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The dynamic property and increasing complexity are the key challenges for modeling financial technology (FinTech) related applications such as stock markets. Over the years, a lot of inflexible predictive strategies have been proposed for predicting stock price movements that failed to achieve satisfactory results especially when a market crash occurs. To cope with this challenge, we propose a prediction framework based on an adversarial training strategy using reinforcement learning for the said FinTech application. The framework uses a heterogeneous knowledge-base including stock prices, tweets, and global indicators. We propose a modified newton-divided difference polynomial (NDDP) for missing data imputation. The informative patterns representing the intrinsic characteristics of financial markets were extracted using long short-term memory networks (LSTM). The two adversarial networks are heterogeneous data fusion representing market crash (HDFM) Q-learning and confrontational Q-learning network. Both networks are trained in an adversarial fashion to increase the effectiveness of prediction even when the financial market is volatile. The experimental results show the importance of global indicators and the proposed adversarial learning network (ALN) for improving the predictive performance in comparison with the existing state-of-the-art works.

Background Chronic wounds are of many etiologies and difficult to treat. Many commercial products to manage such wounds are available, which claim to have good outcomes. Aim of this study was to compare the efficacy of Ionic Silver Solution and Super Oxidized Solution in the management of chronic wounds. Methods Patients with chronic wounds were randomly placed in two groups-Group A (Ionic Silver Solution) and Group B (Super Oxidized Solution) with 30 patients each. The dressings were continued until the wound healed completely or the wound was ready for a definitive procedure. Wound parameters were recorded as per Bates Jensen Wound Assessment Tool (BJWAT) Score. Results FIfty patients completed the study. The scores were compared at the initiation and endpoint of treatment. The pretreatment total for BJWAT was 916 and 924 in group A and group B respectively, which was not statistically significant. Post-treatment improvement was noticed in both the groups and the score decreased to 510 and 675 in group A and group B respectively (p = 0.001). Ionic Silver Solution and Super Oxidized Solution both were found to be effective in improving the overall wound condition. However, Ionic Silver Solution was found to be more effective than Super Oxidized Solution in the healing of chronic wounds. Complete healing was noticed in a small number (6%) of patients. These agents can therefore best prepare the wounds for early surgical intervention. Conclusion Both the agents were found to be safe and useful in the management of chronic wounds. However, Ionic Silver Solution was found to be more effective than the super oxidized solution in this study.

The citrus family provides healthy fruits to humans. The quality and quantity of the citrus fruits depend on the quality of the citrus leaves. Due to the diseases of citrus leaves, the quality and productivity of citrus fruit are degraded. This paper provides a computer automation system to detect the diseases of the citrus leaves using machine learning and deep learning techniques. In this paper, images of citrus leaves are captured using an Android Smartphone in natural environmental light. Three different classes of citrus leaves are collected using the Smartphone and destructive method. These are citrus healthy, citrus greening, and citrus CTV (Citrus Tristeza virus). Citrus images are processed for image resizing, image noise removal, image enhancement, and feature extraction. Features of the images are calculated using Gray Level Co-occurrence Matrix in the color and gray domain of the images. Finally, the detection and classification are done using K- Nearest Neighbor (KNN) and Deep Neural Network (DNN) classifier. The accuracy of the KNN classifier is 89.9% for the K value 3 whereas the accuracy of DNN is 99.89% with an error of 0.0219. The proposed system helps the farmer to detect diseases at an early stage.

Background The COVID-19 pandemic has posed unprecedented challenges and threats to the health care system, particularly affecting the effective delivery of essential health services in resource-poor countries such as Nepal. This study aimed to explore community perceptions of COVID-19 and their experiences towards health services utilization during the pandemic in Province-2 of Nepal. Methods The semi-structured qualitative interviews were conducted among purposively selected participants (n = 41) from a mix of rural and urban settings in all districts (n = 8) of the Province 2 of Nepal. Virtual interviews were conducted between July and August 2020 in local languages. The data were analyzed using thematic network analysis in NVivo 12 Pro. Results The findings of this research are categorized into four global themes: i) Community and stakeholders’ perceptions towards COVID-19; ii) Impact of COVID-19 and lockdown on health services delivery; iii) Community perceptions and experiences of health services during COVID-19; and iv) COVID-19: testing, isolation, and quarantine services. Most participants shared their experience of being worried and anxious about COVID-19 and reported a lack of awareness, misinformation, and stigma as major factors contributing to the spread of COVID-19. Maternity services, immunization, and supply of essential medicine were found to be the most affected areas of health care delivery during the lockdown. Participants reported that the interruptions in health services were mostly due to the closure of health services at local health care facilities, limited affordability, and involvement of private health sectors during the pandemic, fears of COVID-19 transmission among health care workers and within health centers, and disruption of transportation services. In addition, the participants expressed frustrations on poor testing, isolation, and quarantine services related to COVID-19, and poor accountability from the government at all levels towards health services continuation/management during the COVID-19 pandemic. Conclusions This study found that essential health services were severely affected during the COVID-19 pandemic in all districts of Province-2. It is critical to expand and continue the service coverage, and its quality (even more during pandemics), as well as increase public-private sector engagement to ensure the essential health services are available for the population.

Objective: the optimal management of asymptomatic, skull-based meningiomas is not well defined. The aim of this study is to compare the imaging and clinical outcomes of patients with asymptomatic, skull-based meningiomas managed either with upfront stereotactic radiosurgery (SRS) or active surveillance. Methods: this retrospective, multicenter study involved patients with asymptomatic, skull-based meningiomas. The study end-points included local tumor control and the development of new neurological deficits attributable to the tumor. Factors associated with tumor progression and neurological morbidity were also analyzed. Results: the combined unmatched cohort included 417 patients. Following propensity score matching for age, tumor volume, and follow-up 110 patients remained in each cohort. Tumor control was achieved in 98.2% and 61.8% of the SRS and active surveillance cohorts, respectively. SRS was associated with superior local tumor control (p < 0.001, HR = 0.01, 95% CI = 0.002-0.13) compared to active surveillance. Three patients (2.7%) in the SRS cohort and six (5.5%) in the active surveillance cohort exhibited neurological deterioration. One (0.9%) patient in the SRS-treated and 11 (10%) patients in the active surveillance cohort required surgical management of their meningioma during follow-up. Conclusions: SRS is associated with superior local control of asymptomatic, skull-based meningiomas as compared to active surveillance and does so with low morbidity rates. SRS should be offered as an alternative to active surveillance as the initial management of asymptomatic skull base meningiomas. Active surveillance policies do not currently specify the optimal time to intervention when meningioma growth is noted. Our results indicate that if active surveillance is the initial management of choice, SRS should be recommended when radiologic tumor progression is noted and prior to clinical progression., NA

Identifying race, which is a major physical feature in humans, is still a challenging task owing much to the lack of a concrete definition of race and the diversity of population across the globe. In this paper, we try to address the problem of race identification of four broad racial groups namely Caucasian, African, Asian and Indian. The newly developed BUPT Equalised Face dataset bearing about 1.3 M images in unrestricted environment is used to train our deep convolution network (R-Net) which achieves a state-of-the-art accuracy of 97%. To test the validity of this model it is evaluated on other datasets namely UTK and CFD. R-Net is also compared with fine-tuned VGG16 model for race estimation. Experimental results prove the robustness of this model for use in unconstrained environments. And finally, Gradient-weighted Class Activation Mapping (Grad-CAM) is applied to get a visual explanation of the deep learning model.

OBJECTIVE Molecular profiles, such as isocitrate dehydrogenase (IDH) mutation and O6-methylguanine-DNA methyltransferase (MGMT) methylation status, have important prognostic roles for glioblastoma patients. The authors studied the efficacy and safety of stereotactic radiosurgery (SRS) for glioblastoma patients with consideration of molecular tumor profiles. METHODS For this retrospective observational multiinstitutional study, the authors pooled consecutive patients who were treated using SRS for glioblastoma at eight institutions participating in the International Radiosurgery Research Foundation. They evaluated predictors of overall and progression-free survival with consideration of IDH mutation and MGMT methylation status. RESULTS Ninety-six patients (median age 56 years) underwent SRS (median dose 15 Gy and median treatment volume 5.53 cm3) at 147 tumor sites (range 1 to 7). The majority of patients underwent prior fractionated radiation therapy (92%) and temozolomide chemotherapy (98%). Most patients were treated at recurrence (85%), and boost SRS was used for 12% of patients. The majority of patients harbored IDH wild-type (82%) and MGMT-methylated (62%) tumors. Molecular data were unavailable for 33 patients. Median survival durations after SRS were similar between patients harboring IDH wild-type tumors and those with IDH mutant tumors (9.0 months vs 11 months, respectively), as well as between those with MGMT-methylated tumors and those with MGMT-unmethylated tumors (9.8 vs. 9.0 months, respectively). Prescription dose > 15 Gy (OR 0.367, 95% CI 0.190–0.709, p = 0.003) and treatment volume > 5 cm3 (OR 1.036, 95% CI 1.007–1.065, p = 0.014) predicted overall survival after controlling for age and IDH status. Treatment volume > 5 cm3 (OR 2.215, 95% CI 1.159–4.234, p = 0.02) and absence of gross-total resection (OR 0.403, 95% CI 0.208–0.781, p = 0.007) were associated with inferior local control of SRS-treated lesions in multivariate models. Nine patients experienced adverse radiation events after SRS, and 7 patients developed radiation necrosis at 59 to 395 days after SRS. CONCLUSIONS Post-SRS survival was similar as a function of IDH mutation and MGMT promoter methylation status, suggesting that molecular profiles of glioblastoma should be considered when selecting candidates for SRS. SRS prescription dose > 15 Gy and treatment volume ≤ 5 cm3 were associated with longer survival, independent of age and IDH status. Prior gross-total resection and smaller treatment volume were associated with superior local control.

In the Cloud-assisted Internet of Things (IoT), most of the data is sent to the cloud for storage and processing. Data privacy and security are major concerns. To this end, this paper proposes PERT, a Privacy-Enhanced Retrieval Technology for Cloud-assisted IoT. This architecture is designed through an implicit index maintained by edge servers and a hierarchical retrieval model that preserves data privacy by hiding the information of data transmission between the cloud and the edge servers. For the hierarchical retrieval model, we designed a data partition strategy to offload parts of data stored in edge servers that paves for preservation of data privacy. The extensive experiments have displayed the effectiveness of the technology for data privacy. It is also verified that the architecture can reduce computational cost. Compared with the benchmark cloud encrypted storage model, the time cost of this method is significantly reduced.

Introduction Rhinocerebral mucormycosis is extremely fatal, with mortality rates ranging from 85-93% despite the best treatment in immunocompromised patients. We emphasize the importance of early diagnosis, repeated debridement, and aggressive antifungal treatment to reduce mortality. Case summary We report six cases (five male and one female), with a mean age of 51 years who were diagnosed to have mucormycosis from 2017 to 2019. All patients were diabetic. Intracranial involvement and orbital involvement were found in four cases. Facial nerve palsy was seen in two cases, one without any apparent otological involvement. Aggressive serial debridement and amphotericin B was started. Posaconazole was added subsequently to the treatment in two cases. One patient succumbed to the disease five months after discharge. The other five patients are on regular follow-up for a mean duration of 14 months at the end of which two had residual disease which was under control. Discussion Repeated surgical debridement with an early aggressive and combination antifungal therapy can result in good outcomes even in advanced mucormycosis. Concurrent management of the underlying pathology, monitoring of liver and kidney functions, and therapeutic drug monitoring are useful to ensure smooth and effective treatment.

Introduction: A randomized controlled study was conducted to assess modulation of signal transduction genes ( PKA, PKC and ERK) following integrated multimodal approach encompassing pulsed radiofrequency treatment (PRF) of dorsal root ganglion and pregabalin in thoracic postherpetic neuralgia (PHN). Clinical variables such as pain intensity and quality of life were also explored. Material & methods: A total of 40 Patients of PHN were recruited. 20 patients randomly assigned to each of the two groups, group PP administered PRF with pregabalin and group SP administered pregabalin alone. Results: Significant downregulation of PKA and ERK observed in group PP at end of 10th week (p

Objective To compare the differences in adverse effects and efficacy profile between bacillus Calmette-Guerin (BCG) Danish 1331 and BCG Moscow-I strain in management of non-muscle invasive bladder cancer (NMIBC). Methods Clinical data of 188 cases of NMIBC treated with BCG between 2008 and 2018 in our institute were collected prospectively and analysed retrospectively, and 114 patients who completed a minimum of 12 months of follow-up were analysed. Patient and tumor characters, strain of BCG, adverse effects and tumor progression were included for analysis. Intravesical BCG was instilled in intermediate and high-risk patients. Six weeks of induction BCG, followed by three weekly maintenance BCG at 3,6,12, 18 and 24 months was advised in high-risk patients. Results Overall 68 patients received BCG Danish 1331 strain and 46 patients received Moscow-I strain. Patient and tumor characteristics were well balanced between the two groups. The median follow-up period was 42.5 months and 34.5 months in Danish-1331 and Moscow groups, respectively. Adverse events like dropout rate, anti-tubercular treatment requirement and need of cystectomy were higher in Moscow group (n = 31, 67.4%) when compared to Danish 1331 strain (n = 33, 48.5%) (p = 0.046). On direct comparison between Danish-1331 and Moscow strain, there was similar 3-year recurrence-free survival (RFS) (80% vs. 72.9%) and 3-year progression-free survival (PFS) (96.5% vs. 97.8%). Conclusion Study results suggest no significant differences between Danish 1331 and Moscow strain in RFS and PFS, but a significantly higher incidence of moderate to severe adverse events in BCG Moscow strain.

Artificial intelligence and industrial internet of things (IIoT) have been rejuvenating the fault diagnosis systems in Industry 4.0 for avoiding major financial losses caused by faults in rotating machines. Meanwhile, the diagnostic systems are provided with a number of sensory inputs that introduce variations in input space which causes difficulty for the algorithms in edge devices. This issue is generally dealt with bi-view cross-domain learning approach. We propose a soft real-time fault diagnosis system for edge devices using domain adaptation training strategy. The investigation is carried out using deep learning models that can learn representations irrespective of input dimensions. A comparative analysis is performed on a publicly available dataset to evaluate the efficacy of the proposed approach which achieved accuracy of 88.08%. The experimental results show that our method using long short-term memory network achieves the best results for the bearing fault detection in an IIoT environmental setting.

Diabetes is a chronic non-communicable disease caused by several different routes, which has attracted increasing attention. In order to speed up the development of new selective drugs, machine learning (ML) technology has been applied in the process of diabetes drug development and opens up a new blueprint for drug design. This review provides a comprehensive portrayal of the application of ML in antidiabetic drug use.

Introduction Globally, nine million people are injured due to fire, heat and hot substances every year with a mortality rate of 1.34%. Research shows conflicting reports regarding sex as a risk factor for mortality in patient with burns. We analysed whether sex is a risk factor for in-hospital mortality in patients admitted with burns in urban India. Methods A subgroup analysis of patients with burns as mechanism of injury was done from a multi-centre prospective observational study ‘Towards Improved Trauma Care Outcomes (TITCO)’ in India conducted in October 2013 to December 2015. Results 1209 patients were identified as having suffered burns from the TITCO study. The mean age was 23 years with 58.9% females. The overall 30 day in-hospital mortality was 574 (48.5%). Among patients who succumbed, 72% were females and 27% were males. We did a multivariable logistic regression and found that females were at a significantly higher odds of death compared with males (OR=1.73 95%CI=1.06-2.80, p value=0.02). After performing a sex and age stratified analysis, females in the age group of 15-44 years had a significantly higher number of deaths compared to males in that group. Conclusion In this multi-center study from urban Indian university hospitals, sex was identified as an independent risk factor of mortality in patients admitted with burns. Females have an increased odds of mortality from burns.

The quantification of 3D shape aesthetics has so far focused on specific shape features and manually defined criteria such as the curvature and the rule of thirds respectively. In this paper, we build a model of 3D shape aesthetics directly from human aesthetics preference data and show it to be well aligned with human perception of aesthetics. To build this model, we first crowdsource a large number of human aesthetics preferences by showing shapes in pairs in an online study and then use the same to build a 3D shape multi-view based deep neural network architecture to allow us learn a measure of 3D shape aesthetics. In comparison to previous approaches, we do not use any pre-defined notions of aesthetics to build our model. Our algorithmically computed measure of shape aesthetics is beneficial to a range of applications in graphics such as search, visualization and scene composition.

The solid fuel ducted Ramjet systems (SFDR) are extremely capable of propelling high- speed missiles. They have a specific application in the configuration of air-to-air missiles with a high degree of interception. It is a modification from the traditional solid fuel ramjet system by using an external duct for thrust variation. This system provides higher effectiveness against maneuvering jets compared to single and dual pulse rocket system as it can vary thrust by varying fuel and air quantity for combustion. Even though with high effectiveness, an enemy fighter jet that is having higher thrust engines can outmaneuver SFDR by gaining significant lift during the end-stage which reduces its killing probability; this emphasized the development of a new missile system that provides more lift during the end-stage. A new SFDR concept is proposed in the present work that can gain more lift. The provision of a deflector is made in the duct to study the lift characteristics. Optimum lift force was obtained from the detailed analysis. Moreover, the study was extended by changing the deflector dimensions. Fluent fluid flow analysis is performed in simulation software named ANSYS to study the lift characteristics. Before that, 3D modelling is done with the help of NX software.

Spectral Doppler ultrasound velocimetry involves systematic analysis of the spectrum of frequencies that constitute the Doppler signal. This chapter presents a general perspective on Doppler signal anlyses and describes the spectral Doppler ultrasound devices commercially available for clinical use. They include continuous-wave (CW) Doppler, pulsed-wave (PW) Doppler and duplex Doppler devices. Within the realm of obstetric usage, the application needs are diverse and require various choices of equipment. For example, fetal Doppler echocardiography requires advanced duplex ultrasound instrumentation, which combines the capabilities of high-resolution two-dimensional imaging with the PW Doppler mode and an acoustic power output appropriate for fetal application. For umbilical arterial hemodynamic assessment, simpler, substantially less expensive CW Doppler equipment with a spectral analyzer may be sufficient. It is essential therefore that one develop a basic understanding of the implementation of Doppler ultrasound technology.

Sub-acromial pain syndrome (SAPS) in overhead athletes is the most common reason for shoulder pain. As a rational decision, the medical treatments of today will likely be the best cure for this particular population. Conservative techniques are generally utilised to treat inflammation and pain through electrophysical approaches or to control the subacromial space to avoid impingement by rotator cuff and scapular muscle exercises, as the SAPS (subacromial pressure) mechanism remains unclear. The aim of this analysis is to assess the efficiency of these measures for pain reduction and function improvement. The literature, the best research source to be used, was searched using such search engines as PubMed, Medline, and Google Scholar. The articles were chosen in a manner that relates to the study objective and also their scientific relevance. This research may inform that in subjects with a reduced subacromial space, exercise can have a greater impact on overhead athletes. The effectiveness of centred therapy with Extracorporeal Shockwave (ESWT) on severe plantar fasciitis is uncertain. A greater cohort with its training efficiency in comparison with the conventional physiotherapy programme is required to demonstrate the efficacy of SAPS bodyblade exercise on overhead athletes.

Background and aims The prognosis of patients with cardiac arrest following trauma is poor. Our objectives were: (1) to determine outcomes of patients following in-hospital cardiac arrest posttrauma and admitted to the intensive care unit (ICU) and (2) to identify characteristics associated with in-hospital mortality. Materials and methods This was a single-center retrospective analysis of patients admitted to ICU after resuscitation following in-hospital cardiac arrest between January 2017 and July 2018. Patients with isolated head injuries and multiple cardiac arrests were excluded. Bivariate analysis was done to determine a significant association between baseline characteristics and in-hospital mortality. Results A total of 37 patients were included. About 35.1% of trauma subjects survived hospital discharge. Bivariate analysis showed positive association between admission Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores with in-hospital mortality. Other characteristics, such as age, duration of cardiopulmonary resuscitation (CPR), and serum lactate levels on admission, were not associated with in-hospital mortality. Conclusion Despite being at lower survival following a cardiac arrest after trauma, approximately one-third of the patients survived hospital discharge. This implies that aggressive support of this population is not necessarily futile. Optimization of postresuscitation physiological factors and their impacts on outcomes for these patients need further studies. How to cite this article Soni KD, Rai N, Aggarwal R, Trikha A. Outcomes of Trauma Victims with Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Centre: A Retrospective Cohort Study. Indian J Crit Care Med 2021;25(12):1408–1412.

Introduction Obesity has been considered as one of the independent risk factors for a severe form of coronavirus disease-2019 (COVID-19) and relationship between obesity, critical illness, and infection is still poorly understood. We herein discuss clinical course and outcome of critically ill obese patients with COVID-19 admitted to critical care unit. Materials and methods We retrospectively analyzed data of critically ill obese patients hospitalized with COVID-19 over a span of 6 months. Management was guided according to the institutional protocol. Collected data included demographic parameters (age, sex, comorbidities, and body mass index (BMI)), complications, inflammatory markers (interleukin (IL)-6, Ferritin), length of mechanical ventilation, length of intensive care unit (ICU) stay, and inhospital death. Results There was no appreciable difference in terms of demographics, inflammatory markers, predictors of mortality scores, and comorbidity indices between the survivors and nonsurvivors. Among outcome analysis, there was a statistically significant difference between ventilator days between survivors and nonsurvivors (p = 0.003**). Conclusion Obesity itself is a significant risk factor for severe COVID-19 infection; however, if efficiently managed and in a protocol-determined manner, it can have a favorable outcome. How to cite this article Kaur M, Aggarwal R, Ganesh V, Kumar R, Patel N, Ayub A, et al. Clinical Course and Outcome of Critically Ill Obese Patients with COVID-19 Admitted in Intensive Care Unit of a Single Center: Our Experience and Review. Indian J Crit Care Med 2021;25(12):1382–1386.

Background Pulmonary embolism (PE) commonly complicates SARS-CoV-2 infection but there is heterogeneity in incidence and mortality in the single center reports and risk factors. Purpose To determine the incidence of PE in COVID-19 and its associations with clinical and laboratory parameters. Methods Electronic medical records were searched retrospectively for demographic, clinical and laboratory data and outcomes in patients admitted with COVID-19 at 4 hospitals March-June 2020. PE on CT pulmonary angiography (CTPA) and perfusion scintigraphy was correlated with clinical and laboratory parameters. D-dimer was used to predict PE and the obtained threshold underwent an external validation on 85 hospitalized patients with COVID-19 at a 5th hospital. We also assessed the association between right heart strain and embolic burden in patients with PE undergoing echocardiography. Results Four-hundred-thirteen patients with COVID-19 (230 men, aged 20-98 years, mean + SD = 60+16 years) were evaluated. PE was diagnosed in 25% (102/413, 95%CI: 21%-29%) of hospitalized patients with COVID-19, undergoing CTPA or perfusion scintigraphy. PE was observed in 29% (21/73, 95%CI:19% -41%) of ICU vs. 24% (81/340, 95%CI:20% -29%) of non-ICU patients (p=0.37). PE was associated with male sex(Odds Ratio=OR[95% CI]: 1.7[1.1-2.8], p=0.02), smoking (OR[95% CI]:1.8[1.01-3.4], p=0.04) and increased d-dimer (p 1600 ng/mL predicts PE with 100% sensitivity and 62% specificity in an external validation cohort. Embolic burden was higher in patients with right heart strain among the patients with PE undergoing echocardiogram (p=0.03). Conclusion Pulmonary embolism incidence was 25% in patients hospitalized with COVID-19 suspected of PE. D-dimer>1600ng/mL was sensitive for identifying which patients need CTPA. See also the editorial by Ketai.

Artificial Intelligence (AI) has given significant solutions to the healthcare domain for analyzing various chronic diseases. With the advent of high-end systems, i.e., Graphics Processing Units, AI widespread the healthcare domain, where human experts dominate. AI techniques make the early identification and diagnosis of diseases, which aid the clinicians in mitigating the associated risk. This survey comprehensively reviews the existing literature on AI-assisted chronic disease prediction by considering cancer, heart, and brain-related diseases. However, research is underway to design and develop efficient AI techniques to aid the early prediction of diseases and render valuable insights into the patient’s profile. We conclude with the open issues and challenges faced by the current AI techniques for the prediction and early detection of chronic diseases and discuss future work in the diagnosis of these diseases.

Objective. In the recent time, endoradionuclide therapy for metastatic castration-resistant prostate carcinoma employing 177Lu-PSMA-617 has yielded encouraging results and several clinical trials with the agent are currently ongoing. Routine preparation of 177Lu-PSMA-617 patient doses can be made simpler and convenient, if the ingredients essential for radiolabeling are made available in a ready-to-use lyophilized form. Methods. PSMA-617 freeze-dried kit was formulated and used for the preparation of 177Lu-PSMA-617 clinical dose with high radiochemical purity using low/medium specific activity 177Lu. Detailed radiochemical studies were performed to determine the maximum activity and volume of 177LuCl3, which can be added in the kit for the formulation of 177Lu-PSMA-617. Studies were also performed to determine the shelf life of the kit to ensure its long-term usage. Studies were performed in buffer as well as human serum medium to determine the stability of the 177Lu-PSMA-617 complex after storing in respective media up to 7 days postpreparation. About ten patient doses of 177Lu-PSMA-617 were administered, and posttherapy scans were acquired. Results. The formulated freeze-dried kit of PSMA-617 could be radiolabeled with an average percentage radiochemical purity > 98.53 ± 0.38 . The freeze-dried kit was found suitable for tolerating up to 0.5 mL of 177LuCl3 (in 0.01 N HCl) and specific activity of 555 MBq/μg (15 mCi/μg) for the preparation of the patient dose of 177Lu-PSMA-617. The 177Lu-PSMA-617 complex prepared using the freeze-dried kit of PSMA-617 was observed to maintain % radiochemical purity (RCP) of 96.74 ± 0.87 and 94.81 ± 2.66 , respectively, even after storing up to 7 days in buffer and human serum, respectively. 177Lu-PSMA-617 prepared using the in-house formulated freeze-dried kit of PSMA-617 exhibited accumulation in metastatic lesions picked up in a pretherapy PET scan. Reduction in number as well as size of lesions was observed in posttherapy scans acquired after two months of administering the first therapeutic dose of 177Lu-PSMA-617. Conclusions. The freeze-dried kit of PSMA-617 could be used for the preparation of 177Lu-PSMA-617 with high radiochemical purity (>98%) in a reproducible manner. 177Lu-PSMA-617 prepared using the developed kit was successfully evaluated in patients suffering from metastatic prostate cancer.

Involvement of community health workers (CHWs) within task-sharing to bridge the mental health treatment gap has been proven to be efficacious in randomized controlled trials. The impact of mental health programs based on task-sharing paradigm greatly depends on the performance of CHWs which, in-turn, is influenced by their readiness for change. However, there is dearth of literature assessing the role of readiness for change as an important predicator of CHW performance. The aim of this study is to examine the applicability of the readiness for change model and investigate its cultural and contextual nuances among Accredited Social Health Activists (ASHAs), a cadre of CHWs in India, to understand their engagement in mental health task-sharing. We conducted in-depth, semi-structured interviews with a purposive sample of n = 12 key informants including ASHAs and other healthcare professionals in Sehore district, India. The interview guide consisted of open-ended questions based on the readiness for change factors including ASHAs' attitudes towards their role in mental health care, perception of capability to implement mental health task-sharing, of support from the public health system, etc. Framework analysis with a combined inductive-deductive approach was employed to code the data and generate themes. Participants endorsed three readiness for change themes relevant to task-sharing among ASHAs including change valence or value ascribed to task-sharing, change-efficacy or the perceived ability to implement task-sharing, and job valence or value ascribed to their regular job role. In addition, they provided insights into the culturally and contextually salient aspects of these factors. Themes of personal empowerment, gaining respect and trust from community, professional duty, relationship with supervisors, and lack of resources availability were majorly highlighted. This is the first study to qualitatively investigate the applicability of the readiness for change model and its culture- and context-specific nuances among a cadre of non-specialist health workers in India. Our findings posit that implementation science models should strongly consider the culture and context within which they are being applied to enhance fit and relevance. Further, our results should be taken into consideration to adapt and validate measurement tools and build readiness for change in this population.

Ambulatory Care Sensitive Conditions (ACSC) represent a significant source of health care spending in the United States. Existing literature is largely descriptive and there is limited information about how an emergency department (ED) visit or hospitalization for ACSCs is related to prior ambulatory care visits. A retrospective, observational study was conducted using health records from a large midwestern health system during a 20-month period between 2012 and 2014. Our primary variables were (1) type of care setting (i.e., ED visit or hospitalization) and (2) whether the patient received ambulatory care services in the 14, 30, and 60 days before the ED visit or hospital admission. Of patients seen in the ED for ACSCs, 11.9%, 16.3%, and 21.67% were seen in ambulatory care in the 14, 30, and 60 days prior, respectively. Of those hospitalized for ACSCs, 29.1%, 39.9%, and 53% were seen in ambulatory care in the 14, 30, and 60 days prior, respectively. These results highlight a potential lost opportunity to address ACSCs in the ambulatory care setting. Such knowledge can inform interventions to reduce avoidable ACSC-related acute care use and health care costs, and improve patient outcomes.

Objective Isocitrate dehydrogenase (IDH) mutation status is recommended used for diagnosis and prognostication of glioblastoma patients. We studied efficacy and safety of stereotactic radiosurgery (SRS) for patients with recurrent IDH-wt glioblastoma. Methods Consecutive patients treated with SRS for IDH-wt glioblastoma were pooled for this retrospective observational international multi-institutional study from institutions participating in the International Radiosurgery Research Foundation. Results Sixty patients (median age 61 years) underwent SRS (median dose 15 Gy and median treatment volume: 7.01 cm3) for IDH-wt glioblastoma. All patients had histories of surgery and chemotherapy with temozolomide, and 98% underwent fractionated radiation therapy. MGMT status was available for 42 patients, of which half of patients had MGMT mutant glioblastomas. During median post-SRS imaging follow-up of 6 months, 52% of patients experienced tumor progression. Median post-SRS progression free survival was 4 months. SRS prescription dose of > 14 Gy predicted longer progression free survival [HR 0.357 95% (0.164-0.777) p = 0.009]. Fifty-percent of patients died during post-SRS clinical follow-up that ranged from 1 to 33 months. SRS treatment volume of > 5 cc emerged as an independent predictor of shorter post-SRS overall survival [HR 2.802 95% CI (1.219-6.444) p = 0.02]. Adverse radiation events (ARE) suggestive of radiation necrosis were diagnosed in 6/55 (10%) patients and were managed conservatively in the majority of patients. Conclusions SRS prescription dose of > 14 Gy is associated with longer progression free survival while tumor volume of > 5 cc is associated with shorter overall survival after SRS for IDH-wt glioblastomas. AREs are rare and are typically managed conservatively.

Breath analysis by secondary electrospray ionization-high resolution mass spectrometry (SESI-HRMS) offers the possibility to measure comprehensive metabolic profiles. The technology is currently being deployed in several clinical settings in Switzerland and China. However, patients are required to exhale directly into the device located in a dedicated room. Consequently, clinical implementation in patients incapable of performing necessary exhalation maneuvers (e.g., infants) or immobile (e.g., too weak, elderly, or in intensive care) remains a challenge. The aim of this study was to develop a method to extend such breath analysis capabilities to this subpopulation of patients by collecting breath samples remotely (offline) and promptly (within 10 min) transfer them to SESI-HRMS for chemical analysis. We initially assessed the method in adults by comparing breath mass spectra collected offline with Nalophan bags against spectra of breath samples collected in real time. In total, 13 adults provided 176 pairs of real-time and offline measurements. Lin's concordance correlation coefficient (CCC) was used to estimate the agreement between offline and real-time analyses. Here, 1249 mass spectral features (55% of total detected) exhibited Lin's CCC > 0.6. Subsequently, the method was successfully deployed to analyze breath samples from infants (n = 16), obtaining as a result SESI-HRMS breath profiles. To demonstrate the clinical feasibility of the method, we measured in parallel other clinical variables: (i) lung function, which characterizes the breathing patterns, and (ii) nitric oxide, which is a surrogate marker of airway inflammation. As a showcase, we focused our analysis on the exhaled oxidative stress marker 4-hydroxynonenal and its association with nitric oxide and minute ventilation.

Objectives: To determine the prevalence of violence among medical doctors in public sector hospitals of Karachi relating to physical violence, psychological violence (verbal and bullying/mobbing), sexual harassment and racial harassment). Methods: A cross-sectional study was carried out in three public sector hospitals in Karachi (JPMC, Civil Hospital and Sindh Government Lyari General Hospital Karachi). Medical doctors of any age and gender who worked in outpatient departments, wards, and emergency departments were eligible to participate in the study. A validated WHO-designed questionnaire was used, with questions about exposure to violence, the source and types of violence, and socio-demographic information. In descriptive statistics, frequencies and percentages were reported for all categorical variables. The Chi-square and Fisher's exact tests were used to investigate the relationship between workplace violence and other types of violence. Results: 350 questionnaires were distributed to qualified medical doctors in total. Only 300 of them responded, for an 85.7 percent response rate. The majority of respondents were under the age of 40, and male gender was slightly more exposed to violence. The majority of the doctors were subjected to verbal abuse as well as bullying and mobbing. Conclusion: It was then concluded that any type of violence was common in doctors aged >35 years and male gender was more exposed to any violence as compare to female gander. The main type of violence was verbal violence in our study, whereas racial harassment and sexual harassment was also seen.