Sleep need driven oscillation of glutamate synaptic phenotype

Sleep loss increases AMPA-synaptic strength and number in the neocortex. However, this is only part of the synaptic sleep loss response. We report increased AMPA/NMDA EPSC ratio in frontal-cortical pyramidal neurons of layers 2-3. Silent synapses are absent, decreasing the plastic potential to convert silent NMDA to active AMPA synapses. These sleep loss changes are recovered by sleep. Sleep genes are enriched for synaptic shaping cellular components controlling glutamate synapse phenotype, overlap with autism risk genes and are primarily observed in excitatory pyramidal neurons projecting intra-telencephalically. These genes are enriched with genes controlled by the transcription factor, MEF2c and its repressor, HDAC4. Thus, sleep genes under the influence of MEF2c and HDAC4, can provide a framework within which motor learning and training occurs mediated by sleep-dependent oscillation of glutamate-synaptic phenotypes.

Measurement of energy and directional distribution of neutron ambient dose equivalent for the 7Li(p,n)7Be reaction

Double differential neutron fluence distributions were measured in the 7Li(p,n)7Be reaction for proton beam energies 7, 9 and 12 MeV. Seven liquid scintillator based detectors were employed to measure neutron fluence distributions using the Time of Flight technique. Neutron ambient dose equivalents were determined from the measured fluence distribution using ICRP (International Commission on Radiological Protection) recommended fluence to dose equivalent conversion coefficients. Neutron dose equivalents were also measured using a conventional BF3 detector based REM counter. Ambient dose equivalent measured by the REM counter is found to be in agreement with that determined from the neutron fluence spectra within their uncertainties. Angular distributions of the ambient dose equivalents were also determined from the measured fluence distributions at different angles.

Label-Free Optical Technologies for Middle-Ear Diseases

Medical applications of optical technology have increased tremendously in recent decades. Label-free techniques have the unique advantage of investigating biological samples in vivo without introducing exogenous agents. This is especially beneficial for a rapid clinical translation as it reduces the need for toxicity studies and regulatory approval for exogenous labels. Emerging applications have utilized label-free optical technology for screening, diagnosis, and surgical guidance. Advancements in detection technology and rapid improvements in artificial intelligence have expedited the clinical implementation of some optical technologies. Among numerous biomedical application areas, middle-ear disease is a unique space where label-free technology has great potential. The middle ear has a unique anatomical location that can be accessed through a dark channel, the external auditory canal; it can be sampled through a tympanic membrane of approximately 100 microns in thickness. The tympanic membrane is the only membrane in the body that is surrounded by air on both sides, under normal conditions. Despite these favorable characteristics, current examination modalities for middle-ear space utilize century-old technology such as white-light otoscopy. This paper reviews existing label-free imaging technologies and their current progress in visualizing middle-ear diseases. We discuss potential opportunities, barriers, and practical considerations when transitioning label-free technology to clinical applications.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

AI-Powered Biomolecular-Specific and Label-Free Multispectral Imaging Rapidly Detects Malignant Neoplasm in Surgically Excised Breast Tissue Specimens

CONTEXT.—

Repeated surgery is necessary for 20% to 40% of breast conservation surgeries owing to the unavailability of any adjunctive, accurate, and objective tool in the surgeon's hand for real-time margin assessment to achieve the desired balance of oncologic and cosmetic outcomes.

OBJECTIVE.—

To assess the feasibility of using a multispectral autofluorescence imaging device for discriminating malignant neoplasm from normal breast tissue in pathology as a critical step in the development of a device for intraoperative use, and to demonstrate the device's utility for use in processing and prioritizing specimens during frozen section and in the pathology grossing room.

DESIGN.—

We performed a preliminary assessment of our device, called the TumorMAP system, on 172 fresh tissue blocks from 115 patients obtained from lumpectomy specimens at the time of initial gross examination and compared the device results with gold standard pathology evaluation.

RESULTS.—

The preliminary results demonstrate the potential of our device in detecting breast cancer in fresh tissue samples with a sensitivity of 82%, a specificity of 91%, a positive predictive value of 84%, and a negative predictive value of 89%.

CONCLUSIONS.—

Our results suggest that the TumorMAP system is suitable for the detection of malignant neoplasm in freshly excised breast specimens and has the potential to evaluate resection margins in real time.

Cryoconservation of in vitro grown shoot tips of Cicer microphyllum: A crop wild relative of chickpea

BACKGROUND

Cicer microphyllum Benth. is a crop wild relative (CWR) of chickpea (C. arietinum L.), that possess useful genes for cold and drought tolerance. The species is being conserved in the In Vitro Active Genebank for short- to medium-term conservation. Cryopreservation would be a useful complementary approach for its long-term conservation.

OBJECTIVE

The current work aimed to develop an efficient cryoconservation protocol for cryobanking of C. microphyllum shoot tips.

MATERIALS AND METHODS

In vitro shoot tips excised from 4-month old shoot cultures grown on B5 + 0.5 mg/L KIN + 0.1 mg/L NAA + 10 mg/L AgNO3 medium were cryoconserved using a droplet-vitrification technique. Post-thaw regrowth was evaluated after: (i) preculture medium (B5 basal, B5 + 3, 4, 6 and 10% sucrose), (ii) preculture incubation temperature (25 ± 2, 10, 8 and 22/5 degree C), (iii) PVS2 duration (10, 20, 30. 40, 50 and 60 min) and (iv) regrowth medium (B5) supplemented with 0.5 mg/L KIN + 0.1 NAA mg/L; 0.5 mg/L KIN + 0.1 mg/L NAA + 10 mg/L AgNO3; 0.2 mg/L BAP + 10 mg/L AgNO3; 0.2 mg/L BAP + 20 mg/L AgNO3 and 0.2 mg/L BAP + 30 mg/L AgNO3.

RESULTS

In vitro shoot tips grown on B5 + 0.5 mg/L KIN + 0.1 mg/L NAA + 10 mg/L AgNO3, precultured on B5 + 6% sucrose at 10 degree C for 3 days, followed by PVS2 treatment for 20 min, unloading solution for 60 min and regrowth on B5 + 0.2 mg/L BAP + 20 mg/L AgNO3 resulted in highest survival (57%) and regrowth (40%) after cryoconservation.

CONCLUSION

The standardized protocol was successfully used for cryobanking of in vitro shoot tips of C. microphyllum in the In Vitro Base Genebank of ICAR-NBPGR, New Delhi. Doi.org/10.54680/fr23610110412.

Hippocampal Avoidance Whole BRAIN Radiotherapy (HA-WBRT) with Simultaneous Integrated BOOST (SIB) vs. HA-WBRT in Multiple Brain Metastases: A Dosimetric Comparison

PURPOSE/OBJECTIVE(S)

There has been a paradigm shift in managing multiple brain metastases. Various options include SRS, WBRT, and WBRT with Hippocampal avoidance (HA-WBRT). There is no consensus for the treatment of multiple brain metastases (>3 brain metastases). A new technique that has proven feasible is dose escalation in the form of simultaneous integrated boost. The aim of this study was to compare the dosimetry parameters of HA-WBRT plus simultaneous integrated boost versus HA-WBRT alone in multiple brain metastases.

MATERIALS/METHODS

In a prospective trial,16 patients with multiple brain metastasis (≥ 3) from various primaries with good performance scores (ECOG PS ≤ 2) are recruited. All patients underwent CT simulation (1.5 mm slice thickness) and RT plans for HA-WBRT with (SIB) and HA-WBRT alone were made. A 5 mm margin was given to the bilateral hippocampus for Hippocampal Avoidance. In the HA-WBRT plan for the PTV i.e., whole brain plus 3 mm margin minus hippocampal avoidance region (H.A.), a dose of 30 Gy in 10 fractions is prescribed over two weeks. In HA-WBRT with SIB, a dose of 30 Gy in 10 fractions over two weeks is prescribed for the PTV, which is the clinical target volume, minus the hippocampal avoidance region (H.A.) minus the PTV Mets (1 mm margin to the GTV). A simultaneous Integrated Boost of 42.5 Gy in 10 # over two weeks is prescribed for PTVmets. Planning was done using a VMAT technique with 6MV F.F.F. beam energy in a treatment planning software.

RESULTS

The mean B/L hippocampus volume is 3.47 cc. The mean dose of PTV D98% in HA-WBRT plans is 27.45 Gy, whereas in HA-WBRT with S.I.B. is 27.36 Gy (p = 0.90). V30 mean dose in HA-WBRT plans is 93.35%, and the mean dose in HA-WBRT SIB is 91.87% (p = 0.12). PTV D2% mean dose in HA-WBRT Is 36.06 Gy, and in HA-WBRT -S.I.B., it is 40.58 (p< 0.001). The mean bilateral hippocampus Dmax in HA-WBRT is 14.85 Gy, and in HA-WBRT-SIB is 14.25 Gy (p = 0.35). The mean Bilateral hippocampus D100% is 9.14 Gy in HA-WBRT and 9.01 Gy in HA-WBRT-SIB (p = 0.54). The mean brainstem Dmax in HA-WBRT is 36.82 Gy compared to 38.55 Gy in HA-WBRT-SIB (p = 0.02).

CONCLUSION

In patients planned for a simultaneous boost along with hippocampal sparing whole brain radiotherapy, the mean dose to the hippocampal region did not increase. The Dmax of Brainstem, optic chiasma is significantly higher in HA-WBRT-). Our study, the mean dose to PTVmets is more than 45 Gy and more than 50 Gy to GTV with a BED of more than 65 Gy (α/ß = 10) to the metastases, which is equivalent to some ablative dose regimens. Simultaneous integrated boost along with hippocampal sparing radiotherapy thus helps in sparing the hippocampus and delivering higher doses to the metastases and intermediate doses to the rest of the brain, addressing the microscopic disease.

Multiple Sessions vs. Single Session Image-Based Intracavitary Brachytherapy for Locally Advanced Cervical Cancer: A Randomized Control Trial

PURPOSE/OBJECTIVE(S)

The objectives of this study are: 1) To compare the acute toxicity caused in the treatment of locally advanced cervical cancer (LACC) treated with weekly multiple applications vs. a single application for image-guided intracavitary High Dose Rate (HDR) brachytherapy (BT) after External Beam Radiation Therapy (EBRT) 2) To compare the loco-regional control of cancer at six months in the two arms MATERIALS/METHODS: In a prospective study, 40 patients with biopsy-proven LACC with FIGO-2018 stage IIB-IIIC1 disease, underwent EBRT to the pelvis at a dose of 50.4 Gy/ 28 fractions over 5.5 weeks with weekly concurrent cisplatin. After completion of EBRT, they were randomized into two arms with 20 patients each. In the Control arm (Arm-A), BT sessions were given with weekly 3 applications whereas, in the experimental arm (Arm-B), all the sessions were given with a single application at 6-12 hours intervals with aim of the high-risk clinical target volume receiving >80 Gy EQD2 and 2 cm3 of the bladder and rectum/sigmoid receiving <85 Gy and <75 Gy, respectively. The OAR contouring was done on CT RESULTS: All 40 patients were treated as per protocol. The mean duration of treatment including EBRT and BT was 73.15 days [95% CI 68.63-77.66] in Arm A and 55.85 days [95% CI 52.11-59.58] in Arm B which was significant. After 6 months, 37 patients came for follow-up, all 19 patients in Arm A had Grade 1 or Grade 2 rectal toxicity. In Arm B as well all 18 patients had Grade 1 or Grade 2 rectal toxicity. Bladder toxicity was Grade 1 or Grade 2 in 18 patients and Grade 3 severity in 1 patient among Arm A. Among 18 patients of Arm B, bladder toxicity of Grade 1 or Grade 2 was seen in 16 patients, and 2 patients had grade 3 toxicity. 2 patients in Arm A and 3 in Arm B complained of Grade 1 urinary incontinence. Moreover, Abdominal pain at 6 months was of Grade 1 in around 6 patients in Arm A but 14 patients had abdominal pain in Arm B which was of Grade 1 in 8, 4 had grade 2 and 2 patients had grade 3 severity abdominal pain. In the monthly analysis of acute toxicity, none of the patients showed Grade 3 or 4 toxicity at the 1st, 2nd, or 3rd month of completion of treatment. When comparing local control in both arms at 6 months, 2 patients had treatment failure in the Experimental Arm compared to only 1 patient in the Control Arm CONCLUSION: Single Application Multiple Fraction Intracavitary Brachytherapy post concurrent CTRT is a safe option for the treatment of locally advanced cervical cancer. When compared to the weekly application arm, single-application ICRT showed a comparable acute toxicity profile and comparable local control rates as well. Some patients in Single Application Arm showed abdominal pain which needs to be investigated with further trials. The overall treatment time in the single application arm is significantly lower than the standard weekly application arm.

Proximal humerus fractures: A review of current practice

The management of proximal humeral fractures (PHF) remains controversial. Its incidence is increasing. Patients should be meticulously assessed clinically for co-morbidities and neuro-vascular injuries. Radiological investigation helps provide information on the fracture configuration and dislocations. Enhanced by 3-dimensional CT scanning, these further help in decision making and operative planning. PHF classifications have been demonstrated to have poor intra-observer and inter-observer reliability. Research has identified some radiographic predictive factors for humeral head ischaemia and likely failure of surgical fixation. The range of management options include non-operative treatment, operative fixation, intramedullary nailing and arthroplasty (hemiarthroplasty, reverse shoulder replacement). The majority of PHFs are stable injuries and non-operative management is usually successful. Some degree of malunion is readily tolerated especially by elderly patients. Surgical management of significantly displaced, unstable proximal humerus fractures should aim to stabilise the fracture adequately and provide satisfactory function for the long term. Management of the greater tuberosity is pivotal for the eventual outcome. When fixation may appear to be compromised by poor bone quality, likely poor function, age related rotator cuff degeneration or likely humeral head ischaemia clinicians may opt for arthroplasty. Successful hemiarthroplasty outcomes are dependent on sufficient healing of the tuberosity and recovery of the rotator cuff integrity. Reverse shoulder replacement can predictably deliver good functional outcomes for the shoulder in elderly patients, where rotator cuff dysfunction is suspected or as a revision procedure following failure of other surgical interventions. As opposed to hemiarthroplasty, which has shown a downward trend, there has been an increasing trend towards the use of reverse shoulder replacement in proximal humeral fractures. The management of PHFs should be patient specific, fracture specific and meet the functional demands and needs of the individual patient. The surgeon's skill set and clinical experience also plays an important role in the options of management available.

Dispositional mindfulness, alexithymia and sensory processing: Emerging insights from habituation of the acoustic startle reflex response

There is growing evidence of beneficial effects of mindfulness developed through engaging in mindfulness training/practices on sensory and cognitive processing, emotion regulation and mental health. Mindfulness has also been conceptualised as a dispositional 'trait', i.e. the naturally-occurring ability of meditation-naïve individuals to display, in varying degree, a non-judgmental non-reactive present-moment awareness in everyday life. In this study we examined possible associations between dispositional mindfulness, alexithymia and sensory processing. Eye-blink startle responses to acoustic stimuli of varying intensity [90-dB or 100-dB over 70-dB (A) background] were assessed in 26 meditation-naïve adults (50 % men) using electromyographic recordings of the orbicularis muscle. All participants completed the Five Facet Mindfulness Questionnaire and the 20-item Toronto Alexithymia Scale. A negative association was found between dispositional mindfulness and alexithymia (r = -0.513). There was stronger startle habituation to 100-dB, compared to 90-dB probes. Stronger startle habituation (larger negative habitation slope values) to 100-dB probes was significantly associated with higher dispositional mindfulness (r = -0.528) and with lower alexithymia at trend level (r = 0.333). As indicated by commonality analysis, 10.6 % of explained variance in habituation (100-dB probes) was common to both alexithymia and mindfulness, 17.3 % was unique to mindfulness, but alexithymia made negligible unique contribution (0.5 %). These findings indicate similar startle habituation pattern in people with a high level of dispositional mindfulness to that reported previously by Antonova et al. (2015) in people with moderate mindfulness meditation practice intensity. Future studies should investigate the mechanisms, such as interoceptive awareness, that might underly these relationships.

Indigenous institutions as adaptive measures to environmental dynamics: an ethnographic study of Loba Community of Upper Mustang, Nepal

This paper investigates how different institutions of Loba communities of the Upper Mustang work together and facilitate the community to cope with the environmental dynamics in the region. The indigenous institutions are place-based, and their evolution is concerned with reducing vulnerability and enhancing the resilience capacity of place-based communities to cope with and adapt to local natural and socio-cultural environmental dynamics. The paper is based on anthropological fieldwork. Qualitative data were collected by applying observation and interviews. The paper presents the role of the galbo, (Lo King), ghenba (Village Chief), Lama (Monk), and dhongba (Household) as local institutions that act in close relation and make community-level decisions. The findings reveal that the King is seen as the leader whose governance best suited to the local natural environment, cultural practices, and economy. The Lama plays a major role in reinforcing local rules, while the Ghenba is an agent who mediates the Lo King and people in materializing rules and operationalizing institutional mechanisms. The Dhongbas are units of production of the local social-ecosystem that are entitled to use local resources within the context of the institution’s agreed rules, norms, and values. These local institutions are cooperating well, successfully regulating, managing, and protecting agricultural, forest, and pasture lands, and maintaining the monuments in Lo-manthang for centuries. However, recent social-environmental dynamics such as climate change, migration, and modernization are reducing the relevancies of traditional norms and practices. Nevertheless, the institutions are working hard to continue their existence by frequently modifying their rules and norms.

High-throughput digital pathology via a handheld, multiplexed, and AI-powered ptychographic whole slide scanner

The recent advent of whole slide imaging (WSI) systems has moved digital pathology closer to diagnostic applications and clinical practices. Integrating WSI with machine learning promises the growth of this field in upcoming years. Here we report the design and implementation of a handheld, colour-multiplexed, and AI-powered ptychographic whole slide scanner for digital pathology applications. This handheld scanner is built using low-cost and off-the-shelf components, including red, green, and blue laser diodes for sample illumination, a modified stage for programmable sample positioning, and a synchronized image sensor pair for data acquisition. We smear a monolayer of goat blood cells on the main sensor for high-resolution lensless coded ptychographic imaging. The synchronized secondary sensor acts as a non-contact encoder for precisely tracking the absolute object position for ptychographic reconstruction. For WSI, we introduce a new phase-contrast-based focus metric for post-acquisition autofocusing of both stained and unstained specimens. We show that the scanner can resolve the 388-nm linewidth on the resolution target and acquire gigapixel images with a 14 mm × 11 mm area in ∼70 seconds. The imaging performance is validated with regular stained pathology slides, unstained thyroid smears, and malaria-infected blood smears. The deep neural network developed in this study further enables high-throughput cytometric analysis using the recovered complex amplitude. The reported do-it-yourself scanner offers a portable solution to transform the high-end WSI system into one that can be made widely available at a low cost. The capability of high-throughput quantitative phase imaging may also find applications in rapid on-site evaluations.

EPIDEMIOLOGY AND SEASONAL VARIATION OF APPENDICITIS – A SINGLE CENTER RETROSPECTIVE STUDY FROM NORTH-EAST INDIA

Background. Acute appendicitis is the most common surgical emergency presenting in emergency department, and appendectomy is one of the most common surgeries. There is a wide variation in the incidence of acute appendicitis reported for different countries, different regions, race, sex, age and also seasons. Objective. The aim of this study was to understand the epidemiological trend and the seasonal variation of appendicitis in the northeast region of India. Methods. It was a retrospective hospital-based study conducted in Jan 2016 – Dec 2020 at a Tertiary Care Teaching Hospital in the northeast region of India. The patient data were obtained from the Medical Record Department of the hospital and the data regarding the weather was obtained from the Indian Meteorological Department (IMD) and the website www.worldweather.com. The statistical analysis was done using SPSS software version 24.0, and the seasonal variation was studied using Kruskal Wallis test. Results. Acute appendicitis affected both the sexes equally with a marginal higher incidence in males. It also had higher peak during the second and third decade of life in both the sexes. The incidence of acute appendicitis was high in the pre-monsoon and monsoon season with peak in the monsoon season. Conclusions. Acute appendicitis is more common during the pre-monsoon and monsoon season, a period known for humidity, high incidence of bacterial and viral infections.

Bronco T (Shirisadi kasaya), a polyherbal formulation prevents LPS induced septicemia in rats

OBJECTIVE

Here, Bronco T (BT), a polyherbal formulation developed in 1984 for treating asthma, has been repurposed against septicemia-induced ALI.

MATERIALS AND METHODS

Lipopolysaccharides (3 mg/kg BW) were injected intraperitoneally before 24 hours of surgery to assess the cardiorespiratory parameters, blood PaO2/FiO2 and MPO, pulmonary water content and histological changes in the lungs. The pentoxifylline (PTX) (25 mg/kg BW) was used as the positive control and given one hour before LPS. BT was given 3 hours (orally at different doses of 3, 1.5 and 0.75 g/kg BW) before LPS.

RESULTS

The LPS treated group showed significant bradypnea, hypotension and bradycardia, through elongated peaks (RR) and (MAP) respectively and finally death after 95 minutes of LPS injection. The PTX and BT (3 g/kg BW) pretreatment significantly prevented these changes (dose-dependent in the BT group). The survival in these groups was maintained up to 190 min after LPS. The Pentoxifylline showed a better response (75%) than Bronco T (72%). In both the treatments, a significant decrease in pulmonary water content and minimal neutrophil infiltration and intact alveoli-capillary membrane was seen in the transverse section (T.S) of the lungs.

CONCLUSIONS

Significant improvement was noted in survival time with lesser tissue damage and improved pulmonary function was observed by pre-treating with Bronco T in LPS induced septicemia.

Injectable amnion hydrogel-mediated delivery of adipose-derived stem cells for osteoarthritis treatment

Current treatment strategies for osteoarthritis (OA) predominantly address symptoms with limited disease-modifying potential. There is a growing interest in the use of adipose-derived stem cells (ADSCs) for OA treatment and developing biomimetic injectable hydrogels as cell delivery systems. Biomimetic injectable hydrogels can simulate the native tissue microenvironment by providing appropriate biological and chemical cues for tissue regeneration. A biomimetic injectable hydrogel using amnion membrane (AM) was developed which can self-assemble in situ and retain the stem cells at the target site. In the present study, we evaluated the efficacy of intraarticular injections of AM hydrogels with and without ADSCs in reducing inflammation and cartilage degeneration in a collagenase-induced OA rat model. A week after the induction of OA, rats were treated with control (phosphate-buffered saline), ADSCs, AM gel, and AM-ADSCs. Inflammation and cartilage regeneration was evaluated by joint swelling, analysis of serum by cytokine profiling and Raman spectroscopy, gross appearance, and histology. Both AM and ADSC possess antiinflammatory and chondroprotective properties to target the sites of inflammation in an osteoarthritic joint, thereby reducing the inflammation-mediated damage to the articular cartilage. The present study demonstrated the potential of AM hydrogel to foster cartilage tissue regeneration, a comparable regenerative effect of AM hydrogel and ADSCs, and the synergistic antiinflammatory and chondroprotective effects of AM and ADSC to regenerate cartilage tissue in a rat OA model.

Primitive neuroectodermal tumor of the kidney: a rare case

Background

Primitive neuroectodermal tumor commonly occurs in bones and is equivalent to Ewing’s sarcoma. Very few cases have been reported in the literature and they had a very different presentation and very aggressive behavior.

Case presentation

We present a case of a young 23-year-old male who presented with complaints of pain in left lumbar region of abdomen since 8 months and hematuria off and on. CT scan of the abdomen was done which revealed a large heterogeneously enhancing mass lesion in the left lumbar region arising from the superior and mid-pole of left kidney showing multiple non-enhancing necrotic areas. A diagnosis of left renal cell carcinoma was kept. Through the transperitoneal approach, the left kidney was approached and a left radical nephrectomy was done. The histopathology report revealed the tumor cells to be positive for CD99 and focally positive for Vimentin and negative for cytokeratin thereby making a diagnosis of primary neuroectodermal tumor (PNET).

Conclusions

Renal PNET is a rare renal malignancy that should be kept in the differential diagnosis of a renal SOL especially when it is a presenting feature in adolescent and young adult. It has a very aggressive course and multimodal therapy has to be considered in its treatment

ADULT-ONSET CYSTIC HYGROMA IN AXILLA: A RARE CASE REPORT FROM INDIA AND LITERATURE REVIEW

Background. Cystic hygroma (CH), occurs in 1/6000 live births and in 90% of cases develops in age less than 2 years old. They are mainly located in cervicofacial region. Adult-onset CH is very rare. Objective. The aim of this study is to review literature to discuss the clinical presentation, diagnosis, and treatment of CH in adults through a case report of unilocular CH in the axillary region in an adult male from India. Methods. A first case report of unilocular CH in axillary region in an adult male from India is being investigated. Results. Here we report a case of unilocular CH in the axillary region in a 49-year-old male with a 14x16x8 cm cystic swelling in left axilla with a history of aspiration failure. Contrast-enhanced MRI (CEMRI) showed well-defined thin walled, unilocular cystic lesion which appeared hyperintense on T2 & STIR and hypointense on T1W1 and showed thin peripheral rim of enhancement on post contrast images. The patient underwent surgical excision and the diagnosis of a pathological CH was established. His postoperative recovery was uneventful and had no evidence of recurrence. Conclusion. Due to rarity of adult-onset unilocular CH in axilla, its evaluation for prompt diagnosis and definitive treatment to prevent recurrence and complications is urgent. Furthermore, this is the first reported case from India which has been successfully managed at a peripheral hospital in Northeast-India and our report of this case contributes to the evidences supporting the role of CH in a differential diagnosis for masses in the adult axilla, especially in acute phase with no predisposing factors.

Advancing Raman spectroscopy from research to clinic: Translational potential and challenges

Raman spectroscopy has emerged as a non-invasive and versatile diagnostic technique due to its ability to provide molecule-specific information with ultrahigh sensitivity at near-physiological conditions. Despite exhibiting substantial potential, its translation from optical bench to clinical settings has been impacted by associated limitations. This perspective discusses recent clinical and biomedical applications of Raman spectroscopy and technological advancements that provide valuable insights and encouragement for resolving some of the most challenging hurdles.

Raman and quantitative phase imaging allow morpho-molecular recognition of malignancy and stages of B-cell acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is one of the most common malignancies that account for nearly one-third of all pediatric cancers. The current diagnostic assays are time-consuming, labor-intensive, and require expensive reagents. Here, we report a label-free approach featuring diffraction phase imaging and Raman microscopy that can retrieve both morphological and molecular attributes for label-free optical phenotyping of individual B cells. By investigating leukemia cell lines of early and late stages along with the healthy B cells, we show that phase images can capture subtle morphological differences among the healthy, early, and late stages of leukemic cells. By exploiting its biomolecular specificity, we demonstrate that Raman microscopy is capable of accurately identifying not only different stages of leukemia cells but also individual cell lines at each stage. Overall, our study provides a rationale for employing this hybrid modality to screen leukemia cells using the widefield QPI and using Raman microscopy for accurate differentiation of early and late-stage phenotypes. This contrast-free and rapid diagnostic tool exhibits great promise for clinical diagnosis and staging of leukemia in the near future.

Thermal desorption effects on fragment ion production from multi-photon ionized uridine and selected analogues

Experiments on neutral gas-phase nucleosides are often complicated by thermal lability. Previous mass spectrometry studies of nucleosides have identified enhanced relative production of nucleobase ions (e.g. uracil⁺ from uridine) as a function of desorption temperature to be the critical indicator of thermal decomposition. On this basis, the present multi-photon ionization (MPI) experiments demonstrate that laser-based thermal desorption is effective for producing uridine, 5-methyluridine, and 2′-deoxyuridine targets without thermal decomposition. Our experiments also revealed one notable thermal dependence: the relative production of the sugar ion C₅H₉O₄⁺ from intact uridine increased substantially with the desorption laser power and this only occurred at MPI wavelengths below 250 nm (full range studied 222–265 nm). We argue that this effect can only be rationalized plausibly in terms of changing populations of different isomers, tautomers, or conformers in the target as a function of the thermal desorption conditions. Furthermore, the wavelength threshold behavior of this thermally-sensitive MPI channel indicates a critical dependence on neutral excited state dynamics between the absorption of the first and second photons. The experimental results are complemented by density functional theory (DFT) optimizations of the lowest-energy structure of uridine and two further conformers distinguished by different orientations of the hydroxymethyl group on the sugar part of the molecule. The energies of the transitions states between these three conformers are low compared with the energy required for decomposition.

This work reveals the first experimental evidence supporting isomer-dependence in the radiation response of a nucleoside.

“Clots and Failures” A Case of COVID-19 Causing STEMI and Persistent Cardiogenic Shock Ultimately Requiring LVAD

Introduction

We present a case of COVID-19 causing hypercoagulability and inflammatory stress leading to STEMI in a patient who went on to develop persistent cardiogenic shock requiring LVA) implantation.

Case Report

57-year-old lady developed COVID-19 infection in May 2020. In June 2020, she presented with chest pain, was noted to have STEMI on EKG, complicated by cardiac arrest with ROSC in 14 minutes. She was in cardiogenic shock as well and was started on veno-arterial ECMO. She underwent left anterior descending artery stent placement. Further hospitalization was complicated by persistent cardiogenic shock and complete heart block and underwent pacemaker and cardiac-defibrillator implantation. She developed pulmonary edema, acute kidney injury requiring hemodialysis, shock liver, and persistent cardiogenic shock. She was weaned off VA-ECMO after 4 days but continued to have severely reduced cardiac function. RHC revealed severe volume overload, pulmonary venous hypertension, low cardiac output, and right heart dysfunction. Echo showed severe LV dysfunction with an EF of 15%. A femoral intra-aortic balloon pump(IABP) was placed on July 7, 2020. An attempt was made to wean her off of IABP on July 10^th,however, it was unsuccessful and she was transitioned to axillary intra-aortic balloon pump. She remained IABP dependent thereafter and on July 15th, given persistent cardiogenic shock, decision was made to pursue advanced heart failure therapies. After multi-disciplinary discussion, the decision to pursue LVAD implantation was made. She underwent a successful LVAD implantation on July 20^th . She failed an extubation trial and underwent tracheostomy on July 23^rd . Post LVAD, she developed atrial fibrillation and was started on digoxin and amiodarone. Her symptoms improved and she was subsequently discharged to rehabilitation in late August on amiodarone, digoxin, metoprolol, prasugrel, warfarin, spironolactone and lisinopril. The detailed timeline is shown in figure 1.

Summary

Hypercoagulability and severe inflammatory stress leading to life-threatening illness is a significant complication of COVID-19 infection. A low threshold for suspecting and treating hypercoagulability and inflammatory induced myocardial ischemia and injury and cardiogenic shock is a reasonable strategy to decrease acute as well as chronic morbidity and mortality.

ECMO for Critically Ill COVID-19 with ARDS: A Case Series

Introduction

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) as bridge to recovery in critically ill COVID-19 continues to be commonly utilized strategy in cases with persistent respiratory failure refractory to traditional ventilation support

Case Report

We report 5 cases of severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2) who were treated with ECMO (Table 1). All 5 cases presented with fever, cough and shortness of breath and a positive nasopharyngeal swab for SARS-CoV-2 on admission. Case 1, 2, 3 and 5 patients were hypoxemic with saturation less than 90% on admission and decompensated rapidly, whereas Case 4 decompensated after day 14. Mechanical ventilation failed to provide adequate oxygenation in all 5 cases; case 2,3 and 5 were started on recruitment measures with proning while it was not possible for case 1 owing to morbid obesity. Proning was not possible in the case 4 as patient became severely hypoxemic while patient was undergoing mechanical thrombectomy. The case 1-4 remained on ECMO for 19, 17, 17 and 2 days respectively. All except case 2 had improvement in APACHEII and SOFA score after ECMO initiation. All 5 patients had elevated inflammatory markers of serum ferritin, D-dimer, Lactate dehydrogenase (LDH), C-reactive protein (CRP) which trended down after a few days of ECMO initiation All 5 patients received high dose steroids during their stay in the ICU. Case 4 and 5 passed away after compassionate extubation. Case 1-3 had prolonged hospital course with complication of hospital acquired pneumonia requiring multiple courses of broad-spectrum antibiotics.

Summary

Our observational report of 5 patients reports the use of ECMO in critically ill SARS-CoV-2 with ARDS and difficult to maintain saturation despite mechanical ventilation and proning with recovery for 3 patients. However, given the lack of ECMO centers; this is not a readily available option. Further studies are warranted to investigate the role of ECMO in SARRS-CoV-2 and careful identification of appropriate candidates.

Coarse Raman and optical diffraction tomographic imaging enable label-free phenotyping of isogenic breast cancer cells of varying metastatic potential

Identification of the metastatic potential represents one of the most important tasks for molecular imaging of cancer. While molecular imaging of metastases has witnessed substantial progress as an area of clinical inquiry, determining precisely what differentiates the metastatic phenotype has proven to be more elusive. In this study, we utilize both the morphological and molecular information provided by 3D optical diffraction tomography and Raman spectroscopy, respectively, to propose a label-free route for optical phenotyping of cancer cells at single-cell resolution. By using an isogenic panel of cell lines derived from MDA-MB-231 breast cancer cells that vary in their metastatic potential, we show that 3D refractive index tomograms can capture subtle morphological differences among the parental, circulating tumor cells, and lung metastatic cells. By leveraging its molecular specificity, we demonstrate that coarse Raman microscopy is capable of rapidly mapping a sufficient number of cells for training a random forest classifier that can accurately predict the metastatic potential of cells at a single-cell level. We also perform multivariate curve resolution alternating least squares decomposition of the spectral dataset to demarcate spectra from cytoplasm and nucleus, and test the feasibility of identifying metastatic phenotypes using the spectra only from the cytoplasmic and nuclear regions. Overall, our study provides a rationale for employing coarse Raman mapping to substantially reduce measurement time thereby enabling the acquisition of reasonably large training datasets that hold the key for label-free single-cell analysis and, consequently, for differentiation of indolent from aggressive phenotypes.

Agricultural adaptation to climate change in the trans-Himalaya: a study of Loba Community of Lo-manthang, Upper Mustang, Nepal

This paper presents community interference on agricultural ecology against climate change impacts in Lo-manthang, Upper-Mustang, Nepal. The peoples’ response strategies are based on traditional agroecological knowledge. This study applied the human ecological approach (Cause ➔ Effect ➔ Response) to analyze continuity and change in the agricultural practice of the indigenous Loba community of the Trans-Himalaya. Data were generated through anthropological fieldwork using quasi-ethnomethodology. Qualitative data on changing climate was further supported by the analysis of meteorological records of last 40 years from the nearest station. The overall impression of the study is that the Lobas are hardly adapting to the dynamics of socio-environmental factors as climatic, geo-environmental, and politico-institutional changes. The strategy adopted to respond to the impacts of change on the local livelihoods is particularly associated with altering traditional agricultural practices. Indigenous knowledge-based systems of farm, labor, and resource management, accompanied by changes in food preference (food value) and linking agriculture with spiritual practice, are specific adaptation options, further supported by emerging options such as occupational modernization and migration. However, not all of these strategies produced positive outcomes in the local socio-ecological system of Lo-manthang. Therefore, policymakers should recognize Trans-Himalayan environmental uniqueness and its sensitivity to different drivers while designing policy to address them.

SARS-CoV-2 and Plasmodium falciparum common immunodominant regions may explain low COVID-19 incidence in the malaria-endemic belt

Coronavirus disease 2019 (COVID-19) has caused significant morbidity and mortality and new cases are on the rise globally, yet malaria-endemic areas report statistically significant lower incidences. We identified potential shared targets for an immune response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by immune determinants' shared identities with P. falciparum using the Immune Epitope Database and Analysis Resource Immune 9.0 browser tool. Probable cross-reactivity is suggested through HLA-A∗02:01 and subsequent CD8+ T-cell activation. The apparent immunodominant epitope conservation between SARS-CoV-2 (N and open reading frame (ORF) 1ab) and P. falciparum thrombospondin-related anonymous protein (TRAP) may underlie the low COVID-19 incidence in the malaria-endemic zone by providing immunity against virus infection to those previously infected with Plasmodium. Additionally, we hypothesize that the shared epitopes which lie within antigens that aid in the establishment of the P. falciparum erythrocyte invasion may be an alternative route for SARS-CoV-2 via the erythrocyte CD147 receptor, although this remains to be proven.

Simple And Cost-Effective Classics Are Back- Revisiting The Role Of Urine Microscopic Analysis For Assessing Severity Of Renal Involvement In Lupus Nephritis

Casestudy

Urinalysis is important to assess disease activity in Lupus nephritis (LN). Hematuria, pyuria, cellular/granular casts and proteinuria are scored separately for assessing renal activity in SLEDAI. However, pyuria is not specific, and could indicate infection. We studied the correlation of microscopic urinalysis and degree of lymphocyturia with histological ISN/RPS 2018 class of LN.

Methods

Pre-biopsy urine was collected in 76 LN patients. The urine sediment was analyzed using light and phase- contrast microscope. Smear stained with supravital stain Sternheimer Malbin, was assessed semi-quantitatively for lymphocytes (per HPF). Renal biopsy was classified into proliferative (Class III/IV ± V)[N=64] and non-proliferative LN (Class I, II, V, VI) [N=12].

Results

48 patients had active urinary sediment. Cellular and/or granular casts were identified only in proliferativeLN (n=15/64; 23.4%). Hematuria (Range 0-65/HPF) was seen in 45 patients. Dysmorphic RBCs were identified in proliferative (n=17/41; mean 9.9 RBCs/HPF) and were absent in non-proliferative LN (mean 1.4 RBCs/HPF). 20 of the 34 patients with pyuria showed predominant lymphocytes. Lymphocyturia (Range 0-20/HPF) was significantly higher in proliferative LN (Mean 4.6/HPF) as compared to non-proliferative LN (Mean 1.5/HPF). Degree of pyuria or proteinuria had no correlation with biopsy class or activity. Lymphocyturia and hematuria showed correlation with biopsy activity index (r=0.30 and 0.39; p&lt;0.05 and &lt;0.001 respectively). A cut-off of average 6 RBCs/HPF or 5 lymphocytes/HPF could correctly identify proliferative LN with 100% specificity (p&lt;0.001; AUC 0.72 and 0.74 respectively, combined AUC 0.81) and sensitivity of 0.42 and 0.36 respectively.

Conclusion

Although renal biopsy is the gold standard for assessment of renal lesions in LN, urine lymphocytes ≥5 and RBCs ≥6/HPF have a high specificity to differentiate proliferative and non-proliferative LN. This may be especially important in patients having comorbidities contraindicating a renal biopsy. Defining urine sediments using lymphocytes can increase the specificity of clinical activity indices.

Identification and Staging of B-Cell Acute Lymphoblastic Leukemia Using Quantitative Phase Imaging and Machine Learning

Identification and classification of leukemia cells in a rapid and label-free fashion is clinically challenging and thus presents a prime arena for implementing new diagnostic tools. Quantitative phase imaging, which maps optical path length delays introduced by the specimen, has been demonstrated to discern cellular phenotypes based on differential morphological attributes. Rapid acquisition capability and the availability of label-free images with high information content have enabled researchers to use machine learning (ML) to reveal latent features. We developed a set of ML classifiers, including convolutional neural networks, to discern healthy B cells from lymphoblasts and classify stages of B cell acute lymphoblastic leukemia. Here, we show that the average dry mass and volume of normal B cells are lower than those of cancerous cells and that these morphologic parameters increase further alongside disease progression. We find that the relaxed training requirements of a ML approach are conducive to the classification of cell type, with minimal space, training time, and memory requirements. Our findings pave the way for a larger study on clinical samples of acute lymphoblastic leukemia, with the overarching goal of its broader use in hematopathology, where the prospect of objective diagnoses with minimal sample preparation remains highly desirable.

Ultrasound is a reliable and faster tool for confirmation of endotracheal intubation compared to chest auscultation and capnography when performed by novice anaesthesia residents - A prospective controlled clinical trial

Background

Anesthesia trainee may initially take longer time to intubate and unintentionally place the endotracheal tube (ETT) in the esophagus. The present study determined if ultrasound is the fastest method of confirmation of correct placement of ETT compared to capnography, and chest auscultation in trainees.

Methods

First year anesthesia residents performed intubation in 120 patients recruited after ethical clearance and informed consent. Time to visualize flutter in trachea, double trachea sign, time to appearance of first and sixth capnography, and time to execute chest auscultation was noted.

Results

Ultrasonography was statistically fastest method to determine endotracheal intubation (36.50 ± 15.14 seconds) vs unilateral chest auscultation (50.29 ± 15.50 seconds) vs bilateral chest auscultation (51.90 ± 15.98 seconds) vs capnography first waveform (53.57 ± 15.97 seconds) vs capnography sixth waveform (61.67 ± 15.88 seconds).

Conclusion

When teaching endotracheal intubation to novice anesthesia residents using conventional direct laryngoscopy, ultrasonography is the fastest method to confirm correct ETT placement compared to capnograph and chest auscultation. Mentor can guide trainee to direct ETT towards trachea and can promptly detect esophageal intubation by double trachea sign.

Proximal humerus fracture-dislocation managed by mini-open reduction and percutaneous screw fixation

BACKGROUND

We describe a minimally open reduction and percutaneous fixation technique for three- and four-part proximal humeral fracture-dislocations which preserves soft tissues.

METHODS

Eleven consecutive patients with three-and four-part proximal humeral fracture-dislocations (eight anterior, three posterior dislocations) were treated this way. The dislocation is reduced using a mini-open deltopectoral approach with a horizontal split in subscapularis. Fracture fragments are fixed with percutaneous screws. Constant and Oxford Shoulder Score were collected prospectively.

RESULTS

Mean age was 51 years (range 32-65). Mean follow-up was 36 months (range 24-72 months). At last follow-up mean Constant score was 75 (range 64-86) compared to 88 (range 85-92) for the uninjured shoulder. Mean Oxford shoulder score was 41 (range 34-46). One patient developed avascular necrosis. Screw back out was seen in three patients. These were removed under local anaesthesia. There were no screw penetrations of articular surface. One patient suffered a radial nerve neuropraxia which resolved.

CONCLUSION

These results are promising and comparable to published literature with other means of fixation for this complex problem. Due to minimal soft tissue dissection the complications rate is low.

Most Hemodynamically Stable Method for Change From High to Low Anesthesia Flow: A Randomized Controlled Trial Comparing State Entropy, High Fresh Gas Flow for 10 Minutes, and 0.8 Ratio of End-Expired Agent Concentration to Inspired Agent Concentration

This study was undertaken to determine the most hemodynamically stable method to low-flow anesthesia (LFA) between 10-minute administration of high fresh gas flow, 0.8 equilibration ratio (Fe/Fi), and state entropy (SE) between 40 and 60, a marker for adequate depth of anesthesia. Change from high fresh gas flow to LFA was done in 3 groups of 30 patients each: group T (time): 10 minutes; group R (ratio): Fe/Fi = 0.8, and group SE: SE = 40 to 50. A decrease in mean blood pressure or heart rate was treated with ephedrine or atropine, with study termination at more than 2 boluses of either. In group SE, no patient required ephedrine or atropine. The requirement for ephedrine was statistically higher in groups R and T than group SE. Atropine requirement was statistically higher in group R vs groups T and SE. In group R, the mean (SD) time to LFA was 43.9 (20.37) minutes, and in group SE was 151.9 (74.4) seconds. Hypotension or bradycardia did not occur when LFA was started at SE of 40 to 50 after anesthesia induction compared with LFA at 10 minutes, which caused hypotension, and Fe/Fi of 0.8, which caused hypotension and bradycardia.

High Power Density Low-Lead-Piezoceramic-Polymer Composite Energy Harvester

Polymer-piezoceramic composites show mutual properties of piezoceramics and polymers that can be efficiently utilized in energy harvesting applications. Here we fabricated 0-3 composite films using high-performance low-lead piezoceramic (x)Bi(Ni_1/2Zr_1/2)O₃-(1-x)PbTiO₃ (BNZ-PT) as ceramic filler and polyvinylidene fluoride (PVDF) as polymer matrix. Unlike the conventional morphotropic phase boundary piezoelectrics such as the (1-x)PbTiO₃-(x)PbZrO₃, the large piezoelectric response of the BNZ-PT can be obtained by poling-induced cubic-like-to-tetragonal phase transformation. This leads to high piezoelectric coefficient of the PVDF-BNZ-PT composite films as well as high-energy harvesting performance. Composite films with different volume fractions of ceramic showed surface power density of 1.3- [Formula: see text]/cm², and volume power density of 72.2- [Formula: see text]/cm³ using simple bending and unbending movements. Energy harvester in the form of cantilever fixed at both ends showed surface power density of 56.97- [Formula: see text]/cm² and volume power density of 3165- [Formula: see text]/cm³ in response to impact pressure pulses. The generated power from the composite films is comparable to composite energy generators reported to date. The volume power density, however, is highest to the best of our knowledge among the reported 0-3 polymer-piezoceramic composite energy harvesters.

Integration of diffraction phase microscopy and Raman imaging for label-free morpho-molecular assessment of live cells

Label-free quantitative imaging is highly desirable for studying live cells by extracting pathophysiological information without perturbing cell functions. Here, we demonstrate a novel label-free multimodal optical imaging system with the capability of providing comprehensive morphological and molecular attributes of live cells. Our morpho-molecular microscopy (3M) system draws on the combined strength of quantitative phase microscopy (QPM) and Raman microscopy to probe the morphological features and molecular fingerprinting characteristics of each cell under observation. While the commonr-path geometry of our QPM system allows for highly sensitive phase measurement, the Raman microscopy is equipped with dual excitation wavelengths and utilizes the same detection and dispersion system, making it a distinctive multi-wavelength system with a small footprint. We demonstrate the applicability of the 3M system by investigating nucleated and nonnucleated cells. This integrated label-free platform has a promising potential in preclinical research, as well as in clinical diagnosis in the near future.

Hand function outcome in closed small bone fractures treated by open reduction and internal fixation by mini plate or closed crossed pinning: a randomized controlled trail

PURPOSE

No study in literature clearly gives advantage of one method of surgical fixation of fracture over the other in metacarpal and phalangeal bones of hand comparing wider outcome measures.

MATERIALS AND METHODS

A randomized controlled trial between closed reduction and percutaneous Kirschner wire fixation or open reduction and internal fixation with mini fragment plates was conducted. A total of 32 patients with 16 in each group were taken in tertiary-level teaching hospital from 2014 to 2016. Four patients lost to follow-up apart from 32 studied. Inclusion criteria were age group 16-60 years, fresh (3 days) closed shaft fractures of metacarpal and phalanges. Outcome evaluated were time to union of fracture, degree of strength achieved measured with dynamometer, DASH scoring, range of motion of hand and each digit.

RESULTS

Both groups were comparable in terms of return to full hand function, union and total range of motion. K wire fixation results were slightly better than plating group in terms of early DASH score and grip strength after fixation.

CONCLUSION

No modality was found to be superior for fixation of small bone fractures of hand. But K wire being cheaper and without inherent complication of plating like scar and tendon irritation, K wire fixation is preferred over plating in shaft fractures of metacarpal and phalanges.

LEVEL OF EVIDENCE

Level I Therapeutic study.