Increased growth temperature and vitamin B12 supplementation reduces the lag time for rapid pathogen identification in BHI agar and blood cultures

Background: Rapid diagnostics of pathogens is essential to prescribe appropriate antibiotic therapy. The current methods for pathogen detection require the bacteria to grow in a culture medium, which is time-consuming. This increases the mortality rate and global burden of antimicrobial resistance. Culture-free detection methods are still under development and are not common in the clinical routine. Therefore, decreasing the culture time for accurately detecting infection and resistance is vital for diagnosis. Methods: This study investigated easy-to-implement factors (in a minimal laboratory set-up), including inoculum size, incubation temperature, and additional supplementation (e.g., vitamin B12 and trace metals), that can significantly reduce the bacterial lag time (tlag). These factors were arranged in simple two-level factorial designs using Gram-positive cocci (Staphylococcus aureus), Gram-positive bacilli (Bacillus subtilis), and Gram-negative bacilli (Escherichia coli and Pseudomonas aeruginosa) bacteria, including clinical isolates with known antimicrobial resistance profiles. Blood samples spiked with a clinical isolate of E. coli CCUG 17620 (Culture Collection University of Gothenburg) were also tested to see the effect of elevated incubation temperature on bacterial growth in blood cultures. Results: We observed that increased incubation temperature (42°C) along with vitamin B12 supplementation significantly reduced the tlag (10 – 115 minutes or 4% - 49%) in pure clinical isolates and blood samples spiked with E. coli CCUG17620. In the case of the blood sample, PCR results also detected bacterial DNA after only 3h of incubation and at three times the CFU/mL. Conclusion: Enrichment of bacterial culture media with growth supplements such as vitamin B12 and increased incubation temperature can be a cheap and rapid method for the early detection of pathogens. This proof-of-concept study is restricted to a few bacterial strains and growth conditions. In the future, the effect of other growth conditions and difficult-to-culture bacteria should be explored to shorten the lag phase.

Increased growth temperature and vitamin B12 supplementation reduces the lag time for rapid pathogen identification in BHI agar and blood cultures

Background: The rapid diagnostics of pathogens is essential to prescribe appropriate and early antibiotic therapy. The current methods for pathogen detection require the bacteria to grow in a culture medium, which is time-consuming. This increases the mortality rate and the global burden of antimicrobial resistance. Culture-free detection methods are still under development and are not used in the clinical routine. Therefore decreasing the culture time for accurate detection of infection and resistance is vital for diagnosis. Methods: In this study, we wanted to investigate easy-to-implement factors (in a minimal laboratory set-up), including inoculum size, incubation temperature, and additional supplementation (e.g., vitamin B12 and trace metals), that can significantly reduce the lag time (tlag). These factors were arranged in simple two-level factorial designs using Gram-positive (Escherichia coli and Pseudomonas aeruginosa) and Gram-negative (Staphylococcus aureus and Bacillus subtilis) bacteria, including clinical isolates with known antimicrobial resistance profiles. Blood samples spiked with a clinical isolate of E. coli CCUG17620 were also tested to see the effect of elevated incubation temperature on bacterial growth in blood cultures. Results: We observed that increased incubation temperature (42°C) along with vitamin B12 supplementation significantly reduced the tlag (10 – 115 minutes or 4% - 49%) in pure clinical isolates and blood samples spiked with E. coli CCUG17620. In the case of the blood sample, PCR results also detected bacterial DNA after only 3h of incubation and at three times the CFU/mL. Conclusions: Enrichment of bacterial culture media with growth supplements such as vitamin B12 and increased incubation temperature can be a cheap and rapid method for the early detection of pathogens. This is a proof-of-concept study restricted to a few bacterial strains and growth conditions. In the future, the effect of other growth conditions and difficult-to-culture bacteria should be explored to shorten the lag phase.

Ulinastatin Add-on to Standard of Care in Critically Ill COVID-19 Patients: A Multicenter, Retrospective Study

AIM

To assess the impact on 30-day mortality with ulinastatin (ULI) used as add-on to standard of care (SOC) compared to SOC alone in coronavirus disease (COVID-19) patients requiring admission to the intensive care unit (ICU).

MATERIALS AND METHODS

In this multicentric, retrospective study, we collected data on clinical, laboratory, and outcome parameters in patients with COVID-19. Thirty-day mortality outcome was compared among patients treated with SOC alone and ULI used as add-on to SOC. Odds ratio (OR) and 95% confidence intervals (CI) were determined to identify the predictors of 30-day mortality.

RESULTS

Ninety-four patients were identified and enrolled in both groups with comparable baseline parameters. On univariate analysis, 30-day mortality was significantly lower in ULI plus SOC group than SOC alone group (36.2 vs 51.1%, OR 0.54, 95% CI 0.30-0.97, p = 0.040). The effect on mortality was more pronounced in patients who did not require intubation (10.9 vs 34.0%, OR 0.24, 95% CI 0.09-0.66, p = 0.006) and with early administration (within 72 hours of admission) of ULI (30.7 vs 57.9%, OR 0.32, 95% CI 0.11-0.91, p = 0.032). On multivariate analysis, only intubation predicted mortality (adjusted OR 10.13, 95% CI 3.77-27.25, p<0.0001) and the effect of ULI on survival was not significant (adjusted OR 0.58, 95% CI 0.22-1.52, p = 0.270).

CONCLUSION

Given the limited options for COVID-19 patients treated in ICU, early administration of ULI may be helpful, especially in patients not requiring intubation to improve the outcomes. Further, a large, randomized study is warranted to confirm these findings.

Retrospective Cohort Observational Study to compare the Effect of Mycobacterium w along with Standard of Care vs Standard of Care alone in critically ill COVID-19 Patients

BACKGROUND

COVID-19 has created enormous health crisis in India due to limited available treatments. Majority of the physicians use sepsis as a prototype to understand the pathophysiology of COVID-19 as there are similarities. Heat-killed Mycobacterium w (Mw) (Inj. Mw®) is a known immunomodulator, which is approved for the treatment of gram-negative sepsis. This observational study was aimed to evaluate the role of Mw along with standard of care (SOC) in critically ill COVID-19 patients.

METHODS

Total 448 patients' data (intervention group: 298 in Mw plus SOC vs 150 in SOC alone) with reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed critically ill COVID-19 patients who were admitted at five tertiary care centers were evaluated. They were observed for changes in laboratory [C-reactive protein (CRP), D-dimer, ferritin, lactate dehydrogenase (LDH), and interleukin-6 (IL-6)] parameters, hospital stay, intensive care unit (ICU) stay, and discharge status after giving 0.3 mL intradermal Mw for 3 consecutive days along with SOC during hospitalization. Standard of care included injectable steroids, remdesivir, and heparin. Data were analyzed using STATA 14.2 (StataCorp., College Station, Texas, USA).

RESULTS

In baseline characteristics, Mw plus SOC arm had more critically ill patients as seen by higher high-resolution computed tomography (HRCT) score, higher lab values [CRP, ferritin, D-dimer, LDH, creatinine, alanine aminotransferase (ALT)], and more oxygen requirement as compared to SOC alone. Mycobacterium w arm had significantly higher mortality rate in ICU and hospital. Both hospital stay and ICU stay were longer in Mw arm. However, subgroup analysis found that early initiation of Mw (<3 days vs >3 days) was associated with significantly lesser odds of mortality and lesser odds of intubation requirement. Early initiation of Mw (<3 days vs >3 days) also resulted in significantly lesser duration of stay in the ICU along with reduction of CRP, D-dimer, and LDH. Moreover, further analysis of early initiation of Mw (<3 days vs control) resulted in significant reduction in lab values (procalcitonin, CRP, ferritin, LDH, and D-dimer).

CONCLUSION

Mw when added to SOC was found to associate with significantly increased risk of mortality and increased length of hospital stay. However, time since admission to administration of Mw was a significant predictor of in-ICU deaths in multivariate analysis. Early initiation of Mw (<3 days) was observed to be a protective factor against ICU deaths from the multivariate logistic regression model. However, large randomized controlled trials are required to support the same.

POS1565-PARE ASSESSMENT OF QUALITY AND RELIABILITY OF YOUTUBE VIDEOS FOR PATIENT AND PHYSICIAN EDUCATION ON INFLAMMATORY MYOSITIS

Background

Nowadays 80% of internet users access health information online, with YouTube being the second most popular search website worldwide. This study was undertaken to assess the reliability and quality of videos pertaining to myositis on YouTube and identify lacunae in information material on the platform.

Objectives

This study aims to assess the quality and profile of myositis information videos on YouTube, and to compare and delineate attributes of useful and not useful videos using standard metrics.

Methods

A thorough search was carried out on YouTube using 9 search terms related to myositis. The inclusion criteria were primary English content related to myositis, acceptable audio-video quality, and multi-part videos to be considered as one, while duplicates and advertisements were excluded. The videos were classified as useful, not useful or misleading, and patient experiences (Figure 1).

Figure 1.

Flowchart of selection of YouTube videos for the study

Reliability of the videos was determined using the 5-point modified DISCERN (mDISCERN) criteria and quality by the 5-point Global Quality Scale (GQS) and 4-point JAMA scoring system. Score-based usefulness was defined as mDISCERN >4 or GQS >4 or JAMA >3. All values are in median and IQR.

Results

Of 453 analyzed videos 74% and 2% provided useful and not useful information respectively. 24% were patient experiences, and 324 (71%) were intended specifically for patients while 313 (69%) were for healthcare providers and students. Nearly one-thirds (n=143) reported information related to treatment of myositis.

Noteworthily, useful and not useful videos had similar views count. However, number of likes and daily viewership were higher for useful videos (p=0.024, p=0.046). Nearly half (47%) of useful videos were by professional medical societies/patient support groups while not useful ones were often by nonmedical media (38%).

Useful videos had higher mDISCERN reliability scores [4(3-4) vs 2(1-3), p<0.001] and better quality on GQS [4.5 (3.5-5) vs 1 (1-2.8), p<0.001] and JAMA [3 (3-4) vs 2.25 (2-3), p=0.004]. Physician predicted usefulness was discordant with score-based usefulness(κ=0.129). However, GQS score emerged significant (p=0.008) for predicting video usefulness in multivariate analysis (Table 1).

Table 1.

Factors predicting usefulness of video in binary logistic regression.

VariableB coefficientS.E.Exp (B) and 95% CIp valueIntended audience Anyone/General public-5.452.5860.004 (0.0-0.68)0.035Average GQS-2.861.0760.05 (0.007-0.47)0.008

GQS Global Quality Scale

. Exp (B) is odd’s ratio, p<0.05 is significant

Conclusion

Majority of English YouTube videos on myositis provide useful information for patients, largely related to treatment of myositis. However, the dynamic nature of YouTube could potentially change this equation in the future and physicians should correct any misinformation identified in face-to-face meetings or teleconsultations. High quality useful videos, often predicted by validated scores and produced by professional medical societies should be promoted as the first line of content consumed.

Disclosure of Interests

None declared

The Second- vs First-wave COVID-19: More of the Same or a Lot Worse? A Comparison of Mortality between the Two Waves in Patients Admitted to Intensive Care Units in Nine Hospitals in Western Maharashtra

Background

India, along with the rest of the world, faced the challenging severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. The second wave in India lagged behind that in the Western world, due to different timing of seasons. There is scarce data about the differences between the two waves, for intensive care unit (ICU) patients. We present the data of 3,498 patients from 9 ICUs of western Maharashtra.

Materials and methods

We collected prospective data of hospitalized, RT-PCR confirmed, coronavirus-2019 (COVID-19) patients, from nine tertiary centers, after institutional ethics committee (IEC) approval. Then, we segregated and analyzed the data of patients admitted to the ICU, for comorbidities, high-resolution computed tomography (HRCT) score, ventilatory support, etc. The primary outcomes were ICU and hospital mortality. We also performed multivariable analysis for predictors of ICU mortality.

Results

Overall, there were 3,498 ICU patients. In the first wave, 1,921 patients needed ICU admission, while in the second wave, 1,577 patients. Patients in the second wave had significantly higher ICU (26.1 vs 13.4%, p <0.001) and hospital mortality (29.9 vs 18.2%, p <0.001) and need for ventilatory support of any type. More patients received steroids during the second wave. On multivariable regression, male gender, ICU admission during the second wave, increasing HRCT score, and need for intubation and mechanical ventilation were significant predictors of ICU mortality.

Conclusion

ICU patients admitted during the two waves were of the similar age, but there were more females, and more patients had comorbidities during the second wave. The ICU and hospital mortality were significantly higher during the second wave.

How to cite this article

Zirpe KG, Dixit S, Kulkarni AP, Pandit RA, Ranganathan P, Prasad S, et al. The Second- vs First-wave COVID-19: More of the Same or a Lot Worse? A Comparison of Mortality between the Two Waves in Patients Admitted to Intensive Care Units in Nine Hospitals in Western Maharashtra. Indian J Crit Care Med 2021; 25(12):1343-1348.

Stepwise interventions for improving hand hygiene compliance in a level 3 academic neonatal intensive care unit in north India

OBJECTIVE

We evaluated effect of sequentially introducing four WHO-recommended interventions to promote hand-hygiene compliance in tertiary-care NICU.

STUDY DESIGN

Four dedicated research nurses directly observed doctors and nurses to record success in hand-hygiene opportunities at randomly selected NICU beds and randomly sampled time-slots in four phases (of 4-weeks each): I-Baseline, II-Self-directed learning; III-Participatory learning; IV-Closed-Circuit Television (CCTV); and V-CCTV-plus (with feedback).

FINDINGS

Hand-hygiene compliance changed from 61.8% (baseline) to 77% (end) with overall relative change: 24.6% (95% CI 18, 32; p value= 0.003); compared with preceding phase, relative changes of 21% (15, 28; <0.001), 4% (0, 8; 0.008), -10% (-13, -6; <0.001), and 10% (5, 15; <0.001) during phases II, III, IV, and V, respectively were observed. Rise in hand-hygiene compliance was higher for after-WHO-moments (12.7%; upto 2.5-folds for moment 5, <0.001) compared to before-WHO-moments (5.2%). Educational interventions, feedback and monitoring WHO moments can improve hand-hygiene compliance significantly among health-care providers in NICU.

Strength of Association between Infarct Volume and Clinical Outcome Depends on the Magnitude of Infarct Size: Results from the ESCAPE-NA1 Trial

BACKGROUND AND PURPOSE

Infarct volume is an important predictor of clinical outcome in acute stroke. We hypothesized that the association of infarct volume and clinical outcome changes with the magnitude of infarct size.

MATERIALS AND METHODS

Data were derived from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, in which patients with acute stroke with large-vessel occlusion were randomized to endovascular treatment plus either nerinetide or a placebo. Infarct volume was manually segmented on 24-hour noncontrast CT or DWI. The relationship between infarct volume and good outcome, defined as mRS 0-2 at 90 days, was plotted. Patients were categorized on the basis of visual grouping at the curve shoulders of the infarct volume/outcome plot. The relationship between infarct volume and adjusted probability of good outcome was fitted with linear or polynomial functions as appropriate in each group.

RESULTS

We included 1099 individuals in the study. Median infarct volume at 24 hours was 24.9 mL (interquartile range [IQR] = 6.6-92.2 mL). On the basis of the infarct volume/outcome plot, 4 infarct volume groups were defined (IQR = 0-15 mL, 15.1-70 mL, 70.1-200 mL, >200 mL). Proportions of good outcome in the 4 groups were 359/431 (83.3%), 219/337 (65.0%), 71/201 (35.3%), and 16/130 (12.3%), respectively. In small infarcts (IQR = 0-15 mL), no relationship with outcome was appreciated. In patients with intermediate infarct volume (IQR = 15-200 mL), there was progressive importance of volume as an outcome predictor. In infarcts of > 200 mL, outcomes were overall poor.

CONCLUSIONS

The relationship between infarct volume and clinical outcome varies nonlinearly with the magnitude of infarct size. Infarct volume was linearly associated with decreased chances of achieving good outcome in patients with moderate-to-large infarcts, but not in those with small infarcts. In very large infarcts, a near-deterministic association with poor outcome was seen.

Effectiveness and safety of dolutegravir two-drug regimens in virologically suppressed people living with HIV: a systematic literature review and meta-analysis of real-world evidence

Objectives

Dolutegravir (DTG) is widely recommended within three‐drug regimens. However, similar efficacy and tolerability have also been achieved with DTG within two‐drug regimens in clinical trials. This study evaluated the real‐world effectiveness and discontinuations in people living with HIV‐1 (PLHIV) switching to DTG with lamivudine (3TC) or rilpivirine (RPV).

Methods

This was a one‐arm meta‐analysis utilizing data from a systematic literature review. Data from real‐world evidence studies of DTG + RPV and DTG + 3TC were extracted, pooled and analysed. The primary outcome was the proportion of patients with viral failure (VF; ≥ 50 copies/mL in two consecutive measurements and/or ≥ 1000 copies/mL in a single measurement) at week 48 (W48) and week 96 (W96). Other outcomes included virological suppression (VS; < 50 copies/mL) and discontinuations (W48 and W96). Estimates were calculated for VF, VS as per snapshot (VSS) and on treatment analysis (VSOT), and discontinuations.

Results

Pooled mean estimates of VF for DTG + 3TC and DTG + RPV were 0.8% [95% confidence interval (CI): 0.4–1.3] and 0.6% (95% CI: 0.0–1.6), respectively, at W48. VSS rate at W48 was 85.0% (95% CI: 82.3–87.5) for DTG + 3TC regimen and 92.4% (95% CI: 85.0–97.7) in the DTG + RPV regimen. The DTG + 3TC and DTG + RPV regimens led to discontinuations in 13.6% (95% CI: 11.1–16.2) and 7.2% (95% CI: 2.1–14.4) of patients, respectively, at W48. Similar results were observed at W96.

Conclusions

Treatment with DTG + 3TC or DTG + RPV in clinical practice provides a low rate of VF and a high rate of VS when initiated in virologically suppressed PLHIV with diverse backgrounds.

130 Expression of selected biomarker candidate genes to confer invitro maturation in Indian buffaloes

Invitro maturation (IVM) of oocytes is a crucial step and is directly related to better embryo production in buffaloes. Therefore, we planned to study gene expression of GDF9, HAS2, SPRY1, ARHGAP22, COL18A1, and GPC4 genes in IVM and immature cumulus–oocyte complexes (COCs). The COCs were recovered from follicles of slaughter origin ovaries of native buffaloes. COCs were observed under stereo zoom microscope and categorized in four grades according to morphology. Of the four grades, the first three grade COCs were considered and randomly allotted in two groups: immature treatment group (n=263) and IVM treatment group (n=272). IVM of COCs was carried out in 100-μL drops of BO-IVM medium overlaying embryo tested oil in a 35-mm petri dish under 5% CO2 in a 39.0°C incubator for 24h. Cumulus of COCs of both groups were removed by treating with 0.25% trypsin, and oocytes were stored in RNALater for future use. The expression of genes was evaluated using quantitative PCR, and the relative expression of each gene was calculated using the ΔΔCt method with efficiency correction. The logarithmic transformation of fold change (log2FC) of each candidate gene in the IVM oocyte group was computed against the immature oocyte group based on the observed cycle threshold values. Appropriate standard deviations were determined based on the observed deviations among the triplicates. The expression in the IVM treatment group of previously reported upregulated genes (GDF9, HAS2, SPRY1) was higher (up to 10-fold) compared with the immature treatment group (reference group). In the present study, relatively lower expression was observed for the other candidate genes (ARHGAP22, COL18A1, GPC4) in the bovine transcripts of oocyte, which were previously also reported as being downregulated.

Obese patients and robotic colorectal surgery: systematic review and meta-analysis

BACKGROUND

Obesity is a major health problem, demonstrated to double the risk of colorectal cancer. The benefits of robotic colorectal surgery in obese patients remain largely unknown. This meta-analysis evaluated the clinical and pathological outcomes of robotic colorectal surgery in obese and non-obese patients.

METHODS

MEDLINE, Embase, Global Health, Healthcare Management Information Consortium (HMIC) and Midwives Information and Resources Service (MIDIRS) databases were searched on 1 August 2018 with no language restriction. Meta-analysis was performed according to PRISMA guidelines. Obese patients (BMI 30 kg/m2 or above) undergoing robotic colorectal cancer resections were compared with non-obese patients. Included outcome measures were: operative outcomes (duration of surgery, conversion to laparotomy, blood loss), postoperative complications, hospital length of stay and pathological outcomes (number of retrieved lymph nodes, positive circumferential resection margins and length of distal margin in rectal surgery).

RESULTS

A total of 131 full-text articles were reviewed, of which 12 met the inclusion criteria and were included in the final analysis. There were 3166 non-obese and 1420 obese patients. A longer duration of surgery was documented in obese compared with non-obese patients (weighted mean difference -21·99 (95 per cent c.i. -31·52 to -12·46) min; P < 0·001). Obese patients had a higher rate of conversion to laparotomy than non-obese patients (odds ratio 1·99, 95 per cent c.i. 1·54 to 2·56; P < 0·001). Blood loss, postoperative complications, length of hospital stay and pathological outcomes were not significantly different in obese and non-obese patients.

CONCLUSION

Robotic surgery in obese patients results in a significantly longer duration of surgery and higher conversion rates than in non-obese patients. Further studies should focus on better stratification of the obese population with colorectal disease as candidates for robotic procedures.

Remote wireless vital signs monitoring on the ward for early detection of deteriorating patients: A case series

INTRODUCTION

Remote wireless monitoring is a new technology that allows the continuous recording of ward patients' vital signs, supporting nurses by measuring vital signs frequently and accurately. A case series is presented to illustrate how these systems might contribute to improved patient surveillance.

METHODS AND RESULTS

Five hospitals in three European countries installed a remote wireless vital signs monitoring system on medical or surgical wards. Heart rate, respiratory rate and temperature were measured by the system every 2 min. Four cases of (paroxysmal) atrial fibrillation are presented, two cases of sepsis and one case each of pyrexia, cardiogenic pulmonary edema and pulmonary embolisms. All cases show that the remote monitoring system revealed the first signs of ventilatory and circulatory deterioration before a change in the trends of the respective values became obvious by manual vital signs measurement.

DISCUSSION

This case series illustrates that a wireless remote vital signs monitoring system on medical and surgical wards has the potential to reduce time to detect deteriorating patients.

Biofilm Formation by Uropathogens and Their Susceptibility Towards Antimicrobial Therapy

Introduction: Urinary tract infection (UTI) is the most common health care associated infection caused by various pathogenic bacteria. Biofilms are communities of bacteria that are held together by exopolymeric substances that protect against the antimicrobial therapy and other environmental assaults. The aim of this study was to estimate the prevalence of biofilm forming bacteria in Nepalese population and to study the emergence of antimicrobial resistance among biofilm producing bacteria in comparison to non-biofilm producing bacteria. Methods: A total of 785 clean-caught-mid-stream urine samples were collected. After isolation and identification of uropathogens, they were further processed for detection of biofilm formation by two methods (Congo Red Agar method and Tissue Culture Plate method) as well as for antibiotic sensitivity test. Results: Out of total collected samples, 12.74% were found to be associated with UTI, among them 67% were Escherichia coli, 10% were Klebsiella spp, 7% were Pseudomonas spp, 6% were Staphyloccous aureus, 4% were Enterobacter spp, 3% were Proteus spp, 2% were Citrobacter spp and remaining 1% was Staphylococcus saprophyticus. Among isolated organisms, the ratio of bioflim positive organism to bioflim negative organism was found to be 9:11. Nitrofurantoin, Tobramycin, Chloramphenicol, Amikacin and Imipenem were found to be significantly more sensitive in biofilm negative bacteria as compared to biofilm positive bacteria with p values of 0.000, 0.001, 0.000, 0.000 and 0.001. Conclusions: The prevalence rate of multidrug resistance in bacterial uropathogens was higher in biofilm producers as compared to non-biofilm producers. Biofilm forming characteristic of bacteria make them more resistant to antibiotics.

Laparoscopic repair of type III/IV giant para-oesophageal herniae with biological prosthesis: a single centre experience

PURPOSE

Repair of giant paraoesophageal herniae (GPEH) is technically challenging and requires significant experience in advanced foregut surgery. Controversy continues on suture versus mesh cruroplasty with the most recent systematic review and meta-analysis putting the onus on the operating surgeon. Study aim was to review whether the biological prosthesis (non-cross-linked bovine pericardium and porcine dermis) and the technique adopted for patients with GPEH had an influence on clinical and radiological recurrences.

METHOD

A retrospective analysis of a prospectively collected data of 60 consecutive patients with confirmed 5 cm hiatus hernia and ≥ 30% stomach displacement in the thorax that were operated in the upper gastrointestinal unit of a large district general hospital between September 2010 and August 2017. Pre and post-surgery Gastro-Oesophageal Reflux Disease Questionnaire [(GORD-HRQOL)] and a follow up contrast study were completed.

RESULTS

60 included 2 (3%) and 58 (97%) emergency and elective procedures respectively with a male: female ratio of 1:3, age 71* (Median) (42-89) years, BMI 29* (19-42) and 26 (43%) with ASA III/IV. Investigations confirmed 46* (37-88) mm and 42* (34-77) mm transverse and antero-posterior hiatal defect respectively with 60* (30-100)% displacement of stomach into chest. Operative time and length of stay was 180* (120-510) minutes and 2* (1-30) days respectively. One (2%) converted for bleeding and 2 (3%) peri-operative deaths. Five (8%), 5 (8%) and 4 (7%) have dysphagia, symptomatic and radiological recurrences respectively. GORD-HRQOL recorded preoperatively was 27* (10-39) dropping significantly postoperatively to 0* (0-21) (P < 0.005) with 95% patient satisfaction at a follow up of 60* (36-84) months.

CONCLUSIONS

Our technique of laparoscopic GPEH repair with biological prosthesis is safe with a reduced symptomatic and radiological recurrence and an acceptable morbidity and mortality.

In search of effective H1N1 neuraminidase inhibitor by molecular docking, antiviral evaluation and membrane interaction studies using NMR

Considering the need for discovery of new antiviral drugs, in view to combat the issue of resistance particularly to anti-influenza drugs, a series of 2'-amino, 3'-amino and 2', 4'-dihydroxy chalcone derivatives were designed. Structure-based drug design was used to design inhibitors of influenza virus - H1N1 neuraminidase enzyme. These were further optimized by a combination of iterative medicinal chemistry principles and molecular docking. Based on the best docking scores, some chalcone derivatives were synthesized and characterized by infrared spectroscopy (IR) and proton nuclear magnetic resonance (NMR). The molecules were evaluated for their anti-influenza action against influenza A/Pune isolate/2009 (H1N1) virus by in vitro enzyme-based assay (neuraminidase inhibition assay). We have then selected few of them for multinuclear NMR studies, 31P NMR, in order to probe the molecular mechanism of their antiviral action. Reasonably good correlation between docking scores; anti-influenza activity; and 31P NMR results were observed. The computational predictions were in consensus with the experimental results. It was observed that among tested compounds, derivative 1A, viz. 2', 4'-dihydroxy-4-methoxy chalcone, showed highest activity (IC50 = 2.23 μmol/l) against the virus under study. This derivative 1A can be explored further to provide a future therapeutic option for the treatment and prophylaxis of H1N1 viral infections.

Developing tool and Measuring Integration Characteristics of Basic Science Curriculum to Improve Curriculum Integration

Background Integrated curriculum enhances students' learning and the retention of knowledge. At Patan Academy of Health Sciences, integrated organ system based curriculum is used with Problem Based Learning as the principle teaching learning method to foster students' learning. In addition, other approaches of integration were under taken such as integrated assessment; logical arrangement teaching learning methods (lectures and practicals); joint effort of faculty in curriculum planning and delivery; conducive environment to foster hidden curriculum. This study describes the perception of faculty and students on integration characteristics of Basic Science curriculum. Objective To measure the integration characteristics of Basic Science Curriculum. Method Tool was developed to measure integration characteristics of Basic Science Curriculum and ensure whether such planned integration has been achieved. Mixed method was used to measure the perception of the integration characteristics i) quantitatively by questionnaire survey to faculty and students ii) qualitatively by in-depth interview of students. Result Both faculty and students perceived that all the blocks in Basic Science was well integrated in the quantitative questionnaire survey. But, in the in-depth interview, students perceived integration of curriculum in organ system blocks were better integrated compared to Principle of Human Biology blocks where fundamentals of basic science disciplines were delivered. Students reflected that Problem Based Learning not only integrated Basic Science disciplines but also with clinical sciences and the social context. But, students perceived that Community Health Sciences curriculum was not so well integrated with Basic Science subjects. Conclusion Overall, this study showed that planned integration in Basic Science curriculum was successfully executed during curriculum implementation.

Blazar spectral variability as explained by a twisted inhomogeneous jet

Blazars are active galactic nuclei, which are powerful sources of radiation whose central engine is located in the core of the host galaxy. Blazar emission is dominated by non-thermal radiation from a jet that moves relativistically towards us, and therefore undergoes Doppler beaming. This beaming causes flux enhancement and contraction of the variability timescales, so that most blazars appear as luminous sources characterized by noticeable and fast changes in brightness at all frequencies. The mechanism that produces this unpredictable variability is under debate, but proposed mechanisms include injection, acceleration and cooling of particles, with possible intervention of shock waves or turbulence. Changes in the viewing angle of the observed emitting knots or jet regions have also been suggested as an explanation of flaring events and can also explain specific properties of blazar emission, such as intra-day variability, quasi-periodicity and the delay of radio flux variations relative to optical changes. Such a geometric interpretation, however, is not universally accepted because alternative explanations based on changes in physical conditions-such as the size and speed of the emitting zone, the magnetic field, the number of emitting particles and their energy distribution-can explain snapshots of the spectral behaviour of blazars in many cases. Here we report the results of optical-to-radio-wavelength monitoring of the blazar CTA 102 and show that the observed long-term trends of the flux and spectral variability are best explained by an inhomogeneous, curved jet that undergoes changes in orientation over time. We propose that magnetohydrodynamic instabilities or rotation of the twisted jet cause different jet regions to change their orientation and hence their relative Doppler factors. In particular, the extreme optical outburst of 2016-2017 (brightness increase of six magnitudes) occurred when the corresponding emitting region had a small viewing angle. The agreement between observations and theoretical predictions can be seen as further validation of the relativistic beaming theory.

Deposition and spatial variation of thoron decay products in a thoron experimental house using the Direct Thoron Progeny Sensors

Experiments have been carried out using the deposition-based Direct Thoron Progeny Sensors (DTPS) in a thoron experimental house. The objective was to study the thoron decay product characteristics such as the deposition velocities, spatial variability and dependence on aerosol particle concentrations. Since the deposition velocity is an important characteristic in the calibration of the DTPS, it is very important to study its dependence on aerosol concentration in a controlled environment. At low aerosol concentration (1500 particles/cm³) the mean effective deposition velocity was measured to be 0.159 ± 0.045 m h^-1; at high aerosol concentration (30 000 particles/cm³) it decreased to 0.079 ± 0.009 m h^-1. The deposition velocity for the attached fraction of the thoron decay products did not change with increasing aerosol concentration, showing measurement results of 0.048 ± 0.005 m h^-1 and 0.043 ± 0.014 m h^-1, respectively. At low particle concentration, the effective deposition velocity showed large scattering within the room at different distances from center. The attached fraction deposition velocity remained uniform at different distances from the wall. The measurements in the thoron experimental house can be used as a sensitivity test of the DTPS in an indoor environment with changing aerosol concentration. The uniform spatial distribution of thoron decay products was confirmed within the experimental house. This indicates that direct measurement of thoron decay product concentration should be carried out instead of inferring it from thoron gas concentration, which is very inhomogeneous within the experimental house.

Effectiveness of amitriptyline and lamotrigine in traumatic spinal cord injury-induced neuropathic pain: a randomized longitudinal comparative study

STUDY DESIGN

Randomized longitudinal comparative study.

OBJECTIVES

To compare the efficacy of lamotrigine and amitriptyline in the management of traumatic spinal cord injury (SCI)-induced neuropathic pain (NP).

SETTING

Sawai Man Singh Medical College and Hospital, Jaipur, India.

METHODS

A total of 147 individuals with NP were randomized for a 3-week trial of either amitriptyline or lamotrigine. Amitriptyline was administered orally at doses of 25, 50 and 100 mg once daily at night time, and lamotrigine was administered orally at doses of 25, 50 and 100 mg twice daily, both for 1 week by means of optional titration. Assessment of NP was done at baseline and thereafter at 1, 2 and 3 weeks using Short-form MC Gill Pain Questionnaire-2 (SFMPQ2) scores.

RESULTS

There was a significant difference between the mean values of the SFMPQ2 score at baseline and those at each follow-up for amitriptyline. Similar results were seen in the lamotrigine group. When the differences in mean SFMPQ2 scores at different time frames from baseline were compared with those of the other group, values were found to be nonsignificant as seen on the Mann-Whitney U-test.

CONCLUSIONS

These findings support the use of both amitriptyline and lamotrigine in the management of NP after traumatic SCI.

Effect of 220Rn gas concentration distribution on its transmission from a delay chamber: evolving a CFD-based uniformity index

(220)Rn mitigation can be achieved by delay chamber technique, which relies on the advantage of its short half-life. However, flow rate as well as inlet-outlet position for the delay chamber can have a significant impact on (220)Rn concentration distribution patterns and hence transmission factor. In the present study, computational fluid dynamics simulations to estimate the concentration distribution has been carried out in a chamber of 0.5 m(3) for the combination of six different inlet-outlet positions and five different flow rates. Subsequently, the transmission factor (TF) for the chamber was evaluated and found to be highly dependent on the flow rate and inlet-outlet positions. For ease of scale up, the dependency of TF on the flow rate and the inlet-outlet positions is best summarised by relative transmission factor (RTF), which is the ratio of the TFs for the case of inlet and outlet on different faces to that on the same face.

NMR-based metabonomics for understanding the influence of dormant female genital tuberculosis on metabolism of the human endometrium

STUDY QUESTION

Does investigation of metabolic perturbations in endometrial tissue of women with dormant genital tuberculosis (GTB) during the window of implantation (WOI) assist in improving the understanding of endometrial receptivity?

SUMMARY ANSWER

In dormant GTB cases significant alterations in endometrial tissue metabolites occur, largely related to energy metabolism and amino acid biosynthesis in dormant GTB cases.

WHAT IS KNOWN ALREADY

As an intracellular pathogen, Mycobacterium tuberculosis strongly influences the metabolism of host cells causing metabolic dysregulation. It is also accepted that dormant GTB impairs the receptive status of the endometrium. Global metabolic profiling is useful for an understanding of disease progression and distinguishing between diseased and non-diseased groups.

STUDY DESIGN, SIZE, DURATION

Endometrial tissue samples were collected from patients reporting at the tertiary infertility care center during the period September 2011-March 2013. Women having tested positive for GTB were considered as the study group (n = 24). Normal healthy women undergoing sterilization (n = 26) and unexplained infertile women with repeated IVF failure (n = 21) volunteered to participate as controls.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Endometrial tissue samples were collected 6-10 days after confirmation of ovulation. PCR and BACTEC-460 culture were used for diagnosing GTB. Proton nuclear magnetic resonance (1H NMR) spectra of tissue were recorded using a 700 MHz Bruker Avance AV III spectrometer. Following phase and baseline correction of all NMR spectra by Bruker Topspin 2.1 software, spectral peak alignment of the data was performed. Multivariate analysis was applied to all spectra and individual metabolites identified and multiple correlation analysis was performed.

MAIN RESULTS AND THE ROLE OF CHANCE

Leucine, isoleucine, acetate, lactate, glutamate, glutamine, methionine, lysine, creatine, glycogen, glycine, proline and choline were found to be significantly increased (P < 0.05) in endometrial tissue of women with dormant GTB compared with unexplained infertile women with repeated implantation failure. Valine, citrate, succinate and aspartate were also observed to be significantly up-regulated (P < 0.01). Furthermore, a significant decrease in glucose (P < 0.05), threonine (P < 0.05), tyrosine (P < 0.01) and phenylalanine (P < 0.0001) was observed in women with dormant GTB. Pearson's correlation analysis between the expression of various endometrial receptivity markers and metabolites showed a significant negative correlation (-0.236 to -0.545, P < 0.05). Also, the metabolites were positively correlated with endometrial receptivity markers (0.207 to 0.618, P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

It is often difficult to diagnose dormant GTB because it tends to exist without any clinical signs or symptoms. In addition, the diagnosis of GTB by culture remains a challenge due to low detection rates and its paucibacillary nature. Testing for prostate-specific antigen or the Y chromosome in order to account for the possible influences of recent exposure to semen on endometrial metabolism would be important.

WIDER IMPLICATIONS OF THE FINDINGS

The metabolic changes associated with the dormant tubercle infection are of potential relevance to clinicians for the treatment of dormant GTB-related infertility.

STUDY FUNDING/COMPETING INTERESTS

Government of India, Indian Council of Medical Research. There are no conflicts of interest.

Dexamethasone may be the most efficacious corticosteroid for use as monotherapy in castration-resistant prostate cancer

Corticosteroids have been used in the therapy for castration-resistant prostate cancer (CRPC) for decades, both as monotherapy and in combination with additional agents. In this article the authors report the results of a phase II trial of dexamethasone versus prednisolone as monotherapy for CRPC. The study suggests improved PSA and radiographic response rates as well as improved time to PSA progression for dexamethasone over prednisolone therapy; however the differences only trend toward statistical significance. Nonetheless, in light of these data, when treating patients with corticosteroid monotherapy for CRPC it may be prudent to consider using daily dexamethasone over prednisone/prednisolone.

Evaluation of the immature platelet fraction as an indicator of platelet recovery in dengue patients

INTRODUCTION

Thrombocytopenia is a common complication in many disorders (such as aplastic anemia, ITP, dengue fever,), the etiology being multifactorial. Immature platelet fraction (IPF) is a new parameter which is a measure of reticulated platelets that reflects the rate of thrombopoiesis. We tried to evaluate IPF as an indicator to predict the recovery of platelets in patients with dengue.

METHODS

A total of 32 patients suffering from dengue fever (as confirmed by NS1 antigen or IgM antibody positivity for dengue) were taken for the study. The platelet count and IPF value of all these patients were evaluated on a daily basis.

RESULTS

It was found out that IPF has a strong correlation with the recovery of platelet counts in patients with dengue. 84.3% patients showed recovery within 24 h after attaining the peak IPF, 93.75% of the patients showed recovery within 24-48 h of the rise of the IPF compared with the previous day's value, and 100% patients showed a recovery within 24 h of the fall of the IPF compared with the previous days. It was also observed that 93.75% of the patients show platelet recovery within 24-48 h if the IPF was more than 10%.

CONCLUSION

Based on our study, we concluded that IPF can be used to evaluate the recovery of platelets in patients with dengue. It holds a great promise of becoming a reliable future guide for decisions concerning platelet transfusions.