Calotropis procera (L.) mediated synthesis of AgNPs and their application to control leaf spot of Hibiscus rosa-sinensis (L.)

Abstract Nature is gifted with a wide range of ornamental plants, which beautify and clean the nature. Due to its great aesthetic value, there is a need to protect these plants from a variety of biotic and abiotic stresses. Hibiscus rosa-sinensis (L.) is an ornamental plant and it is commonly known as China rose or shoeblack plant. It is affected by several fungal and bacterial pathogens. Current study was designed to isolate leaf spot pathogen of H. rosa-sinensis and its control using silver nanoparticles (AgNPs). Based on molecular and morphological features, the isolated leaf spot pathogen was identified as Aspergillus niger. AgNPs were synthesized in the leaf extract of Calotropis procera and characterized. UV-vis spectral analysis displayed discrete plasmon resonance bands on the surface of synthesized AgNPs, depicting the presence of aromatic amino acids. Fourier transform infrared spectroscopy (FTIR) described the presence of C-O, NH, C-H, and O-H functional groups, which act as stabilizing and reducing molecules. X-ray diffraction (XRD) revealed the average size (~32.43 nm) of AgNPs and scanning electron microscopy (SEM) depicted their spherical nature. In this study, in vitro and in vivo antifungal activity of AgNPs was investigated. In vitro antifungal activity analysis revealed the highest growth inhibition of mycelia (87%) at 1.0 mg/ml concentration of AgNPs. The same concentration of AgNPs tremendously inhibited the spread of disease on infected leaves of H. rosa-sinensis. These results demonstrated significant disease control ability of AgNPs and suggested their use on different ornamental plants.

Impact of COVID-19 pandemic on head-neck cancer referral and treatment pathway in North East London

INTRODUCTION

The COVID-19 pandemic has led to wide-ranging disruption of head-neck cancer (HNC) service provision in the UK. Early reports suggest delays in referral, diagnosis and initiation of treatment for new cancer cases compared with before the pandemic.

METHODS

The HNC service was studied retrospectively for the time-periods between 1 January 2020 to 31 October 2020 (hereafter 'post-COVID') and 1 January 2019 to 31 October 2019 (hereafter 'pre-COVID'). We analysed: (1) the number of cases treated at our centre, (2) stage of disease at presentation and (3) treatment delivery times.

RESULTS

In the post-COVID period, the total number of HNC cases treated decreased (48 vs 56 pre-COVID). There was increase in advanced stage at presentation (58% vs 42% pre-COVID) and a significant increase in the need for airway stabilisation (13 vs 5 pre-COVID; p=0.03). Average time from referral to treatment was significantly prolonged (72.5 days vs 49.23 days pre-COVID; p=0.03). Two-week wait referrals were seen in HNC clinics at median time of 11.9 days, compared with 7.1 days during the pre-COVID period (p=0.07). However, there was no delay in the initiation of first treatment after the decision to treat (29.2 days vs 24.7 days pre-COVID; p=0.58).

CONCLUSION

The results of this study call for early referral at the primary care level and rapid radiopathological confirmation at the tertiary level to prevent delays in diagnosis of new HNC cases.

Oral Dextrose gel use in asymptomatic hypoglycemic newborns decreases NICU admissions and parenteral dextrose therapy: A retrospective study

BACKGROUND

Neonatal hypoglycemia is one of the most common causes of admission to neonatal intensive care unit requiring intravenous dextrose therapy. Administration of IV dextrose and transfer to the NICU may interfere with parent-infant bonding, breastfeeding, and has financial implications.

OBJECTIVE

Retrospective study to evaluate the effect of dextrose gel supplementation for asymptomatic hypoglycemia in reducing NICU admissions and intravenous dextrose therapy.

METHOD

A retrospective study conducted for eight months each before and after introduction of dextrose gel in the management of asymptomatic neonatal hypoglycemia. Asymptomatic hypoglycemic infants were given only feeds in pre dextrose gel period and dextrose gel along with feeds in the dextrose gel period. Rates of admission to NICU and the need of IV dextrose therapy were evaluated.

RESULTS

High risk characteristics (Prematurity, Large for Gestational Age, small for Gestational Age, Infants of diabetic mother etc.) were equally distributed among both the cohorts. Primary outcome results showed significant reduction in NICU admissions from 396/1801(22%) to 329/1783 (18.5%) (odds ratio, 95% CI 1.24(1.05-1.46, p 0.008). There was significant reduction in IV dextrose therapy requirement from 277/1405 (15.4%) to 182/1454 (10.2%) (odds ratio, 95% CI 1.59(1.31- 1.95, p <  0.001).Babies discharged on predominant breast feeding showed significant improvement from 237/396(59.8%) in the pre dextrose gel period to 240/329 (72.9%) (odds ratio, 95% CI 0.82(0.73-0.90, p <  0.001) in dextrose gel period.

CONCLUSIONS

Dextrose gel supplementation with feeds reduced NICU admissions, the need for parenteral dextrose therapy, avoided maternal separation and promoted breastfeeding.

The surprises in optical coherence tomography (OCT) findings in patients presenting with in-stent restenosis: the road less travelled

Funding Acknowledgements

Type of funding sources: None.

Background

Morphological features of neointimal tissue play a pivotal role in the pathophysiology of In-Stent Restenosis (ISR) after percutaneous coronary intervention, hence understanding these features and patterns is crucial.

Purpose

The present study was designed to qualitatively and quantitatively assess neointimal characteristics of lesions using OCT in patients presenting with ISR.

Methods

This was a single-center, prospective, observational study performed between 1st August 2020 and 30th December 2021 at a tertiary-care center in India. Patients diagnosed with stable angina and acute coronary syndrome with post-procedural angiographically documented restenosis (&gt;50%) were included. Qualitative and quantitative assessment of neointimal hyperplasia patterns was performed using OCT.

Results

A total of 34 patients with ISR were studied. Neointimal hyperplasia was classified as (i) homogenous group (n=18) and (ii) non-homogenous group (n=16). As many as 14 (77.8%) diabetics belonged to the homogenous group. Predominant plaque characteristics such as neoatherosclerosis, cholesterol crystals, and calcium were documented in 14 (77.8%), 12 (66.7%), and 11 (61.1%) patients in the homogenous group and in 10 (62.5%), 10 (62.5%), and 9 (56.2%) patients in the non-homogenous group, respectively. Unexpanded stent struts were identified in 11 (61.1%) and 11 (68.8%) patients in the homogenous and non-homogenous groups, respectively. Mean strut thickness was 93.73 ± 31.03 µm and 83.54 ± 18.0 µm, ISR was 72.50 ± 15.93% and 65.37 ± 21.69%, the neointimal thickness was 588.06 ± 167.82 mm and 666.25 ± 218.05 mm, and neointimal hyperplasia was 54.54 ± 11.23% and 59.26 ± 8.86% in the homogenous and non-homogenous groups, respectively.

Conclusion

Neoatherosclerosis and stent underexpansion was predominantly observed in our study, which was in contrast to most of the existing literature [1,2,3], and only diabetes was found to be significantly associated with homogenous neointimal hyperplasia, irrespective of the generation of the stent.

Head-neck dissection course during COVID-19 pandemic: challenges, adaptations and how we did it

INTRODUCTION

Cadaveric dissection courses have come to a standstill since the onset of the COVID-19 pandemic. In addition to limited operative opportunities, cancellation of such courses has severely impacted surgical training, especially in a craft-based specialty such as head-neck surgery. The aim of this educational project was to: (1) study the feasibility of an in-person head-neck cadaveric dissection course during COVID-19 pandemic; and (2) validate the educational benefit of this teaching method to ear, nose and throat (ENT) trainees.

METHODS

We developed a 2-day head-neck cadaveric dissection course for ENT trainees. The course programme covered essential head-neck open surgical procedures. Content validity (subjective feedback) was assessed using a 5-point Likert scale. Construct validity (objective usefulness) was evaluated via two pre- and post-course questionnaires, estimating knowledge of head-neck surgical anatomy and self-assessment of levels of confidence with head-neck procedures, respectively.

RESULTS

A risk assessment was conducted and a protocol developed (risk was deemed to be low/tolerable). Content validity showed high satisfaction compared with a median Likert score of 3, 'average' (p=0.000002). For construct validity, the mean score per question improved significantly (p=0.001). Overall levels of confidence showed a trend towards improvement (p=0.08). There was significant improvement in laryngectomy (p=0.01) and level I dissection (p=0.01), with an indication of improvement in level II-V dissection (p=0.07).

CONCLUSIONS

We demonstrated that a cadaveric dissection course, using thorough risk assessment and protocol, could be safely conducted with high content and construct validation during these unprecedented times. This is an invaluable learning environment that needs to be encouraged despite infection control restrictions.

TH3.6 Comparison Between Preoperative MRI and Postoperative Histopathological Staging in Rectal Cancer Surgery (RCS)

Aim

To evaluate diagnostic values of preoperative MRI imaging staging in comparison to postoperative histopathological staging (HPS) in rectal cancer surgery.

Methods

A retrospective chart auditing was performed on all RCS patients from 2019 till 2021. Data collected included patient demographic, preoperative MRI imaging and postoperative histopathological analysis.

Results

A total number of 83 rectal surgeries were performed during the given period, mean age was 67(±11) and 60% were males. 62.7% (52) of patients underwent anterior resection (low AR 27.7%). APR and Hartmann's procedure were performed in 27.7% and 6% of patients. Complete resection was achieved in 95.2% with average LN harvest of 20.5 (±5.8) nodes. The most common Tumour (T) burdens on preoperative MRI and postoperative HPS were T2 (45.6%) and T3 (44.5%) respectively with MRI diagnostic accuracy of 47%. Lymph nodes analysis showed diagnostic preoperative predictive values of 56.6%. Extramural vascular invasion (EMVI) was accounted in 68 Pre-MRI with diagnostic accuracy of 50.6%. Pre-MRI evaluated 69 CRM and accurately commented in 73.5%. Although Pre-MRI staging had tendency to over-stage tumour burden, lymph nodes analysis and EMVI in around 30% of reported cases. It showed accuracy in diagnostic values in CRM prediction with around 73%.

Conclusion

Preoperative MRI diagnostic values showed differences when compared with postoperative histopathological analysis. Pre-MRI showed a tendency to over-staging in tumour size, LNs and EMVI. However, Pre-MRI showed favourable values in accurately describing CRM which is the main factor affecting the outcome of surgery and the ongoing treatment.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Spatial distribution and determinants of HIV prevalence among adults in urban Ethiopia: Findings from the Ethiopia Population-based HIV Impact Assessment Survey (2017–2018)

The design and evaluation of national HIV programs often rely on aggregated national data, which may obscure localized HIV epidemics. In Ethiopia, even though the national adult HIV prevalence has decreased, little information is available about local areas and subpopulations. To inform HIV prevention efforts for specific populations, we identified geographic locations and drivers of HIV transmission. We used data from adults aged 15–64 years who participated in the Ethiopian Population-based HIV Impact Assessment survey (October 2017–April 2018). Location-related information for the survey clusters was obtained from the 2007 Ethiopia population census. Spatial autocorrelation of HIV prevalence data were analyzed via a Global Moran’s I test. Geographically weighted regression analysis was used to show the relationship of covariates. The finding indicated that uncircumcised men in certain hotspot towns and divorced or widowed individuals in hotspot woredas/towns might have contributed to the average increase in HIV prevalence in the hotspot areas. Hotspot analysis findings indicated that, localized, context-specific intervention efforts tailored to at-risk populations, such as divorced or widowed women or uncircumcised men, could decrease HIV transmission and prevalence in urban Ethiopia.

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.

Adapting strategies for effective and efficient pediatric HIV case finding in low prevalence countries: risk screening tool for testing children presenting at high-risk entry points in Ethiopia

Background

Implementing effective and efficient case-finding strategies is crucial to increasing pediatric antiretroviral therapy coverage. In Ethiopia, universal HIV testing is conducted for children presenting at high-risk entry points including malnutrition treatment, inpatient wards, tuberculosis (TB) clinics, index testing for children of positive adults, and referral of orphans and vulnerable children (OVC); however, low positivity rates observed at inpatient, malnutrition and OVC entry points warrant re-assessing current case-finding strategies. The aim of this study is to develop HIV risk screening tool applicable for testing children presenting at inpatient, malnutrition and OVC entry points in low-HIV prevalence settings.

Methods

The study was conducted from May 2017–March 2018 at 29 public health facilities in Amhara and Addis Ababa regions of Ethiopia. All children 2–14 years presenting to five high-risk entry points including malnutrition treatment, inpatient wards, tuberculosis (TB) clinics, index testing for children of positive adults, and referral of orphans and vulnerable children (OVC) were enrolled after consent. Data were collected from registers, medical records, and caregiver interviews. Screening tools were constructed using predictors of HIV positivity as screening items by applying both logistic regression and an unweighted method. Sensitivity, specificity and number needed to test (NNT) to identify one new child living with HIV (CLHIV) were estimated for each tool.

Results

The screening tools had similar sensitivity of 95%. However, the specificities of tools produced by logistic regression methods (61.4 and 65.6%) which are practically applicable were higher than those achieved by the unweighted method (53.6). Applying these tools could result in 58‒63% reduction in the NNT compared to universal testing approach while maintaining the overall number of CLHIV identified.

Conclusion

The screening tools developed using logistic regression method could significantly improve HIV testing efficiency among children presenting to malnutrition, inpatient, and OVC entry points in Ethiopia while maintaining case identification. These tools are simplified to practically implement and can potentially be validated for use at various entry points. HIV programs in low-prevalence countries can also further investigate and optimize these tools in their settings.

No-slip billiards with particles of variable mass distribution

Astute variations in the geometry of mathematical billiard tables have been and continue to be a source of understanding their wide range of dynamical behaviors, from regular to chaotic. Viewing standard specular billiards in the broader setting of no-slip (or rough) collisions, we show that an equally rich spectrum of dynamics can be called forth by varying the mass distribution of the colliding particle. We look at three two-parameter families of billiards varying both the geometry of the table and the particle, including as special cases examples of standard billiards demonstrating dynamics from integrable to chaotic, and show that markedly divergent dynamics may arise by changing only the mass distribution. Furthermore, for certain parameters, billiards emerge, which display unusual dynamics, including examples of full measure periodic billiards, conjectured to be nonexistent for the standard billiards in Euclidean domains.

Correlation of signal averaged electrocardiography findings with fibrosis on cardiac magnetic resonance imaging

Background

Signal averaged electrocardiogram (SAECG) is a non invasive test to record delayed depolarization of myocardium with slow conduction that can potentially be the substrate for monomorphic ventricular tachycardia in high risk patients. Cardiac magnetic resonance imaging (cMRI) techniques for fibrosis imaging using late gadolinium enhancement (LGE) and T1 mapping remain the gold standard for characterization of myocardial tissue and triaging patients for risk of ventricular arrhythmias. However, cMRI remains unavailable in some areas, is time consuming, expensive and impossible for some patients to obtain due to claustrophobia, renal impairment or implanted hardware. To date, data is lacking with regards to correlation of findings between these two modalities.

Purpose

To investigate whether late potentials identified by SAECG correlate with the presence of fibrosis seen with cMRI. If correlation is established, SAECG could potentially be used as a non-invasive, cheaper, more convenient and readily available tool for risk stratification in patients at high risk for ventricular arrhythmias.

Methods

SAECGs were obtained in 25 consecutive patients undergoing cMRI. Patients with wide QRS (&gt;120 ms) on ECG were excluded. Positive SAECG was defined as at least 1/3 abnormal criteria. Standard criteria were used. Results of the 2 modalities were compared. Sensitivity and specificity of SAECG for diagnosing fibrosis on cMRI were calculated.

Results

The mean age of the patients was 50.3±5.8 years and the mean ejection fraction was 48.9±5.8% as determined by cMRI. Forty-eight percent of the patients had fibrosis on cMRI by either LGE, T1 mapping or both. The sensitivity and specificity of SAECG were 75% and 100%, respectively. Seven patients had history of ventricular tachycardia and 6 patients had dilated cardiomyopathy.

Conclusion

SAECG is extremely specific in identifying patients with myocardial fibrosis on cMRI. A positive test may confer a lesser indication to pursue cMRI solely for purposes of risk stratification, and may correlate with risk of ventricular arrhythmia.

Funding Acknowledgement

Type of funding sources: None.

124 The Microsurgical Learning Curve: Can We Make the First Steps Faster and Safer; A Cadaveric Study with A Novel Principle of Learning

Aim

Learning anew surgical technique can be a daunting experience for both the teacher and learner. Raising free flaps is a complex process, and our aim is to find out whether using Hi-fidelity simulation on cadavers can make the learning faster and safer.

Method

We used fresh frozen cadavers according to our local protocols. In the first stage of the study, we used 4 upper limbs in the first instance using different dye techniques. We use these in an international course and obtain feedback from the trainees.

Results

To a novel learner, we found that using a bright green dye was the important factor in making the first steps of learning easier and faster. This is perhaps due to the confounding information when raising the flap. We found that it made understanding the concept of free flap raising much faster when clarified with colour. It also made anticipating the steps easier when identifying the perforators. To an experienced trainee/consultant: We found teaching the concept of perforators easier, the ease of finding the perforators would raise confidence of the novel trainees. They will be able to conceptualize the principles of flap raising much faster. They believed it would also make them quicker at anticipating steps of the procedure.

Conclusions

Learning is an incredible process that we still have to better control and understand. Using simple tricks such as colour changes can make initial learning faster, which means cheaper and safer

Seroprevalence and risk factors for SARS-CoV-2 Infection in selected urban areas in Ethiopia: a cross-sectional evaluation during July 2020

BACKGROUND

Ethiopia reported the first case of COVID-19 on 13th March, 2020 with community transmission ensuing by mid-May. A national, population-based serosurvey against anti-SARS-CoV-2 IgG was conducted to measure the prevalence of prior COVID-19 infections and better approximate the burden across major towns in Ethiopia.

METHODS

We conducted a cross-sectional, population-based serosurvey from June 24 to July 8, 2020 in 14 major urban areas. Two-stage cluster sampling was used to randomly select enumeration areas and households. All persons aged ≥15 years were enrolled. Serum samples were tested by Abbott™ ARCHITECT™ assay for SARS-CoV-2 IgG antibodies. National COVID-19 surveillance data on the median date of the serosurvey is analyzed for comparison.

FINDINGS

Adjusted seroprevalence was 3.5% (95% CI: 3.2%-3.8%) after controlling for age, sex and test kit performance. Males (3.7%) and females (3.3%) were nearly equally infected, while middle-aged adults '40-65 years' had the highest (4.0%) prevalence. Gambella (7.5%), Dire Dawa (6.2%) and Jigjiga (6.1%) were the most affected towns. About 6.7% and 8.0% of seropositives had symptoms and chronic underlying illness, respectively. A surveillance system had identified 4,416 RT-PCR confirmed cases in Addis Ababa.

INTERPRETATION

This serosurvey shows that a majority of urban Ethiopians remain uninfected with SARS-CoV-2. Most anti-SARS-CoV-2 IgG positive cases were asymptomatic with no underlying illness, keeping case detection to a minimum.

Factors associated with unawareness of HIV-positive status in urban Ethiopia: Evidence from the Ethiopia population-based HIV impact assessment 2017-2018

Background

The HIV epidemic in Ethiopia is concentrated in urban areas. Ethiopia conducted a Population-based HIV Impact Assessment (EPHIA) in urban areas between October 2017 and April 2018 to measure the status of the country’s response to the epidemic.

Methods

We conducted field data collection and HIV testing in randomly selected households using the national, rapid testing algorithm with laboratory confirmation of seropositive samples using a supplemental assay. In addition to self-report on HIV diagnosis and treatment, all HIV-positive participants were screened for a set of HIV antiretroviral (ARV) drugs indicative of the first- and second-line regimens. We calculated weighted frequencies and 95% confidence intervals to assess regional variation in participants’ level of unawareness of their HIV-positive status (adjusted for ARV status).

Results

We interviewed 20,170 survey participants 15–64 years of age, of which 19,136 (95%) were tested for HIV, 614 (3.2%) tested positive, and 119 (21%) of HIV-positive persons were unaware of their HIV status. Progress towards the UNAIDS first 90 target (90% of people living with HIV would be aware of their HIV status by 2020) substantially differed by administrative region of the country. In the bivariate analysis using log binomial regression, three regions (Oromia, Addis Ababa, and Harari), male gender, and young age (15–24 years) were significantly associated with awareness of HIV positive status. In multivariate analysis, the same variables were associated with awareness of HIV-positive status.

Conclusion

One-fifth of the HIV-positive urban population were unaware of their HIV-positive status. The number of unaware HIV-positive individuals has a different distribution than the HIV prevalence. National and regional planning and monitoring activities could address this potentially substantial source of undetected HIV infection by increasing HIV testing among young people, men and individuals who do not use condoms.

Using ethnographic film in tackling podoconiosis

Background

Ethiopia has one of the worst podoconiosis rates in the world, affecting >1.5 million patients. We present our ethnographic film ‘Tigist, the story of a girl with podoconiosis’ and its potential use in tackling podoconiosis.

Methods

We conducted visual ethnography, consisting of video-recorded participant observations and interviews with seven patients, three healthcare workers and two podoconiosis experts.

Results

We acquired video recordings of social moments, the state of podoconiosis patients’ bodies and minds, their emotions and the impact of poverty.

Conclusions

Our film allows for an intensified understanding of patients’ daily experiences with podoconiosis, potentially impacting care, awareness and medical teaching programs.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

The predictive value of CHA2DS2-VASc score on adverse in-hospital outcomes among patients with the acute coronary syndrome and atrial fibrillation who undergo PCI

Background

Patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) and having concomitant atrial fibrillation (AF) have a greater risk of adverse short- and long-term outcomes and death compared with patients in the same setting but without AF. On the other hand, the predictive value of CHA2DS2-VASc score in terms of in-hospital mortality and periprocedural adverse events following PCI among patients with ACS and AF is unknown.

Purpose

We retrospectively analyzed data of patients with the main admission diagnosis of ACS that underwent PCI and had AF during the 2004–2014 period from the large nationwide US National Inpatient Sample (NIS) database.

Methods

A CHA2DS2-VASc score was calculated for each patient and incorporated into a multivariable-adjusted logistic regression to determine its independent impact on in-hospital outcomes consisting of death, acute kidney injury (AKI), bleeding, vascular injury, and stroke/transient ischemic attack (TIA).

Results

A total of 283,890 patients with AF who underwent PCI following ACS were included in the analysis. The average reported prevalence of the AF in the whole cohort was 10.0% with a significant trend (p&lt;0.001) of increase during the observed 10-year period. The average age of the cohort was 72.1±11 years, 63.4% were male while the median CHA2DS2-VASc score was 3 (IQR 2–4). Crude rates of adverse in-hospital outcomes were significantly higher among patient groups with higher CHA2DS2-VASc score (Table 1). Following adjustment for baseline covariates, incremental increase in CHA2DS2-VASc score was independently associated with an increased odds of in-hospital death (OR 1.20, CI 95% 1.18–1.22), periprocedural vascular injury (OR 1.18, 95% CI 1.17–1.20), bleeding (OR 1.17, 95% CI 1.16–1.18), stroke/TIA (OR 1.17, 95% CI 1.15–1.19), and AKI (OR 1.05, 95% CI 1.04–1.06) (Figure 1).

Conclusions

The CHA2DS2-VASc score provides important prognostic information in ACS patients with AF undergoing PCI and is independently associated with in-hospital death and periprocedural adverse events. Therefore, CHA2DS2-VASc score could be used as a practical and inexpensive tool for risk stratification in this population.

Figure 1

Funding Acknowledgement

Type of funding source: None

The Rhipicephalus appendiculatus tick vector of Theileria parva is absent from cape buffalo (Syncerus caffer) populations and associated ecosystems in northern Uganda

Rhipicephalus appendiculatus is the major tick vector of Theileria parva, an apicomplexan protozoan parasite that causes the most economically important and lethal disease of cattle in East and central Africa. The African cape buffalo (Syncerus caffer) is the major wildlife host of T. parva from southern Uganda and Kenya to southern Africa. We show herein that R. appendiculatus appears to be absent from the two largest national parks in northern Uganda. Syncerus caffer is common in both of these national parks, specifically Murchison falls (MFNP) and Kidepo Valley (KVNP). We re-confirmed the previously reported absence of T. parva in buffalo sampled in the two northern parks based on RLB data using a nested PCR based on the T. parva p104 gene. By contrast, T. parva-infected R. appendiculatus ticks and parasite-infected buffalo were present in Lake Mburo (LMNP) in South central Uganda. This suggests that the distribution of R. appendiculatus, which is predicted to include the higher rainfall regions of northern Uganda, may be limited by additional, as yet unknown factors.

P1732The additive value of pre- and post-reperfusion cardiac troponin T levels in risk stratification of patients with ST-segment elevation myocardial infarction

Background

Despite therapeutic advances, mortality rates following ST-segment elevation myocardial infarction (STEMI) are still alarmingly high. There is conflicting evidence regarding the prognostic role of high-sensitivity cardiac troponin T (hs-cTnT) measurements before and after primary percutaneous coronary intervention (PPCI) over traditional predictors of mortality in STEMI patients.

Purpose

To determine the additive prognostic value of pre- and 12h post-PPCI hs-cTnT levels in STEMI patients

Methods

Retrospective longitudinal study including 3,113 consecutive STEMI patients treated with PPCI at a university hospital covering a population of 1.6 million in the North East of England. Clinical, procedural, and laboratory data were prospectively collected during patient hospitalization while hs-cTnT measurements were performed at admission to the catheterization laboratory and at 12h post-PPCI. Median follow-up was 53 months. The study endpoints were in-hospital and overall mortality. Mortality data were obtained from the UK Office of National Statistics.

Results

Admission hs-cTnT >515ng/L (4th quartile) was independently associated with in-hospital mortality [HR=2.39 per highest to lower quartiles; 95% CI: 1.44 to 3.97; p=0.001] after multivariate adjustment for a core clinical model of in-hospital mortality prediction. Likewise, admission hs-cTnT >515ng/L independently predicted overall mortality (HR=1.25 per highest to lower quartiles; 95% CI: 1.00 to 1.57; p=0.044) after adjustment for covariates significantly associated with this endpoint. Admission hs-cTnT correctly reclassified risk for in-hospital death [net reclassification index (NRI)=44.1%, p<0.001) and overall mortality (NRI=60.4%, p<0.001). Conversely, 12h hs-cTnT was not independently associated with mortality.

Conclusion

Admission, but not 12h post-reperfusion, hs-cTnT predicts mortality and improves risk stratification in the PPCI era. These results support the role of hs-cTnT in risk stratification of post-STEMI patients and challenge the cost-effectiveness of routine 12h hs-cTnT measurements.

Assessment of the prevalence of Theileria lestoquardi in sheep from the Sudan using serological and molecular methods

Malignant theileriosis of sheep and goats caused by Theileria lestoquardi is considered to be among the most important tick borne diseases in the Sudan. Information on the prevalence of the disease in different parts of the Sudan is limited. The purpose of this study was to estimate the prevalence of the disease in five states of the Sudan using molecular and serological assays. A total of 393 blood and serum samples from clinically asymptomatic sheep were analysed using nested reverse line blot (nRLB) and loop mediated isothermal amplification (LAMP), as well as an enzyme-linked immunosorbent assay (ELISA). The results indicated a sero-prevalence of 33.8% while RLB and LAMP assays revealed molecular prevalences of 29.5 and 22.6% respectively. The prevalence of Theileria lestoquardi varied significantly according to the geographical origin of the infected animals, whereas age and gender did not have a significant effect. RLB data indicated that T. lestoquardi usually occurred as a co-infection with the non-pathogenic Theileria ovis. Using RLB as a gold standard, a sensitivity of 68.1% and a specificity of 96.4% were recorded for LAMP and a sensitivity of 75.9% and a specificity of 83.8% for ELISA. The Kappa coefficient between nRLB and LAMP indicated a significant level of agreement (0.692), but only moderate concordance (0.572) between nRLB and ELISA. The results of the present study confirm and extend earlier findings regarding the widespread of T. lestoquardi infections in sheep in the Sudan. The data provide evidence that should enable the veterinary authorities to deploy appropriate control measures.

European consensus on the standardization of robotic total mesorectal excision for rectal cancer

AIM

Surgery for rectal cancer is challenging for both technical and anatomical reasons. The European Academy of Robotic Colorectal Surgery (EARCS) provides a competency-based training programme through a standardized approach. However, there is no consensus on technical standards for robotic surgery when used during surgery for rectal cancer. The aim of this consensus study was to establish operative standards for anterior resection incorporating total mesorectal excision (TME) using robotic techniques, based on recommendations of expert European colorectal surgeons.

METHOD

A Delphi questionnaire with a 72-item statement was sent through an electronic survey tool to 24 EARCS faculty members from 10 different countries who were selected based on expertise in robotic colorectal surgery. The task was divided into theatre setup, colonic mobilization and rectal dissection, and each task area was further divided into several subtasks. The levels of agreement (A* > 95% agreement, A > 90%, B > 80% and C > 70%) were considered adequate while agreement of < 70% was considered inadequate. Once consensus was reached, a draft document was compiled and sent out for final approval.

RESULTS

The average length of experience of robotic colorectal surgery for participants in this study was 6 years. Initial agreement was 87%; in nine items, it was < 70%. After suggested modifications, the average level of agreement for all items reached 94% in the second round (range 0.75-1).

CONCLUSION

This is the first European consensus on the standardization of robotic TME. It provides a baseline for technical standards and structured training in robotic rectal surgery.

Findings from aetiological investigation of Auditory Neuropathy Spectrum Disorder in children referred to cochlear implant programs

OBJECTIVES

Auditory neuropathy spectrum disorder (ANSD) is an audiological diagnosis characterised by hearing dysfunction in the presence of intact outer hair cell function in the cochlea. ANSD is thought to account for 7-10% of all childhood permanent hearing impairment, and can result from a range of pathological processes. This paper describes the rationale, methods and findings from the aetiological investigation of ANSD.

METHODS

Retrospective audit of four cochlear implant programmes.

RESULTS

97 patients were identified. 79% of patients were identified before the age of one. Prematurity and jaundice were the most frequently identified aetiological factors. 33 patients had cochlear nerve deficiency on imaging. Genetic diagnoses identified included otoferlin, SX010 gene, connexin 26 and A1FM1 gene mutations. ANSD was seen in conjunction with syndromes including Kallman syndrome, CHARGE syndrome, X-linked deafness, SOTOS syndrome, Brown Vieletto Van Laere syndrome, and CAPOS syndrome.

DISCUSSION

We present a two-level system of aetiological investigation that is clinically practical. Patients with ANSD sufficiently severe to consider cochlear implantation are generally identified at an early age. Aetiological investigation is important to guide prognosis and identify comorbidity.

CONCLUSION

Prematurity and jaundice are the most commonly identified aetiological factors in ANSD. Imaging findings identify crucial factors in a significant minority. An important minority may have genetic and syndromic diagnoses that require further management.

Sensitivity and specificity of screening tools and smear microscopy in active tuberculosis case finding

SETTING

Community based five pulmonary tuberculosis (PTB) surveys among adults.

OBJECTIVES

Estimate sensitivity and specificity of screening tools for PTB and sputum microscopy.

METHODS

For each survey site, we estimated sensitivity and specificity of different screening criteria and microscopy against culture; pooled estimates were obtained using Random Effects Model.

RESULTS

Sensitivity of cough alone, screening for any symptom (persistent cough ≥2 weeks, fever or chest pain ≥1 month, hemoptysis), any symptom or history of anti-TB treatment (h/o ATT) were 56.2%, 66% and 71.2% respectively; specificities were 95.3%, 93.8% and 92.7% respectively. X-ray when used alone for primary screening had sensitivity and specificity of 76.6% and 97.3% respectively. When used along with screening for cough, these figures were 94.3% and 93.1%, and 100% and 97.3% when used with any symptom and h/o ATT. When used for secondary screening, sensitivity and specificity of X-ray was 66.8% and 87.8% respectively after primary screening for cough, 65.0% and 89.8% after screening for any symptom, and 67.1% and 86.7% when used after screening for any symptom or h/o ATT. Pooled sensitivity and specificity of smear was 46.2% and 99.3% respectively.

CONCLUSION

Program managers may use these estimates while evaluating algorithms for active case finding.

Robotic vs laparoscopic rectal surgery in high-risk patients

AIM

Laparoscopic rectal surgery is associated with a steep learning curve and high conversion rate despite progress in equipment design and consistent practice. The robotic system has shown an advantage over the laparoscopic approach due to stable three-dimensional views, improved dexterity and better ergonomics. These factors make the robotic approach more favourable for rectal surgery. The aim of this study was to compare the perioperative outcomes of laparoscopic and robotic rectal cancer surgery in high-risk patients.

METHOD

A prospectively collected dataset for high-risk patients who underwent rectal cancer surgery between May 2013 and November 2015 was analysed. Patients with any of the following characteristics were defined as high risk: a body mass index ≥30, male gender, preoperative chemoradiotherapy, tumour <8 cm from the anal verge and previous abdominal surgery.

RESULTS

In total, 184 high-risk patients were identified: 99 in the robotic group and 85 in the laparoscopic group. Robotic surgery was associated with a significantly higher sphincter preservation rate (86% vs 74%, P = 0.045), shorter operative time (240 vs 270 min, P = 0.013) and hospital stay (7 vs 9 days, P = 0.001), less blood loss (10 vs 100 ml, P < 0.001) and a smaller conversion rate to open surgery (0% vs 5%, P = 0.043) compared with the laparoscopic technique. Reoperation, anastomotic leak rate, 30-day mortality and oncological outcomes were comparable between the two techniques.

CONCLUSION

Robotic surgery in high-risk patients is associated with higher sphincter preservation, reduced blood loss, smaller conversion rates, and shorter operating time and hospital stay. However, further studies are required to evaluate this notion.

Repurposing of Anti-Diabetic Agents for the Treatment of Cognitive Impairment and Mood Disorders

Impairments in cognitive function represent a consistent, non-specific, and clinically significant feature in metabolic, mood, and dementing disorders. The foregoing observation is instantiated by evidence demonstrating that these disorders share pathophysiological mechanisms including, but not limited to, aberrant insulin signaling, inflammation, and glucocorticoid activity. Moreover, these mechanisms have been consistently reported to increase vulnerability to and/or exacerbate impairments in cognitive function. Notwithstanding evidence suggesting a bidirectional relationship between disturbances in the metabolic milieu, mood, and increased risk for dementia, efficacious treatments that target cognitive impairments in these populations do not presently exist. Taken together, it is proposed that anti-diabetic agents may aid the management of mood disorders and future risk for dementia through disease modification by targeting underlying pathophysiological mechanisms (e.g., aberrant metabolic function) rather than focusing solely on symptom mitigation. The current aim is to provide a brief narrative review of extant studies that report on the potential neurotherapeutic effects of anti-diabetic agents on disturbances in mood and impairments in cognitive function.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Standardized technique for single-docking robotic rectal surgery

AIM

The aim of this technical note is to describe our standardized technique for rectal surgery using a single-docking totally robotic approach.

METHOD

The data related to patients who underwent single-docking robotic rectal surgery were analysed for the feasibility of this approach.

RESULTS

This technique was used in 124 consecutive patients who underwent rectal resection since July 2013. Male to female ratio of patients was 2:1 while median age was 67 years (range 24-92). The median operating time was 240 min (range 105-456), whilst blood loss was 10 ml (range 0-200). There was no evidence of intra-operative complications or conversions to either a laparoscopic or an open procedure. The median length of stay was 7 days (range 3-48).

CONCLUSION

A single-docking technique for robotic rectal surgery is safe and feasible. It can be considered as standard approach for pelvic robotic surgery.

Three-step standardized approach for complete mobilization of the splenic flexure during robotic rectal cancer surgery

AIM

The aim of this technical note is to describe a three-step technique for expeditious and complete mobilization of the splenic flexure (CMSF) during single docking totally robotic rectal cancer surgery.

METHOD

A prospectively maintained database was searched for all patients who underwent single docking totally robotic rectal cancer surgery with CMSF through a stepwise technique.

RESULTS

We studied 89 patients underwent CMSF during single docking totally robotic lower anterior resection for rectal cancer.

CONCLUSION

The technique demonstrates that CMSF can be performed with a standardized approach using the natural embryological planes of surgery. Moreover, this technique does not involve any change in patient's position on the operating table or undocking the robotic system. We have included an intra-operative video recording to demonstrate the technique.

Totally robotic rectal resection: an experience of the first 100 consecutive cases

INTRODUCTION

Robotic surgery provides an alternative option for a minimal access approach. It provides a stable platform with high definition three-dimensional views and improved access, which enhances the capabilities for precise dissection in a narrow surgical field. These distinctive features have made it an attractive option for colorectal surgeons.

AIM

The aim of this study was to present a standardised technique for single-docking robotic rectal resection and to analyse clinical outcomes of the first 100 robotic rectal procedures performed in a single centre between May 2013 and April 2015.

METHOD

Prospectively collected data related to 100 consecutive patients who underwent single-docking robotic rectal surgery was analysed for surgical and oncological outcomes.

RESULTS

Sixty-six patients were male, the median age was 67 years (range-24-92). Eighteen patients had neo-adjuvant chemoradiotherapy whilst 23 patients had BMI >30. Procedures performed included anterior resection (n = 74), abdominoperineal resection (n = 10), completion proctectomy (n = 9), restorative proctectomy with ileal pouch-anal anastomosis (IPAA) (n = 5) and Hartmann's procedure (n = 2). The median operating time was 240 min (range-135-456), and median blood loss was 10 ml (range 0-200). There was no conversion or intra-operative complication. Median length of stay was 7 days (range, 3-48) and readmission rate was 12 %. Thirty-day mortality was zero. Postoperatively, two patients had an anastomotic leak whilst two had small bowel obstruction. The median lymph node harvest was 18 (range, 6-43).

CONCLUSION

The single-docking robotic technique should be considered as an alternative option for rectal surgery. This approach is safe and feasible and in our study it has demonstrated favourable clinical outcomes.