Oral Cavity Cancers: Ethnic Differences in Radiotherapy Outcomes in a Majority South Asian Leicester Community

AIMS

Squamous cell carcinoma oral cavity cancers (SCCOCCs) have a higher reported incidence in South Asian countries. We sought to compare presenting stage and outcome by ethnicity in patients with SCCOCC treated with radical radiotherapy in a single centre in the UK.

MATERIALS AND METHODS

All patients with SCCOCC treated with radical radiotherapy at an oncology department in Leicester (UK) between 2011 and 2017 were identified. Baseline demographic, clinical data and 2-year treatment outcomes were reported.

RESULTS

Of the 109 patients included, 40 were South Asian and 59 were non-South Asian. South Asians had significantly poorer 2-year disease-free survival compared with non-South Asians (54.6% versus 73%, P = 0.01).

CONCLUSION

Our analysis suggests that South Asians with SCCOCC have poorer outcomes despite a younger age and similar disease characteristics. Environmental, social factors and differing biology of disease may be responsible and further research is required to inform targeted interventions.

Emergence of Long-Range Angular Correlations in Low-Multiplicity Proton-Proton Collisions

This Letter presents the measurement of near-side associated per-trigger yields, denoted ridge yields, from the analysis of angular correlations of charged hadrons in proton-proton collisions at sqrt[s]=13  TeV. Long-range ridge yields are extracted for pairs of charged particles with a pseudorapidity difference of 1.4<|Δη|<1.8 and a transverse momentum of 1 Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

First Measurement of the |t| Dependence of Incoherent J/ψ Photonuclear Production

The first measurement of the cross section for incoherent photonuclear production of J/ψ vector mesons as a function of the Mandelstam |t| variable is presented. The measurement was carried out with the ALICE detector at midrapidity, |y|<0.8, using ultraperipheral collisions of Pb nuclei at a center-of-mass energy per nucleon pair of sqrt[s_{NN}]=5.02  TeV. This rapidity interval corresponds to a Bjorken-x range (0.3-1.4)×10^{-3}. Cross sections are given in five |t| intervals in the range 0.04<|t|<1  GeV^{2} and compared to the predictions by different models. Models that ignore quantum fluctuations of the gluon density in the colliding hadron predict a |t| dependence of the cross section much steeper than in data. The inclusion of such fluctuations in the same models provides a better description of the data.

Long COVID-19 and primary care: Challenges, management and recommendations

Long COVID-19, also known as post-acute sequelae of SARS-CoV-2 infection (PASC), is characterized by persistent symptoms after COVID-19 onset. This article explores the challenges, management strategies, and recommendations for addressing long COVID-19 in primary care settings. The epidemiology of long COVID-19 reveals significant variability, with a substantial portion of COVID-19 survivors experiencing post-acute symptoms. Pathophysiological mechanisms include viral persistence, endothelial dysfunction, autoimmunity, neurological dysregulation, and gastrointestinal dysbiosis. Multiple risk factors, including age, sex, pre-existing comorbidities, smoking, BMI, and acute COVID-19 severity, influence the development of long COVID-19. Effective management requires proactive measures such as vaccination, identification of high-risk populations, public awareness, and post-infection vaccination. Collaboration of primary care physicians with specialists is essential for holistic and individualized patient care. This article underscores the role of primary care physicians in diagnosing, managing, and mitigating the long-term effects of COVID-19.

Novel Chitosan-Coated Liposomes Coloaded with Exemestane and Genistein for an Effective Breast Cancer Therapy

For achieving high effectiveness in the management of breast cancer, coadministration of drugs has attracted a lot of interest as a mode of therapy when compared to a single chemotherapeutic agent that often results in reduced therapeutic end results. Owing to their proven effectiveness, good patient compliance, and lower costs, oral anticancer drugs have received much attention. In the present work, we formulated the chitosan-coated nanoliposomes loaded with two lipophilic agents, namely, exemestane (EXE) and genistein (GEN). The formulation was prepared using the ethanol injection method, which is considered a simple method for getting the nanoliposomes. The formulation was optimized using Box-Behnken design (BBD) and was extensively characterized for particle size, ζ-potential, Fourier transform infrared (FTIR), differential scanning calorimetry (DSC), and X-ray diffraction (XRD) analysis. The sizes of conventional and coated liposomes were found to be 104.6 ± 3.8 and 120.3 ± 6.4 nm with a low polydispersity index of 0.399 and 0.381, respectively. The ζ-potential of the liposomes was observed to be -16.56 mV, which changed to a positive value of +22.4 mV, clearly indicating the complete coating of the nanoliposomes by the chitosan. The average encapsulation efficiency was found to be between 70 and 80% for all prepared formulations. The compatibility of the drug with excipients and complete dispersion of the drug inside the system were verified by FTIR, XRD, and DSC studies. Furthermore, the in vitro release studies concluded the sustained release pattern following the Korsmeyer-Peppas model as the best-fitting model with Fickian diffusion. Ex vivo studies showed better permeation of the chitosan-coated liposomes, which was further confirmed by confocal studies. The prepared chitosan-coated liposomes showed superior antioxidant activity (94.56%) and enhanced % cytotoxicity (IC50 7.253 ± 0.34 μM) compared to the uncoated liposomes. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay displayed better cytotoxicity of the chitosan-coated nanoliposomes compared to the plain drug, showing the better penetration and enhanced bioavailability of drugs inside the cells. The formulation was found to be safe for administration, which was confirmed using the toxicity studies performed on an animal model. The above data suggested that poorly soluble lipophilic drugs could be successfully delivered via chitosan-coated liposomes for their effective delivery in breast cancer.

Evidence of a Hardening in the Cosmic Ray Proton Spectrum at around 166 TeV Observed by the GRAPES-3 Experiment

We present the measurement of the cosmic ray proton spectrum from 50 TeV to 1.3 PeV using 7.81×10^{6} extensive air shower events recorded by the ground-based GRAPES-3 experiment between 1 January 2014 and 26 October 2015 with a live time of 460 day. Our measurements provide an overlap with direct observations by satellite and balloon-based experiments. The electromagnetic and muon components in the shower were measured by a dense array of plastic scintillator detectors and a tracking muon telescope, respectively. The relative composition of the proton primary from the air shower data containing all primary particles was extracted using the multiplicity distribution of muons which is a sensitive observable for mass composition. The observed proton spectrum suggests a spectral hardening at ∼166  TeV and disfavors a single power law description of the spectrum up to the Knee energy (∼3  PeV).

NMR based Serum metabolomics revealed metabolic signatures associated with oxidative stress and mitochondrial damage in brain stroke

Brain stroke (BS, also known as a cerebrovascular accident), represents a serious global health crisis. It has been a leading cause of permanent disability and unfortunately, frequent fatalities due to lack of timely medical intervention. While progress has been made in prevention and management, the complexities and consequences of stroke continue to pose significant challenges, especially, its impact on patient's quality of life and independence. During stroke, there is a substantial decrease in oxygen supply to the brain leading to alteration of cellular metabolic pathways, including those involved in mitochondrial-damage, leading to mitochondrial-dysfunction. The present proof-of-the-concept metabolomics study has been performed to gain insights into the metabolic pathways altered following a brain stroke and discover new potential targets for timely interventions to mitigate the effects of cellular and mitochondrial damage in BS. The serum metabolic profiles of 108 BS-patients were measured using 800 MHz NMR spectroscopy and compared with 60 age and sex matched normal control (NC) subjects. Compared to NC, the serum levels of glutamate, TCA-cycle intermediates (such as citrate, succinate, etc.), and membrane metabolites (betaine, choline, etc.) were found to be decreased BS patients, whereas those of methionine, mannose, mannitol, phenylalanine, urea, creatine and organic acids (such as 3-hydroxybutyrate and acetone) were found to be elevated in BS patients. These metabolic changes hinted towards hypoxia mediated mitochondrial dysfunction in BS-patients. Further, the area under receiver operating characteristic curve (ROC) values for five metabolic features (methionine, mannitol, phenylalanine, mannose and urea) found to be more than 0.9 suggesting their high sensitivity and specificity for differentiating BS from NC subjects.

ψ(2S) Suppression in Pb-Pb Collisions at the LHC

The production of the ψ(2S) charmonium state was measured with ALICE in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV, in the dimuon decay channel. A significant signal was observed for the first time at LHC energies down to zero transverse momentum, at forward rapidity (2.5 Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

GCMS characterization and biological potential of the seeds and aerial part of Galium tricorne Stokes

Abstract Natural products have long been proven very effective against various challenging diseases including cancer and bacterial infections. Galium tricorne is one of the important source of natural products, which has not been explored till date in spite of its profound ethnomedicinal prominence. The current study has been designed to explore the biological potential of G. tricorne and to extract and isolate chemical constituents from its aerial part and seeds respectively along with identification of their chemical constituents. Phytochemical screening was performed to figure out the presence of secondary metabolite in G. tricorne. Crude Methanolic extract (Gt.Crd), which was obtained from the aerial part while the fatty acids were extracted from the seeds, which were later on analyzed by GCMS. Similarly, Well Diffusion and MTT method were used for antibacterial activity and cancer cell line assay respectively. To evaluate the cytotoxic potential, brine shrimps were used. Likewise, in Gas Chromatography-Mass Spectroscopy (GC-MS) analysis a total number of 23 compounds were identified in Gt.Crd extract out of which 7 compounds were sorted out to have some sort of toxicity profile. In the same fashion, 5 fatty acids were identified in the seeds of G. tricorne. Moreover, among the fractions, chloroform fraction (Gt.Chf) exhibited greater zone of inhibition (ZOI) 20.37 mm followed by Gt.Crd 18.40 mm against S. aureus and S. pyogenes respectively. In cytotoxicity Gt.Chf was more active followed by ethyl acetate fraction (Gt.Eta) by exhibiting 88.32±0.62% (LC50=60 µg/mL) and 73.95±2.25% (LC50=80 µg/mL) respectively at 1000 µg/mL concentration of the tested sample. Gt.Chf exhibited greater cell line inhibitory activity (IC50=61 µg/mL) against HeLa cell line. Similarly, Gt.Crd displayed IC50 values of 167.84 µg/mL and 175.46 µg/mL against HeLa and NIH/3T3 cell line respectively. Based on the literature review and screenings, it may be concluded that the aerial part and seeds of G. tricorne are the rich sources of bioactive compounds. The results of the current study also authenticate the scientific background for the ethnomedicinal uses of G. tricorne.

Measurements of Groomed-Jet Substructure of Charm Jets Tagged by D^{0} Mesons in Proton-Proton Collisions at sqrt[s]=13 TeV

Understanding the role of parton mass and Casimir color factors in the quantum chromodynamics parton shower represents an important step in characterizing the emission properties of heavy quarks. Recent experimental advances in jet substructure techniques have provided the opportunity to isolate and characterize gluon emissions from heavy quarks. In this Letter, the first direct experimental constraint on the charm-quark splitting function is presented, obtained via the measurement of the groomed shared momentum fraction of the first splitting in charm jets, tagged by a reconstructed D^{0} meson. The measurement is made in proton-proton collisions at sqrt[s]=13  TeV, in the low jet transverse-momentum interval of 15≤p_{T}^{jet ch}<30  GeV/c where the emission properties are sensitive to parton mass effects. In addition, the opening angle of the first perturbative emission of the charm quark, as well as the number of perturbative emissions it undergoes, is reported. Comparisons to measurements of an inclusive-jet sample show a steeper splitting function for charm quarks compared with gluons and light quarks. Charm quarks also undergo fewer perturbative emissions in the parton shower, with a reduced probability of large-angle emissions.

Impact of the COVID-19 Pandemic on Outcomes for Patients with Lung Cancer Receiving Curative-intent Radiotherapy in the UK

AIMS

Previous work found that during the first wave of the COVID-19 pandemic, 34% of patients with lung cancer treated with curative-intent radiotherapy in the UK had a change to their centre's usual standard of care treatment (Banfill et al. Clin Oncol 2022;34:19-27). We present the impact of these changes on patient outcomes.

MATERIALS AND METHODS

The COVID-RT Lung database was a prospective multicentre UK cohort study including patients with stage I-III lung cancer referred for and/or treated with radical radiotherapy between April and October 2020. Data were collected on patient demographics, radiotherapy and systemic treatments, toxicity, relapse and death. Multivariable Cox and logistic regression were used to assess the impact of having a change to radiotherapy on survival, distant relapse and grade ≥3 acute toxicity. The impact of omitting chemotherapy on survival and relapse was assessed using multivariable Cox regression.

RESULTS

Patient and follow-up forms were available for 1280 patients. Seven hundred and sixty-five (59.8%) patients were aged over 70 years and 603 (47.1%) were female. The median follow-up was 213 days (119, 376). Patients with stage I-II non-small cell lung cancer (NSCLC) who had a change to their radiotherapy had no significant increase in distant relapse (P = 0.859) or death (P = 0.884); however, they did have increased odds of grade ≥3 acute toxicity (P = 0.0348). Patients with stage III NSCLC who had a change to their radiotherapy had no significant increase in distant relapse (P = 0.216) or death (P = 0.789); however, they did have increased odds of grade ≥3 acute toxicity (P < 0.001). Patients with stage III NSCLC who had their chemotherapy omitted had no significant increase in distant relapse (P = 0.0827) or death (P = 0.0661).

CONCLUSION

This study suggests that changes to radiotherapy and chemotherapy made in response to the COVID-19 pandemic did not significantly affect distant relapse or survival. Changes to radiotherapy, namely increased hypofractionation, led to increased odds of grade ≥3 acute toxicity. These results are important, as hypofractionated treatments can help to reduce hospital attendances in the context of potential future emergency situations.

Contextual influence of the COVID-19 pandemic on pregnant women's emotional regulation abilities

INTRODUCTION

Emotional regulation is a key factor that could determine the quality of becoming a parent. Since pregnancy is accompanied by changes in the emotional system, fluctuations in emotional regulation may also occur during this period. In 2020, the COVID-19 pandemic had major psychological repercussions on the general population which could have also affected emotional regulation capacities.

OBJECTIVE

The objective of this study was to determine whether emotional regulation has characteristics during pregnancy and to evaluate the influence of the COVID-19 pandemic on the emotional regulation of pregnant women.

METHOD

One hundred fifty-one women aged between 19 and 42 years old participated in this study. Their emotional regulation abilities were assessed using the Difficulties Emotion Regulation Scale before and during the pandemic. A two-factor multivariate analysis of covariance, "parental status" (pregnant vs. childless) and "time of data collection" (before vs. during COVID-19), was conducted to compare the emotional regulation abilities of pregnant women with those of childless women before and during the pandemic.

RESULTS

(1) Prior to the pandemic, pregnant women exhibited better emotional regulation skills than childless women, characterized by greater acceptance and understanding of their emotions. (2) During the pandemic: (a) pregnant women's emotional regulation scores were comparable to those of women without children. (b) They also had more difficulty than pre-pandemic pregnant women in identifying their emotions.

CONCLUSION

The lack of improvement in emotional regulation skills in pregnant women during the COVID-19 pandemic is a specific impact of COVID on this population. This could affect their mental health, as well as the emotional adjustment of the mother towards her baby.

Measurement of the Lifetime and Λ Separation Energy of _{Λ}^{3}H

The most precise measurements to date of the _{Λ}^{3}H lifetime τ and Λ separation energy B_{Λ} are obtained using the data sample of Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV collected by ALICE at the LHC. The _{Λ}^{3}H is reconstructed via its charged two-body mesonic decay channel (_{Λ}^{3}H→^{3}He+π^{-} and the charge-conjugate process). The measured values τ=[253±11(stat)±6(syst)]  ps and B_{Λ}=[102±63(stat)±67(syst)]  keV are compatible with predictions from effective field theories and confirm that the _{Λ}^{3}H structure is consistent with a weakly bound system.

Measurement of the J/ψ Polarization with Respect to the Event Plane in Pb-Pb Collisions at the LHC

We study the polarization of inclusive J/ψ produced in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV at the LHC in the dimuon channel, via the measurement of the angular distribution of its decay products. We perform the study in the rapidity region 2.5 Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

First Measurement of Antideuteron Number Fluctuations at Energies Available at the Large Hadron Collider

The first measurement of event-by-event antideuteron number fluctuations in high energy heavy-ion collisions is presented. The measurements are carried out at midrapidity (|η|<0.8) as a function of collision centrality in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV using the ALICE detector. A significant negative correlation between the produced antiprotons and antideuterons is observed in all collision centralities. The results are compared with a state-of-the-art coalescence calculation. While it describes the ratio of higher order cumulants of the antideuteron multiplicity distribution, it fails to describe quantitatively the magnitude of the correlation between antiproton and antideuteron production. On the other hand, thermal-statistical model calculations describe all the measured observables within uncertainties only for correlation volumes that are different with respect to those describing proton yields and a similar measurement of net-proton number fluctuations.

Enhanced Deuteron Coalescence Probability in Jets

The transverse-momentum (p_{T}) spectra and coalescence parameters B_{2} of (anti)deuterons are measured in p-p collisions at sqrt[s]=13  TeV for the first time in and out of jets. In this measurement, the direction of the leading particle with the highest p_{T} in the event (p_{T}^{lead}>5  GeV/c) is used as an approximation for the jet axis. The event is consequently divided into three azimuthal regions, and the jet signal is obtained as the difference between the toward region, that contains jet fragmentation products in addition to the underlying event (UE), and the transverse region, which is dominated by the UE. The coalescence parameter in the jet is found to be approximately a factor of 10 larger than that in the underlying event. This experimental observation is consistent with the coalescence picture and can be attributed to the smaller average phase-space distance between nucleons in the jet cone as compared with the underlying event. The results presented in this Letter are compared to predictions from a simple nucleon coalescence model, where the phase-space distributions of nucleons are generated using pythia8 with the Monash 2013 tuning, and to predictions from a deuteron production model based on ordinary nuclear reactions with parametrized energy-dependent cross sections tuned on data. The latter model is implemented in pythia8.3. Both models reproduce the observed large difference between in-jet and out-of-jet coalescence parameters, although the almost flat trend of the B_{2}^{Jet} is not reproduced by the models, which instead give a decreasing trend.

Polymer-lipid hybrid nanoparticles of exemestane for improved oral bioavailability and anti-tumor efficacy: An extensive preclinical investigation

Exemestane (EXE), an irreversible aromatase inhibitor, is primarily used as a first-line therapy for estrogen receptor-positive breast cancer patients. However, complex physicochemical characteristics of EXE limit its oral bioavailability (<10%) and anti-breast cancer efficacy. The present study aimed to develop a novel nanocarrier system to improve the oral bioavailability and anti-breast cancer efficacy of EXE. In this perspective, EXE-loaded TPGS-based polymer lipid hybrid nanoparticles (EXE-TPGS-PLHNPs) were prepared by the nanoprecipitation method and evaluated for their potential in improving oral bioavailability, safety, and therapeutic efficacy in the animal model. EXE-TPGS-PLHNPs showed significantly higher intestinal permeation in comparison to EXE-PLHNPs (without TPGS) and free EXE. After oral administration, EXE-TPGS-PLHNPs and EXE-PLHNPs revealed 3.58 and 4.69 times higher oral bioavailability in Wistar rats compared to the conventional EXE suspension. The results of the acute toxicity experiment suggested that the developed nanocarrier was safe for oral administration. Furthermore, EXE-TPGS-PLHNPs and EXE-PLHNPs represented much better anti-breast cancer activity in Balb/c mice bearing MCF-7 tumor xenograft with tumor inhibition rate of 72.72% and 61.94% respectively in comparison with the conventional EXE suspension (30.79%) after 21 days of oral chemotherapy. In addition, insignificant changes in the histopathological examination of vital organs and hematological analysis further confirm the safety of the developed PLHNPs. Therefore, the findings of the present investigation advocated that the encapsulation of EXE in PLHNPs can be a promising approach for oral chemotherapy of breast cancer.

Higher Incidence of Unruptured Intracranial Aneurysms among Black and Hispanic Women on Screening MRA in Large Urban Populations

BACKGROUND AND PURPOSE

Intracranial aneurysms have a reported prevalence of 1%-2% in the general population. Currently, only patients with a strong family history or autosomal dominant polycystic kidney disease are screened for intracranial aneurysms using MRA. The purpose of this study was to determine whether there are other specific patient populations at risk that should be offered screening for intracranial aneurysms.

MATERIALS AND METHODS

This is a retrospective case-control study of adult patients who underwent a screening MRA of their brain at our comprehensive stroke center from 2011 to 2020. Patients with a history of a known brain aneurysm were excluded. Data were extracted on patient demographics and medical comorbidities. Bivariate analyses were performed, followed by multivariable logistic regression, to identify factors associated with a positive MRA screen for incidental aneurysms.

RESULTS

Of 24,397 patients eligible for this study, 2084 screened positive for a possible intracranial aneurysm. On bivariate analysis, significant differences were present in the following categories: age, sex, race and ethnicity, chronic constipation, and hyperlipidemia. On logistic regression analysis, older age (+10 years: OR = 10.01; 95% CI, 10.01-10.02; P = .001), female sex (OR = 1.37; 95% CI, 1.24-1.51; P = .001), non-Hispanic Black (OR = 1.19; 95% CI, 1.02-1.40; P = .031), and Hispanic ethnicity (OR = 1.35; 95% CI, 1.16-1.58; P = .001) versus non-Hispanic White remained significant when adjusted for other factors.

CONCLUSIONS

Targeted screening for high-risk elderly women of Black or Hispanic descent will yield higher positive findings for brain aneurysms, which may mitigate the risk of rupture. Whether this is a cost-effective approach has yet to be determined.

Post-acute phase and sequelae management of epidermal necrolysis: an international, multidisciplinary DELPHI-based consensus

BACKGROUND

Long-term sequelae are frequent and often disabling after epidermal necrolysis (Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)). However, consensus on the modalities of management of these sequelae is lacking.

OBJECTIVES

We conducted an international multicentric DELPHI exercise to establish a multidisciplinary expert consensus to standardize recommendations regarding management of SJS/TEN sequelae.

METHODS

Participants were sent a survey via the online tool "Survey Monkey" consisting of 54 statements organized into 8 topics: general recommendations, professionals involved, skin, oral mucosa and teeth, eyes, genital area, mental health, and allergy workup. Participants evaluated the level of appropriateness of each statement on a scale of 1 (extremely inappropriate) to 9 (extremely appropriate). Results were analyzed according to the RAND/UCLA Appropriateness Method.

RESULTS

Fifty-two healthcare professionals participated. After the first round, a consensus was obtained for 100% of 54 initially proposed statements (disagreement index < 1). Among them, 50 statements were agreed upon as 'appropriate'; four statements were considered 'uncertain', and ultimately finally discarded.

CONCLUSIONS

Our DELPHI-based expert consensus should help guide physicians in conducting a prolonged multidisciplinary follow-up of sequelae in SJS-TEN.

Final Study Report of Andexanet Alfa for Major Bleeding With Factor Xa Inhibitors

BACKGROUND

Andexanet alfa is a modified recombinant inactive factor Xa (FXa) designed to reverse FXa inhibitors. ANNEXA-4 (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) was a multicenter, prospective, phase-3b/4, single-group cohort study that evaluated andexanet alfa in patients with acute major bleeding. The results of the final analyses are presented.

METHODS

Patients with acute major bleeding within 18 hours of FXa inhibitor administration were enrolled. Co-primary end points were anti-FXa activity change from baseline during andexanet alfa treatment and excellent or good hemostatic efficacy, defined by a scale used in previous reversal studies, at 12 hours. The efficacy population included patients with baseline anti-FXa activity levels above predefined thresholds (≥75 ng/mL for apixaban and rivaroxaban, ≥40 ng/mL for edoxaban, and ≥0.25 IU/mL for enoxaparin; reported in the same units used for calibrators) who were adjudicated as meeting major bleeding criteria (modified International Society of Thrombosis and Haemostasis definition). The safety population included all patients. Major bleeding criteria, hemostatic efficacy, thrombotic events (stratified by occurring before or after restart of either prophylactic [ie, a lower dose, for prevention rather than treatment] or full-dose oral anticoagulation), and deaths were assessed by an independent adjudication committee. Median endogenous thrombin potential at baseline and across the follow-up period was a secondary outcome.

RESULTS

There were 479 patients enrolled (mean age, 78 years; 54% male, 86% White; 81% anticoagulated for atrial fibrillation at a median time of 11.4 hours since last dose, with 245 (51%) on apixaban, 176 (37%) on rivaroxaban, 36 (8%) on edoxaban, and 22 (5%) on enoxaparin. Bleeding was predominantly intracranial (n=331 [69%]) or gastrointestinal (n=109 [23%]). In evaluable apixaban patients (n=172), median anti-FXa activity decreased from 146.9 ng/mL to 10.0 ng/mL (reduction, 93% [95% CI, 94-93]); in rivaroxaban patients (n=132), it decreased from 214.6 ng/mL to 10.8 ng/mL (94% [95% CI, 95-93]); in edoxaban patients (n=28), it decreased from 121.1 ng/mL to 24.4 ng/mL (71% [95% CI, 82-65); and in enoxaparin patients (n=17), it decreased from 0.48 IU/mL to 0.11 IU/mL (75% [95% CI, 79-67]). Excellent or good hemostasis occurred in 274 of 342 evaluable patients (80% [95% CI, 75-84]). In the safety population, thrombotic events occurred in 50 patients (10%); in 16 patients, this occurred during treatment with prophylactic anticoagulation that began after the bleeding event. No thrombotic episodes occurred after oral anticoagulation restart. Specific to certain populations, reduction of anti-FXa activity from baseline to nadir significantly predicted hemostatic efficacy in patients with intracranial hemorrhage (area under the receiver operating characteristic curve, 0.62 [95% CI, 0.54-0.70]) and correlated with lower mortality in patients <75 years of age (adjusted P=0.022; unadjusted P=0.003). Median endogenous thrombin potential was within the normal range by the end of andexanet alfa bolus through 24 hours for all FXa inhibitors.

CONCLUSIONS

In patients with major bleeding associated with the use of FXa inhibitors, treatment with andexanet alfa reduced anti-FXa activity and was associated with good or excellent hemostatic efficacy in 80% of patients.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02329327.

Evaluation of neurological testing for hand-arm vibration syndrome

BACKGROUND

The neurological component of hand-arm vibration syndrome (HAVS) uses the Stockholm Workshop Scale sensorineural (SWS SN) stages for classification. Proximal compressive neuropathies are common in HAVS and the symptoms are similar to SN HAVS. The SWS may not be a valid staging tool if a patient has comorbid proximal compression neuropathy.

AIMS

To evaluate the prevalence of proximal compression neuropathy in patients presenting for HAVS assessment and examine the association between compressive neuropathies and SWS SN.

METHODS

A standardized assessment protocol was used to assess 431 patients for HAVS at St. Michael's Hospital, Toronto, Ontario. The prevalence of median and ulnar compressive neuropathies was determined. The association between proximal compression neuropathies and SWS SN stage (0/1 versus 2/3) was evaluated using Chi-square and Fisher's exact tests as well as multivariable logistic regression.

RESULTS

Most patients (79%) reported numbness and 20% had reduced sensory perception (SWS SN Stage 2/3). Almost half (45%) had median neuropathy at the wrist and 7% had ulnar neuropathy. There was no association between the SWS SN stage and median or ulnar neuropathy.

CONCLUSIONS

Two neurological lesions should be investigated in patients presenting for HAVS assessment: compressive neuropathy and digital neuropathy. The prevalence of compressive neuropathies is high in patients being assessed for HAVS and therefore nerve conduction studies (NCS) should be included in HAVS assessment protocols. Comorbid proximal neuropathy does not affect the SWS SN stage; therefore, NCS and SWS SN seem to be measuring different neurological outcomes in HAVS patients.

Designing of new tetrahydro-β-carboline-based ABCG2 inhibitors using 3D-QSAR, molecular docking, and DFT tools

Human ATP-binding cassette superfamily G member 2 (ABCG2) protein is a member of the ABC transporter family, which is responsible for multidrug resistance (MDR) in cancerous cells. MDR reduces the effectiveness of chemotherapy in breast cancer, which is one of the leading causes of death in women globally. MDR in cancer cells is one of the immediate signs of progression of resistance; thus, various anticancer drugs can be designed. To reduce MDR, we utilized the tetrahydro-β-carboline (THβC) compound library. We accomplished a three-dimensional quantitative structure-activity relationship (3D-QSAR), scaffold hopping to design a new library of compounds of THβC, and further molecular docking, induced-fit docking (IFD), molecular mechanics energies combined with generalized born and surface area continuum solvation (MM-GBSA), drug-like features, ADMET properties, and density functional theory (DFT) studies were performed. From these studies, the best 3D-QSAR model (r2 = 0.99, q2 = 0.92) was found, and the necessity of electrostatic, steric, and hydrophobic field effects were determined that could modulate bioactivity. Moreover, based on electrostatic, steric, and hydrophobic field notations, new THβC derivatives (3409) were designed. These findings might provide new insight for researchers to perform in vitro and in vivo studies for better antagonists against MDR in treating breast cancer.Communicated by Ramaswamy H. Sarma.

Emotional intelligence and academic performance among medical students - a correlational study

OBJECTIVE

Emotional intelligence is the ability to monitor one's emotions and feelings and those of others, to distinguish between them, and to use this information to guide one's thoughts and actions. A growing body of evidence suggests that highly emotionally intelligent student groups have better academic performance, better emotional awareness, and relationship management. We set forward to determine if any such positive relation exists among medical students.

MATERIALS AND METHODS

A descriptive cross-sectional study was conducted on undergraduate medical students of Majmaah University. Convenient sampling was done to enroll the consenting students. A self-administered questionnaire on emotional intelligence was adapted from a model by Paul Mohapel. The questions based on a 5-point Likert scale assessed the four domains of emotional intelligence i.e., emotional awareness, emotional intelligence; demographic details and grade-point averages (GPA) were also collected. The data was tabulated and analyzed using SPSS 22.0 (IBM Corp., Armonk, NY, USA).

RESULTS

Hundred and forty medical undergraduates enrolled in the study with a male-to-female ratio of 1:06. The median semester score was 4.47 (range 1.1-5.8) and the median cumulative score was 4.44 (range 2.8-5.0). The emotional management score was highest among those with a CGPA >4.50 (p=0.048). A significantly higher mean emotional awareness score (p<0.001), social-emotional awareness score (p<0.001), and relationship management score (p=0.030), and the mean EQ total was higher among males than for females (p<0.001). A small but significant correlation was observed and also with EQ total score (r= 0.18, p= 0.032).

CONCLUSIONS

Emotional management affects the academic performance of medical students. There should be more sessions to improve the emotional intelligence of the students so that it can aid in their academic performance.

Double-diffusive Hamel-Jeffrey flow of nanofluid in a convergent/divergent permeable medium under zero mass flux

In the recent era, the nanofluid's transportation due to the Jeffrey-Hemal flow phenomenon (i.e., carrying fluid through a converging/diverging channel) has significant applications in numerous engineering and science technologies. Therefore, multi-disciplinary evolution and research motivated us to present current attempt. The aim of this attempt is to present Jeffrey-Hamel mechanism of the nanofluid through non-parallel channel under thermally balance non-Darcy permeable medium impacts. The nanomaterial is represented using the Buongiorno nanofluid model. The investigation also includes zero mass flux impacts as well as variable rheological fluid properties. The influences of temperature jump are also encountered in the current analysis. The governing flow expressions under the Jeffrey-Hemal analysis are made dimensionless utilizing the similarity variables. The dimensionless equations are then solved using the analytical scheme (homotopy method) and the obtained series solutions are convergent. The influences of the involved parameters on concerned profiles are investigated through graphs. Force of drag, Nusselt and Sherwood numbers are elaborated graphically. In this analysis, intensification in Prandtl number enhances the heat transfer rate whereas decrement is seen in heat transfer rate for larger thermal slip parameter. Further, mass diffusivity parameter adversely affects the mass transfer rate. The current analysis incorporates numerous industrial and technological processes including transportation, material synthesis, microfluidics, high-power Xrays, biomedical, solid-state lighting, microelectronics, scientific measurement, medicine, molten polymers extrusion via converging dies, cold drawing operation related to polymer industry etc.

A time and motion study in pediatric ER of the Secondary Hospital in Al Jouf Region, Saudi Arabia

OBJECTIVE

In the hospital setting, long waiting times and the lengthy formal process have increased the inefficiency and mismanagement resulting in the missing chance of saving the patients' life. Our aim was to assess the time wastage of every patient coming from reception to the actual emergency unit, to analyze the factor associated with the time lapse that occurs during every visit, and to see the effect of training on the services provided in the Pediatric emergency room.

SUBJECTS AND METHODS

An intervention study was carried out in the following secondary care hospital in the Al Jouf region, Saudi Arabia: Esawiyah Hospital, Haditha Hospital, King Faisal Hospital, and Gurayat General Hospital among 400 study participants for 12 months. The study was carried out in 2 phases: pre-training, a period of training for hospital staff, and post-training data collection. Templates were generated on an MS Excel sheet and analysis of data was done using SPSS software. Percentages and proportions were calculated for descriptive statistics.

RESULTS

Male and female patients were in the ratio of nearly 1:1. Training has significantly reduced the time to doctor consultation (U = 188, p < 0.001), and the time difference pre- and post-training from triage to consultation in a pediatric emergency is not significant (U = 16,769, p = 0.01). There is a strongly significant association (p < 0.001) between Canadian Triage and Acuity Scale (CTAS) implementation in triage. The practice of giving intravenous (IV) antibiotics in the emergency room has reduced significantly (p < 0.001) post-training.

CONCLUSIONS

Training has a significant impact on the services provided in the pediatric emergency room.

Epilepsia Partialis Continua that Improved in a Pediatric Patient with Sub-dural Empyema

In epilepsia partialis continua (EPC), the EEG tracings may fail to show epileptiform activity because the electrical activity is too subtle or too deep to be picked up by surface electrodes. EPC can occur at any age and may have many etiologies, including genetic, metabolic, structural, infectious, and idiopathic. Typical EEG in EPC is characterized by discharges of cortical origin that commonly consist of sharp waves, spikes or periodic lateralized epileptiform discharge; however, EEG findings at large are variable and often not even identified. Here we present a pediatric case of EPC in the setting of subdural empyema with atypical EEG seizure associated with focal clonic activity who made rapid improvements.

The psychological burden of disease among patients undergoing cervical spine surgery: Are we underestimating our patients' inherent disability?

BACKGROUND

Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations.

RESEARCH QUESTION

Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease?

MATERIALS AND METHODS

Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses.

RESULTS

47 patients were enrolled (age: 56.0 years,BMI: 29.7kg/m²). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all P<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs. 17.6; P<0.001) and PCS (27.4 vs. 19.3;P<0.001).

DISCUSSION AND CONCLUSION

Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated.

LEVEL OF EVIDENCE

Level III.

Knowledge, attitude and practices regarding dengue and its vector among medical practitioners in Malakand region, Pakistan

Abstract Dengue fever (DF) is increasingly recognized as one of the world’s major mosquito borne diseases and causes significant morbidity and mortality in tropical and subtropical countries. Dengue fever is endemic in most part of Pakistan and continues to be a public health concern. Knowledge, attitude and practices can play an important role in management of the disease. Current study was aimed to determine the level of knowledge, attitude and practices regarding dengue fever among health practitioners, to study the level of knowledge and attitude with preventive practices for dengue fever. A cross sectional study was carried out in medical practitioners of the four districts of Malakand region during October to November 2019. A pre-structured questionnaire was used to collect data from medical practitioners. Data was analyzed using Graph Pad version 5. Significant value was considered when less than 0.05 (at 95% confidence of interval). The results revealed that most of participants have seen dengue vector (62%), the media being the most quoted source of information. Nearly 81.2% participants were aware from transmission of dengue fever is by mosquito bite. Practices based upon preventive measures were found to be predominantly focused towards prevention of mosquito bites rather than elimination of breeding places. Although the knowledge regarding DF and mosquito control measure was quite high among the medical practitioners but this knowledge was not put into practice. Further studies are required to aware the people about dengue and its vector in order to get prevention and control.

Significance of Orlistat in management of dyslipidemia, systolic blood pressure and body mass index

OBJECTIVE

The current study intends to find out the efficacy of Orlistat in the management of hyperlipidemia, Systolic Blood Pressure (SBP) and Body Mass Index (BMI).

MATERIALS AND METHODS

This retrospective study has evaluated the lipid profiles of the patients, who have been using metformin therapy for Type 2 diabetes. The study has obtained data regarding the parameters like triglyceride, Total cholesterol (TC), LDL cholesterol, HDL cholesterol and LDL/HDL ratio, systolic blood pressure and Body Mass Index (BMI). Random distribution of patients was done into placebo and Orlistat groups. The placebo group received only metformin, and patients in the Orlistat group received Orlistat along with metformin. After 24 weeks, the follow-up study was done, and statistical analysis was conducted.

RESULTS

The study found that the Orlistat group has significant improvement (p<0.05) more improvement in LDL cholesterol, HDL cholesterol, Total cholesterol, LDL/HDL Ratio and Triglycerides, while BMI and systolic blood pressure did not show a significant difference between placebo and Orlistat group.

CONCLUSIONS

This study has concluded that Orlistat can be used for significant improvement in lipid profile. The study also found that Orlistat may not have a significant effect on reducing BMI and blood pressure without adequate lifestyle modification.

P-144 THE ABDOMINAL BINDERS FOLLOWING ABDOMINAL WALL RECONSTRUCTIVE SURGERY: USEFUL OR USELESS? - A META-ANALYSIS

Aim

Despite a recent meta-analysis published in SAGE in 2021 by a group of chinese researchers, which included 10 RCTs, the research committee for this study felt that a substantial volume of recent literature, including 7 RCTs and 3 high value non-RCT newly published articles have not been included in the latest meta-analysis and a new study is required, to understand the clinical usefulness of abdominal binders, following abdominal wall reconstructive surgery. Furthermore, no recent studies looked at the long-term impact of abdominal binders and whether their use prevent hernia recurrence, if applied from the immediate post-op period.

Material & Methods

A thorough review of all medical literature published in english language since year 2000 and to date was carried out, using the following keywords: “hernia”, “hernia repair”, “abdominal wall reconstruction” and “abdominal binder”. 17 randomised control trials and 3 non-RCT studies (systematic reviews and surveys) were included in the study. A total of 5216 patients were included in the 20 studies included. The databases searched were PubMed, Medbase, Jama and Embase.

Results/Conclusions

The use of abdominal binders following abdominal wall surgery suggests a better pain control when compared with non-users group. This contributes to earlier mobilisation and by this preventing secondary post-op complications. There is building evidence that in long term the use of abdominal binders reduces the risk of hernia recurrence and this could be in relation to decreased post-op pain and earlier return to a normal activities in the immediate post-op period.

Comparative analysis between mono approach and multi approaches in managing T2DM: a survey-based study

OBJECTIVE

The aim of the study was to analytically compare the therapeutic effect of the addition of diet modification and regular exercise to oral agents.

MATERIALS AND METHODS

This cross-sectional study surveyed 1248 participants via online and offline modes by employing a questionnaire about an individual's management of diabetes. Group 1 patients follow Single Approach Management for Type 2 Diabetes Mellitus (T2DM), while Group 2 and Group 3 patients follow Multi-Approach Management for T2DM. Based on the answers, the participants were classified into three groups. The diagnostic criteria of Diabetes Mellitus Type-2 in this study were done by determining morning Fasting Blood Sugar (FBS) and glycated Hemoglobin (HbA1c).

RESULTS

The current study found 656 single oral agent users and 592 combination regimens users among all the study participants. The study also found that, among all participants, 511 patients were on mild to moderate diet modification while 325 patients were on moderate to severe diet modification. The study also noted that 232 males and 215 females took Complementary and Alternative Medicines (CAM). Of 447 patients, 12 showed menstrual abnormalities (2.6%), and 18 had mild diarrhoea (4%). The study also found that there is a vital significance of lowering FBS and HbA1c with the management strategies (p=0.000). The study showed a strong association between group 3 and improved FBS and HbA1c (p=0.000).

CONCLUSIONS

This study reveals that diet modification and regular exercise improve FBS and HbA1c levels significantly. Hence, diet modification and exercise can be added as adjuvants and should be incorporated into the management guidelines of T2DM.

Detection of right atrial thrombus in a woman with pulmonary embolism and right heart compromise by bedside echocardiography

A 59-year-old female with a history of stage IV lung adenocarcinoma presented with worsening shortness of breath and cough over several weeks. She was tachycardic, hypotensive, and tachypneic. Portable chest x-ray suggested bilateral pleural effusions and computed tomography angiography (CTA) revealed bilateral pulmonary emboli (PE) with suspected right heart strain. Upon admission to the medical intensive care unit for treatment of PE, bedside echocardiography was performed to direct management. Indicators of cor pulmonale and right heart strain were apparent including right ventricle dilation, reduced tricuspid systolic excursion, and a deformed left ventricle with “D sign”. Most notably, a right atrial thrombus was detected, a finding not initially seen on CTA. Ultimately, prompt detection of the effects on the right ventricle by bedside echocardiography directed the next step in this patient's clinical course without delay.

Design and evaluation of pyrimidine derivatives as potent inhibitors of ABCG2, a breast cancer resistance protein

The protein ATP-binding cassette subfamily G member 2 (ABCG2) is one of the major factors behind multidrug resistance (MDR) in breast cancer. We performed three-dimensional quantitative structure-activity relationship (3D-QSAR) modelling, docking, and molecular dynamics (MD) simulation to design pyrimidine-based ABCG2 antagonists. The developed QSAR model (r 2 = 0.92, q 2 = 0.82, and good cross-validated r 2 = 0.73) dictate requirement of electrostatic, and hydrophobic fields for modulating bioactivity. Based on this rationale, we designed and screened 1010 new compounds, among them 2 (ND-510 and ND-500) exhibit excellent drug-like features. Comparative molecular docking, MM/GBSA and ADMET profiles were determined to understand the interactive poses, affinity, and drug-likeness of the designed compounds. Furthermore, MD simulations were performed with the ABCG2 receptor, and the results were compared with the two earlier synthesized active compounds. The outcomes of the study will help researchers to develop new antagonists for treatment of MDR breast cancer.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13205-022-03231-1.

Pharmacological attributes of Bacopa monnieri extract: Current updates and clinical manifestation

Bacopa monnieri has been used for centuries in Ayurvedic medicine, alone or in combination with other herbs, as a memory and learning enhancer, sedative, and anti-epileptic. This review aimed to highlight the health benefits of B. monnieri extracts (BME), focusing on anti-cancer and neurodegenerative diseases. We examined the clinical studies on phytochemistry and pharmacological application of BME. We further highlighted the mechanism of action of these extracts in varying types of cancer and their therapeutic implications. In addition, we investigated the underlying molecular mechanism in therapeutic interventions, toxicities, safety concerns and synergistic potential in cognition and neuroprotection. Overall, this review provides deeper insights into the therapeutic implications of Brahmi as a lead formulation for treating neurological disorders and exerting cognitive-enhancing effects.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Hypertriton Production in p-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The study of nuclei and antinuclei production has proven to be a powerful tool to investigate the formation mechanism of loosely bound states in high-energy hadronic collisions. The first measurement of the production of _{Λ}^{3}H in p-Pb collisions at sqrt[s_{NN}]=5.02  TeV is presented in this Letter. Its production yield measured in the rapidity interval -1<y<0 for the 40% highest-multiplicity p-Pb collisions is dN/dy=[6.3±1.8(stat)±1.2(syst)]×10^{-7}. The measurement is compared with the expectations of statistical hadronization and coalescence models, which describe the nucleosynthesis in hadronic collisions. These two models predict very different yields of the hypertriton in charged particle multiplicity environments relevant to small collision systems such as p-Pb, and therefore the measurement of dN/dy is crucial to distinguish between them. The precision of this measurement leads to the exclusion with a significance larger than 6.9σ of some configurations of the statistical hadronization model, thus constraining the theory behind the production of loosely bound states at hadron colliders.