Priorities, opportunities, and challenges for integrating microorganisms into Earth system models for climate change prediction

Climate change jeopardizes human health, global biodiversity, and sustainability of the biosphere. To make reliable predictions about climate change, scientists use Earth system models (ESMs) that integrate physical, chemical, and biological processes occurring on land, the oceans, and the atmosphere. Although critical for catalyzing coupled biogeochemical processes, microorganisms have traditionally been left out of ESMs. Here, we generate a "top 10" list of priorities, opportunities, and challenges for the explicit integration of microorganisms into ESMs. We discuss the need for coarse-graining microbial information into functionally relevant categories, as well as the capacity for microorganisms to rapidly evolve in response to climate-change drivers. Microbiologists are uniquely positioned to collect novel and valuable information necessary for next-generation ESMs, but this requires data harmonization and transdisciplinary collaboration to effectively guide adaptation strategies and mitigation policy.

Surgery's Rosetta Stone: Natural language processing to predict discharge and readmission after general surgery

BACKGROUND

This study aimed to examine the accuracy with which multiple natural language processing artificial intelligence models could predict discharge and readmissions after general surgery.

METHODS

Natural language processing models were derived and validated to predict discharge within the next 48 hours and 7 days and readmission within 30 days (based on daily ward round notes and discharge summaries, respectively) for general surgery inpatients at 2 South Australian hospitals. Natural language processing models included logistic regression, artificial neural networks, and Bidirectional Encoder Representations from Transformers.

RESULTS

For discharge prediction analyses, 14,690 admissions were included. For readmission prediction analyses, 12,457 patients were included. For prediction of discharge within 48 hours, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.86 and 0.86 for Bidirectional Encoder Representations from Transformers, 0.82 and 0.81 for logistic regression, and 0.82 and 0.81 for artificial neural networks. For prediction of discharge within 7 days, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.82 and 0.81 for Bidirectional Encoder Representations from Transformers, 0.75 and 0.72 for logistic regression, and 0.68 and 0.67 for artificial neural networks. For readmission prediction within 30 days, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.55 and 0.59 for Bidirectional Encoder Representations from Transformers and 0.77 and 0.62 for logistic regression.

CONCLUSION

Modern natural language processing models, particularly Bidirectional Encoder Representations from Transformers, can effectively and accurately identify general surgery patients who will be discharged in the next 48 hours. However, these approaches are less capable of identifying general surgery patients who will be discharged within the next 7 days or who will experience readmission within 30 days of discharge.

Artificial intelligence for predicting acute appendicitis: a systematic review

BACKGROUND

Paediatric appendicitis may be challenging to diagnose, and outcomes difficult to predict. While diagnostic and prognostic scores exist, artificial intelligence (AI) may be able to assist with these tasks.

METHOD

A systematic review was conducted aiming to evaluate the currently available evidence regarding the use of AI in the diagnosis and prognostication of paediatric appendicitis. In accordance with the PRISMA guidelines, the databases PubMed, EMBASE, and Cochrane Library were searched. This review was prospectively registered on PROSPERO.

RESULTS

Ten studies met inclusion criteria. All studies described the derivation and validation of AI models, and none described evaluation of the implementation of these models. Commonly used input parameters included varying combinations of demographic, clinical, laboratory, and imaging characteristics. While multiple studies used histopathological examination as the ground truth for a diagnosis of appendicitis, less robust techniques, such as the use of ICD10 codes, were also employed. Commonly used algorithms have included random forest models and artificial neural networks. High levels of model performance have been described for diagnosis of appendicitis and, to a lesser extent, subtypes of appendicitis (such as complicated versus uncomplicated appendicitis). Most studies did not provide all measures of model performance required to assess clinical usability.

CONCLUSIONS

The available evidence suggests the creation of prediction models for diagnosis and classification of appendicitis using AI techniques, is being increasingly explored. However, further implementation studies are required to demonstrate benefit in system or patient-centred outcomes with model deployment and to progress these models to the stage of clinical usability.

A phase II study of metformin plus pemetrexed and carboplatin in patients with non-squamous non-small cell lung cancer (METALUNG)

Immune checkpoint inhibitors (ICIs) ± chemotherapy is the standard treatment for driver mutation-negative non-small cell lung cancer (NSCLC). However, accessibility to ICIs in LMICs is limited due to high cost, and platinum-based chemotherapy remains the mainstay of treatment. Metformin has anticancer properties, and studies suggest synergism between metformin and pemetrexed. Based on preclinical evidence, this combination may be more beneficial for STK11-mutated NSCLC, a subgroup, inherently resistant to ICIs. In this Simon two-stage, single-arm phase 2 trial, we investigated metformin with pemetrexed-carboplatin (PC) in patients with treatment-naive stage IV non-squamous NSCLC. The primary outcome was 6-month progression-free survival (PFS) rate. Secondary outcomes were safety, overall survival (OS), overall response rate (ORR), proportion of STK11 mutation, and effect of STK11 mutation on 6-month PFS rate. The study was terminated for futility after interim analysis. The median follow-up was 34.1 months. The 6-month PFS rate was 28% (95% CI 12.4-0.46). The median PFS and OS were 4.5 (95% CI 2.2-6.1) and 7.4 months (95% CI 5.3-15.3), respectively. The ORR was 72%. Gastrointestinal toxicities were the most common. No grade 4/5 toxicities were reported. Targeted sequencing was possible in nine cases. Two patients had STK11 mutation and a poor outcome (PFS < 12 weeks). We could not demonstrate the benefit of metformin with CP in terms of improvement in 6-month PFS rate; however, the combination was safe (CTRI/2019/02/017815).

The clinical and genetic features of hereditary pancreatitis in South Australia

Objective

To characterise the clinical phenotypes and genetic variants of hereditary pancreatitis in people diagnosed in South Australia.

Design, setting, participants

Cross‐sectional study of people who received molecular diagnoses of hereditary pancreatitis from one of four major diagnostic services in South Australia, 1 January 2006 – 30 June 2021.

Main outcome measures

Genotypic and clinical features of people with hereditary pancreatitis, including age at onset, attack frequency, pain indices, use of opioid medications, and physical and mental health impact of hereditary pancreatitis.

Results

We identified 44 people from ten families who received molecular diagnoses of hereditary pancreatitis during 2006–21 (including 25 Indigenous people [57%] and 27 women [61%]): 36 with PRSS1, five with SPINK1, and three with PRSS1 and SPINK1 mutations (determined by whole exome sequencing). Symptom onset before the age of ten years was reported by 37 people (84%). Pancreatitis‐related pain during the preceding four weeks was described as moderate or high by 35 people (79%); 38 people regularly used opioids (86%). Fifteen patients had diabetes mellitus (34%), and eight had undergone pancreatic surgery (18%). The estimated prevalence of hereditary pancreatitis was 1.1 (95% CI, 0.72–1.4) cases per 100 000 population for non‐Indigenous and 71 (95% CI, 66–77) cases per 100 000 population for Indigenous South Australians. Among people with adult‐onset chronic pancreatitis admitted to South Australian public hospitals during 2001–2019, the proportions of Indigenous people (12%) and women (38%) were smaller than we report for hereditary pancreatitis.

Conclusion

The estimated prevalence of hereditary pancreatitis in South Australia is higher than in Europe. PRSS1 gene mutations are important causes, particularly among Indigenous young people.

Central nervous system infections caused by pathogenic free-living amoebae: An Indian perspective

Pathogenic free-living amoebae (FLA), namely Acanthamoeba sp., Naegleria fowleri and Balamuthia mandrillaris are distributed worldwide. These neurotropic amoebae can cause fatal central nervous system (CNS) infections in humans. This review deals with the demographic characteristics, symptoms, diagnosis, and treatment outcomes of patients with CNS infections caused by FLA documented in India. There have been 42, 25, and 4 case reports of Acanthamoeba granulomatous amoebic encephalitis (GAE), N. fowleri primary amoebic meningoencephalitis (PAM), and B. mandrillaris meningoencephalitis (BAE), respectively. Overall, 17% of Acanthamoeba GAE patients and one of the four BAE patients had some form of immunosuppression, and more than half of the N. fowleri PAM cases had history of exposure to freshwater. Acanthamoeba GAE, PAM, and BAE were most commonly seen in males. Fever, headache, vomiting, seizures, and altered sensorium appear to be common symptoms in these patients. Some patients showed multiple lesions with edema, exudates or hydrocephalus in their brain CT/MRI. The cerebrospinal fluid (CSF) of these patients showed elevated protein and WBC levels. Direct microscopy of CSF was positive for amoebic trophozoites in 69% of Acanthamoeba GAE and 96% of PAM patients. One-fourth of the Acanthamoeba GAE and all the BAE patients were diagnosed only by histopathology following autopsy/biopsy samples. Twenty-one Acanthamoeba GAE survivors were treated with cotrimoxazole, rifampicin, and ketoconazole/amphotericin B, and all eleven PAM survivors were treated with amphotericin B alongside other drugs. A thorough search for these organisms in CNS samples is necessary to develop optimum treatment strategies.

Dose-dense Paclitaxel and Carboplatin as Neoadjuvant Chemotherapy for Stage IIB/IIIA Non-small Cell Lung Cancer - A Phase II trial

AIMS

The approach to potentially resectable non-small cell lung cancer (NSCLC) remains controversial. There is a benefit of neoadjuvant chemotherapy (NACT), but the ideal regimen is unknown. We evaluated the efficacy and safety of dose-dense NACT in potentially resectable NSCLC in this phase II trial.

MATERIALS AND METHODS

Paclitaxel at 80 mg/m² on days 1, 8 and 15 with AUC-6 carboplatin on day 1, 3 weekly for four cycles was evaluated as NACT. Patients with Eastern Cooperative Oncology Group performance status 0-2, stage IIB and IIIA (with only non-bulky N2 nodes) were included. The primary end point was the objective response rate. Secondary end points included toxicity, progression-free survival, recurrence-free survival, complete resection rate and overall survival. The relative dose intensity (RDI) was calculated to define tolerability (CTRI/2016/05/006916).

RESULTS

In total, 37 patients were enrolled (median age 55 years). Most (78.8%) were smokers. Most patients had adenocarcinoma (57.6%) and stage IIIA disease (81.0%) according to the seventh American Joint Committee on Cancer staging system. Seventy-eight per cent of patients completed four cycles. The objective response rate was 75.6% with a complete response in 10.8%. The mean RDI of paclitaxel was 88.61%, with 68.0% of patients able to maintain an RDI ≥85.0%. In total, 187 toxicity events were recorded (120 grade 1, 64 grade 2 and three grade 3 events). Common toxicities were peripheral neuropathy (20.3%), myalgia (19.8%), nausea (15.7%) and neutropenia (10.2%). There were no treatment-related deaths. Seventeen patients underwent surgery (lobectomy 82.4%). After a median follow-up of 47 months (95% confidence interval 27-50.7 months), the median progression-free survival was 9.6 months (7.4-17.4) and overall survival was 29.2 months (16.0-37.2).

CONCLUSION

Dose-dense paclitaxel-carboplatin is feasible, safe and efficacious and should be evaluated further in potentially resectable NSCLC.

Improving quality and efficiency of care for advanced appendicitis in children

BACKGROUND

Complicated appendicitis encompasses a spectrum of severity with heterogeneity in definition and substantial variation in care. Enhanced recovery after surgery or 'fast-track' protocols aim to reduce practice variation by standardizing care. These initiatives may improve quality and efficiency of care, preserve resources and expedite discharge. This study aims to evaluate the impact of a standardized Enhanced Recovery Pathway (ERP) on the post-operative recovery of children with a subset of complicated appendicitis termed 'advanced' appendicitis.

METHODS

We defined advanced appendicitis as gangrenous or suppurative appendicitis without perforation, contained iatrogenic perforation, or localized purulent fluid. Children with operative findings reflecting these criteria were enrolled in the ERP protocol. Key protocol components include early upgrade of diet, avoidance of intravenous analgesia, abridged intravenous antibiotics, early ambulation and standardized discharge criteria. The study period was May 2018 to June 2019. A historical cohort was used as the comparator group.

RESULTS

Outcomes for 44 children treated under the ERP were compared to 44 historical controls. There was a 20% reduction in median post-operative length of stay (1.80 vs. 2.24 days, p = 0.02). Intravenous analgesia was received by fewer patients (6.8% vs. 36.4%, p = 0.01) with significant reduction in antiemetic requirement (p = 0.03). No significant difference in 30-day complication rates was observed.

CONCLUSION

Reduced post-operative length of stay and reduction in practice variation were achieved after implementation of a 'fast-track' protocol for children with advanced appendicitis. Additional benefits of this protocol include reduced provision of intravenous morphine analgesia, decreased resource use and cost savings.

Australian experience with total pancreatectomy with islet autotransplantation to treat chronic pancreatitis

BACKGROUND

This study aimed to describe the clinical outcomes of total pancreatectomy with islet autotransplantation (TP-IAT) in Australia.

METHODS

Individuals selected for TP-IAT surgery according to the Minnesota Criteria (Appendix) without evidence of diabetes were evaluated including time to transplantation from pancreatectomy, islet numbers infused and post-transplantation HbA1c, C-peptide, total daily insulin and analgesic requirement.

RESULTS

Sixteen individuals underwent TP-IAT from Australia and New Zealand between 2010 and 2020. Two recipients are deceased. The median islet equivalents/kg infused was 4244 (interquartile range (IQR) 2290-7300). The median C-peptide 1 month post-TP-IAT was 384 (IQR 210-579) pmol/L and at median 29.5 (IQR 14.5-46.5) months from transplant was 395 (IQR 139-862) pmol/L. Insulin independence was achieved in eight of 15 (53.3%) surviving recipients. A higher islet equivalents transplanted was most strongly associated with the likelihood of insulin independence (P < 0.05). Of the 15 surviving recipients, 14 demonstrated substantial reduction in analgesic requirement.

CONCLUSION

The TP-IAT programme in Australia has been a successful new therapy for the management of individuals with chronic pancreatitis including hereditary forms refractory to medical treatment to improve pain management with 50% insulin independence rates.

Who manages health workforce in the States of India: Profile, knowledge and perceptions of the team

Problem

Human resources in the public health sector is of prime importance in a limited resource setting country, who at times work in a high-pressure, limited resource environment and where skilled staff continue to remain in short supply. The role of Human Resource for Health (HRH) team responsible for managing this health workforce is crucial. They play an important role in improving the human resource practices and creating an enabling organizational culture for optimal resource utilization. The paper explores the profile of the HRH teams of the states of India, their knowledge levels, and perceptions of their role.

Methods

The participants were HR Managers from 29 states of India who look after HRH in National Health Mission and State Health Departments. Cross-sectional survey tool was used for data collection. Quantitative data analysis included univariate and bivariate analysis. One Way ANOVA test of significance and post-hoc tests using Tukey's method was used to ascertain the groups with significant difference.

Results

Most of the HRH team members are postgraduates or have management background. Their experience varies from &lt;1year to &gt; 25 years. Mostly of them perceive their role to be limited to implementing bare essential HRM practices, mostly administrative. The educational qualification of the members did not have any significant bearing on their technical knowledge related to HRM practices; but their experience in public health sector showed a significant association.

Lessons

This study lends evidence to the principle that professionals who have been in the system for long, know about HRH and the associated policies better, and hence may be better equipped to handle HRH and establish good HR Management (HRM) systems. Better role clarity among the HRH teams, expansion of their current scope of work to include advanced practices of HRM and continuous capacity building mechanisms are needed to help strengthen the development and management of HRH.

Key messages

This study, a first of its kind in the country, lend evidence related to the principle for deciding the profile of team who should be entrusted with managing and development of HRH. The Study gives evidence to focus on the role clarity of HRH to zero down their knowledge and skills gaps and enhance their competencies through better capacity building.

Variation in ureteric re-implantation for Australian children

BACKGROUND

Management options for vesicoureteric reflux are numerous, increasingly diversifying and debated. There is longstanding anecdotal opinion of inexplicable regional variation in vesicoureteric reflux management in Australia. This study investigates temporal trends in ureteric re-implantation for children, and variation between states and territories.

METHODS

Ureteric re-implantation data for children aged 0-14 years were retrieved from the Medicare Benefits Scheme item reports database for the 20-year period from 1998-2017. Claims data were population adjusted for each state then standardized for age using Australian Bureau of Statistics records. National and regional trends were calculated using joinpoint regression. Comparison between eastern (New South Wales, Victoria, Queensland, Tasmania, Australian Capital Territory) and western or central (Western Australia, South Australia) states was performed using the Mann-Whitney U-test.

RESULTS

There were 4919 procedure rebate claims during the study period. A national decrease in claim rates of 6.3% per 100 000 children was identified (P < 0.001). This was derived from significant decreases observed in eastern states. There was a threefold higher claim rate in Western Australia and South Australia per annum compared to the remainder of the country (4.0 versus 12.6 per 100 000; P < 0.001). For the most recent 5 years of the study period, this difference increased to a sevenfold higher rate (1.6 versus 11.1; P < 0.001).

CONCLUSION

There has been a dramatic nationwide decline in the rate of ureteric re-implantation procedure claims. Regional disparity between each side of the country is widening. Further research is required to determine if this degree of variation is warranted or unwarranted. The observed regional variation facilitates opportunity for a nationwide pragmatic clinical trial.

Loop mediated isothermal amplification assay for detection of Trichomonas vaginalis in vaginal swabs among symptomatic women from North India

Trichomonas vaginalis is one of the most common curable sexually transmitted pathogens infecting both men and women worldwide. Unlike traditional methods such as microscopy and culture, nucleic acid amplification tests rapidly detect this agent, assisting in treatment. Conventional polymerase chain reaction (PCR), the loop-mediated isothermal amplification (LAMP), and the Xpert TV assay were evaluated using 28 microscopy positive T. vaginalis samples and 125 microscopy negative samples from symptomatic females of reproductive age. The sensitivity of all tests was 100% and the specificity was 100%, 100%, and 99·2% for PCR, Xpert TV, and LAMP, respectively. The inter-rater reliability was excellent for PCR: Xpert TV (kappa-coefficient = 1) and good for LAMP assay: Xpert TV/PCR (kappa-coefficient = 0·98) and conventional PCR: LAMP (kappa-coefficient = 0·98). The study highlights the importance of PCR for screening T. vaginalis in women, particularly in laboratories where the Xpert-TV assay is not available or not affordable. The LAMP assay showed a lower positive predictive value which merits further evaluation. SIGNIFICANCE AND IMPACT OF THE STUDY: Trichomonas vaginalis is a common sexually transmitted pathogen associated with considerable morbidity and risk of complications. Due to the limitations of traditional diagnostic modalities, three molecular assays were compared: conventional polymerase chain reaction (PCR), Xpert TV assay, and loop mediated isothermal amplification (LAMP) assay for detecting T. vaginalis in symptomatic females. All tests had a sensitivity of 100% and the inter-rater reliability was excellent for PCR: Xpert TV, and good for LAMP assay: Xpert TV/PCR. The translational impact of this study lies in the possible use of conventional PCR and LAMP in laboratories where the Xpert TV assay is not available or not affordable.

Upper Gastrointestinal Function in Morbidly Obese Adolescents Before and 6 Months After Gastric Banding

BACKGROUND

The effects of laparoscopic adjustable gastric band (LAGB) placement on upper gastrointestinal tract function in obese adolescents are unknown. Therefore, our aim was to determine the short-term effects of LAGB on esophageal motility, gastroesophageal reflux, gastric emptying, appetite-regulatory hormones, and perceptions of post-prandial hunger and fullness.

METHODS

This study was part of a prospective cohort study (March 2009-December 2015) in one tertiary referral hospital. The study included obese adolescents (14-18 years) with a body mass index (BMI) > 40 (or ≥ 35 with comorbidities). Gastric emptying was assessed by ¹³C-octanoic acid breath test, pharyngeal, and esophageal motor function by high-resolution manometry with impedance (HRIM), and appetite and other perceptions using 100-mm visual analogue scales. Dysphagia symptoms were scored using a Dakkak questionnaire. Data were compared pre- and post-LAGB placement and at a 6-month follow-up.

RESULTS

Based upon analysis of 15 adolescents, at the 6-month follow-up, LAGB placement: (i) led to a significant reduction in weight and BMI; (ii) increased fullness and decreased hunger post-meal; (iii) increased symptoms of dysphagia after solid food; and, despite these effects, (iv) caused little or no changes to appetite hormones, while (v) effects on gastric emptying, esophageal motility, esophageal bolus transport, and esophageal emptying were not significant.

CONCLUSION

In adolescents, LAGB improved BMI and altered the sensitivity to nutrients without significant effects on upper gastrointestinal tract physiology at the 6-month follow-up.

Long-term neurodevelopment outcome of caffeine versus aminophylline therapy for apnea of prematurity

OBJECTIVE

Methylxanthines are the most commonly prescribed drug in neonatal setups. However, Clinicians show indecision in choosing the right agent for Apnea of Prematurity in most of the developing countries. Present study aimed to compare rate of mortality and survival with normal neurodevelopment outcome at 18 to 24 months of corrected age, between Caffeine- and Aminophylline-treated infants for apnea of prematurity.

METHODS

240 infants were randomly allocated to caffeine and aminophylline for apnea of prematurity during February 2012 to January 2015. Long-term neurodevelopmental assessment was done only from children who had attained corrected age of 18 to 24 months during April 2014 to February 2016. Cognitive, language and motor deficits were assessed by Bayley Scale of infant and toddler development (BSID - III). Postnatal characteristics such as hearing and visual impairments during NICU stay were noted and same were followed up.

RESULTS

Infants allocated to caffeine group showed 83% less risk of getting cognitive impairment (RR 0.16; CI 95% range 0.02 to 1.36), 50% less risk of developing motor deficits (RR 0.50; CI 95% range 0.12 to 1.95) and 24% less risk of developing language problems (RR 0.76; CI 95% range 0.36 to 1.58). However in all the neurodevelopment domains the difference between groups was not statistically significant. Risk of mortality in caffeine group was 9% less over aminophylline group which was statistically non-significant (RR - 0.92; CI 95% range - 0.45 to 1.84; p = 0.81). Physical growth parameters were found to be similar in both the groups. Risk of developing visual abnormality and hearing impairments was also statistically non-significant between the groups.

CONCLUSION

Caffeine and aminophylline showed similar effects in reducing the rate of mortality and improving the survival without neurodevelopment delays; though the clinical significance of caffeine over aminophylline cannot be undermined.

A study of dysphagia symptoms and esophageal body function in children undergoing anti-reflux surgery

BACKGROUND

The role of high-resolution esophageal impedance manometry (HRIM) for establishing risk for dysphagia after anti-reflux surgery is unclear. We conducted a prospective study of children with primary gastroesophageal reflux (GER) disease, for whom symptoms of dysphagia were determined pre-operatively and then post-operatively and we examined for features that may predict post-operative dysphagia.

METHODS

Thirteen children (aged 6.8-15.5 years) undergoing work-up prior to 360o Nissen fundoplication were included in the study. A dysphagia score assessed symptoms at pre-operative study and post-operatively (mean 1.4 years). A HRIM procedure recorded 5-ml liquid, 5-ml viscous and 2-cm solid boluses. We assessed esophageal motility, esophago-gastric junction (EGJ) morphology, EGJ contractility and pressure-flow variables indicative of bolus distension pressures and bolus clearance pressures. A composite pressure-flow index score was also derived.

RESULTS

Pre-operative pressure-flow index was positively correlated with post-operative dysphagia score (viscous bolus r = 0.771, p < 0.005). Of three variables that comprise the pressure-flow index, the ramp pressure measured during bolus clearance was the main driver of the effect seen (viscous bolus r = 0.819, p < 0.005).

CONCLUSIONS

In order to mitigate symptoms in relation to anti-reflux surgery, dysphagia symptoms and esophageal function need to be pre-operatively assessed. In patients with normal motility, an elevated pressure-flow index may predict post-operative dysphagia.

Improving ability of RSV microneutralization assay to detect G-specific and cross-reactive neutralizing antibodies through immortalized cell line selection

Respiratory syncytial virus (RSV) is a significant cause of bronchiolitis and pneumonia. Protection against RSV is associated with neutralizing antibodies against the fusion (F) and attachment (G) glycoproteins. Several RSV vaccine candidates are in development, but their immunogenicity is hard to compare due to the little-understood differences between multiple RSV neutralizing antibody assays used. Existing assays utilize primarily Vero or HEp-2 cells, but their ability to detect G-neutralizing antibodies or antibodies against specific RSV strains is unclear. In this work, we developed an RSV microneutralization assay (MNA) using unmodified RSV and immortalized cell line derived from human airway epithelial cells (A549). Performance of A549-, HEp-2- and Vero-based MNA was compared under the same assay conditions (fixed amount of virus and cells) with regards to detection of neutralizing antibodies against RSV A or B viruses, G-reactive neutralizing antibodies, and effect of complement. Our results indicate that A549 cells yield the highest MNA titers, particularly in the RSV A/A2 MNA, are least susceptible to complement-enhancing effect of neutralizing titer readout and are superior to Vero or HEp-2 MNA at recognizing G-reactive neutralizing antibodies when no complement is used. Vero cells, however, can be more consistent at recognizing neutralizing antibodies against multiple RSV strains. The choice of substrate cells thus affects the outcome of MNA, as some immortalized cells better support detection of broader range of neutralizing antibodies, while others facilitate detection of G-targeting neutralizing antibodies, a long-thought prerogative of primary airway epithelial cells.

Effects of concurrent training on physical health and performance

The primary objective of this narrative review was to evaluate the current literature and to provide further insight into the role of concurrent training on various components of physical health or performance. Literature was obtained by electronic searches of databases using specific keywords. Combined effect of training sessions proved to be as beneficial as drug interactions. Results from cross-sectional, longitudinal, and intervention studies are reviewed and discussed with main focus on physical parameters, such as body composition, physiological parameters, molecular adaptation, athlete’s perspective, order of execution, interference phenomena and recovery. In conclusion, concurrent resistance and endurance training is an effective method for enhancing overall fitness as well as improving quality of life.

Chemotherapy and targeted therapy in the management of cervical cancer

Management of cervical cancer has undergone refinement in the past two decades; concurrent chemo-radiation (CCRT) (with cisplatin alone or in combination) is currently the standard treatment approach for patients with locally advanced disease (FIGO stage IIB-IVA). About 30%-40% of such patients fail to achieve complete response; alternative approaches are needed to improve outcome for them. Treatment with bevacizumab (an inhibitor of vascular endothelial growth factor) along with chemotherapy is associated with improved survival in patients with recurrent or metastatic cervical cancer. Weekly paclitaxel and carboplatin for 4-6 weeks as dose dense chemotherapy prior to CCRT is currently under study in a phase III, multicentric trial. Role of adjuvant chemotherapy after CCRT in patients with positive lymph nodes, larger tumor volume and those with stage III-IVA disease needs further exploration. Novel agents targeting molecular pathways are currently being studied. Recent development of immune check point inhibitors is exciting, results of ongoing studies are awaited with interest.

Can common serum biomarkers predict complicated appendicitis in children?

PURPOSE

As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis.

METHODS

Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal-Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)].

RESULTS

Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5-12, 38% 13-17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5-12- (p < 0.0001) and 13-17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 10⁹/L in 58% CA and 43% SA (p < 0.0001).

CONCLUSIONS

Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

Global trends in paediatric robot-assisted urological surgery: a bibliometric and Progressive Scholarly Acceptance analysis

The inaugural robot-assisted urological procedure in a child was performed in 2002. This study aims to catalogue the impact of this technology by utilizing bibliographic data as a surrogate measure for global diffusion activity and to appraise the quality of evidence in this field. A systematic literature search was performed to retrieve all reported cases of paediatric robot-assisted urological surgery published between 2003 and 2016. The status of scientific community acceptance was determined using a newly developed analysis model named progressive scholarly acceptance. A total of 151 publications were identified that reported 3688 procedures in 3372 patients. The most reported procedures were pyeloplasty (n = 1923) and ureteral reimplantation (n = 1120). There were 16 countries and 48 institutions represented in the literature. On average, the total case volume reported in the literature more than doubled each year (mean value increase 236.6% per annum). The level of evidence for original studies remains limited to case reports, case series and retrospective comparative studies. Progressive Scholarly Acceptance charts indicate that robot-assisted techniques for pyeloplasty or ureteral reimplantation are yet to be accepted by the scientific community. Global adoption trends for robotic surgery in paediatric urology have been progressive but remain low volume. Pyeloplasty and ureteral reimplantation are dominant applications. Robot-assisted techniques for these procedures are not supported by high quality evidence at present. Next-generation robots are forecast to be smaller, cheaper, more advanced and customized for paediatric patients. Ongoing critical evaluation must occur simultaneously with expected technology evolution.

Localized insulin amyloidosis with use of concentrated insulin: a potential complication

BACKGROUND

Insulin-derived amyloidosis is a rare form of amyloidosis composed of insulin fibrils. The pH and concentration of insulin are known to influence the conformational state of the insulin hormone, with an increasing concentration favouring a more complex conformation. Concentrated insulin delivers a large amount of insulin to a localized area, raising the possibility of inducing conformational changes, forming insulin fibrils and leading to localized insulin amyloidosis.

CASE REPORT

A middle-aged woman with long history of Type 2 diabetes mellitus, treated with concentrated human insulin (U-500 insulin) presented with nodular lesions at the site of her daily insulin injections. A punch biopsy of the nodules showed skin with dermal amyloidosis staining favourably with Congo Red stain. The amyloid tumours were resected and areas positive for Congo Red stain were sent for liquid chromatography tandem mass spectrometry, which showed a peptide profile consistent with amyloid insulin.

CONCLUSION

Concentrated insulin was first introduced in 1952, however, it is only over the last two decades that it has been used increasingly, in congruence with the increasing incidence of obesity and diabetes mellitus seen in the USA. Only a few cases of insulin amyloidosis at the site of injection have been described in literature. With the increase in the use of insulin, this complication seems to be occurring more frequently. This is the first case report of a person with diabetes mellitus who developed localized insulin amyloidosis with the use of concentrated insulin, and points towards a potential complication of developing insulin amyloidosis with the use of concentrated insulin.

Micturating cystourethrogram as a tool for investigating UTI in children - An institutional audit

BACKGROUND

Micturating cystourethrograms (MCUG) are the gold standard for evaluating vesicoureteric reflux (VUR). There is a growing consensus for increasing the threshold for performing MCUGs following urinary tract infections (UTI) in children. There are several varying guidelines. It is important to detect high-grade reflux in the setting of an UTI because of potential long-term complications.

OBJECTIVE

This audit aimed to retrospectively: (1) identify the conformance rate of local guidelines at the Women's and Children's Hospital (WCH); (2) assess predictors for an abnormal MCUG; and (3) compare local guidelines against the Royal Children's Hospital, Melbourne (RCH), National Institute for Healthcare and Excellence (NICE), and American Academy of Pediatrics (AAP) guidelines for selectively detecting high-grade reflux.

METHOD

The number of MCUGs performed from 2008 to 2012 at the WCH radiology department was collected. Patients undergoing MCUG during the 2012 calendar year were identified. Only children having an initial MCUG as part of an UTI investigation with prerequisite imaging as per guidelines were included. Each child's age, sex, referral source, reason, renal ultrasound (RUS) prior to the MCUG, MCUG result and VUR grade were recorded. The WCH guidelines were applied to determine conformance, to evaluate predictors for an abnormal MCUG, and compared against other retrospectively applied guidelines (RCH, NICE, AAP).

RESULTS/DISCUSSION

There was complete data for 168 children who underwent MCUG as part of an UTI investigation (median age 0.79 years, range 0.12-8.74, male:female 67:101). There were 67/168 abnormal MCUGs (62 children with VUR, five bladder diverticulum), and 97 refluxing renal units (43 high-grade VUR units). No posterior urethral valves (PUV) were identified as part of the UTI investigation. A total of 143/168 patients had prior RUS (normal:abnormal 67:76). The WCH guidelines had 82% conformance. There was no statistically significant association between an abnormal MCUG and age, sex, referral source, reason, or prior RUS result. The WCH guidelines may have missed five children with high-grade VUR (four children had surgery), compared with RCH, APP and NICE, with 8, 15, and 17 children, respectively, having high-grade VUR (two, five, and five children had surgery, respectively) show in the Summary Table. The retrospective study had limitations and possible selection bias (children with UTI without a MCUG). There were no standard treatment approaches for VUR; hence establishing a MCUG guideline is difficult. An alternative is the top-down approach.

CONCLUSION

Current institutional guidelines for considering MCUG following UTI in children vary considerably. The MCUG guidelines at any institution must take into account the local management guidelines for high-grade VUR.

Fast-track surgery for uncomplicated appendicitis in children: a matched case-control study

BACKGROUND

Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case-control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children.

METHODS

Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach.

RESULTS

Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P < 0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P < 0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057.

CONCLUSION

Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.

Free living amoebae in water sources of critical units in a tertiary care hospital in India

BACKGROUND

Isolation of free-living amoebae (FLA) is reported sparsely from water taps, ventilators, air conditioners, haemodialysis units and dental irrigation systems of hospitals worldwide. Their prevalence in hospital environment especially in wards having immunocompromised patients may pose a risk to this group of susceptible population as they may cause disease themselves or may carry pathogens inside them. No study from India has performed such surveillance.

OBJECTIVE

To evaluate extent of FLA contamination in water sources of bone marrow transplant (BMT) intensive care unit (ICU), transplant ICU, haemodialysis unit and high dependency unit in a tertiary care hospital in India.

MATERIALS AND METHODS

A total of hundred samples including fifty each of tap water samples and swabs from mouth of taps used for drinking, bathing and hand washing purposes in these units were collected according to standard procedure. Samples were inoculated onto non-nutrient agar plates at room temperature followed by morphological confirmation. Molecular identification including polymerase chain reaction (PCR) and sequencing was performed in culture positive samples.

RESULTS

Four tap water samples and ten swab samples showed growth of trophozoites and cyst formation. Morphologically, four amoebae resembled Acanthamoeba spp. which was further confirmed by PCR and sequencing showed them to be of T3 and T4 genotypes.

CONCLUSION

The presence of these FLA in hospital water sources emphasises the urgent need of implementing effective preventive measures. Further studies are required to estimate the true prevalence of FLA in Indian hospitals by taking larger number of samples.

Development of touch down-multiplex PCR for the diagnosis of toxoplasmosis

PURPOSE

The diagnosis of toxoplasmosis is challenging since conventional methods like culture and immunofluorescence are not universally available. Serology, which is used regularly might be negative during early phase of infection and in immunosuppressed patients or may remain positive for a long time. Several molecular tests have been used for the diagnosis of toxoplasmosis, but none of them have an internal control which would inform us regarding the presence of polymerase chain reaction (PCR) inhibitors thus, undermining the confidence of a laboratory physician.

MATERIALS AND METHODS

We designed a multiplex PCR containing primers targeting human beta globin gene which would act as internal control and two primers against the B1 gene and 5s gene which aid in sensitive detection of T. gondii.

RESULTS

Multiplex PCR had a sensitivity of 83.3% and specificity of 100%.

CONCLUSION

Multiplex PCR may provide a sensitive and specific tool for diagnosis of human toxoplasmosis.

Emergence of Balamuthia mandrillaris meningoencephalitis in India

We report two cases of fatal chronic meningoencephalitis caused by Balamuthia mandrillaris in immunocompetent men. Diagnosis of amoebic meningoencephalitis was made ante-mortem in one case and postmortem in another by histopathological examination and confirmed by demonstration of B. mandrillaris deoxyribonucleic acid (DNA) by polymerase chain reaction (PCR).

Robotic surgery in children: adopt now, await, or dismiss?

The role of robot-assisted surgery in children remains controversial. This article aims to distil this debate into an evidence informed decision-making taxonomy; to adopt this technology (1) now, (2) later, or (3) not at all. Robot-assistance is safe, feasible and effective in selected cases as an adjunctive tool to enhance capabilities of minimally invasive surgery, as it is known today. At present, expectations of rigid multi-arm robotic systems to deliver higher quality care are over-estimated and poorly substantiated by evidence. Such systems are associated with high costs. Further comparative effectiveness evidence is needed to define the case-mix for which robot-assistance might be indicated. It seems unlikely that we should expect compelling patient benefits when it is only the mode of minimally invasive surgery that differs. Only large higher-volume institutions that share the robot amongst multiple specialty groups are likely to be able to sustain higher associated costs with today's technology. Nevertheless, there is great potential for next-generation surgical robotics to enable better ways to treat childhood surgical diseases through less invasive techniques that are not possible today. This will demand customized technology for selected patient populations or procedures. Several prototype robots exclusively designed for pediatric use are already under development. Financial affordability must be a high priority to ensure clinical accessibility.