of people's attitude as "negative", "positive" or "neutral" based on tweets. A sample of 2000 tweets (500 from each country) were thematically analysed to explore the people's perception concerning COVID-19 vaccines across the countries. The attitudes towards COVID-19 vaccines varied by countries. Negative attitudes were observed to be highest in India (58.48%), followed by United Kingdom (33.22%), Australia (31.42%) and South Africa (28.88%). Positive attitudes towards vaccines were highest in the United Kingdom (21.09%). The qualitative analysis yielded eight themes namely (i) vaccine shortages, (ii) vaccine side-effects, (iii) distrust on COVID-19 vaccines, (iv) voices for vaccine equity, (v) awareness about vaccines, (vi) myth busters, (vii) vaccines work and (viii) vaccines are safe. The twitter discourse reflected the evolving situation of COVID-19 pandemic and vaccination strategies, lacunae and positives in the respective countries studied.

Optimizing leachate treatment with titanium oxide-impregnated activated carbon (TiO2@ASC) in a fixed-bed column: characterization, modeling, and prediction study

This research focused on the application of a fixed bed column filled with immobilized titanium oxide-loaded almond shell carbon (TiO2@ASC) for the treatment of leachate. The adsorption performance of synthesized TiO2@ASC in fixed bed column is analyzed using adsorption experiments and modeling study. The characteristics of synthesized materials are determined by several instrumental techniques like BET, XRD, FTIR, and FESEM-EDX. The flow rate, initial concentration of COD and NH3-N, and bed height were optimized to determine the effectiveness of leachate treatment. The linear bed depth service time (BDST) plots equations with a correlation coefficient of greater than 0.98 confirmed the model's accuracy for COD and NH3-N adsorption in column structure. The adsorption process was found to be well predicted by an artificial neural network (ANN) model with a root mean square error of 0.0172 and 0.0167 for COD and NH3-N reduction, respectively. The immobilized adsorbent was regenerated using HCl and was found to be reusable for up to three cycles, promoting material sustainability. This study is aimed to contribute towards SDG 6 and SDG11 by United Nations Sustainable Development Goals.

First case report of Cyclosporiasis from eastern India: Incidence of Cyclospora cayetanensis in a patient with unusual diarrheal symptoms

Cyclospora cayetanensis, a recently described coccidian parasite causes severe gastroenteric disease worldwide. Limited studies are found on the incidence of C. cayetanensis infection from India; hence remains largely unknown. To date, no case of cyclosporiasis from eastern India has been reported. In this study, we described an incidental case of C. cayetanensis in a 30 years old Bengali female patient with no travel history from eastern India. In June 2022, the patient presented with a history of diarrhoea persisting for more than two months with continuous passage foul smelling stools for which she took multiple antibiotics that were ineffective. There were no Salmonella, Shigella, or Vibrio-like organisms in the patient's faecal sample, and Toxin A/B of Clostridium difficile was also not detected by ELISA. The patient was HIV-negative. Finally, UV autofluorescence and DNA-based diagnosis confirmed the presence of C. cayetanensis, and the treatment with a combination of appropriate antibiotics was successful. This case report could raise awareness about C. cayetanensis associated diarrhoeal cases in India.

Multi-drug resistant (MDR) and extensively drug-resistant (XDR) bacteraemia rates among cancer patients in an oncology hospital in eastern India: an 11-year retrospective observational study

Background

Trend analysis of bacteraemias caused by multi-drug resistant (MDR) and extensively drug resistant (XDR) bacteria helps to assess efficacy of infection prevention and control (IPC) practices. Data on the trends of MDR and XDR bacteraemias are lacking from cancer patients in India.

Aims

To report antibiotic resistance rates over time in bacteraemias and to assess the effect of IPC practices where patient isolation facilities were limited on the rates and trends of MDR and XDR bacteraemias from a cancer centre in eastern India.

Methods

A retrospective observational study was conducted in a specialist cancer hospital in India from 2011 to 2021. The study included both patients with haematological and solid organ malignancy. Data on blood cultures and surveillance culture samples were analysed. Blood cultures were processed using BACT/ALERT® (bioMérieux, Marcy-l'Étoile, France) and the identification and antibiotic susceptibilities of bacteria were performed using VITEK® 2 (bioMérieux, Marcy-l'Étoile, France). Surveillance cultures for MDR/XDR bacteria were performed on a subset of patients and processed based on a modified method described previously.

Findings

3rd-generation cephalosporin-resistant Gram negative bacilli were the commonest cause of MDR bacteraemia (57.6%) followed by carbapenem resistant organisms (CRO) (35.7%). Bacteraemias caused by vancomycin-resistant enterococci (VRE), meticillin-resistant Staphylococcus aureus (MRSA) and colistin-resistant Gram negative bacilli were responsible for 1.3%, 2.3% and 3.0% of laboratory confirmed bloodstream infections (BSI) respectively. The ranges of the rates of MDR/XDR BSI per 1000 in-patients during the study period were: MRSA (1-1.18), VRE (0-0.88), 3^rd generation cephalosporin-resistant Gram negative bacilli (10.10-20.32), CRO (5.05-13.07) and colistin-resistant Gram negative bacilli (E. coli, Klebsiella, Pseudomonas aeruginosa, Acinetobacter spp (0-1.3). Surveillance cultures collected from a subset of patients showed ranges of MRSA detection in 0-2.11%, VRE in 1.67%-7.49%, 3^rd generation cephalosporin-resistant Gram negative bacilli in 55%-89.91% and carbapenem resistant Gram negative bacilli in 18.33%-31.11% of patients.

Conclusion

This is one of few studies providing trend data for MDR/XDR bacteraemia rates among cancer patients in India over a decade. In a high prevalence setting it was possible to keep the rates of MDR/XDR bacteraemia controlled with IPC strategies and without adequate isolation facilities. The results are of potential interest to policy makers, IPC specialists and clinicians.

Unusual Intracerebral Hemorrhage Secondary to Delayed Posttraumatic Middle Meningeal Artery Pseudoaneurysm, Successfully Treated by Endovascular N-Butyl Cyanoacrylate Embolization

Pseudoaneurysm of the middle meningeal artery, presenting as a delayed sequela of trauma, being a rare entity, may sometimes present as an acute intraparenchymal hemorrhage, with a risk of rerupture and mortality. The optimal management in acute settings remains undetermined. We, hereby, report a case of elderly gentleman with a history of a road traffic accident. Noncontrast computed tomography (NCCT) brain was reported to have left parietal hemorrhagic contusion without any mass effect. The patient was managed conservatively without any major neurological deficits. After 7 months, the patient presented with severe headache, altered sensorium, and right hemiparesis. NCCT brain showed acute left thalamocapsular hemorrhage with minimal subarachnoid hemorrhage with associated mass effect and impending herniation. Considering the fall in patient's baseline Glasgow comma scale response, pupillary asymmetry, and CT findings, immediate decompression and hematoma evacuation were advised. In view of atypical morphology, the patient was planned for urgent digital subtraction angiography prior to the surgery to rule out the ruptured aneurysm or pial arterio-venous fistula. Selective angiography of the left external carotid artery demonstrated a dissecting pseudoaneurysm feeding from the middle meningeal artery (MMA), which was embolized using n-butyl cyanoacrylate (NBCA). Postprocedure DynaCT revealed the left temporal bone fracture, indicating this pseudoaneurysm to be most likely posttraumatic delayed sequelae. Postembolization, the patient underwent surgical decompression and excision of hematoma. Patient's neurological status gradually improved and was discharged with the minimal deficit. Our case highlights the importance of awareness of the posttraumatic MMA pseudoaneurysm as an uncommon but treatable entity, which can be easily diagnosed using cerebral angiography and amenable to safe and effective endovascular embolization using NBCA.

Molecular epidemiology of SARS-CoV-2 in healthcare workers and identification of viral genomic correlates of transmissibility and vaccine break through infection: A retrospective observational study from a cancer hospital in eastern India

PURPOSE

Despite COVID vaccination with ChAdOx1 ncov-19 (COVISHIELD®) (ChAdOx1 ncov-19) a large number of healthcare workers (HCWs) were getting infected in wave-2 of the pandemic in a cancer hospital of India. It was important therefore to determine the genotypes responsible for vaccine breakthrough infections.

METHODS & OBJECTIVES

Retrospective observational study of HCWs. Whole genome sequencing of SARS CoV-2 using Illumina NovaSeq was done. Mutations from both waves were compared to identify genomic correlates of transmissibility and vaccine breakthrough infections.

RESULTS

Vaccine breakthrough infections were seen in 127 HCWs out of 1806 fully vaccinated staff (7.03%). Median number of HCWs infected per day in wave-1 was 0.92 versus 3.25 in wave-2. Majority of wave-1 samples belonged to B.1 and B.1.1 lineage. Variant of concern- Delta variant (90%), and variant of interest- Kappa variant (10%), was seen in only wave-2 samples. Total mutation observed in wave-2 samples (median ​= ​44) was 1.8 times than wave-1 sample (median ​= ​24). Spike protein in wave-2 samples had 13 non-synonymous mutation as compared to 8 seen in wave-1 samples. E484Q-vaccine escape mutant was detected in five samples of wave-2; T478K - highly infectious mutation was seen in 31 samples of wave-2. We identified a novelcoding disruptive in-frame deletion (c.467_472delAGTTCA, p. Glu156_Arg158delinsGly) in the Spike protein. This mutation was seen only in wave-2 (78%, n ​= ​39) samples.

CONCLUSION

The circulating virus strains in wave-2 infections demonstrated a greater degree of infectivity. There was a significant change in the genotypes observed in wave-1 and wave-2 infections along with almost twice the number of mutations. We noted that vaccine breakthrough infections (although mostly mild).

Utilization of Construction and Demolition Mix Waste in the Fired Brick Production: The Impact on Mechanical Properties

The European Green Deal, which emphasizes zero-waste economies, and waste recycling in construction and building materials, has arisen due to significant worldwide needs for solid waste recovery and usage. This ambitious study focuses on recycling mixed construction and demolition (C&D) waste into burnt bricks and investigating the influence of firing temperature. While pursuing its objectives, this is dependent on raw material characterization and burnt-brick product quality assessment. The recycling of mixed C&D waste is explored by mixing the waste into two soil types (alluvial and laterite) in ratios ranging from 5% to 45% at three firing temperatures (700 °C, 850 °C and 900 °C). The utilization of mixed C&D waste in amounts of 10% at 700 °C and 25% at 850 °C and 900 °C fulfilled the Indian standard. Although a fire at 700 °C results in less optimal waste utilization, it is beneficial and recommended for reducing the carbon footprint and energy use. Additional mineralogical and microstructural analyzes are performed on the optimal fired samples. The study's findings are promising for sustainable resource usage, reducing carbon footprint, and reducing waste disposal volume. This research is a big step toward the Sustainable Development Goals of the United Nations and a circular economy.

Hazardous giant pharyngoesophageal liposarcoma

A man in his early 80s presented to the otorhinolaryngology department with progressively worsening dysphagia to solids and a recent episode of difficulty breathing accompanied by a very brief expulsion of a solid mass from the mouth. Based on the endoscopic appearance of a fatty lesion of an elongated mass with a thick stalk on the posterior pharyngeal wall, a diagnosis of the benign fibrovascular polyp was given after clinical and radiological correlation. The pharyngeal polyp was resected at the base of its pedicle by transoral endoscopy with a thunder beat vessel sealing device. Histopathological examination of the mass revealed a well-differentiated liposarcoma composed of mature adipocytes. Following surgical excision, the patient made a full recovery. This case signifies the integrated role of preoperative biopsy, new surgical technologies and targeted therapies in managing pharyngoesophageal polyps.

Multi-Level High-Throughput Screening for Discovery of Ligands That Inhibit Insulin Aggregation

We have developed a multi-level virtual screening protocol to identify lead molecules from the FDA inactives database that can inhibit insulin aggregation. The method is based on the presence of structural and interaction specificity in non-native aggregation pathway protein-protein interactions. Some key challenges specific to the present problem, when compared with native protein association, include structural heterogeneity of the protein species involved, multiple association pathways, and relatively higher probability of conformational rearrangement of the association complex. In this multi-step method, the inactives database was first screened using the dominant pharmacophore features of previously identified molecules shown to significantly inhibit insulin aggregation nucleation by binding to its aggregation-prone conformers. We then performed ensemble docking of several low-energy ligand conformations on these aggregation-prone conformers followed by molecular dynamics simulations and binding affinity calculations on a subset of docked complexes to identify a final set of five potential lead molecules to inhibit insulin aggregation nucleation. Their effect on aggregation inhibition was extensively investigated by incubating insulin under aggregation-prone aqueous buffer conditions (low pH, high temperature). Aggregation kinetics were characterized using size exclusion chromatography and Thioflavin T fluorescence assay, and the secondary structure was determined using circular dichroism spectroscopy. Riboflavin provided the best aggregation inhibition, with 85% native monomer retention after 48 h incubation under aggregation-prone conditions, whereas the no-ligand formulation showed complete monomer loss after 36 h. Further, insulin incubated with two of the screened inactives (aspartame, riboflavin) had the characteristic α-helical dip in CD spectra, while the no-ligand formulation showed a change to β-sheet rich conformations.

Computation of the Protein Conformational Transition Pathway on Ligand Binding by Linear Response-Driven Molecular Dynamics

While extremely important for relating the protein structure to its biological function, determination of the protein conformational transition pathway upon ligand binding is made difficult due to the transient nature of intermediates, a large and rugged conformational space, and coupling between protein dynamics and ligand-protein interactions. Existing methods that rely on prior knowledge of the bound (holo) state structure are restrictive. A second concern relates to the correspondence of intermediates obtained to the metastable states on the apo → holo transition pathway. Here, we have taken the protein apo structure and ligand-binding site as only inputs and combined an elastic network model (ENM) representation of the protein Hamiltonian with linear response theory (LRT) for protein-ligand interactions to identify the set of slow normal modes of protein vibrations that have a high overlap with the direction of the protein conformational change. The structural displacement along the chosen direction was performed using excited normal modes molecular dynamics (MDeNM) simulations rather than by the direct use of LRT. Herein, the MDeNM excitation velocity was optimized on-the-fly on the basis of its coupling to protein dynamics and ligand-protein interactions. Thus, a determined set of structures was validated against crystallographic and simulation data on four protein-ligand systems, namely, adenylate kinase-di(adenosine-5')pentaphosphate, ribose binding protein-β-d-ribopyranose, DNA β-glucosyltransferase-uridine-5'-diphosphate, and G-protein α subunit-guanosine-5'-triphosphate, which present important differences in protein conformational heterogeneity, ligand binding mechanism, viz. induced-fit or conformational selection, extent, and nonlinearity in protein conformational changes upon ligand binding, and presence of allosteric effects. The obtained set of intermediates was used as an input to path metadynamics simulations to obtain the free energy profile for the apo → holo transition.

Y Stenting in Wide-Necked Bifurcation Aneurysms: A Single-Center Experience

Stent-assisted coiling is an endovascular means of managing wide-necked bifurcation aneurysms. In spite of the wide availability of various newer devices in managing such difficult aneurysms, the Y stenting offers a safe and cost-effective alternative to treat such cases in resource poor settings. This article provides an insight of our initial six cases of Y stent-assisted coiling along with their follow-up over a period of 6 months with no recanalization in any case. It also highlights the various technical aspects involved in such cases. One case had recurrent subdural hematoma probably due to use of antiplatelets and another patient had sudden dip in level of consciousness probably due to hematoma expansion that might also have been due to antiplatelet usage. However, none of the cases had any issues regarding stent migration, malapposition, and dissection. In our experience, Neuroform Atlas stent used for Y stenting offers a safe and technically easy alternative to various newer bifurcation devices.

Nidus delineation and dosimetric comparison in arteriovenous malformation in stereotactic radiosurgery by using MRI and 3DCT angiography

Purpose/Objectives

Accurate delineation of target is key to any successful radiosurgery. C-arm Dyna CT/ 3DCT angiography (3DCTA) has the potential of improving the accuracy of nidus delineation in intracranial arteriovenous malformations (AVM) due to high temporo-spatial resolution of vessel architecture. Here, we present a comparison of nidus delineation and dosimetric parameters between digital 3DCTA and MRI.

Materials/Methods

Ten consecutive patients treated for intracranial AVMs were included in this study. All patients underwent MRI/MRA, and 3DCTA and all images were co-registered. AVM were delineated using 3DCTA (GTV_3DCTA) and contrast enhanced MRI/MRA (GTV_MRI). Hausdorff distance (HD) matrices and dice similarity coefficient (DSC) matrices were analysed. Stereotactic radiosurgery plans were developed for both the volumes for all patients and statistical analysis were performed with T-test.

Results

Mean volumes of GTV_3DCTA and GTV_MRI were 1.771 cc (SD 1.794cc, range 0.124-4.191cc) and 2.183cc (SD 2.16cc, range 0.221-6.133cc), respectively. Significant deviation (p=0.018) was found when taking GTV_MRI as a primary and comparing it to GTV_3DCTA (MD=0.723cc±0.816cc). Similar result was observed with GTV_3DCTA as primary and GTV_MRI as secondary (MD=0.188cc, SD=0.193cc, p=0.024). Maximum HD was in the range of 1.71 to 7.44mm (mean=4.27mm, SD=1.56). For GTV_3DCTA based plans, significant deviation was found between GTV_MRI and GTV_3DCTA in dose coverage and the mean difference was 22.17% (SD 16.73). In GTV_MRI based plans, the mean CIRTOG deteriorated from 1.33 to 2.18 for GTV_MRI and GTV_3DCTA, respectively. Significant deviation was found in CI_RTOG (0.005) and mean deviation was 0.86(SD=0.72) when comparing GTV_MRI and GTV_3DCTA. Highly significant (p=0.002) deviation was found in CI_Paddick between GTV_MRI and GTV_3DCTA for GTV_MRI based plans with mean difference of 0.26(SD=0.4, for GTV_MRI=0.3, GTV_3DCTA=0.46).

Conclusion

Nidus volume was significantly altered with the use of 3DCTA compared to that of MRA/MRI images. Multimodality imaging is crucial for accurate target delineation, and successful radiosurgical obliteration of nidus.

Multiscale Model for Quantitative Prediction of Insulin Aggregation Nucleation Kinetics

We combined kinetic, thermodynamic, and structural information from single-molecule (protein folding) and two-molecule (association) explicit-solvent simulations for determination of kinetic parameters in protein aggregation nucleation with insulin as the model protein. A structural bioinformatics approach was developed to account for heterogeneity of aggregation-prone species, with the transition complex theory found applicable in modeling association kinetics involving non-native species. Specifically, the kinetic pathway for formation of aggregation-prone oligomeric species was found to contain a structurally specific dominant binding mode, making the kinetic process similar to native protein association. The kinetic parameters thus obtained were used in a population balance model, and accurate predictions for aggregation nucleation time varying over 2 orders of magnitude with changes in either insulin concentration or an aggregation-inhibitor ligand concentration were obtained, while an empirical parameter set was not found to be transferable for prediction of ligand effects. Further, this physically determined kinetic parameter set provided several mechanistic insights, such as identification of the rate-limiting step in aggregation nucleation and a quantitative explanation for the switch from Arrhenius to non-Arrhenius aggregation kinetics around the melting temperature of insulin.

Bispidine as a β-strand nucleator: from a β-arch to self-assembled cages and vesicles

The development of synthetic scaffolds that nucleate well-folded secondary structures is highly challenging. Herein, we designed and synthesized a series of core-modified peptides (F1, F2, F3, and F4) that fold into β-strand structures. These bispidine-scaffolded peptides were studied by CD, IR, NMR, single crystal XRD, and Molecular Dynamics (MD) simulations to investigate their conformational preferences. Solid-state and solution studies revealed that bispidine is a versatile scaffold that could be placed either at the terminal or at the middle of the peptide strand for nucleating the β-strand structure. Scaffolds that nucleate an isolated β-strand conformation are rare. Bispidine placed at the C-terminus of the peptide chain could nucleate a β-strand conformation, while bispidine placed at the middle resulted in a β-arch conformation. This nucleation activity stems from the ability to restrict the psi torsion angle (ψ) through intramolecular C5 hydrogen bonding between the equatorial hydrogen(s) of bispidine and the carbonyl oxygen(s) of the amino acid close to the scaffold. Furthermore, the bispidine peptidomimetic with a super secondary structure, namely β-arch, assembled into single-hole submicron cages and spherical vesicles as evident from microscopic studies. The design logic defined here will be a significant strategy for the development of β-strand mimetics and super secondary structures.

Importance and results of sterility testing of various products in a microbiology laboratory of eastern India

Components of blood products from Blood bank, stem cells products from Haemotapoietic Stem Cell Transplant unit, CSSD (Central Sterile Supply Department) items, and pharrrmaceutical products, were sterility tested by liquid culture. 2.91% of the total 3122 samples sent for sterility testing from various departments were positive (i.e. showing contamination). CSSD products showed no contamination (0/37); products from blood bank and bone marrow transplant unit showed a contamination rate of 2.03% (47/2307) and 4.64% (31/667) respectively. The average cost of sterility test was Rs. 302 (INR). Sterility test requires stringent aseptic precautions which is resource intensive.

Ghost Aneurysm in Atraumatic Acute Subdural Hematoma: A Sign of Caution or a Mere Finding - A Case Report

Atraumatic subdural bleed often presents with diagnostic and management dilemma. This is a case of a 36-year male who presented with acute onset headache while at rest without any focal neurodeficit. Computed Tomographic Scan of brain revealed subdural hematoma. Cerebral Digital Subtraction Angiography showed a same sided focal dye extravasation which corresponded exactly to the inner margin of the subdural bleed. Though the patient opted out for surgical management this imaging and DSA finding correlated with the “Ghost Aneurysm” concept in acute atraumatic subdural bleeds and its early recognition is an important imaging marker for caution for hematoma expansion.

An integrated permeable reactive barrier and photobioreactor approach for simultaneous removal of nitrate, phosphate and hexavalent chromium: A combined batch and continuous flow study

In this study, simultaneous removal of nitrate (NO₃^-), phosphate (PO₄^3-) and hexavalent chromium (Cr(VI)) from wastewater was investigated using a novel integrated filtration unit consisting of adsorbent based permeable reactive barrier (AB-PRB) and biosorption based photobioreactor (BSB-PBR). AB-PRB was comprising a mixture of low-cost adsorbents in an optimum proportion, whereas BSB-PBR carried C. vulgaris microalgae cultivated in controlled environment. The batch analysis for AB-PRB showed maximum removal efficiency of 95.7% and 98.0% for NO₃^- and PO₄^3-, at pH-6, whereas 84.0% for Cr(VI) at pH-4. However, continuous flow study showed decreasing trend in removal efficiency of NO₃^-, PO₄^3- and Cr(VI) with increasing flow rate from 10 ml min^-1 to 30 ml min^-1. Further, in BSB-PBR, maximum removal of 98.2% was achieved for Cr(VI) of 1.0 mg L^-1 initial concentration at 3.3 days of hydraulic retention time (HRT). This study provides a novel integrated remediation approach for efficient removal of unlike contaminants.

Zwitterions for impedance spectroscopy: The new buffers in town

Studying the role of buffers in impedance spectroscopy is a relatively unexplored area. We demonstrate a special class of biologically relevant buffers known as Good's zwitterionic buffers that show improved performance over standard electrolyte buffers (e.g. PBS) currently widely used in impedance spectroscopy measurements of bacterial suspensions. Our theoretical and experimental comparisons of conductivity of classical and zwitterionic buffers at various different concentrations show that ion-ion interaction effects are significantly higher in zwitterionic buffers as compared to classical buffers at the concentrations at which they are used. This and the fact that zwitterions have larger sizes leads to the lowering of their conductivity which significantly improves their impedance sensing ability. We illustrate through an example of heat-induced ionic release in model S. typhi and S. aureus bacteria that having a low conductivity buffer is indeed beneficial for biological impedance measurements. In fact, the best buffer for impedance studies can be chosen solely based on their electrical properties as long as they are also biologically compatible. This gives Good's zwitterionic buffers an edge over conventional media as they satisfy both these criteria.

Multivariate analysis of adaptive response to ferulic acid and p-coumaric acid after physiological stresses in Cronobacter sakazakii

AIM

The present study demonstrated the antimicrobial activity of ferulic acid and p-coumaric acid against unstressed and stressed (cold stressed, starved and desiccated) Cronobacter sakazakii in laboratory media (37°C) and reconstituted powdered infant formulation (PIF) with mild heat treatment (50°C).

METHODS AND RESULTS

Five phenolics, namely, quercetin, rutin, caffeic acid, ferulic acid and p-coumaric acid, were tested for antimicrobial activities against five strains of C. sakazakii either unstressed or stressed. Strain specific higher resistance to ferulic acid and p-coumaric acid was observed after stress adaptation in laboratory media. The effect of cross protection was validated using reconstituted PIF as delivery vehicle of selected compounds. Both p-coumaric acid and ferulic acid showed inhibition of C. sakazakii in a dose and time dependent manner as revealed by their viable cell counts. Principal component analysis revealed that the desiccated cells were more sensitive to phenolics in reconstituted PIF.

CONCLUSIONS

Only ferulic acid and p-coumaric acid showed marked antibacterial activity with minimum inhibitory concentration in the range of 2·5-5 mg ml^-1 for unstressed C. sakazakii cells in tryptone soy broth. The maximum inhibition was achieved with 20 mg ml^-1 of both the tested polyphenols in reconstituted PIF. Cold stress and starvation stress did not impart any protection nor increased the susceptibility of C. sakazakii, whereas desiccation resulted in increased susceptibility to phenolic compounds.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results obtained in this study helps in understanding the effect of environmental stresses during processing on susceptibility of C. sakazakii to natural antimicrobial agents. Future transcriptomic studies and functional genetic studies are warranted to understand the strain specific stress responses for the development of better control methods possibly by using these natural antagonists.

Using circular economy principles to recycle materials in guiding the design of a wet scrubber-reactor for indoor air disinfection from coronavirus and other pathogens

An arduous need exists to discover rapid solutions to avoid the accelerated spread of coronavirus especially through the indoor environments like offices, hospitals, and airports. One such measure could be to disinfect the air, especially in indoor environments. The goal of this work is to propose a novel design of a wet scrubber-reactor to deactivate airborne microbes using circular economy principles. Based on Fenton's reaction mechanism, the system proposed here will deactivate airborne microbes (bioaerosols) such as SARS-CoV-2. The proposed design relies on using a highly porous clay-glass open-cell structure as an easily reproducible and cheap material. The principle behind this technique is an in-situ decomposition of hydrogen peroxide into highly reactive oxygen species and free radicals. The high porosity of a tailored ceramic structure provides a high contact area between atomized oxygen, free radicals and supplied polluted air. The design is shown to comply with the needs of achieving sustainable development goals.

Acute Aneurysmal Subarachnoid Haemorrhage following Coital Headache successfully treated with Endovascular Flow Diversion

          Headache associated with sexual activity is a difficult diagnosis for physicians and sometimes underlies grave etiologies. One such cause associated with high morbidity and mortality is subarachnoid hemorrhage due to aneurysm rupture. This is a case of a 39 year old male, presenting with coital headache for few episodes. CT showed subarachnoid hemorrhage, Fischer Grade 3. Digital subtraction angiography revealed Right Internal carotid artery very small aneurysm which was endovascularly managed with FRED (flow-redirection endoluminal device, Microvention, Aliso Viejo, California, USA) flow diverter placement across the aneurysm. Follow up revealed complete resolution of aneurysm with no residual clinical symptoms. The following case reveals the importance of identifying sexual headache as a presenting symptom of grave etiology like aneurysmal rupture and its early diagnosis and management to avoid mortality.      

Whole blood interleukin-2 release test to detect and characterize rare circulating gluten-specific T cell responses in coeliac disease

Whole blood cytokine release assays (CRA) assessing cellular immunity to gluten could simplify the diagnosis and monitoring of coeliac disease (CD). We aimed to determine the effectiveness of electrochemiluminescence CRA to detect responses to immunodominant gliadin peptides. HLA-DQ2·5⁺ CD adults (cohort 1, n = 6; cohort 2, n = 12) and unaffected controls (cohort 3, n = 9) were enrolled. Cohort 1 had 3-day gluten challenge (GC). Blood was collected at baseline, and for cohort 1 also at 3 h, 6 h and 6 days after commencing 3-day GC. Gliadin peptide-stimulated proliferation, interferon (IFN)-γ enzyme-linked immunospot (ELISPOT) and 14- and 3-plex electrochemiluminescence CRA were performed. Poisson distribution analysis was used to estimate responding cell frequencies. In cohort 1, interleukin (IL)-2 dominated the gliadin peptide-stimulated cytokine release profile in whole blood. GC caused systemic IL-2 release acutely and increased gliadin peptide-stimulated IFN-γ ELISPOT and whole blood CRA responses. Whole blood CRA after GC was dominated by IL-2, but also included IFN-γ, C-X-C motif chemokine ligand 10/IFN-γ-induced protein 10 (CXCL10/IP-10), CXCL9/monokine induced by IFN-γ (MIG), IL-10, chemokine (C-C motif) ligand 3/macrophage inflammatory protein 1-alpha (CCL3/MIP-1α), TNF-α and IL-8/CXCL8. In cohorts 2 and 3, gliadin peptide-stimulated whole blood IL-2 release was 100% specific and 92% sensitive for CD patients on a gluten-free diet; the estimated frequency of cells in CD blood secreting IL-2 to α-gliadin peptide was 0·5 to 11 per ml. Whole blood IL-2 release successfully mapped human leucocyte antigen (HLA)-DQ2·5-restricted epitopes in an α-gliadin peptide library using CD blood before and after GC. Whole blood IL-2 release assay using electrochemiluminescence is a sensitive test for rare gliadin-specific T cells in CD, and could aid in monitoring and diagnosis. Larger studies and validation with tetramer-based assays are warranted.

Solutions of Critical Raw Materials Issues Regarding Iron-Based Alloys

The Critical Raw Materials (CRMs) list has been defined based on economic importance and supply risk by the European Commission. This review paper describes two issues regarding critical raw materials: the possibilities of their substitution in iron-based alloys and the use of iron-based alloys instead of other materials in order to save CRMs. This review covers strategies for saving chromium in stainless steel, substitution or lowering the amounts of carbide-forming elements (especially tungsten and vanadium) in tool steel and alternative iron-based CRM-free and low-CRM materials: austempered ductile cast iron, high-temperature alloys based on intermetallics of iron and sintered diamond tools with an iron-containing low-cobalt binder.