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Background: Cervical carcinoma is the fourth most common cancer and leading cause of cancer related deaths in women worldwide. Brachytherapy is an important part in the treatment of cervical cancer. Delivering HDR Intracavitary Brachytherapy in the Covid-19 era is challenging. Objective: To compare the dosimetry and treatment outcomes between two fractionation schedules of 9Gy in 2 fractions v/s 7Gy in 3 fractions of high dose rate Brachytherapy in patients with locally advanced carcinoma cervix. Methods: A randomized observational study was carried out on 80 histopathologically proven squamous cell carcinoma patients of cervix. All patients were treated with EBRT 50Gy in 25 fractions over a period of 5 weeks (2Gy/#) with concurrent weekly cisplatin 30mg/m2. After assessing fitness for brachytherapy, patients in the study arm received HDR intracavitary brachytherapy in 9Gy for 2 fractions v/s 7Gy for 3 fractions in the control arm. Results: The median time of follow-up was 14 months for the study (range 7 – 20 months). Local control rate was 89.75% for study arm and 92.30% for control arm. One year disease free survival in the study arm was 76.92% as compared to 74.35% in the control arm. Median disease-free survival was better in the study arm (14 months v/s 12 months) with a trend of significant benefit. Rectal and bladder toxicities were comparable in both the arms. Median dose to ICRU bladder and rectal point, and EQD2 dose in both arms were not found to be statistically significant. Conclusion: Both the regimes were found to be safe. Disease response and toxicities were also similar in both the arms. There was a better patient compliance with 9Gy for 2 fractions schedule in view of lesser number of fractions resulting in less hospital visit in the Covid-19 pandemic.

The impact of social media on contemporary culture has been unprecedented, making it the most significant medium of our times. While it has had a positive effect on people's worldview, social media has also been linked to a rise in undesirable phenomena such as cyberbullying, cyberstalking, and cybercrime. Cyberbullying, in particular, can have a negative impact on individuals' mental health and has even been identified as the root cause of mental health issues in some cases. The proliferation of sexually explicit comments and the spread of rumors by multiple individuals are some of the negative influences that have been observed in the social media ecosystem. In recent years, academics have been increasingly concerned about the indicators of online harassment. Our goal is to develop a system that can detect instances of online abuse using Natural Language Processing (NLP) and Naïve Bayes, among other techniques. The cultural norms have shifted dramatically due to the rapid transmission of the COVID-19 virus, resulting in a rise in cyberbullying, especially among adolescents. The younger generation is more likely to engage in this practice, which has become more widespread with the stratospheric rise in popularity of various online engagement-promoting platforms. The COVID-19 pandemic has changed the way people interact online and has contributed to an increase in cyberbullying. As more people began working from home, bullying became a more significant concern. Our proposed system includes modules for data cleansing, text mining, word embedding, and regression analysis, among others. We utilize the Lemmatization technique for text mining, which enhances the model's precision. We also utilize the Vader emotion for feature extraction, which generates word vectors that are scattered numerical representations of word attributes. Additionally, Naive Bayes is used for data categorization to prevent overfitting in the proposed model. This would help in creating vectors that connect words with similar meanings

There is need for an additional source of finance in form of foreign direct investment (FDI) in the Indian manufacturing sector due to its long-term engagement between the investors and the host country. Further FDI in the manufacturing sector is gaining importance because of the benefits the manufacturing sector reaps as a result of technology spillover brought through FDI. Therefore the objective of the study is to assess the impact of Foreign Direct Investment on the manufacturing sector output of the Indian economy for the period of 1991–2020. Methods such as bounds test, Autoregressive Distributed Lag Model (ARDL) and Granger causality are used to study the impact of FDI and the interaction of FDI and human capital as two different variables on the output of the manufacturing sector in the Indian economy. Also, the technology-enhancing effect of FDI is addressed in the current study. The results of the study reveal that the inflow of FDI leads to an increase in manufacturing sector output. Further, it concludes that the higher the level of education (human capital) and the greater the technology gap between host and home country, the more is the technology spillover, and hence more prominent is the impact of FDI on the output of the manufacturing sector.

Pregnant women are more vulnerable to infection by germs in the environment. Keeping the body clean helps prevent infection. Washing hands with soap is the most important hygiene action she can take, especially before preparing food and after going to the toilet. If possible, a pregnant woman should wash her body every day with clean water — especially her genital area. Dental hygiene is also important during pregnancy because increased estrogen levels can cause swelling and increased sensitivity in gum tissues. The aim of this study was to check knowledge of pregnant women on good hygiene practices to stay healthy and protect unborn child.The survey of 72 pregnant women was conducted with questionnaire through Google forms on the knowledge ofhygiene practices during pregnancy. Most respondents(76.39%)had knowledge of body hygiene during pregnancy. Almost all the respondents (73.61%)had knowledge of pregnancy striae treatments. All the respondents (100%) had knowledge on clothing hygiene (e.g. cleanliness & sterile). Around 69.44 %respondents had knowledge on addictioneffects and 63.88 % had knowledge on dental hygiene.

Artificial Neural Networks (ANNs), Deep Learning, and AI Deep learning is a subset of machine learning. In order to create pictures with a greater resolution, a high-resolution GAN combines a deep network with an opponent network. An approach to generative modelling that uses deep learning techniques like convolutional neural networks is known as generative adversarial networks, or GAN. In the Super-Resolution Generative Adversarial Network (SRGAN), a Generative Adversarial Network (GAN) may transform low-resolution images into super resolution images that are more finely detailed and of higher quality. In the past, CNNs were used to produce incredibly precise and detailed images. However, they could have trouble recalling specifics and usually draw hazy visuals which can be overcome by SRGAN.

XRD patterns of the as-prepared samples indicate the glassy nature with evidence of some crystallites embedded in the glass matrix of the samples.

Plausible structural rearrangement after the doping of graphene in glassy selenium.

Psoriasis is a systemic inflammatory disease with an increased risk of atherosclerotic events and premature cardiovascular disease. S100A7, A8/A9, and A12 are protein complexes that are produced by activated neutrophils, monocytes, and keratinocytes in psoriasis. Lipid-rich necrotic core (LRNC) is a high-risk coronary plaque feature previously found to be associated with cardiovascular risk factors and psoriasis severity. LRNC can decrease with biologic therapy, but how this occurs remains unknown. We investigated the relationship between S100 proteins, LRNC, and biologic therapy in psoriasis. S100A8/A9 associated with LRNC in fully adjusted models (β = 0.27, P = 0.009; n = 125 patients with psoriasis with available coronary computed tomography angiography scans; LRNC analyses; and serum S100A7, S100A8, S100A9, S100A12, and S100A8/A9 levels). At 1 year, in patients receiving biologic therapy (36 of 73 patients had 1-year coronary computed tomography angiography scans available), a 79% reduction in S100A8/A9 levels (‒172 [‒291.7 to 26.4] vs. ‒29.9 [‒137.9 to 50.5]; P = 0.04) and a 0.6 mm

Background Compliance with evidence-based treatment guidelines for gastric cancer across the United States is poor. This pilot study aimed to create and evaluate a change package for disseminating information on the staging and treatment of gastric cancer during multidisciplinary tumor boards and for identifying barriers to implementation. Methods The change package included a 10-min video, a brief knowledge assessment, and a discussion guide. Commission on Cancer-accredited sites that perform gastrectomy were invited to participate. Participants completed the Organizational Readiness for Implementing Change (ORIC) scale (range, 12–60) and scales to measure the feasibility, acceptability, and appropriateness (score range, 4–20). Semi-structured interviews were conducted to further define inner and outer setting barriers. Results Seven centers participated in the study. A total of 74 participants completed the pre-video knowledge assessment, and 55 participants completed the post-video assessment. The recommendations found to be most controversial were separate staging laparoscopy and modified D2 lymphadenectomy. Sum scores were calculated for acceptability (mean, 17.43 ± 2.51) appropriateness (mean, 16.86 ± 3.24), and feasibility (mean, 16.14 ± 3.07) of the change package. The ORIC scores (mean, 46.57 ± 8.22) correlated with responses to the open-ended questions. The key barriers identified were patient volume, skills in the procedures, and attitudes and beliefs. Conclusions The change package was moderately to highly feasible, appropriate, and acceptable. The activity identified specific recommendations for gastric cancer care that are considered controversial and local barriers to implementation. Future efforts could focus on building skills and knowledge as well as the more difficult issue of attitudes and beliefs.

In an effort to mitigate the COVID-19 outbreak, government authorities have taken various initiatives. The effectiveness of these mitigation measures is highly dependent on cooperation of all members of society. The knowledge, attitudes and practices people hold toward the disease play an integral role in determining a society’s readiness to accept behavioral change measures from health authorities. The aim of this study was to determine the knowledge levels, attitudes, and practices toward COVID-19 among the pregnant women from Tapovan Centers of Gujarat which are affiliated by Children’s University. The survey of 56 pregnant women was conducted with questionnaire through Google forms on COVID-19 to determine their attitude and precaution practices. All participants (100%) were acquainted with the knowledge on precaution practices (e.g.,avoiding crowds, hand hygiene, wearing of face masks) to be safe from COVID-19. Most participants (98.2%) were taking precautions and following practice to be safe from COVID-19. Almost half of the participants (51.8%) have a fear of COVID-19. The results highlight the importance of consistent efforts from the government as well as the need for the health education programs to improve levels of attitudes and precaution practices.

ObjectivesPremature cardiovascular events in systemic lupus erythematosus (SLE) contribute to morbidity and mortality, with no effective preventive strategies described to date. Immune dysregulation and metabolic disturbances appear to play prominent roles in the induction of vascular disease in SLE. The peroxisome proliferator activated receptor-gamma agonist pioglitazone (PGZ suppresses vascular damage and immune dysregulation in murine lupus and improves endothelial dysfunction in other inflammatory diseases. We hypothesised that PGZ could improve vascular dysfunction and cardiometabolic parameters in SLE.MethodsEighty SLE subjects with mild to severe disease activity were randomised to a sequence of PGZ followed by placebo for 3 months, or vice versa, in a double-blind, cross-over design with a 2-month wash-out period. Primary endpoints were parameters of endothelial function and arterial inflammation, measured by multimodal assessments. Additional outcome measures of disease activity, neutrophil dysregulation, metabolic disturbances and gene expression studies were performed.ResultsSeventy-two subjects completed the study. PGZ was associated with a significant reduction in Cardio-Ankle Vascular Index (a measure of arterial stiffness) compared with placebo. Various metabolic parameters improved with PGZ, including insulin resistance and lipoprotein profiles. Circulating neutrophil extracellular trap levels also significantly decreased with PGZ compared with placebo. Most adverse events experienced while on PGZ were mild and resolved with reduction in PGZ dose.ConclusionPGZ was well tolerated and induced significant improvement in vascular stiffness and cardiometabolic parameters in SLE. The results suggest that PGZ should be further explored as a modulator of cardiovascular disease risk in SLE.Trial registration numberNCT02338999.

Background: Patiromer and sodium polystyrene sulfonate (SPS) are cation-exchangers approved for the treatment of chronic hyperkalemia. Data regarding their efficacy acutely is lacking. Despite this, both drugs are frequently used in the emergent setting. Objective: The purpose of this study was to compare the potassium reduction of patiromer to SPS within 6 to 24 hours following a single dose. Methods: This retrospective quality improvement project included hyperkalemic patients receiving 1 dose of patiromer or SPS and had a second potassium level drawn in 6 to 24 hours. Doses of 8.4 g of patiromer and 15 g of SPS were considered “low dose” while 16.8 g of patiromer and 30 g of SPS were considered “high dose.” The presence of a dose-response relationship was assessed through a linear regression analysis. Results: Mean (SD) potassium reduction was higher in SPS than patiromer [0.76 (0.63) mEq/L vs 0.32 (0.65) mEq/L, ( P = .001)]. A dose response relationship was not demonstrated in low versus high dose groups [−0.21 (0.14), P = .13] and CKD, ESRD, and renal transplant patients when compared to patients with normal renal function [0.11 (0.17), P = .51, −0.07 (0.19), P = −0.07 (0.19), P = .73, and −0.10 (0.22), P = .65]. Conclusions: This study suggests a clinically significant reduction in potassium with SPS compared to patiromer. Although SPS was successful in demonstrating this outcome, due to well-documented adverse reactions in the literature and a time to onset of 6 hours, it cannot be recommended for use in acute hyperkalemia either.

Background We aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010–2011. Methods An observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs. Results On the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality. Conclusions Hospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care. Registered at clinicaltrials.gov (NCT03631927). How to cite this article Divatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al. Intensive Care in India in 2018–2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2021;25(10):1093–1107.

Background Psoriasis is an immune-mediated disease associated with excess risk for cardiovascular disease (CVD). Guidelines recognize psoriasis as a CVD risk enhancer; however, psoriasis patients often do not have CVD risk factors identified nor managed. Objective This study examines strategies to improve CVD prevention care from the perspective of physicians and patients with psoriasis. Methods Qualitative interviews were conducted using the Consolidated Framework for Implementation Research to examine the perspectives of physicians (N = 16) and patients with psoriatic disease (N = 16) on barriers and facilitators to CVD prevention. Interviews were transcribed and coded using an integrated approach designed to enhance reliability and validity using NVivo software. Results We found 3 major themes suggesting areas to target for the future: (1) Appropriateness: perceptions of whether CVD care should be deployed in this setting by both physicians and patients, (2) Feasibility: whether CVD prevention care could be integrated into the current structure of specialist practice, and (3) Care Coordination: an interest by all parties to better integrate a team approach in CVD preventative care to reduce duplicative efforts, work practically in an already existing system rather than reinventing the wheel, and progress with the patients’ best interests in mind. Conclusions These findings will inform the design of a clinical trial comparing the effectiveness of specialist clinician implementation of CVD guideline-based prevention care in patients with psoriasis. Ultimately, this study aims to increase the lifespan and health of patients living with psoriatic disease by decreasing barriers to their receiving appropriate CVD prevention care.

Statin treatment is a potent lipid-lowering therapy associated with decreased cardiovascular risk and mortality. Recent studies including the PARADIGM trial have demonstrated the impact of statins on promoting calcified coronary plaque.The degree of systemic inflammation impacts the amount of increase in coronary plaque calcification over 2 years of statin treatment.A subgroup of 142 participants was analyzed from the Risk Stratification with Image Guidance of HMG CoA Reductase Inhibitor Therapy (RIGHT) study (NCT01212900), who were on statin treatment and underwent cardiac computed tomography angiography (CCTA) at baseline and 2-year follow-up. This cohort was stratified by baseline median levels of high-sensitivity hs-CRP and analyzed with linear regressions using Stata-17 (StataCorp).In the high versus low hs-CRP group, patients with higher baseline median hs-CRP had increased BMI (median [IQR]; 29 [27-31] vs. 27 [24-28]; p .001), hypertension (59% vs. 41%; p = .03), and LDL-C levels (97 [77-113] vs. 87 [75-97] mg/dl; p = .01). After 2 years of statin treatment, the high hs-CRP group had significant increase in dense-calcified coronary burden versus the low hs-CRP group (1.27 vs. 0.32 mmStatin treatment over 2 years associated with a significant increase in coronary calcification in patients with higher systemic inflammation, as measured by hs-CRP. These findings suggest that systemic inflammation plays a role in coronary calcification and further studies should be performed to better elucidate these findings.

Opioids constitute the fastest-growing drug problem among children and adolescents in the United States. Recent heavy media coverage on the opioid prescription epidemic has garnered increased attention from prescribers and policymakers. The purpose of this study was to analyze trends in opioid prescribing for nonoperatively managed pediatric fractures and dislocations in order to examine changes in opioid-prescribing patterns across various U.S. regions.A retrospective review of the national Pediatric Health Information System (PHIS) database comprising 42 pediatric hospitals was performed to identify pediatric fractures and dislocations presenting to the emergency department (ED) or outpatient clinics from 2004 to 2017. We included patients with the 10 most frequently encountered diagnoses who were nonoperatively managed and were discharged home the same day. To account for hospital variation, we utilized a mixed-effects logistic regression model.The final cohort included 134,931 patients, with a mean age (and standard deviation) of 12.57 ± 2.00 years (range, 10 to 18 years); 69.23% of patients were male. Overall, 51.69% of patients were prescribed at least 1 opioid dose during their ED or clinic visits. Of the patients receiving opioids, 72.04% were male and 54.10% were insured through a private insurance plan. When prescription trends were compared according to regions, children were more likely to be prescribed opioids in the South (71.37% more likely) and the Midwest (26.17% more likely) than in the Northeast.Although the opioid prescription rates in all 4 regions have decreased dramatically over the years, some regions were quicker than others in responding to the opioid epidemic. A significant interregional variability in opioid-prescribing practices still exists, but an overall downward trend in opioid prescription rates for acute pain management in conservatively treated pediatric fractures and dislocations is evidence of progress in tackling the opioid crisis.Opioid-related misuse is a national epidemic and reducing the use of opioids in pediatric orthopaedic procedures is critical. Although regional variability in opioid-prescribing practices still exists, an overall downward trend in opioid prescription rates for acute pain management in conservatively treated pediatric fractures and dislocations is evidence of progress in tackling the opioid crisis.

Magnetic resonance imaging (MRI) sagittal alignment is a measure that has been described and validated in the adult population as a means of distinguishing normal knees from those with anterior cruciate ligament (ACL) injury, but this measure has not been formally assessed among pediatric patients. The purpose of this study was to (1) assess the reliability of this MRI-based measure in a pediatric cohort, and (2) validate its ability to distinguish between ACL and non-ACL-injured knees in this population.A consecutive series of knee MRI examinations performed at our center were reviewed to identify studies of pediatric patients (1) with ACL injury, and (2) without significant pathology. Patient age, sex, physeal status (open, closing, or closed), knee laterality, and magnet strength (1.5 or 3-Tesla) were collected. The sagittal alignment was measured in both medial and lateral tibiofemoral compartments using a previously described method. Mean anterior tibial translation was then calculated for each study. Inter-rater and intrarater reliability testing was performed on a subset of randomly-selected patients from each cohort by three raters by calculating intraclass correlation coefficients. Sagittal alignment measurements of all patients were then completed by a single author after reliability was confirmed. The medial and lateral compartment translation and mean anterior tibial translation measurements of normal and ACL-injured knees were compared.Inclusion criteria were met by 131 studies: 86 from uninjured knees (normal cohort) and 45 knees with ACL injury (ACL cohort). Studies were performed at a mean age of 13.4 with a near equivalent sex distribution. Inter-rater and intrarater reliability were good to excellent for all measures for patients in both normal and ACL cohorts. Normal and ACL-injured knees demonstrated a significant difference in anterior tibial translation in all measured regions. The mean anterior tibia translation for ACL-injured knees was 2.01 mm (95% confidence interval: 1.03-2.98) versus -0.44 mm (95% confidence interval: -0.89-0.014).This study identified good to excellent inter-rater and intrarater reliability of knee sagittal alignment measurements among pediatric patients. It also demonstrated a significant difference in medial compartment, lateral compartment, and mean tibial translation in patients with and without ACL injury, validating previous findings demonstrated in adult cohorts. These findings may be useful in assisting providers in the confirmation of suspected ACL injury and insufficiency and guide operative management in cases of clinical uncertainty.Level III-retrospective comparative study.

Background Psoriasis (PSO) is a skin disorder with systemic inflammation and high coronary artery disease risk. A distinct lipid phenotype occurs in psoriasis, which is characterized by high plasma triglycerides (TGs) with typically normal or even low LDL-C. The extent to which cholesterol on LDL subfractions, such as small dense LDL-C (sdLDL-C), are associated with vulnerable coronary plaque characteristics in PSO remains elusive. Methods A recently developed equation for estimating sdLDL-C from the standard lipid panel was utilized in a PSO cohort (n = 200) with 4-year follow-up of 75 subjects. Coronary plaque burden was assessed by quantitative coronary computed tomography angiography (CCTA). Multivariate regression analyses were used for establishing associations and prognostic value of estimated sdLDL-C. Results Estimated sdLDL-C was positively associated with non-calcified burden (NCB) and fibro-fatty burden (FFB), which remained significant after multivariate adjustment for NCB (β = 0.37; P = 0.050) and LDL-C adjustment for FFB (β = 0.29; P P = 0.015), whereas LDL-C did not. Finally, small LDL particles (S-LDLP) and small HDL particles (S-HDLP), along with large and medium TG-rich lipoproteins (TRLPs) had the most significant positive correlation with estimated sdLDL-C. Conclusions Estimated sdLDL-C has a stronger association than LDL-C with high-risk features of coronary atherosclerotic plaques in psoriasis patients. Clinical trial registration URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01778569

Introduction: Hepatoblastoma is a common malignant liver tumour in children with a peak incidence in the first two years. Its previous mortality was reported to be 24%, but refinements in risk stratification, advances in chemotherapy and application of protocol-based therapy including surgery have resulted in improving long-term outcomes. Methods: We describe our experience of children with hepatoblastoma using the new treatment guidelines who underwent surgery between January 2013 and December 2020 Results: During the aforementioned period, 6 patients with hepatoblastoma (4 male and 2 female) were treated in our unit with median age at presentation being 15 (range 6 – 36) months. One patient was PRETEXT stage I, three were stage II and two were stage III. All of them had chemotherapy prior to surgical resection as per the SIOPEL-3 and SIOPEL-4 protocols varying between 2-4 cycles following which size reduction in the tumors was noted. right hepatectomy in three patients, non-anatomical hepatic resection in one, left lateral hepatectomy in one and left hepatectomy in one. The mean duration of surgery was 205 (range 115- 300) minutes and the mean blood loss was 50 (range 20-150) ml. There was no operative mortality following which all patients then had adjuvant chemotherapy and are alive with a median follow-up of 40.6 (18-104) months. Conclusion: The management of hepatoblastoma has changed significantly following the incorporation of recent updates from international groups into clinical practice. With the use of risk stratification, preoperative and adjuvant chemotherapy, and surgical excision, the overall and event-free survival has improved, reiterating the value of a multidisciplinary approach towards the treatment of this disease.

Epidemiological and clinical studies have demonstrated a consistent relationship between increased systemic inflammation and increased risk of cardiovascular events. In chronic inflammatory states, traditional risk factors only partially account for the development of coronary artery disease (CAD) but underestimate total cardiovascular risk likely due to the residual risk of inflammation. Computed coronary tomography angiography (CCTA) may aid in risk stratification by noninvasively capturing early CAD, identifying high risk plaque morphology and quantifying plaque at baseline and in response to treatment. In this review, we focus on reviewing studies on subclinical atherosclerosis by CCTA in individuals with chronic inflammatory conditions including rheumatoid arthritis (RA), systemic lupus erythematous (SLE), human immunodeficiency virus (HIV) infection and psoriasis. We start with a brief review on the role of inflammation in atherosclerosis, highlight the utility of using CCTA to delineate vessel wall and plaque characteristics and discuss combining CCTA with laboratory studies and emerging technologies to complement traditional risk stratification in chronic inflammatory states.

Introduction. Whipple’s pancreatoduodenectomy (PD) is a formidable operation, associated with a high risk of morbidity and mortality. In the setting of an underlying chronic liver disease, the incidence of complications and mortality increases manifold. Patients and Outcomes. Of the 112 Whipple’s PD performed between 2018 to 2020 at a high-volume HPB and liver transplant centre, 4 patients underwent the surgery in the background of an underlying chronic liver disease (CLD). All except one were performed in Child’s A cirrhotics. There was a single 30-day mortality in this series of 4 patients that occurred in the background of Child’s B cirrhosis. On follow-up at 1 year, there was one more mortality in the series, owing to liver decompensation following chemotherapy. Conclusion. Judicious preoperative selection criteria, adequate preoperative nutritional and physiological optimisation, and prudent weighing of risk vs. benefit of undergoing Whipple’s PD in periampullary malignancies in the setting of CLD are the major determinants of the surgical outcome.

Background and aims Psoriasis is an immune-mediated inflammatory disease with increased risk of myocardial infarction. Preclinical studies in psoriasis models show an association between chronic inflammation and immune cell proliferation in the spleen and bone marrow (BM). We sought to test the hypothesis that splenic and BM 18F-fluorodeoxyglucose (18F-FDG) uptake is heightened in psoriasis and that higher uptake associates with systemic inflammation and subclinical atherosclerotic disease measures in this cohort. Methods Multimodality imaging and biomarker assays were performed in 240 participants (210 with psoriasis and 30 healthy). Splenic and BM uptake was obtained using 18F-FDG positron emission tomography/computed tomography (PET/CT). Coronary artery plaque characteristics including non-calcified burden (NCB) and lipid rich necrotic core (LRNC) were quantified using a dedicated software for CT angiography. All analyses were performed with StataIC 16 (Stata Corp., College Station, TX, USA). Results Splenic and BM 18F-FDG uptake was increased in psoriasis (vs. healthy volunteers) and significantly associated with proatherogenic lipids, immune cells and systemic inflammation. Higher splenic 18F-FDG uptake associated with higher total coronary burden (β = 0.37; p Conclusions Heightened splenic and BM uptake of 18F-FDG is associated with proatherogenic lipids, immune cells, inflammatory markers and coronary artery disease. These findings provide insights into atherogenic mechanisms in psoriasis and suggest that immune cell proliferation in the spleen and BM is associated with subclinical atherosclerosis.

BackgroundSuperior semi-circular canal dehiscence syndrome is a disorder characterised by auditory and vestibular symptoms that can significantly impact quality of life, and yet it has no disease-specific quality of life instrument.MethodThirty-six patients who underwent transmastoid superior semicircular canal resurfacing and plugging were included from an initial cohort of 60 surgically managed patients. A sub-cohort of 19 consecutive patients completed validated symptom and quality of life questionnaires before and after surgery. Of the 36 patients, 31 participated in a telephone semi-structured interview post-operatively.ResultsFollowing surgery, there was a statistically significant improvement in autophony index score (p = 0.02), symptom severity score (p < 0.001) and sound hypersensitivity (p = 0.01). Thematic analysis of telephone interviews suggested three main symptom themes: auditory hypersensitivity, dysequilibrium, headache and concentration difficulties. Dysequilibrium was found to persist post-operatively.ConclusionSurgery improves overall symptoms and quality of life. However, important symptom themes may be overlooked using the outcome measures that are currently available. A unified disease-specific outcome measure is urgently required to better understand the impact of symptoms and measure treatment effects.

For any given body mass index (BMI), individuals vary substantially in fat distribution, and this variation may have important implications for cardiometabolic risk. Here, we study disease associations with BMI-independent variation in visceral (VAT), abdominal subcutaneous (ASAT), and gluteofemoral (GFAT) fat depots in 40,032 individuals of the UK Biobank with body MRI. We apply deep learning models based on two-dimensional body MRI projections to enable near-perfect estimation of fat depot volumes (R2 in heldout dataset = 0.978-0.991 for VAT, ASAT, and GFAT). Next, we derive BMI-adjusted metrics for each fat depot (e.g. VAT adjusted for BMI, VATadjBMI) to quantify local adiposity burden. VATadjBMI is associated with increased risk of type 2 diabetes and coronary artery disease, ASATadjBMI is largely neutral, and GFATadjBMI is associated with reduced risk. These results – describing three metabolically distinct fat depots at scale – clarify the cardiometabolic impact of BMI-independent differences in body fat distribution.

BackgroundLow-density lipoprotein cholesterol (LDL-C) is an established marker for cardiovascular disease (CVD) and a therapeutic target. Oxidized LDL (oxLDL) is known to be associated with excessive inflammation and abnormal lipoprotein metabolism. Chronic inflammatory diseases confer an elevated risk of premature atherosclerosis and adverse cardiovascular events. Whether oxLDL may serve as a potential biomarker for CVD stratification in populations with chronic inflammatory conditions remains understudied.ObjectiveTo perform a systematic review and meta-analysis evaluating the relationship between oxLDL and CVD (defined by incident CVD events, carotid intima-media thickness, presence of coronary plaque) in patients with chronic inflammatory diseases.MethodsA systematic literature search was performed using studies published between 2000 and 2022 from PubMed, Cochrane Library, Embase (Elsevier), CINHAL (EBSCOhost), Scopus (Elsevier), and Web of Science: Core Collection (Clarivate Analytics) databases on the relationship between oxLDL and cardiovascular risk on inflamed population. The pooled effect size was combined using the random effect model and publication bias was assessed if P < 0.05 for the Egger or Begg test along with the funnel plot test.ResultsA total of three observational studies with 1,060 participants were ultimately included in the final meta-analysis. The results demonstrated that oxLDL is significantly increased in participants with CVD in the setting of chronic inflammatory conditions. This meta-analysis suggests that oxLDL may be a useful biomarker in risk stratifying cardiovascular disease in chronically inflamed patients.

Cardiac computed tomography angiography (CTA) is an emerging imaging modality for assessing coronary artery as well as various cardiovascular structures. Recently, deep learning (DL) methods have been successfully applied to many applications of medical image analysis including cardiac CTA structure segmentation. However, DL requires a large amounts of data and high-quality labels for training which can be burdensome to obtain due to its labor-intensive nature. In this study, we aim to develop a fully automatic artificial intelligence (AI) system, named DeepHeartCT, for accurate and rapid cardiac CTA segmentation based on DL. The proposed system was trained using a large clinical dataset with computer-generated labels to segment various cardiovascular structures including left and right ventricles (LV, RV), left and right atria (LA, RA), and LV myocardium (LVM). This new system was trained directly using high-quality computer labels generated from our previously developed multi-atlas based AI system. In addition, a reverse ranking strategy was proposed to assess the segmentation quality in the absence of manual reference labels. This strategy allowed the new framework to assemble optimal computer-generated labels from a large dataset for effective training of a deep convolutional neural network (CNN). A large clinical cardiac CTA studies (n = 1,064) were used to train and validate our framework. The trained model was then tested on another independent dataset with manual labels (n = 60). The Dice score, Hausdorff distance and mean surface distance were used to quantify the segmentation accuracy. The proposed DeepHeartCT framework yields a high median Dice score of 0.90 [interquartile range (IQR), 0.90–0.91], a low median Hausdorff distance of 7 mm (IQR, 4–15 mm) and a low mean surface distance of 0.80 mm (IQR, 0.57–1.29 mm) across all segmented structures. An additional experiment was conducted to evaluate the proposed DL-based AI framework trained with a small vs. large dataset. The results show our framework also performed well when trained on a small optimal training dataset (n = 110) with a significantly reduced training time. These results demonstrated that the proposed DeepHeartCT framework provides accurate and rapid cardiac CTA segmentation that can be readily generalized for handling large-scale medical imaging applications.

Background: Juvenile Osteochondritis Dissecans (JOCD) is a common knee condition that can cause significant morbidity if the lesion does not heal. Arthroscopic drilling is a common surgical treatment for low-grade intact lesions, but its success rate and complications have not been well defined in a large series. Purpose: This study seeks to determine the reoperation rate and the incidence of major complications following arthroscopic drilling of JOCD lesions of the knee. Methods: A query of patients in the Pediatric Health Information System (PHIS) database from 2013 to 2018 was performed for the diagnosis and billing codes specific for arthroscopic drilling of an intact JOCD lesion. Subsequent surgical procedures on ipsilateral and contralateral knees were then analyzed for evidence of additional surgical procedures related to non-healing of the lesion. Results: We identified 1027 patients, 6-17 years of age, who underwent arthroscopic drilling as their initial surgical treatment for a diagnosis of JOCD of the knee. Within 6 months of the original surgery, 27 patients (3%) had a secondary surgery on the ipsilateral knee and 27 patients (3%) had surgery on the contralateral knee. By 2 years, 84 patients (8%) had a secondary surgery on the ipsilateral knee and 38 patients (4%) had surgery on the contralateral knee. Patient age was a significant factor in both the frequency and invasiveness of secondary surgeries, with older patients requiring repeat procedures and more invasive procedures more frequently. Less than 1% of patients underwent another surgical procedure of the knee not specifically to treat the JOCD lesion. Conclusions: The 2-year reoperation rate following drilling of an intact juvenile OCD lesion was 8%. Younger patients were less likely to undergo a subsequent procedure compared to older patients. In addition, if they did require a second procedure, younger patients were less likely to require a salvage-type cartilage procedure. The rate of complications requiring additional knee surgeries was less than 1%.

How does dual-use technology influence cooperation? This study explores how the development of nuclear latency (the technological precursors to nuclear weapons) affects U.S. cooperative overtures toward its possessors. We argue that the ambiguous nature of nuclear latency creates uncertainty about the intentions of its possessors and impacts cooperation. Using event data, we find that a state’s possession of overt lab-scale enrichment and reprocessing facilities is significantly correlated with greater cooperative overtures from the United States toward that country. These overtures may serve as effective tools to counter nuclear proliferation among these states. Yet, when latent states engage in a concerted effort to keep their facilities secret, both at the lab and a more advanced “pilot” stage, this relationship is reversed. These results carry important implications for the impact of emerging, dual-use technologies on international security broadly.

BackgroundMyriad roles for high-density lipoprotein (HDL) beyond atheroprotection include immunologic functions implicated in the severity of coronavirus disease-2019 (COVID-19) in adults. We explored whether there is an association between HDL and COVID-19 severity in youth.MethodsA pediatric cohort (N = 102), who tested positive for COVID-19 across a range of disease manifestations from mild or no symptoms, to acute severe symptoms, to the multisystem inflammatory syndrome of children (MIS-C) was identified. Clinical data were collected from the medical record and reserve plasma aliquots were assessed for lipoproteins by NMR spectroscopy and assayed for HDL functional cholesterol efflux capacity (CEC). Findings were compared by COVID-19 status and symptom severity. Lipoprotein, NMR spectroscopy and CEC data were compared with 30 outpatient COVID negative children.ResultsDecreasing HDL cholesterol (HDL-c), apolipoprotein AI (ApoA-I), total, large and small HDL particles and HDL CEC showed a strong and direct linear dose-response relationship with increasing severity of COVID-19 symptoms. Youth with mild or no symptoms closely resembled the uninfected. An atypical lipoprotein that arises in the presence of severe hepatic inflammation, lipoprotein Z (LP-Z), was absent in COVID-19 negative controls but identified more often in youth with the most severe infections and the lowest HDL parameters. The relationship between HDL CEC and symptom severity and ApoA-I remained significant in a multiply adjusted model that also incorporated age, race/ethnicity, the presence of LP-Z and of GlycA, a composite biomarker reflecting multiple acute phase proteins.ConclusionHDL parameters, especially HDL function, may help identify youth at risk of more severe consequences of COVID-19 and other novel infectious pathogens.

Introduction Fibrofatty plaque burden (FFB) is a high-risk, vulnerable plaque feature comprised of an atheromatous core and fibrous cap with increased risk of coronary artery disease (CAD) [1]. Psoriasis (PSO) is a chronic inflammatory disease linked with atherosclerotic risk and premature cardiovascular disease, driven in part by vulnerable plaque rupture [2,3]. Machine learning (ML) previously showed the prognostic value of FFB in predicting 5-year risk of cardiac-related mortality in patients with CAD [4]. Whether ML can predict FFB in psoriasis is understudied. Purpose To use ML to identify top determinants of FFB by CCTA in PSO. Methods 320 consecutive participants with psoriasis were recruited as part of an ongoing cohort study, of whom 307 had FFB analyzed with coronary computed tomography angiography (CCTA) and quantified by QAngio CT (Medis, The Netherlands). 140 out of 182 potential determinants were subjected to ML algorithms analyzed by random forest and validated by 5-fold cross validation to select the top determinants based on R-square criteria. Lipid concentration and size were measured by nuclear magnetic resonance (NMR) and sdLDL-C was calculated by Sampson's formula. Results The top 21 determinants of FFB at baseline were grouped into 3 categories: cardiometabolic risk factors (BMI, sex, DBP, mean arterial pressure, exercise, heart rate, glucose, anxiety, psoriasis disease duration), clinical measurements (basophils, platelets, hemoglobin, RBC, alkaline phosphatase, ALT, creatinine, neutrophil-to-lymphocyte ratio), and lipoproteins (LDL particle size, apolipoprotein A1, apolipoprotein B-to-A1 ratio, calculated sdLDL-C). Conclusion ML confirmed that FFB strongly correlates with cardiometabolic risk factors, clinical measurements, and lipoproteins. Further investigations into these top determinants of FFB over time may provide insight into potential therapeutic interventions that decrease cardiovascular risk in patients with chronic inflammatory diseases and should be validated in larger studies. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): This study was supported by the National Heart, Lung and Blood Institute (NHLBI) IntramuralResearch Program (ZIA-HL-06193). This research was made possible through the NIH MedicalResearch Scholars Program, a public-private partnership supported jointly by the NIH andcontributions to the Foundation for the NIH from the Doris Duke Charitable Foundation,Genentech, the American Association for Dental Research, the Colgate-Palmolive Company, andother private donors.

Convection-enhanced delivery (CED) is a drug delivery technique used to deliver therapeutics directly to the brain and is a continually evolving technique to treat glioblastoma. Early versions of CED have proven to result in inadequate drug volume dispersed (Vd), increasing the likelihood of tumor recurrence. Fiber optic microneedle devices (FMDs) with the ability to deliver fluid and thermal energy simultaneously have shown an ability to increase Vd, but FMDs have historically had low light transmission efficiency. In this study, we present a new fabrication method, solid fiber inside capillary (SFIC) FMD, and a modified fusion splicing (FS) method with the goal of increasing light delivery efficiency. The modified FS FMD resulted in an increase in light transmission efficiency between 49% and 173% compared to previous prototypes. However, the FS FMD resulted in significantly lower transmission efficiencies compared to the SFIC FMD (p ≤ 0.04) and FS FMDs perform much worse when light-absorptive materials, like black dye, are placed in the bore. The light absorption of a candidate cytotoxic agent, QUAD-CTX, appear to be similar to water, and light delivery through FS FMDs filled with QUAD-CTX achieves a transmission efficiency of 85.6 ± 5.4%. The fabrication process of the SFIC FMDs results in extremely fragile FMDs. Therefore, the use of a modified FS FMD fabrication process appears to be better suited for balancing the desire to increase light transmission efficiency while retaining a sturdy FMD construction.

The blood-brain barrier (BBB) presents a formidable obstacle to the effective delivery of systemically administered pharmacological agents to the brain, with ~5% of candidate drugs capable of effectively penetrating the BBB. A variety of biomaterials and therapeutic delivery devices have recently been developed that facilitate drug delivery to the brain. These technologies have addressed many of the limitations imposed by the BBB by: (1) designing or modifying the physiochemical properties of therapeutic compounds to allow for transport across the BBB; (2) bypassing the BBB by administration of drugs via alternative routes; and (3) transiently disrupting the BBB (BBBD) using biophysical therapies. Here we specifically review colloidal drug carrier delivery systems, intranasal, intrathecal, and direct interstitial drug delivery methods, focused ultrasound BBBD, and pulsed electrical field induced BBBD, as well as the key features of BBB structure and function that are the mechanistic targets of these approaches. Each of these drug delivery technologies are illustrated in the context of their potential clinical applications and limitations in companion animals with naturally occurring intracranial diseases.