In praise of postgraduate career clinics: Translating health professionals' willingness to engagement

AIM

To capture and retain healthcare staff in postgraduate courses relevant to individual career aspirations, service requirements and continuous practice development (CPD) within an English UK university.

DESIGN

Two virtual career clinics for postgraduate practitioners to engage in CPD offers within the university. An online post-enrolment online survey to explore their experiences of engagement with the university.

METHODS

Mixed: qualitative and quantitative methods. Engaging 10 participants attended the career clinics, and 42 participants with an online survey.

RESULTS

The career clinics were well received by participants who mapped CPD requirements and individual career aspirations. The surveys exposed challenges with marketing and enrolment; however, these were mitigated with support. Four recommendations are presented within this paper applicable to the international postgraduate education of all health practitioners.

Co-occurrence of Guillain-Barre syndrome and rheumatoid arthritis in a young female: A case report from a low middle-income country

Key Clinical Message

We present the case of an adult female who had rheumatoid arthritis at first but later tested positive for Guillain-Barré syndrome (GBS). In symptomatic GBS patients (related to large joints), physicians (and therapists) should consider rheumatoid arthritis when risk factors are present.

Abstract

The co-existence of GBS and other autoimmune disorders is uncommon. We present the case of an adult female who had rheumatoid arthritis at first but later tested positive for GBS. Further details are provided regarding the interdisciplinary diagnostic and therapy strategy that led to the patient's complete recovery. An adult female patient with rheumatoid arthritis presented with progressive weakness in her lower limbs, affecting her arm and causing numbness in her left hand and bilateral lower limbs. She has not passed stool for the last 2 days and has experienced gastroenteritis with watery, profuse diarrhea. On admission, the patient was awake, alert, and able to communicate. She had a thorough history of vital signs, with no signs of dehydration, jaundice, pallor, or edema. The patient's lower limbs were hypotonic and her upper limbs were normal. She experienced loss of sensation in her lower limbs, vibration, and proprioception. The patient's EMG-NCS report indicated sensory and motor axonal neuropathy (AMSAN variant). Plasmapheresis sessions were finished in our patient, and a very good result was achieved. In symptomatic GBS patients (related to large joints), physicians (and therapists) should consider rheumatoid arthritis when risk factors are present. Appropriate clinical treatment, which includes prompt evaluation of alternate diagnoses in the case of therapeutic failure, can improve patient outcomes.

Distribution, screening and biochemical characterization of indigenous microalgae for bio-mass and bio-energy production potential from three districts of Pakistan

Abstract Trend of biofuel production from microalgal triacylglycerols is enhancing, because this substrate is a good sustainable and advantageous alternative to oil and gas fuel. In the present study, indigenous micro algal isolates were screened from water (n=30) and soil (n=30) samples collected from three districts of Punjab, Pakistan to evaluate their biofuel production potential. The samples were inoculated on BG – 11 agar medium plates by incubating at room temperature of 25°C providing 1000 lux for 16h light cycle followed by 8h of dark cycle for 15 d. Water samples were found to be rich in microalgae and 65.33% microalgae (49 isolates) were isolated from Faisalabad district. On the basis of microscopic morphology microalgal isolates (n=180) were selected and subjected to lipid detection by Nile red staining assay. Nile red positive isolates (n=23) were processed for biochemical (lipid, protein and carbohydrates) characterization. AIN63 isolate showed higher lipids (17.4%) content as detected by micro vanillin assay. Algal isolate AIN128 showed best protein contents (42.91%) detected by Bradford assay and AIN172 isolate showed higher carbohydrate contents (73.83%) as detected by anthrone assay. The selected algal isolates were also analyzed by Fourier transform infrared (FTIR) spectroscopy for confirmation of carbohydrate, protein and lipid analysis. These indigenous algae have the potential for in-vitro biofuel production from agricultural waste.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Postoperative radiotherapy for high-grade primary cardiac spindle cell sarcoma: a rare entity

A patient in her early 20s presented with blood-stained sputum and shortness of breath. Initially, she was treated for pneumonia. Later, upon exacerbation of symptoms, further investigations were done which exhibited a left atrial mass causing compression of contralateral atrium. She underwent surgical resection of the mass, which was initially mistaken as myxoma. However, histopathological correlation revealed spindle cell sarcoma with focal myogenic differentiation. This case report highlights the role of Radiation Therapy in adjuvant setting with promising impact on improving local control after R2 resection. Cardiac spindle cell sarcoma, being one of the rarest cardiac tumours reported to date, warrants establishment of a Rare Tumour Multidisciplinary Team for management of such malignancies.

Effect of natural and synthetic androgen hormone on sex reversal of Nile Tilapia (Oreochromis niloticus)

The present study aimed to produce a monosex population of all male Nile tilapia (Oreochromis spp.) using 17α-methyl testosterone and common carp testes (as a source of natural androgen). Trial was conducted into two consecutive phases, the first was fry (4-5 days old)administration with negative control (without hormone) and positive control (with hormone) feed viz., MT1:60mg/kg, MT2:70mg/kg (17α-MT), carp testis CT1:70% and CT2:80% for 30 days to reverse the sex of male fish and the second phase was nursing the fingerlings for two months on control diet (32% Crude protein).Results revealed a significant growth rate (P<0.05) in the control group where final weight (4.8±0.34ab) and weight gained was recorded as 0.66±0.03ac. In proximate chemical composition of body meat, CT2 treatment showed maximum retention of crude protein, crude fat, and ash whereas dry matter showed maximum retention in MT2 and CT1 treatments. Morphological and histological examination revealed significant difference (p<0.05) in phenotypic males of Nile tilapia fed with the highest percent in MT-treated diet (MT2) of 95±0.58a while MT1, CT2 and CT1 had males of 85±6.0b, 70±5.0b and 65±6.5b, respectively. It was concluded that synthetic androgen (17αMT) was more effective for masculinization but natural androgen scan be an alternative method to produce male tilapia population in an environment-friendly manner as they are inexpensive, eco-friendly, and radially available. These results suggested that synthetic and natural androgen supplementation in the diet plays a significant role in improving growth performance and body composition.

Betamethasone cream to treat diapers rash causing Cushing syndrome

OBJECTIVES

Betamethasone causing iatrogenic Cushing's syndrome (CS) in infants are rarely reported.

CASE PRESENTATION

In this case report, there were severe signs of CS, such as considerable weight acceleration and concurrent height deceleration, hirsutism and ecchymosis of the face, and buffalo pad, which are often found in adults. Clobetasol propionate, diflucortolone valerate, and dexamethasone nasal sprays were used in the majority of previously reported cases of corticosteroid abuse, whereas this is the first case of CS in an infant as a result of the use of betamethasone cream, also known as betnesol, which is frequently used by mothers in developing countries as a treatment for rashes. In this instance, a severe medication interaction caused by systemic betamethasone cream buildup led to the creation of CS. For the professionals, these patients are a challenge because of drug use without prescription.

CONCLUSIONS

Topical corticosteroid usage puts infants at risk for CS. Because of excessive betamethasone treatment in this child with diaper dermatitis, he acquired CS. It is said to draw attention to the risks of self-medication in developing nations.

Fabrication of La3+ doped Ba1-x La x TiO3 ceramics with improved dielectric and ferroelectric properties using a composite-hydroxide-mediated method

Lanthanum (La³⁺) doped Ba_1-x La _x TiO₃ (x = 0.0, 0.0025, 0.005, 0.0075) ceramics were synthesized by the composite-hydroxide-mediated method. Rietveld refinement of the XRD patterns confirmed the formation of a perovskite crystal structure that transforms from tetragonal to pseudo-cubic with La³⁺ doping content (x). Scanning electron microscopy displayed a dense and homogeneous microstructure with reduced grain size on La³⁺ doping. The frequency and temperature-dependent dielectric measurements showed an improvement in the dielectric permittivity, a decrease in the ferroelectric-paraelectric transition temperature, and an increase in the dielectric diffusivity with increasing La³⁺ doping content. Complex impedance analysis indicated the semiconducting behavior with a positive temperature coefficient of resistance effect, which could be explained in terms of a charge compensation mechanism in the donor doped BaTiO₃. The ferroelectric hysteresis loops revealed that these ceramics are ferroelectric in nature, while an improvement in the energy storage density and energy storage efficiency was observed for the doped samples due to reduced grain size on La³⁺ doping. Here, the sample with x = 0.005 has a high dielectric permittivity, a low dielectric tangent loss, and the highest energy storage efficiency. This makes this composition interesting for energy storage applications.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

162 A Closed Loop Audit Assessing and Improving the Quality of Electronic Discharge Documents in a Neurosurgical Ward for Patient Safety and Continuity of Care

Aim

To assess the quality of neurosurgical electronic discharge documents (EDDs) as per the Scottish Intercollegiate Guidelines Network's (SIGN) discharge document guidelines, and to implement interventions to ensure patient safety and continuity of care.

Method

We performed a closed loop audit on the quality of EDDs at the neurosurgical unit at Ninewells Hospital. We collected six sets of two-weeks’ worth of EDDs from the Tayside EDD system coinciding with foundation trainee changeover times for a representative sample of pre- and intra-COVID-19 EDDs. We analysed our findings and developed interventions in collaboration with the MDT. These included a copy-paste template, educational poster, and presentation, and more. We implemented the interventions and reassessed EDDs after three months.

Results

A total of 207 EDDs were included. Pre-interventions, 88% of the EDDs were inadequate in quality when compared to SIGN’s guidelines. This had 33% reduction post-interventions. The percentage of EDDs adequate in quality doubled post-interventions, from 22% to 43%. The most commonly mistaken or missed criterion pre- and post-intervention was the neurological status on admission and discharge. Others were mistaking presenting complaint for diagnosis and vice versa, and not mentioning follow-up or new medications.

Conclusions

Accurate records of care, including discharge documents, are central to the principles of good medical practice outlined by the GMC. This study showed that EDD quality is compromised due to time pressures, lack of information and constant changeover due to COVID-19. We alleviated this by creating accessible interventions that assure safe patient care despite the challenges of changeover and COVID-19.

404 Can MRI Non-Invasively Measure Blood-Brain-Barrier Permeability?

Aim

Blood brain barrier (BBB) integrity in neurological disease is tested with gadolinium-enhanced Magnetic Resonance Imaging (MRI). Pathology studies have shown gadolinium deposits in brains with intact BBBs, thus raising concern. We propose a novel use of Arterial Spin Labelling (ASL) –a MRI technique which ‘tags’ blood-water making it a tracer– as a safer alternative in assessing BBB permeability. ASL’s ability to capture T2 (transverse relaxation time) changes of tagged water in blood vs. in tissue (post-exchange across the BBB) supports its feasibility.

Method

We developed an ASL protocol and collected data from healthy volunteers (n=5) on a 3T Achieva Scanner with the parameters: echo times (TEs) 30, 40, 50, 60, 70ms; repetition time 4200ms; field of view 240x240x47mm and post label delays (PLDs) 1,000ms and 1,500ms. We calculated mean ASL signal (arb units) from the images at each TE, and then extracted T2(ms) values for each volunteer at each PLD. The primary outcome was the change in T2 across PLDs.

Results

Calculated mean T2s demonstrated a majority of increasing T2s across longer PLDs (n=3) with mean T2 of 55.3+5.3ms at PLD 1,000ms and 62.1+10.8ms at PLD 1,500ms. However, the results are inconclusive as the sample size precluded statistical testing.

Conclusions

We developed an ASL protocol that demonstrated changes in T2 of blood water with time passage, indicating water exchange through the BBB. This supports the use of ASL in assessing BBB permeability, but more wide-scale studies need to be performed.

413 Evaluation of the Validity of Virtual Reality Simulators in the Preclinical Training of Robotic Surgery

Aim

Robotic surgeries are a form of minimally invasive procedures that decrease a patient’s recovery time. They have been increasing in numbers and scope over the past decade. Yet, they do not have a standardized method of training nor accreditation. The significant learning curve associated with it makes it intimidating to approach despite its benefits. This structured review aims to evaluate the validity of virtual reality simulators–tools that help surgeons overcome the learning curve of robotic surgery in a pressure-free environment that ensures patients’ safety. Virtual reality simulators have the potential of increasing the efficiency of robotic surgery as well as its uptake in general.

Method

Literature electronic databases SCOPUS, MEDLINE and PubMed were searched and interrogated for studies related to the aim. Inclusion and exclusion criteria were then applied to filter out more relevant studies. Redundant studies were eliminated, and the s of the remaining studies were examined until relevant studies were selected.

Results

Four prospective clinical trials were found and critically appraised by the Support Unit for Research Evidence (SURE) checklist. All studies comprised the evaluation of the face, content, and construct validity of a VR simulator.

Conclusions

The studies confirmed face, content, and construct validation of specific VR simulators. Hence, they encourage the use of VR simulators in the development of training and accreditation programs for robotic surgery. However, more predictive, and concurrent validation studies must be performed in order to establish the legitimacy of VR simulators as valid tools of training and accreditation.

Community pharmacists' knowledge of direct oral anticoagulants and warfarin in the North of Jordan: a cross sectional study

OBJECTIVE

The aim of this cross-sectional study is to assess community pharmacists' knowledge of the therapeutic aspects of direct oral anticoagulants and warfarin. Another objective was to study the effect of different demographic factors and relevant characteristics on community pharmacists' knowledge of warfarin and direct oral anticoagulants.

MATERIALS AND METHODS

The study was conducted prospectively at community pharmacies in the north of Jordan. Community pharmacists were interviewed using a validated questionnaire consisting of three sections. The first section included demographics and other relevant characteristics. The second and third sections included questions about direct oral anticoagulants and warfarin respectively.

RESULTS

A total of 251 participants completed the questionnaire. Two-thirds of participants knew that direct oral anticoagulants are available in Jordan (67.3%). Of the pharmacists who were able to state at least one direct oral anticoagulant, 60.9% knew at least one main indication. More than half of participating pharmacists had insufficient knowledge (57.8%). Almost half of participants (48.6%) were able to state the most important monitoring parameter of warfarin, and 30.7% were able to state one medication that interacts with warfarin. More than half of participating pharmacists had insufficient knowledge (64.9%). In addition, the results showed that degree of pharmacy, years of experience, university from which pharmacy degree was obtained, and year of graduation were significantly associated with warfarin knowledge.

CONCLUSIONS

Most participating pharmacists had insufficient knowledge with regards to direct oral anticoagulants and warfarin. Doctor of Pharmacy degree were more knowledgeable with regards to warfarin compared to participants with a bachelor's degree in Pharmacy. Continuing educational programs are required to keep community pharmacists up to date with new developments in the pharmaceutical field.

Bio-efficacy of iron and zinc fortified wheat flour along with bio-assessment of its hepatic and renal toxic potential

Abstract Study was planned to assess the bio-efficiency along with toxicity of iron and zinc fortified whole wheat flour in Sprague dawley albino rats. Whole wheat flour was fortified with different dosage of sodium iron EDTA (NaFeEDTA), ferrous sulphate (FeSO4), zinc oxide (ZnO) and zinc sulphate (ZnSO4). The rats (n=3) in each group were fed on fortified wheat flour for 2 months. Liver biomarkers including alkaline phosphatase (ALP), alanine transaminase (ALT), aspartate aminotransferase (AST) and bilirubin were recorded from serum samples. Increased concentration of ZnSO4 affected the liver biomarkers to be highest among all whereas, bilirubin levels were less than the rats fed on control diet. The above mentioned fortificants have negligible effect on renal biomarkers including creatinine and urea. Moreover, hematological parameters were also checked and reportedly, sodium iron EDTA fed rats presented highest amount of hemoglobin, iron and total iron binding capacity. Highest zinc level was observed in rats fed on whole wheat flour fortified with 60mg/Kg Zinc oxide. Microscopic observation of liver tissue depicted that rats fed on iron and zinc fortified wheat flour have more toxic effects whereas, histopathology presentation of kidney tissue has least toxic impact. It has been concluded that mandatory fortification of wheat flour with iron and zinc may cause increased serum biomarkers along with toxicity of vital organs like liver, hence fraction of wheat flour may be fortified to fulfill the requirements of deprived and vulnerable group.

195 The Application of Radiomics in Laryngeal Cancer: The Forgotten Cohort

Background

Radiomics is a novel method of extracting data from medical images that is difficult to visualise through the naked eye. This technique transforms digital images that hold information on pathology into high-dimensional-data for analysis. Radiomics has the potential to enhance laryngeal cancer care and to date, has shown promise in various other specialties.

Aim

The aim of this review is to summarise the applications of this technique to laryngeal cancer and potential future benefits.

Method

A comprehensive systematic review-informed search of the MEDLINE and EMBASE online databases was undertaken. Keywords ‘laryngeal cancer’ OR ‘larynx’ OR ‘larynx cancer’ OR ‘head and neck cancer’ were combined with ‘radiomic’ OR ‘signature’ OR ‘machine learning’ OR ‘artificial intelligence’. Additional articles were obtained from bibliographies using the ‘snowball method’.

Results

Seventeen articles were identified that evaluated the role of radiomics in laryngeal cancer. Two studies affirmed the value of radiomics in improving the accuracy of staging, whilst fifteen studies highlighted the potential prognostic value of radiomics in laryngeal cancer. Twelve (of thirteen) studies incorporated an array of different head and neck cancers in the analysis and only one study assessed laryngeal cancer exclusively.

Conclusions

Literature to date has various limitations including, small and heterogeneous cohorts incorporating patients with head and neck cancers of distinct anatomical subsites and stages. The lack of uniform data on solely laryngeal cancer and radiomics means drawing conclusions is difficult, although these studies have affirmed its value. Further large prospective studies exclusively in laryngeal cancer are required to unlock its true potential.

Chromium supplemented carbohydrate diets for Cirrhinus mrigala: effects on body composition, gut enzyme activity and hematological parameters

A ninety days nutritional trial was directed to explore the effects of dietary chromium on body composition, gut enzyme activity and physiological status of Cirrhinus mrigala by using G & NG corn. Six experimental diets were prepared by using different levels of chromium chloride hexahydrate (0, 0.2, 0.4 mg/kg, each with G & NG corn). For this experimental trial, 480 fingerlings, irrespective of sex were distributed in six aquariums each with replicate. Results revealed that gelatinized corn along with increasing level of Cr2Cl3.6H2O have a positive impact upon body composition of fish. Hematology was positively correlated with chromium chloride hexahydrate supplementation in gelatinized corn. Amylase gut enzyme also showed significant (P<0.05) increase in group fed with chromium chloride hexahydrate supplemented diet (G corn). However, corn with chromium chloride hexahydrate supplementation did not revealed any significant impact on gut protease enzyme activity. From these results it can be concluded that both chromium chloride hexahydrate and gelatinized corn in fish feed are very beneficial to improve body composition, enzymes activity and physiological health status of fish.

Toxicological effects of thimerosal on rat kidney: a histological and biochemical study

Thimerosal is an organomercurial compound, which is used in the preparation of intramuscular immunoglobulin, antivenoms, tattoo inks, skin test antigens, nasal products, ophthalmic drops, and vaccines as a preservative. In most of animal species and humans, the kidney is one of the main sites for mercurial compounds deposition and target organs for toxicity. So, the current research was intended to assess the thimerosal induced nephrotoxicity in male rats. Twenty-four adult male albino rats were categorized into four groups. The first group was a control group. Rats of Group-II, Group-III, and Group-IV were administered with 0.5µg/kg, 10µg/kg, and 50µg/kg of thimerosal once a day, respectively. Thimerosal administration significantly decreased the activities of catalase (CAT), superoxide dismutase (SOD), peroxidase (POD), glutathione reductase (GR), glutathione (GSH), and protein content while increased the thiobarbituric acid reactive substances (TBARS) and hydrogen peroxide (H2O2) levels dose-dependently. Blood urea nitrogen (BUN), creatinine, urobilinogen, urinary proteins, kidney injury molecule-1 (KIM-1), and neutrophil gelatinase-associated lipocalin (NGAL) levels were substantially increased. In contrast, urinary albumin and creatinine clearance was reduced dose-dependently in thimerosal treated groups. The results demonstrated that thimerosal significantly increased the inflammation indicators including nuclear factor kappaB (NF-κB), tumor necrosis factor-α (TNF-α), Interleukin-1β (IL-1β), Interleukin-6 (IL-6) levels and cyclooxygenase-2 (COX-2) activities, DNA and histopathological damages dose-dependently. So, the present findings ascertained that thimerosal exerted nephrotoxicity in male albino rats.

Prospective study examining the use of thrombin-gelatin matrix (Floseal) to prevent post dental extraction haemorrhage in patients with inherited bleeding disorders

The bleeding risk in individuals with inherited bleeding disorders (IBDs) during exodontia is traditionally managed with perioperative coagulation factors and/or desmopressin, in conjunction with systemic and topical perioperative tranexamic acid and meticulous primary closure. Factor replacement is costly, requires specialist input, and carries a risk of developing factor VIII (FVIII) inhibitors. This prospective study was performed to determine whether the use of a standardized Floseal and anti-fibrinolytic protocol could reduce postoperative bleeding in patients with IBDs undergoing dental extraction, as compared to factor replacement. All patients >18 years old attending Queensland Haemophilia Centre between November 2014 and July 2019 who required dental extractions were referred to the Oral and Maxillofacial Unit. Patients were consented for intraoperative Floseal administration instead of factor replacement. All other operative measures remained the same. The bleed rate was assessed against a historical control cohort. There were 34 extraction events in 32 patients. Four of the patients reported postoperative bleeding requiring factor supplementation or desmopressin; the bleeding rate was 11.8%. While not statistically significant, this was a reduction in the bleed rate compared to the traditional protocol (P = 0.35). Third molar extractions were 10.33 times more likely to cause postoperative bleeding (P = 0.018). The Floseal protocol was equipotent to the traditional perioperative factor replacement protocol. Floseal use is more economical, eliminates the risk of peri-procedural FVIII inhibitor development, and provides a haemostatic option for patients with very rare factor deficiencies, pre-existing clotting factor inhibitors, and those with anaphylaxis to clotting concentrates.

Assessment of zinc solubilization potential of zinc-resistant Pseudomonas oleovorans strain ZSB13 isolated from contaminated soil

Zinc is an essential micronutrient that is required for optimum plant growth. It is present in soil in insoluble forms. Bacterial solubilization of soil unavailable form of Zn into available form, is an emerging approach to alleviate the Zn deficiency for plants and human beings. Zinc solubilizing bacteria (ZSB) could be a substitute for chemical Zn fertilizer. The present study aimed to isolate and characterize bacterial species from the contaminated soil and evaluate their Zn solubilizing potential. Zn resistant bacteria were isolated and evaluated for their MIC against Zn. Among the 13 isolated bacterial strains ZSB13 showed maximum MIC value upto 30mM/L. The bacterial strain with the highest resistance against Zn was selected for further analysis. Molecular characterization of ZSB13 was performed by 16S rRNA gene amplification which confirmed it as Pseudomonas oleovorans. Zn solubilization was determined through plate assay and broth medium. Four insoluble salts (zinc oxide (ZnO), zinc carbonate (ZnCO3), zinc sulphite (ZnS) and zinc phosphate (Zn3(PO4)2) were used for solubilization assay. Our results shows 11 mm clear halo zone on agar plates amended with ZnO. Likewise, ZSB13 showed significant release of Zn in broth amended with ZnCO3 (17 and 16.8 ppm) and ZnO (18.2 ppm). Furthermore, Zn resistance genes czcD was also enriched in ZSB13. In our study, bacterial strain comprising Zn solubilization potential has been isolated that could be further used for the growth enhancement of crops.

Development, Characterization, and Evaluation of SLN-Loaded Thermoresponsive Hydrogel System of Topotecan as Biological Macromolecule for Colorectal Delivery

BACKGROUND

Chemotherapeutic drugs cause severe toxicities if administered unprotected, without proper targeting, and controlled release. In this study, we developed topotecan- (TPT-) loaded solid lipid nanoparticles (SLNs) for their chemotherapeutic effect against colorectal cancer. The TPT-SLNs were further incorporated into a thermoresponsive hydrogel system (TRHS) (TPT-SLNs-TRHS) to ensure control release and reduce toxicity of the drug. Microemulsion technique and cold method were, respectively, used to develop TPT-SLNs and TPT-SLNs-TRHS. Particle size, polydispersive index (PDI), and incorporation efficiency (IE) of the TPT-SLNs were determined. Similarly, gelation time, gel strength, and bioadhesive force studies of the TPT-SLNs-TRHS were performed. Additionally, in vitro release and pharmacokinetic and antitumour evaluations of the formulation were done.

RESULTS

TPT-SLNs have uniformly distributed particles with mean size in nanorange (174 nm) and IE of ~90%. TPT-SLNs-TRHS demonstrated suitable gelation properties upon administration into the rat's rectum. Moreover, drug release was exhibited in a control manner over an extended period of time for the incorporated TPT. Pharmacokinetic studies showed enhanced bioavailability of the TPT with improved plasma concentration and AUC. Further, it showed significantly enhanced antitumour effect in tumour-bearing mice as compared to the test formulations.

CONCLUSION

It can be concluded that SLNs incorporated in TRHS could be a potential source of the antitumour drug delivery with better control of the drug release and no toxicity.

Antiadhesion and antibiofilm potential of Fagonia indica from Cholistan desert against clinical multidrug resistant bacteria

High resistance to antimicrobials is associated with biofilm formation responsible for infectious microbes to withstand severe conditions. Therefore, new alternatives are necessary as biofilm inhibitors to control infections. In this study, the antimicrobial and antibiofilm activities of Fagonia indica extracts were evaluated against MDR clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica has antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-1 against multidrug resistant (MDR) clinical isolates. The extract exhibited its antibiofilm effect by altering adherence and disintegration of bacterial cell wall. Fagonia indica had antibacterial effect as minimum inhibitory concentration (MIC) values ranging from 125 to 500 µg mL-1 and minimum bactericidal concentration (MBC) value was 500-3000 µg mL-1 against MDR isolates. The maximum inhibitory effects of Fagonia indica chloroform extract on biofilm formation was observed on Staphylococcus aureus (71.84%) followed by Klebsiella pneumoniae (70.83%) after 48 hrs showing that inhibition is also time dependent. Our results about bacterial cell protein leakage indicated that MDR isolates treated with chloroform extract of Fagonia indica showed maximum protein leakage of K. pneumoniae (59.14 µg mL-1) followed by S. aureus (56.7 µg mL-1). Cell attachment assays indicated that chloroform extract resulted in a 43.5-53.5% inhibition of cell adherence to a polystyrene surface. Our results revealed that extracts of Fagonia indica significantly inhibited biofilm formation among MDR clinical isolates, therefore, could be applied as antimicrobial agents and cost effective biofilm inhibitor against these MDR isolates.

783 Brachial Plexopathy Secondary to Prone Position Used in The Treatment of a Ventilated Patient With COVID-19: A Case Report and Service Improvement Recommendations

Introduction

Prone position has been recommended by many authorities as part of the management of ventilated patients with COVID-19. However, proning with concurrent use of sedation and muscle relaxants carries the hypothetical risk of brachial plexus injuries, thought to be due to stretch and compression of the abducted shoulder.

Case

Recommendations

Conclusions

We present this as a pathology to consider in patients proned during the COVID-19 pandemic; and recommend checking for signs of focal neurological deficits of the upper limb upon removal of paralysis and sedation, with early referral of suspected cases.

878 Comparing Treatment Outcomes for Unruptured Brain Arteriovenous Malformations: A Retrospective Cohort Study

Background

Unruptured brain arteriovenous malformations (bAVMs) carry a lifetime risk of haemorrhage. Treatment strategies include conservative management, microsurgical excision, endovascular treatment (EVT) and radiosurgery (SRS). Optimal treatment selection remains unclear.

Method

A single-centre retrospective cohort study of adult unruptured bAVMs (2007-2019). Patients who underwent intervention were propensity matched using baseline features (age, sex, size, deep drainage, eloquence, and Spetzler-Martin grade) with patients conservatively managed. Rates of neurological disability and mortality due to intervention or bleed were compared.

Results

137 patients (mean age 48 years [SD = 16], males 64) were included; 34 (25%) EVT, 20 (15%) surgery, 31 (22%) SRS and 51 (37%) conservative. After a median follow-up of 49 months (IQR 23-75), rates of disability were as follows: surgery 35%, EVT 21%, SRS 13% and conservative 8%. Matched cohorts (intervention/conservative) were: surgery-19/18, SRS-30/22 and EVT-33/34. Comparison of disability rates across matched cohorts revealed no statistically significant differences (surgery p = 0.07, SRS p = 0.65 and EVT p = 0.11). Three conservatively managed patients died.

Conclusions

Unruptured bAVMs carry a significant risk of neurological morbidity, regardless of intervention choice. Treatment choice may have an impact on patient outcomes but requires investigation of stratified cohorts. Findings are consistent with the nuances of AVM treatment selection.

Masculinization in common carp (Cyprinus carpio) by androgen immersion: The interaction effect of hormone concentration and immersion time

Synthetic androgens (male hormones) administered to fish nursery are being used in aquaculture to avoid sexual differentiation and unwanted spawning at the eggs or the first feeding fry stage of fish. Present trial was conducted with the aim to produce male common carp (Cyprinus carpio) by egg immersion technique. Through this little insight, the effect of different hormone concentrations (17α-methyltestosterone @ HC:150, 300, 450 and 600 µgl-1) with immersion times (IT: 24, 48 and 72 hrs) and their interaction effect (HC x IT) on the hatching percentage of Cyprinus carpio eggs, percent survival and percent of male's production was evaluated specifically. Results showed that egg hatching percentage decreased with increased IT likewise, survival of treated fry was affected by increasing the IT (P<0.001). The main interaction effect of HC x IT showed that the highest percent of male individuals (95%) was obtained at 450-600 µgl-1 HC for 72 hrs IT, followed by 88-92.50% at 150-300 µgl-1 HC for 72-hrsof IT, 87.50% at 48-hrs of IT for rest of the hormone treatments, and lowest 47.50% was recorded in control (P<0.05). Increased percent male of Cyprinus carpio was obtained with increasing HC across all ITs. It was observed that the immersion treatment at 600µgl-1 for 72 hours was more effective to change the sex ratio of pre hatch Cyprinus carpio. A comparative outlook made from this experimental trial that sex induction of Cyprinus carpio by eggs immersion using synthetic male steroid hormone is an alternative safe technique of fish sex reversal in contrast to oral administration of hormone in fish feed.

Assessment of cadmium tolerance and biosorptive potential of Bacillus Cereus GCFSD01 isolated from cadmium contaminated soil

Continuous occurrence of heavy metals is a major cause of environmental pollution due to its toxic effects. At minimum concentrations, these metals are highly reactive and can gather in the food chains and food web, causing major dangers to public health concerns. Soil samples were collected from Paharang drain, Faisalabad. Cadmium tolerant bacteria were isolated and evaluated for their MIC against Cd. The isolated bacterial strain GCFSD01 showed MIC value upto 30 mM/L. The bacterial strain with the highest resistance against Cd was selected for further study. Molecular characterization of bacterial isolate GCFSD01 was performed by 16S rRNA which confirmed it as Bacillus cereus. Optimum growth conditions of bacterial strain were also evaluated. Strain GCFSD01 showed optimum growth at pH 7 and 37 °C temperature. Our result revealed that B. cereus strain GCFSD01 reduced 61.3% Cd after 48 hrs. Multiple metal tolerance and Cd reduction by B. cereus indicate its potential for further use for decontamination of polluted soil.

Two homozygous missense mutations in ITGB3 gene as a cause of Glanzmann Thrombasthenia in four consanguineous Pakistani pedigrees

INTRODUCTION

Glanzmann thrombasthenia (GT) is most common of inherited platelet disorders, resulting from quantitative/qualitative defects in platelet surface integrin αIIbβ3, encoded by ITGA2B and ITGB3 genes. Little is known about clinical and molecular characteristics of GT patients from highly consanguineous Pakistani population.

METHODS

This study analyzed the clinical and molecular spectrum of six GT patients from four unrelated but consanguineous families. Platelet surface expression of αIIbβ3 integrin was determined using flow cytometry analysis. ITGA2B and ITGB3 genes were screened for causative mutations by DNA sequencing. Detected mutations were characterized for their pathogenicity using a variety of in silico tools.

RESULTS

Glanzmann thrombasthenia patients in this study generally presented early in life, had a severe course of clinical disease with transfusion dependency for management of bleeding episodes. Molecular analysis revealed 2 homozygous missense mutations in ITGB3 gene, c.422 A˃G (p.Y141C) in three GT patients from a single pedigree with familial segregation and c.1641 C>G (p.C547W) in three unrelated GT patients from three families manifesting type I GT with severe reduction in platelet αIIbβ3 levels. In silico pathogenicity predictions, multiple sequence alignment and 3D protein modeling unanimously suggested deleterious nature of the detected mutations, possibly due to aberrant disulfide bonding. Of note, clinical diversity was observed even among GT patients with same mutation in GT1 family.

CONCLUSION

This study provides an initial yet important account of clinical and genetic characterization of GT in local patients which may spark further studies to help molecular diagnosis, optimal disease management, and genetic counseling based prevention efforts.

SAT0272 THE VALUE OF CLINICAL AND LABORATORY FEATURES TO PREDICT EXTENT OF LARGE VESSEL VASCULITIS ON PET CT

Background:

Giant cell arteritis (GCA) is an idiopathic vasculitis affecting large and medium-sized vessels. The pattern of arterial involvement is heterogeneous with two overlapping categories recognised: classical cranial GCA and extra-cranial GCA (or large vessel vasculitis – LVV) that predominantly affects the aorta and its proximal branches. Although LVV is present in around 80% of patients with cranial GCA, and around one third will develop large vessel complications, there are no guidelines for which patients should be screened for it (1). We sought to investigate whether clinical and laboratory features were a useful guide to the severity of LVV on FDG PET-CT.

Objectives:

To retrospectively analyse whether baseline patient characteristics are able to predict the extent of large vessel vasculitis on PET-CT.

Methods:

Clinical data for 65 patients referred for a PET-CT scan by Rheumatology at the Freeman Hospital, Newcastle between January 2015 and May 2018 were retrospectively analysed. The most recent full blood count and inflammatory markers prior to the scan were used. Scans were reviewed by a consultant radiologist and trainee. The arterial network was split in to ten potentially involved territories (aortic arch, thoracic aorta, abdominal aorta, iliac vessels, axillary, brachiocephalic, subclavian, carotid, vertebral and femoral arteries. Both the value of highest standardised uptake value (SUV max) and the territory affected was recorded for each positive scan.

Results:

In the period analysed 65 PET-CT scans were requested, mostly (77%) as baseline investigations for symptoms with LVV in the differential diagnosis. Of these 22 (34%) were positive for LVV and in that group the majority of patients (64%) were female. In those with a negative scan, 47.5% were on concurrent steroid treatment compared to 9% with a positive scan. Regression analysis suggested that the number of systemic features (weight loss, pyrexia, polymyalgia) was weakly correlated with the number of affected territories (p=0.04). In contrast there was no correlation between laboratory tests ((CRP (p=0.91), ESR (p=0.46), Hb (p=0.44), platelets (p=0.74)) and the number of territories affected. The aortic arch (47%) was most commonly the territory with the highest degree of FDG uptake (SUV max) followed by the abdominal aorta (21%) and thoracic (10%) and femoral arteries (10%). There was no correlation between SUV max and laboratory tests ((CRP (p=0.55), ESR (p=0.89), Hb (p=0.82), platelets (p=0.17)) or the number of systemic features (p=0.7). There was no significant difference in the number of territories affected between those on steroid treatment at the time of the scan and steroid-naïve patients, albeit the number of positive scans in those on steroid treatment was low (n=5).

Conclusion:

These results suggest that clinical and laboratory features are a poor guide to predicting the maximal severity and extent of disease on FDG PET-CT.

References:

[1]Koster MJ, Matteson EL, Warrington KJ. Large-vessel giant cell arteritis: diagnosis, monitoring and management. Rheumatology (Oxford). 2018;57(suppl_2):ii32-ii42.

Disclosure of Interests:

None declared

Home Based Pulmonary Rehabilitation on Oxygenation Status, Dyspnea and Fatigue in Stable Patients with COPD

Pulmonary rehabilitation (PR) program of a sufficient duration has impact on consequence of COPD. To evaluate the effects of combination of pursed lip breathing (PLB), diaphragmatic breathing (DB) and lower extremity endurance training (LEET) as part of PR program in stable patients with COPD on oxygenation status, dyspnea and fatigue. This prospective interventional study was performed in the Department of Physiology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from July 2010 to June 2011 and was performed on 116 male stable moderate COPD patients aged 50 to 65 years. Among them, 56 patients were without PR (control group) and 60 patients were intervened with PR (experimental group). The experimental patients were advised to perform the home based PR program (PLB, DB and LEET) for 30 minutes duration per session at home twice per day, along with standard drug treatment of COPD for uninterrupted 60 days. The control patients continued their treatment of COPD with standard drug for successive 60 days were advised. To evaluate the effects of PR, Peripheral capillary oxygen saturation (SpO₂, by pulse Oximeter), level of dyspnea and level of fatigue by Modified Borg Scale from baseline to end of six minute walk test (6MWT) of all subjects were recorded on day 0 and day 60 for both the groups. Independent sample 't' test and paired Student's 't' test were done with SPSS software. In the interpretation of results, p value of <0.05 was considered as statistically significant. In the present study, we found less decrement of SpO₂ and less increment of level of dyspnea as well as level of fatigue after 6MWT in the COPD patients with PR on 60th day of follow up. The study reveals that oxygenation status, dyspnea and fatigue improve after execution of regular home based PR program in patients with moderate stable COPD.

ABO-Incompatible Kidney Transplantation: Low Rates of Infectious Complications and Excellent Patient Survival

BACKGROUND

A significant gap exists between demand and supply of organs for patients with end-stage renal disease. To increase the donor pool, kidney transplantation is performed across ABO- and HLA-incompatible barriers. ABO-incompatible kidney transplant (ABOi-KT) recipients are at increased risk of antibody-mediated rejection, infection, and mortality. Hypogammaglobulinemia secondary to immunosuppression is highly prevalent after solid organ transplantation, and intravenous immunoglobulin (IVIG) has been reported to reduce the risks of infections in various settings. We use high-dose IVIG in ABOi-KT recipients perioperatively. We aimed to determine the rate of infectious complications along with graft and patient survival in our ABOi-KT recipients.

METHODS

We included all adult patients who underwent ABOi-KT from the year 2007 to 2016. Patients received rituximab, plasma exchange, and IVIG (2 g/kg body weight). Thymoglobulin and intravenous methylprednisolone were used as induction treatment. Oral prednisone, mycophenolate mofetil, and tacrolimus were used as maintenance therapy.

RESULTS

A total of 77 ABOi-KTs were performed, and the recipients were followed up for a median of 1557 days. Two patients were diagnosed as having BK nephropathy. No patients were diagnosed as having pneumocystis infection, cytomegalovirus disease, herpes simplex, varicella zoster, or fungal infection. One-year graft and patient survival was 94.8% and 100%, respectively.

CONCLUSIONS

In our series of ABOi-KTs, we observed a low risk of infectious complications and excellent patient survival. High-dose IVIG might have reduced infections.

Patients' experience in the early recovery phase after removal of intraoral squamous cell carcinoma with carbon dioxide laser

Laser excision of oral cancer is well established. The aim of this cross-sectional survey was to ask patients about their main symptoms and the severity of them during the first postoperative weeks. We devised a short questionnaire in collaboration with patients, and did a cross-sectional survey of 50 consecutive patients who had laser excision of T1 and T2 oral cancers over a two-year period. The response rate was 76% (38/50). Twenty patients reported that eating was "quite a bit" or "very much of a problem" and 13 reported similar for pain. The main problems were eating (n=27), pain (n=16), numbness (n=14), speech (n=13), and swallowing (n=12). It took 11 patients more than 4 weeks to recover, and 11 of the 20 who were employed needed to take time off work (modal duration 3 or 4 weeks). Thirteen patients sought advice postoperatively from the clinic, ward or secretary's office, general practitioner, or accident and emergency department (or other out-of-hours service). The survey shows that morbidity associated with laser excision is relatively high, and more studies are required to provide a better evidence base that will inform improvements in postoperative recovery and care.

Peripheral Arterial Embolism: Prevalence, Outcome, and the Role of Echocardiography in Management

The aims of this study were to review the prevalence and outcome of all surgically treated upper and lower limb emboli presenting to one vascular unit in the last 3 years and to compare transthoracic with transesophageal echocardiography for defining the source of the embolus. All patients who underwent surgical embolectomy for acute limb ischemia from January 2001 to June 2004 were reviewed. Transthoracic and transesophageal echocardiography were carried out on a subset of consecutive unselected patients. Forty-two patients, with a mean age of 80 years, underwent surgical embolectomy from January 2001 to June 2004 (M/F 1:1.8): 27 for lower limb ischemia and 15 for upper limb ischemia. Two thirds of these patients were found to be in atrial fibrillation at presentation (n=28), of whom less than a third were receiving anticoagulants or antiplatelet agents (n=8). The mean hospital stay was 15 days with 36 patients (86%) being fully anticoagulated before discharge from hospital. The 30-day mortality rate was 11% (n=3/27) with 5 patients requiring fasciotomies (12%) and 3 patients requiring an amputation of the lower limb (11%). Postoperatively, 34 patients (81%) had transthoracic echocardiography (TTE), which demonstrated a source or potential source for thrombus in 19 (56%). Fifteen patients (36%) had transesophageal echocardiography (TEE), which changed the subsequent management in 3 patients. All patients in whom TEE altered clinical management would have required this investigation if standard clinical guidelines were followed. TEE did not identify any additional patients with cardiac embolic sources that were not detected by TTE. Arterial limb emboli are still prevalent, but limb salvage and mortality rates appear to be improving. Despite clear guidelines on anticoagulation for patients in atrial fibrillation, many are not receiving appropriate treatment. Transthoracic echocardiography is a good screening tool for detecting a potential cardiac source for peripheral embolism, with transesophageal echocardiography being reserved for specific indications.

AKT activation controls cell survival in response to HDAC6 inhibition

HDAC6 is emerging as an important therapeutic target for cancer. We investigated mechanisms responsible for survival of tumor cells treated with a HDAC6 inhibitor. Expression of the 20 000 genes examined did not change following HDAC6 treatment in vivo. We found that HDAC6 inhibition led to an increase of AKT activation (P-AKT) in vitro, and genetic knockdown of HDAC6 phenocopied drug-induced AKT activation. The activation of AKT was not observed in PTEN null cells; otherwise, PTEN/PIK3CA expression per se did not predict HDAC6 inhibitor sensitivity. Interestingly, HDAC6 inhibitor treatment led to inactivating phosphorylation of PTEN (P-PTEN Ser380), which likely led to the increased P-AKT in cells that express PTEN. Synergy was observed with phosphatidylinositol 3'-kinases (PI3K) inhibitor treatment in vitro, accompanied by increased caspase 3/7 activity. Furthermore, combination of HDAC6 inhibitor with a PI3K inhibitor caused substantial tumor growth inhibition in vivo compared with either treatment alone, also detectable by Ki-67 immunostaining and (18)F-FLT positron emission tomography (PET). In aggregate AKT activation appears to be a key survival mechanism for HDAC6 inhibitor treatment. Our findings indicate that dual inhibition of HDAC6 and P-AKT may be necessary to substantially inhibit growth of solid tumors.

Integrating Radiology and Anatomy Teaching in Medical Education in the UK--The Evidence, Current Trends, and Future Scope

This review article presents the current evidence of the importance of integrating radiology and anatomy in medical education in the UK, a recommendation by a number of key anatomy, education, and radiology organizations. Current evidence highlights that on average only 5% of total teaching time in medical education is dedicated to radiology. Often, radiology teaching does not adequately fulfill students' learning needs and potentially leaves them underprepared for medical practice. Benefits of integrating radiology and anatomy include improved clinical application of anatomy, an increase in student's interest in anatomy, and ultimately improved radiological interpretation. Various modalities exist for the integration of radiology and anatomy, facilitated by the vast portability of radiological images. It appears that combining radiological resources with traditional anatomy teaching methodology in a blended approach is most beneficial.