Multi-omics analysis identifies potential microbial and metabolite diagnostic biomarkers of bacterial vaginosis

BACKGROUND

Bacterial vaginosis (BV) is a common clinical manifestation of a perturbed vaginal ecology associated with adverse sexual and reproductive health outcomes if left untreated. The existing diagnostic modalities are either cumbersome or require skilled expertise, warranting alternate tests. Application of machine-learning tools to heterogeneous and high-dimensional multi-omics datasets finds promising potential in data integration and may aid biomarker discovery.

OBJECTIVES

The present study aimed to evaluate the potential of the microbiome and metabolome-derived biomarkers in BV diagnosis. Interpretable machine-learning algorithms were used to evaluate the utility of an integrated-omics-derived classification model.

METHODS

Vaginal samples obtained from reproductive-age group women with (n = 40) and without BV (n = 40) were subjected to 16S rRNA amplicon sequencing and LC-MS-based metabolomics. The vaginal microbiome and metabolome were characterized, and machine-learning analysis was performed to build a classification model using biomarkers with the highest diagnostic accuracy.

RESULTS

Microbiome-based diagnostic model exhibited a ROC-AUC (10-fold CV) of 0.84 ± 0.21 and accuracy of 0.79 ± 0.18, and important features were Aerococcus spp., Mycoplasma hominis, Sneathia spp., Lactobacillus spp., Prevotella spp., Gardnerella spp. and Fannyhessea vaginae. The metabolome-derived model displayed superior performance with a ROC-AUC of 0.97 ± 0.07 and an accuracy of 0.92 ± 0.08. Beta-leucine, methylimidazole acetaldehyde, dimethylethanolamine, L-arginine and beta cortol were among key predictive metabolites for BV. A predictive model combining both microbial and metabolite features exhibited a high ROC-AUC of 0.97 ± 0.07 and accuracy of 0.94 ± 0.08 with diagnostic performance only slightly superior to the metabolite-based model.

CONCLUSION

Application of machine-learning tools to multi-omics datasets aid biomarker discovery with high predictive performance. Metabolome-derived classification models were observed to have superior diagnostic performance in predicting BV than microbiome-based biomarkers.

Deciphering Intermediate Nugent scores: Utility of Real-time PCR for Bacterial Vaginosis diagnosis

PURPOSE

To optimize real-time PCR assays for diagnosis of Bacterial Vaginosis (BV) and determine cut-off loads by ROC analysis for Gardnerella vaginalis, Atopobium vaginae and Lactobacillus spp. as compared to Nugent scoring (Gold standard) in clinical samples.

RESULTS

Out of 125 women, 34 were positive, 26 intermediate and 65 negative for BV by Nugent scoring. All three real-time PCR assays were found to be highly sensitive & specific and AUC suggested excellent diagnostic accuracy. An optimal cut-off was >9.45 × 103 copies/ ml, >3.34 × 103 copies/ ml & ≤ 18.63 × 103 copies/ ml for G. vaginalis, A. vaginae and Lactobacillus spp. respectively, in BV positives. Gram staining and qPCR were discordant only in patients with intermediate scores (n = 26) where qPCR identified 15 (57.69%) as positive and 11 (42.3%) as negative.

CONCLUSION

PCR-based molecular BV diagnosis is more accurate and can be used for deciphering intermediate Nugent scores.

Appendectomy and asthma: a search for an association in older subjects

INTRODUCTION

Several risk factors found to be associated with postoperative complications and cancer surgery, which carry a significant morbidity risk to cancer patients. Therefore, prehabilitation is necessary to improve the functional capability and nutritional status of a patient prior to surgery, so that the patient can withstand any postoperative activity and associated deterioration. Thus, this study aims to assess the effectiveness of prehabilitation interventions on the functional status of patients with gastric and oesophageal cancer who underwent esophagectomy and gastrectomy.

MATERIAL AND METHODS

An interventional study was carried out among oesophageal and gastric cancer patients who had undergone surgery at the National Cancer Institute of Malaysia. The prehabilitation process took a maximum of two weeks, depending on the patient's optimisation before surgery. The prehabilitation is based on functional capacity (ECOG performance status), muscle function (handgrip strength), cardio-respiratory function (peak flow meter) and nutritional status (calorie and protein). Postoperative outcomes are measured based on the length of hospital stay, complications, and Clavien-Dindo Classification.

RESULTS

Thirty-one patients were recruited to undergo a prehabilitation intervention prior to gastrectomy (n=21) and esophagectomy (n=10). Demographically, most of the cancer patients were males (67.7%) with an ideal mean of BMI (23.5±6.0). Physically, the majority of them had physical class (ASA grade) Grade 2 (67.7%), ECOG performance status of 1 (61.3%) and SGA grade B (51.6%). The functional capacity and nutritional status showed a significant improvement after one week of prehabilitation interventions: peak expiratory flow meter (p<0.001), handgrip (p<0.001), ECOG performance (p<0.001), walking distance (p<0.001), incentive spirometry (p<0.001), total body calorie (p<0.001) and total body protein (p=0.004). However, those patients who required two weeks of prehabilitation for optimization showed only significant improvement in peak expiratory flow meter (p<0.001), handgrip (p<0.001), and incentive spirometry (p<0.001). Prehabilitation is significantly associated postoperatively with the length of hospital stay (p=0.028), complications (p=0.011) and Clavien-Dindo Classification (p=0.029).

CONCLUSION

Prehabilitation interventions significantly increase the functional capacity and nutritional status of cancer patients preoperatively; concurrently reducing hospital stays and complications postoperatively. However, certain cancer patients might require over two weeks of prehabilitation to improve the patient's functional capacity and reduce complications postoperatively.

Ten fraction hypofractionated stereotactic body radiotherapy for the management of ultracentral lung tumors: a retrospective analysis of dosimetry, outcomes, and toxicity

BACKGROUND

The management of ultracentral thoracic tumors with ablative dose of radiotherapy remains challenging given proximity to critical central structures. We report patient outcomes, toxicity, and dosimetry for ultracentrally located tumors with hypofractionated stereotactic body radiotherapy (hfSBRT).

METHODS

Seventy-eight individuals (50 initial radiotherapy, 28 re-irradiation) undergoing 10 fraction hfSBRT for ultracentrally located thoracic tumors treated between 2009 and 2020 at a single institution were retrospectively reviewed. Overall survival (OS), progression free survival (PFS), and local control (LC) were calculated. Incidence and grade of treatment related toxicity were evaluated. Dosimetric analysis of treatment plans and critical adjacent OARs was performed.

RESULTS

At a median follow up time of 13 months, 1- and 3-year OS, PFS, and LC were 89%/63%, 37%/18%, and 84%/65%, respectively. Median dose was 65 Gy (BED10 = 107.25 Gy). Median primary bronchial tree maximum dose (Dmax) was 60 Gy (V50 = 0.96 cc). Median esophageal Dmax was 38 Gy (V40 = 0 cc). Median great vessel Dmax was 68 Gy (V50 = 3.53 cc). The most common ≥ grade 2 adverse event was pneumonitis, in 15 individuals (20%). Grade 3 or higher toxicity was observed in 9 individuals (12%): three cases of grade 3 pneumonitis (two re-irradiation, one initial radiotherapy), one grade 3 esophageal stricture following re-irradiation, two grade 3 endobronchial obstructions both following initial radiotherapy, and three grade 5 hemoptysis events (two re-irradiation, one initial radiotherapy). One hemoptysis event was categorized as "possibly" related to treatment, while the remaining two events were categorized as "unlikely" related to treatment in patients with clear evidence of disease progression.

CONCLUSIONS

hfSBRT to ultracentral lung tumors delivered over 10 fractions is a safe and effective treatment option, with acceptable rates of toxicity and good rates of tumor control.

TRIAL REGISTRATION

IRB registration number 12573.

Non-surgical organ preservation in laryngeal and hypopharyngeal cancers: an audit from the clinic

BACKGROUND

There is increasing concern regarding efficacy of organ preservation protocol in laryngeal and hypopharyngeal cancers.

METHOD

This study retrospectively assessed disease-related and functional outcomes of 191 patients with non-metastatic laryngeal or hypopharyngeal squamous cell carcinoma treated with curative intent (radiotherapy with or without chemotherapy).

RESULTS

Seventy-six patients (39.8 per cent) had a primary cancer in the larynx, and 115 patients (60.2 per cent) had a primary cancer in the hypopharynx. The median follow up was 39 months. The 3-year time to progression, overall survival, local control and laryngectomy free survival was 56.2 per cent, 76.3 per cent, 73.2 per cent and 67.2 per cent, respectively. At the time of analysis, 83 patients (43.5 per cent) were alive and disease free at their last follow up and did not require tube feeding or tracheostomy. The laryngo-oesophageal dysfunction-free survival was 61 per cent at 3 years.

CONCLUSION

Organ conservation protocols remain the standard of treatment in appropriately selected patients with laryngeal and hypopharyngeal cancers.

Strongyloides colitis, a rare but important mimic of Crohn's disease, resulting in coma and multi-organ failure: a case report

BACKGROUND

Strongyloides colitis is a severe form of strongyloidiasis that carries a high mortality rate if untreated. There is an overlapping clinical presentation between Strongyloides colitis and Crohn's disease. Here, we present a case of a patient who was diagnosed with Crohn's disease and was treated with immunosuppressant therapy which resulted in a poor outcome.

CASE PRESENTATION

A middle-aged, native African male presented with diarrhea, abdominal pain, and weight loss. Colonoscopy showed some patchy inflammation in the caecum, which on biopsy was suggestive of Crohn's disease. He had a short course of steroids before being admitted to an emergency with abdominal pain, diarrhea, malnutrition, and severe weight loss. Initial conservative treatment failed, and he became acutely unwell and septic with peritonitis. Laparotomy was carried out, which showed mild inflammation in the terminal ileum, which was not resected. Postoperatively, the patient became comatose and went into multi-organ dysfunction. He failed to progress, and a further laparotomy and subtotal colectomy were performed on the 12th postoperative day. His multi-organ failure progressed, and he succumbed to death 4 days later.

DISCUSSION

Strongyloides stercoralis is a parasite causing an enteric infection in animals and humans. Strongyloidiasis in immunocompetent individuals is usually an indolent disease. However, in immunocompromised individuals, it can cause hyperinfective syndrome. Patients with strongyloid colitis should undergo colonoscopy and biopsy where acute inflammation with eosinophilic infiltrates indicates parasitic infiltration of the colonic wall. Surgery is generally not indicated, and any surgical intervention with misdiagnosis of a flare-up of IBD can be very detrimental to the patient.

CONCLUSION

Strongyloid colitis can very harmfully mimic Crohn's colitis, and the use of steroids and immunosuppressants can disseminate parasitic infection. Hyperinfection syndrome can lead to sepsis, organ dysfunction, and comma. Disseminated infection carries a high mortality.

19 A Rare Case of Parapharyngeal Schwannoma Mimicking Peritonsillar Abscess in a Young Female Patient

Introduction

Parapharyngeal Space (PPS) tumours are responsible for 0.5% of head and neck cancers. Presenting features can mimic peritonsillar abscess. A differential diagnosis of PPS tumour should therefore be considered in young, systemically well patients with resistant peritonsillar masses.

Aim

To report a rare case of parapharyngeal schwannoma in a fit and well adult female with a focus on investigations and optimal management.

Method

A 29-year-old, Caucasian female presented with a three-week history of a right sided oropharyngeal mass, odynophagia, and dysphonia. A stagnant clinical picture prompted further investigation with Magnetic Resonance Imaging (MRI). This demonstrated a 7cm right sided PPS mass arising from the deep lobe of the right parotid gland. Mass excision and partial, ipsilateral parotidectomy confirmed Schwannoma (neurilemoma).

Results & Discussion

Schwannomas account for a third of PPS tumours. Arising from neurological Schwann cells, they are often encapsulated, benign tumours which are characterised by slow and asymptomatic growth. Presentation often follows mass effects leading to dysphagia, odynophagia, and dysphonia. MRI and FNAC remain the gold standard in confirmation of diagnosis. Insensitivity to radiotherapy ensures that surgical resection is the mainstay of treatment and may utilise the transcervical, transparotid or transmandibular approach.

Conclusion

There is a significant degree of overlap in the epidemiology and presenting features of peritonsillar abscess and PPS tumours. In cases of treatment resistant, chronic peritonsillar masses a differential diagnosis of PPS tumour must therefore be excluded.

Stereotactic body radiotherapy for apical lung tumors: Dosimetric analysis of the brachial plexus and preliminary clinical outcomes

BACKGROUND

Dosimetric constraints of the brachial plexus have not yet been well-established for patients undergoing stereotactic body radiotherapy (SBRT). This study evaluated long-term experience with the treatment of early stage apical lung tumors with SBRT and reports on dosimetric correlates of outcome.

METHODS

Between 2009 and 2018, a total of 78 consecutive patients with 81 apical lung tumors underwent SBRT for T1-3N0 non-small cell lung cancer. Apical tumors were those with tumor epicenter superior to the aortic arch. The brachial plexus (BP) was anatomically contoured according to the Radiation Therapy Oncology Group (RTOG) atlas. Patient medical records were retrospectively reviewed to determine incidence of brachial plexus injury (BPI) and a normal tissue complication probability model (NTCP) was applied to the dosimetric data.

RESULTS

Five patients (6.4%) reported neuropathic symptoms consistent with BPI and occurred a median 11.9 months after treatment (range, 5.2 to 28.1 months). Most common dose and fractionation in those developing BPI were 50 Gy in 5 fractions (4 patients). Symptoms consisted of pain in 2 patients (40.0%), numbness in the hand or axilla in 4 patients (80.0%), and ipsilateral hand weakness in 1 patient (20.0%). In the overall cohort the median BP Dmax (EQD2_{3 Gy}) was 5.13 Gy (range, 0.18 to 217.2 Gy) and in patients with BPI the median BP Dmax (EQD2_{3 Gy}) was 32.14 Gy (range, 13.4 to 99.9 Gy). The NTCP model gave good fit with an area under the curve (AUC) of 0.75 (OR 7.3, 95% CI: 0.8-68.3) for BP Dmax (EQD2_{3 Gy}) threshold of 20 Gy.

CONCLUSION

Significant variation exists in the dose delivered to the brachial plexus for patients treated by SBRT for apical lung tumors. The incidence of neuropathic symptoms in the post-SBRT setting was appreciable and prospective clinical correlation with dosimetric information should be utilized in order to develop evidence-based dose constraints.

1131 The Integration of Cardiothoracic Practical Skills Workshop in The Undergraduate Medical School Curriculum and Its Impact on Promoting Interest in Cardiothoracic Surgery

Aim

Assess if WETLAB workshop encourages the engagement of medical students in CTS surgery

Method

We hosted a cardiac WETLAB workshop, led by a consultant cardiothoracic surgeon. Attendees were taught how to carry out an end-to-side anastomosis on animal tissue. We used pre-and -post exposure questionnaires composed of 10 items to assess the ability of the workshop to improve undergraduate interest in cardiothoracic surgery. The questionnaire included questions around students’ interest in the speciality, previous exposure to the speciality and whether students want to pursue a career in the speciality.

Results

Out of the 12 attendees, 10 completed both questionnaires. The workshop was well received with the overall satisfaction of 9.64 out of 10. It significantly increased respondents’ interest in CTS(z=-0.06, p = 0.01) but did not show any significant difference in encouraging them to pursue surgery. 100% of respondents agreed that specialised practical workshops should be incorporated within the medical school curriculum and that if the opportunity arises, they will attend another in the future.

Conclusions

Specialised practical workshops have the potential to play a significant role in the medical school curriculum in order to enhance exposure to the field of cardiothoracic surgery. This may lead to a positive impact on the number of doctors wishing to pursue this speciality in the future.

193 Evaluation of the ‘One-Stop Diagnostic Head and Neck Lump Clinic' At A Tertiary Head and Neck Centre

An urgent neck lump service was introduced at the Freeman Hospital (Newcastle-Upon-Tyne) in 2017. All 2-week-wait urgent head and neck referrals were triaged into this service. The clinic involves clinical examination by a head and neck specialist and if appropriate an urgent ultrasound scan (USS) in clinic +/- a fine needle aspiration for cytology (FNAC). This centralised system means patients can be diagnosed earlier and thus receive treatment swiftly.

This audit aimed to primarily identify: The prevalence/pick-up rate of cancer diagnosed through the clinic The utilisation of USS/FNAC The time-to-treatment initiation

Data was collated retrospectively through the electronic record system. The initial evaluation was conducted between June-November 2018 (n = 191). The subsequent re-evaluation was performed between September-November 2019 (n = 159), following increased clinic capacity, implementation of methods to increase awareness and a formal triage process.

In the initial evaluation over 6 months (n = 191), 9.9% underwent an USS in the clinic and 9.95% at a later date. 18% of patients underwent a FNAC. 6.8% patients were diagnosed with cancer. The mean time-to-treatment initiation was 36 days.

In the re-evaluation over 3 months (n = 159), 23.2% had an USS in the clinic and 30.2% at a later date. 13% of patients underwent a FNAC. 9.4% of patients were diagnosed with cancer. The mean time-to-treatment initiation was 44 days.

This affirms the benefits of a swift ‘one-stop clinic’. On average, patients diagnosed with cancer had treatment initiation 40-days post-review. Furthermore, even with a triage process only 1 in 10 patients had cancer.

887 A Quality Improvement Project: Implementation of a New Epistaxis Pathway

Introduction

Epistaxis is one of the most common ENT conditions leading to unplanned hospital admission. This closed loop quality improvement project looked at epistaxis admissions, and whether patients could be safely managed on an ambulatory basis with unilateral intranasal packing, through the implementation of a new epistaxis pathway.

Method

Two prospective cycles at a District General Hospital. First cycle: three-month period (October-December 2018); recorded all patients admitted with epistaxis and the percentage with intranasal packing; criteria for discharge with unilateral intranasal packing created (including normal observations, normal clotting/haemoglobin, only on aspirin, safe home environment). Second cycle (after implementation of new pathway): two months (December 2019 and January 2020); recorded all patients admitted with epistaxis or discharged with unilateral intranasal packing; patient feedback obtained.

Results

First cycle: 31 epistaxis admissions; 12 patients met discharge criteria; average length of stay was 1.4 days. Second cycle: 22 epistaxis admissions; 4 admissions were avoided; 2 admissions were unnecessary according to new pathway; no patient-reported issues with pack at home.

Conclusions

Successful creation and initial implementation of pathway with no adverse outcomes. Approximately £1380 of savings through avoided admissions. Pathway expanded and successfully used during COVID-19 to include patients on anticoagulation as suitable for discharge with intranasal packing.

625 Health Economics and Safety of Frontline Carers in the COVID-19 Era: Time to Abolish Routine Group and Save For Emergency Appendicectomies?

Introduction

Face of healthcare, patient safety and protection of healthcare providers has been completely transformed with global health pandemic. However, emergency surgical procedures must still be performed, with the commonest being appendicectomy.

It is common practice across National Health Service trusts to collect a group and save (G&S) sample pre-operatively which increases healthcare staff exposure to the patient and increased use of personal protective equipment in this pandemic.

Method

Prospective study of adult patients undergoing emergency appendicectomy since the transformation of emergency care with COVID-19 induced restrictions compared with patients undergoing the same operation before the pandemic.

Results

179 adult patients underwent emergency appendicectomy over 6-months in 2019–2020, 60 patients in the 12 weeks period from the start of the transformed emergency services due to the pandemic. Pre-operative G&S samples were taken for 60(33.5%) patients in the pre COVID-19 period, whereas 7(11.6%) were taken for patients undergoing appendicectomy during the pandemic. None of the patients in either group had intra-operative blood loss of more than 500 millilitres and none of them required peri-operative blood transfusion

Conclusions

Our study demonstrates that the routine pre-operative G&S can safely be abandoned as a routine practice for all patients undergoing emergency appendicectomy.

The use of whole-body fluorine-18-fluorodeoxyglucose positron emission tomography integrated with computed tomography for accurate staging and surveillance in the case of mucosa-associated lymphoid tissue

We present the case of a 79-year-old male, who was initially treated for mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) of the right eyelid, and later for disease relapse in the stomach. During follow up, he was noted to have developed left arm nodules just medial to the proximal biceps muscle, which were found to be multiply enlarged lymph nodes on subsequent ultrasound imaging. Excisional biopsy of these nodes revealed MALT lymphoma. He was initially referred for consideration of radiation, but a restaging F-18 fluorodeoxyglucose positron emission tomography integrated with computed tomography (F-18 FDG PET/CT) further identified a focus of suspicious uptake in left calf, which was later also biopsy proven to be MALT lymphoma. His disease was upstaged as the result of this later finding, and the overall recommendation for treatment changed to favor systemic treatment with Rituximab.

IMPACT OF MOLECULAR METHOD FOR THE DIAGNOSIS OF ACUTE BACTERIAL MENINGITIS IN A TERTIARY HEALTH CARE CENTRE IN NORTH INDIA

Background. Acute bacterial meningitis is one of the significant infectious diseases that add an immense burden to the health system. Proper management of meningitis is an invincible need to overcome the severe consequences. Objectives. The aim of the study is detection of the etiological agents of acute bacterial meningitis by PCR. Methods. Total 267 CSF samples collected from suspected bacterial meningitis cases were processed for the detection of S. pneumoniae, H. influenzae, N. meningitidis, E. coli and Group B streptococci by conventional and molecular diagnosis method. CSF was inoculated on Blood, chocolate and MacConkey agar plates and incubated at 37 °C for 24-48 hrs. Bacteria grown were identified by Matrix assisted laser desorption/ionization time of flight (MALDI-TOF). Multiplex PCR of the enlisted bacteria was performed using DNA extracted from CSF by DNA extraction kit (Qiagen, USA). Results. 5 (1.87%) out of the total 267 CSF samples were culture positive (3 S. pneumoniae and 2 E. coli) and 28 (10.49%) had detectable DNA by conventional PCR. Out of these 28 samples, 20 (71.43%) were S. pneumoniae and 8 (28.57%) were E. coli. 15 (53.57%) out of total S. pneumoniae were present in children below 5 years of age. Similarly, E. coli was predominant in neonates. Sensitivity and specificity of the PCR was 100% and 95-98% respectively. Conclusions. Streptococcus pneumoniae is the commonest cause of community acquired bacterial meningitis in children below five years of age. Hence, for the promising outcome, PCR should be implemented for the diagnosis of acute bacterial meningitis.

Ultra-central Thoracic Re-irradiation Using 10-fraction Stereotactic Body Radiotherapy for Recurrent Non-small-cell Lung Cancer Tumors: Preliminary Toxicity and Efficacy Outcomes

BACKGROUND

We report our clinical outcomes of patients with recurrent non-small-cell lung cancer (NSCLC) tumors with ultra-central (UC) location treated with hypofractionated 10-fraction stereotactic body radiotherapy (hSBRT) in the context of thoracic re-irradiation.

PATIENTS AND METHODS

This study was conducted from 2009 to 2017 on 20 patients with recurrent NSCLC from previous thoracic radiation treatment who underwent hSBRT to 21 total UC located recurrent tumors. The planning target volumes (PTVs) that overlapped with previous treatment fields (within the 50% isodose line) were included in this analysis with endpoints of overall survival, tumor control, and toxicity.

RESULTS

The median follow-up time was 17.8 months. The median total dose of hSBRT and total biologically effective dose (BED₁₀) were 65 Gy and 107.25 Gy, respectively. The median time from previous treatment was 14.6 months. The 1-year overall survival, progression-free survival, and local control rates were 68%, 35%, and 83%, respectively. The median time to local progression was 13.3 months. The most common toxicity was grade 2 or above pneumonitis (35%). One patient, whose tumor was abutting the esophagus, experienced grade 3 esophagitis. Two (10%) patients died from "unlikely" treatment-related hemorrhage from local tumor progression at 10 and 24 months after hSBRT. Bronchoscopic evaluation of 1 patient suggested endobronchial tumor progression, and clear radiographic evidence of treated hilar tumor progression was documented in the second patient's case.

CONCLUSION

Despite having a high-risk population with recurrent ultra-central NSCLC tumors in the setting of re-irradiation, our results demonstrate that ablative doses of hSBRT may serve as a feasible option for these challenging cases and concur with current reported literature.

Epigastric port retrieval of the gallbladder following laparoscopic cholecystectomy is associated with the reduced risk of port site infection and port site incisional hernia: An updated meta-analysis of randomized controlled trials

Aims

The objective of this article is to compare the surgical outcomes for epigastric port or umbilical port retrieval of the gallbladder (GB) following laparoscopic cholecystectomy (LC).

Methods

The data retrieved from the published randomized, controlled trials (RCT) comparing the surgical outcomes for epigastric port or umbilical port retrieval of the GB following LC was analysed using the principles of meta-analysis. The summated outcome of continuous variables was expressed as standardized mean difference (SMD) and dichotomous data was presented in odds ratio (OR).

Results

Eight RCTs on 2676 patients comparing the surgical outcomes for epigastric port or umbilical port retrieval of the GB following LC were analysed. In the random effects model analysis using the statistical software Review Manager 5.3, the GB retrieval through epigastric port was associated with the reduced duration of operation (SMD, 0.41; 95% CI, 0.18, 0.64; z = 3.52; P = 0.0004). Epigastric retrieval was also associated with reduced risk of surgical site infection (OR, 1.95; 95% CI, 0.75, 5.11; z = 1.36; P = 0.17), and port site incisional hernia (OR, 4.22; 95% CI, 0.43, 41.40; z = 1.24; P = 0.22) compared to umbilical port retrieval though it did not reach statistical significance. The need for port enlargement to retrieve the GB was similar in both groups. In contrast, the umbilical port retrieval of the GB was associated with significantly less post-operative pain (SMD, −0.51; 95% CI, −0.95, −0.06; z = 2.24; P = 0.03), reduced GB perforation rate, reduced port site bleeding rate and reduced difficulty in GB retrieval.

Conclusion

GB retrieval through epigastric port following LC has clinically proven advantage of reduced retrieval site infection rate, lower operation time and incisional hernia rate but at the cost of increased pain at 24 h, higher risk of GB perforation, port site bleeding and technical difficulties.

•

An updated meta-analysis providing better evidence on gall bladder extraction port following laparoscopic cholecystectomy(LC).

•

Epigastric port retrieval of gallbladder following LC has advantage of reduced rate of both infection and incisional hernia.

•

Umbilical port retrieval of gallbladder following LC has advantage of reduced pain, port site bleeding and perforation risk.

•

In conclusion from this meta-analysis epigastric port retrieval seems to be more advantageous compared to the umbilical port.

Variations in antibiotic use across India: multi-centre study through Global Point Prevalence survey

The aim of the study was to assess antimicrobial prescribing patterns, and variation in practice, in India. A point prevalence survey (PPS) was conducted in October to December 2017 in 16 tertiary care hospitals across India. The survey included all inpatients receiving an antimicrobial on the day of PPS and collected data were analysed using a web-based application of the University of Antwerp. In all, 1750 patients were surveyed, of whom 1005 were receiving a total of 1578 antimicrobials. Among the antimicrobials prescribed, 26.87% were for community-acquired infections; 19.20% for hospital-acquired infections; 17.24% for medical prophylaxis; 28.70% for surgical prophylaxis; and 7.99% for other or undetermined reasons. Antibiotic prescribing quality indicators, such as reason in notes and post-prescription review score, were low. This PPS showed widespread antibiotic usage, underlining the need for antibiotic stewardship to promote evidence-based practice.

Treatment of sialorrhoea with repeated ultrasound-guided injections of botulinum toxin A into the parotid and submandibular glands

Botulinum toxin injections are useful in patients with refractory sialorrhoea although the optimum treatment protocol and its efficacy over a long period of follow up are controversial. The aim of our prospective study was to examine the efficacy and complications of a protocol of repeated ultrasound-guided botulinum toxin injections of fixed doses at a tertiary children's hospital. A total of 79 procedures were done in 34 patients who were followed up for two years. The overall complication rate was 3%. The outcome measures considered included the Drooling Frequency Severity Scale (DFSS), visual analogue scale (VAS), and carers' assessments of the reduction in drooling. Our study highlighted two types on non-responders (primary and secondary) of which 3/34 required definitive surgical management. In summary, this study shows that a protocol of repeated injections of fixed doses of botulinum toxin A, while not beneficial in all cases, is a potentially valuable option for the safe and effective treatment of sialorrhoea in children.

In vitro assessment of gentamicin and azithromycin-based combination therapy against Neisseria gonorrhoeae isolates in India

PURPOSE

The public health burden of infections caused by Neisseria gonorrhoeae is magnified due to high rates of resistance to traditional antimicrobials. The aim of this study was to evaluate the in vitro efficacy of an alternative dual therapy comprising gentamicin and azithromycin.

METHODOLOGY

The E-test method was used to determine the minimum inhibitory concentrations (MICs) of gentamicin and azithromycin individually prior to testing in combination using the cross or 90^o angle formation method. A total of 70 clinical isolates of N.gonorrhoeae displaying varying ceftriaxone MICs along with 2 reference strains (WHO K and P) and 1 ceftriaxone-resistant QA isolate were examined. The fractional inhibitory concentration index (FICI) was calculated and the results were interpreted using the following criteria: synergy, FICI ≤0.5; indifference or additive, FICI >0.5 to ≤4.0; and antagonism, FICI >4.0.

RESULTS

A total of 54 (77.1 %) isolates displayed indifference, while 16 (22.9 %) demonstrated synergy. When azithromycin was tested alone, the MICs ranged from 0.016 to 2 µg ml^-1 . However, in combination with gentamicin, the mean MIC value of all isolates decreased from 0.275 µg ml^-1 to 0.090 µg ml^-1 (P=0.05).When gentamicin was tested alone, the MICs ranged from 0.25 to 8 µg ml^-1, with a mean MIC of 4.342 µg ml^-1, whereas in combination with azithromycin it decreased significantly to 2.042 µg ml^-1 (P=0.04).

CONCLUSION

No antagonism was observed in this combination, suggesting that it could be a future treatment option as we prepare for a post-cephalosporin era. However, comprehensive in vivo evaluations are warranted and recommendations should be made based on clinical trials.

Early viral-specific T-cell testing predicts late cytomegalovirus reactivation following liver transplantation

INTRODUCTION

Although antiviral prophylaxis is effective in preventing early cytomegalovirus (CMV) reactivation following liver transplantation (OLT), it predisposes patients to late CMV after prophylaxis has ceased. QuantiFERON-CMV (QFN-CMV, Qiagen, The Netherlands) measures an individual's viral-specific immune response.

METHODS

Fifty-nine OLT recipients were prospectively monitored post-OLT in an observational cohort study. QFN-CMV was performed at regular time-points. An absolute QFN-CMV <0.1 IU/mL was considered non-reactive.

RESULTS

50/59 (84.7%) had a reactive QFN-CMV by M6. 38/59 (64.4%) had antiviral prophylaxis or treatment before M6, with 31/38 (81.6%) developing a reactive QFN-CMV by 6 months. Over 90% already had a reactive result as early as 3 months post transplant, 3 patients (5.08%) developed late CMV between 6-12 months (median 251 days)-all had a non-reactive M6 QFN-CMV. And 2/3 experienced CMV disease. Non-reactive M6 QFN-CMV was significantly associated with late CMV (OR = 54.4, PPV = 0.33, NPV = 1.00, P = .003).

CONCLUSION

Although only 5% of recipients developed late CMV, 2/3 suffered CMV disease. M6 QFN-CMV has an excellent NPV for late CMV, suggesting patients who exhibit a robust ex vivo immune response at M6 can safely cease CMV monitoring. Furthermore, >90% already express viral-specific immunity as early as 3 months. Conceivably, antiviral prophylaxis could be discontinued early in these patients.

Impact of viral hepatitis aetiology on survival outcomes in hepatocellular carcinoma: A large multicentre cohort study

While HBV and HCV are risk factors for HCC, uncertainty exists as to whether these viral infections have prognostic significance in HCC. Thus, we compared the overall survival of patients with HBV, HCV and nonviral HCC, and evaluated whether the presence of HBV and HCV predicts patient outcomes. We conducted a multicentre study of HCC cases diagnosed at six Melbourne tertiary hospitals between Jan 2000-Dec 2014. Patient demographics, liver disease and tumour characteristics and patient outcomes were obtained from hospital databases, computer records and the Victorian Death Registry. Survival outcomes were compared between HBV, HCV and nonviral hepatitis cases and predictors of survival determined using Cox proportional hazards regression. There were 1436 new HCC cases identified including 776 due to viral hepatitis (HBV 235, HCV 511, HBV-HCV 30) and 660 from nonviral causes. The median survival of HBV, HCV and nonviral HCC patients was 59.1, 28.4 and 20.9 months, respectively (P<.0001). On multivariate analysis, independent risk factors for survival included HCC aetiology, gender, BCLC stage, serum AFP, total number and size of lesions, and serum creatinine and albumin. After adjusting for these and method of detection, HBV remained an independent predictor of improved overall survival when compared to both nonviral (HR 0.60%, 95% CI 0.35-0.98; P=.03) and HCV-related HCC (HR 0.51%, 95% CI 0.30-0.85; P=.01). In this large multicentre study, HBV is independently associated with improved overall survival compared with HCV and nonviral-related HCC. Further studies are needed to determine the underlying factor(s) responsible.

Volumetric-modulated arc therapy (VMAT) for whole brain radiotherapy: not only for hippocampal sparing, but also for reduction of dose to organs at risk

A prospective clinical trial, Radiation Therapy Oncology Group (RTOG) 0933, has demonstrated that whole brain radiotherapy (WBRT) using conformal radiation delivery technique with hippocampal avoidance is associated with less memory complications. Further sparing of other organs at risk (OARs) including the scalp, ear canals, cochleae, and parotid glands could be associated with reductions in additional toxicities for patients treated with WBRT. We investigated the feasibility of WBRT using volumetric-modulated arc therapy (VMAT) to spare the hippocampi and the aforementioned OARs. Ten patients previously treated with nonconformal WBRT (NC-WBRT) using opposed lateral beams were retrospectively re-planned using VMAT with hippocampal sparing according to the RTOG 0933 protocol. The OARs (scalp, auditory canals, cochleae, and parotid glands) were considered as dose-constrained structures. VMAT plans were generated for a prescription dose of 30 Gy in 10 fractions. Comparison of the dosimetric parameters achieved by VMAT and NC-WBRT plans was performed using paired t-tests using upper bound p-value of < 0.001. Average beam on time and monitor units (MUs) delivered to the patients on VMAT were compared with those obtained with NC-WBRT. All VMAT plans met RTOG 0933 dosimetric criteria including the dose to hippocampi of 100% of the volume (D_100%) of 8.4 ± 0.3 Gy and maximum dose of 15.6 ± 0.4 Gy, respectively. A statistically significant dose reduction (p < 0.001) to all OARs was achieved. The mean and maximum scalp doses were reduced by an average of 9 Gy (32%) and 2 Gy (6%), respectively. The mean and maximum doses to the auditory canals were reduced from 29.5 ± 0.5 Gy and 31.0 ± 0.4 Gy with NC-WBRT, to 21.8 ± 1.6 Gy (26%) and 27.4 ± 1.4 Gy (12%) with VMAT. VMAT also reduced mean and maximum doses to the cochlea by an average of 4 Gy (13%) and 2 Gy (6%), respectively. The parotid glands mean and maximum doses with VMAT were 4.4 ± 1.9 Gy and 15.7 ± 5.0 Gy, compared to 12.8 ± 4.9 Gy and 30.6 ± 0.5 Gy with NC-WBRT, respectively. The average dose reduction of mean and maximum of parotid glands from VMAT were 65% and 50%, respectively. The average beam on time and MUs were 2.3minutes and 719 on VMAT, and 0.7 minutes and 350 on NC-WBRT. This study demonstrated the feasibility of WBRT using VMAT to not only spare the hippocampi, but also significantly reduce dose to OARs. These advantages of VMAT could potentially decrease the toxicities associated with NC-WBRT and improve patients' quality of life, especially for patients with favorable prognosis receiving WBRT or patients receiving prophylactic cranial irradiation (PCI).

Controlled release of antibiotic amoxicillin drug using carboxymethyl cellulose-cl-poly(lactic acid-co-itaconic acid) hydrogel

In this paper, microwave assisted preparation of carboxymethyl cellulose-cl-poly(lactic acid-co-itaconic acid) (CMC-cl-P(LA-co-IA)) hydrogel was reported via facile graft copolymerization using N,N¹-methylene-bis-acrylamide (MBA) and potassium persulphate as cross linker and initiator. Different reaction parameters were optimized to achieve good yield. The formation of hydrogel was confirmed by characterization techniques such as Fourier transform infrared spectroscopy, field emission scanning electron microscopy, X-ray diffraction, thermo gravimetric analysis, transmission electron microscopy etc. The antimicrobial activities of the hydrogel were studied against Staphylococcus aureus and Escherichia coli. About 95% killing of bacteria was recorded after 24h. The controlled release of amoxicillin drug from hydrogel was evaluated as a function of pH and time. Maximum drug release of 98% was recorded at 2.2 pH after 7h. The kinetic studies showed non-Fickian diffusion of the drug.

Linac-based stereotactic radiosurgery (SRS) in the treatment of refractory trigeminal neuralgia: Detailed description of SRS procedure and reported clinical outcomes

Purpose/Objectives

To present our linac‐based SRS procedural technique for medically and/or surgically refractory trigeminal neuralgia (TN) treatment and simultaneously report our clinical outcomes.

Materials and Methods

Twenty‐seven refractory TN patients who were treated with a single fraction of 80 Gy to TN. Treatment delivery was performed with a 4 mm cone size using 7‐arc arrangement with differential‐weighting for Novalis‐TX with six MV‐SRS (1000 MU/min) beam and minimized dose to the brainstem. Before each treatment, Winston–Lutz quality assurance (QA) with submillimeter accuracy was performed. Clinical treatment response was evaluated using Barrow Neurological Institute (BNI) pain intensity score, rated from I to V.

Results

Out of 27 patients, 22 (81%) and 5 (19%) suffered from typical and atypical TN, respectively, and had median follow‐up interval of 12.5 months (ranged: 1–53 months). For 80 Gy prescriptions, delivered total average MU was 19440 ± 611. Average beam‐on‐time was 19.4 ± 0.6 min. Maximum dose and dose to 0.5 cc of brainstem were 13.4 ± 2.1 Gy (ranged: 8.4–15.9 Gy) and 3.6 ± 0.4 Gy (ranged: 3.0–4.9 Gy), respectively. With a median follow‐up of 12.5 months (ranged: 1–45 months) in typical TN patients, the proportion of patients achieving overall pain relief was 82%, of which half achieved a complete pain relief with BNI score of I‐II and half demonstrated partial pain reduction with BNI score of IIIA‐IIIB. Four typical TN patients (18%) had no response to radiosurgery treatment. Of the patients who responded to treatment, actuarial pain recurrence free survival rates were approximately 100%, 75%, and 50% at 12 months, 15 months, and 24 months, respectively. Five atypical TN patients were included, who did not respond to treatment (BNI score: IV–V). However, no radiation‐induced cranial‐toxicity was observed in all patients treated.

Conclusion

Linac‐based SRS for medically and/or surgically refractory TN is a fast, effective, and safe treatment option for patients with typical TN who had excellent response rates. Patients, who achieve response to treatment, often have durable response rates with moderate actuarial pain recurrence free survival. Longer follow‐up interval is anticipated to confirm our clinical observations.

Assessing the impact of a program for late surgical intervention in early-blind children

OBJECTIVE

Many blind children in the developing world are unable to obtain timely treatment due to lack of financial and medical resources. Can public health programs that identify and treat such children several years after the onset of blindness enhance their quality of life? The notion that visual development is subject to an early 'critical period' argues against this possibility. However, there are inadequate empirical data from humans on this issue. To address this need, we examined the quality of life of children living in India and who were treated for early-onset blindness (before one year of age), due to cataracts or corneal opacities.

STUDY DESIGN

Survey study.

METHODS

As part of an ongoing scientific effort named Project Prakash, we screened over 40,000 children in rural northern India to identify those suffering from early-onset blindness. They were provided eye surgeries in a tertiary care ophthalmic center in New Delhi. We subsequently surveyed 64 Prakash children, ranging in age from 5 to 22 years and obtained their responses on a multi-dimensional quality of life questionnaire.

RESULTS

Nearly all of the subjects indicated that their quality of life had improved after treatment. Children reported marked enhancement in their mobility, independence, and safety, and also in social integration. Surprisingly, we found no significant correlations between quality of life metrics and factors such as age at treatment, gender, time since treatment, and pre-surgery and post-surgery acuity.

CONCLUSIONS

A key question for public health policy makers is whether a program of surgical intervention for older blind children is likely to be beneficial, or if the resources are better spent on rehabilitation via vocational training and assistive devices. The marked improvements in quality of life we find in our data strongly argue for the provision of surgical care regardless of a child's age.