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Docosahexaenoic acid (DHA) shows anti-inflammatory/proresolution effects in the brain. Higher red blood cell (RBC) DHA in humans is associated with improved cognitive performance and a lower risk for suicide. Here, we hypothesized that binding to the 18 kDa translocator protein (TSPO), a proxy for microglia levels, will be higher in individuals with low DHA relative to high DHA levels. We also postulated that higher TSPO would predict poor cognitive performance and impaired stress resilience.RBC DHA screening was performed in 320 healthy males. [sup11/supC]PBR28 positron emission tomography was used to measure binding to TSPO in 38 and 32 males in the lowest and highest RBC DHA quartiles. Volumes of distribution expressed relative to total plasma ligand concentration (VsubT/sub) was derived using an arterial input function-based kinetic analysis in 14 brain regions.[sup11/supC]PBR28 VsubT/subwas significantly lower (by 12% and 20% in C/T and C/C rs6971 genotypes) in males with low RBC DHA than in males with high RBC DHA. Regional VsubT/subwas correlated positively and negatively with RBC DHA and serum triglycerides, respectively. No relationships between VsubT/suband cognitive performance or stress resilience measures were present.Contrary to our hypothesis, we found lower TSPO binding in low-DHA than in high-DHA subjects. It is unclear as to whether low TSPO binding reflects differences in microglia levels and/or triglyceride metabolism in this study. Future studies with specific targets are necessary to confirm the effect of DHA on microglia. These results underscore the need to consider lipid parameters as a factor when interpreting TSPO positron emission tomography clinical findings.

There is experimental and clinical data to indicate the contribution of immune-escape mechanisms in relapsed/refractory pediatric leukemia. Studies have shown the accumulation of mutations that translate to peptides containing tumor-specific epitopes (neoantigens). The effectiveness of neoantigen-based vaccines has been shown in several clinical trials in adults. Though the initial results are encouraging, this knowledge must be developed to account for the uniqueness of pediatric cancer biology. We have completed the initial proof-of-concept analysis on a high-risk pediatric leukemia specimen and identified usable neoantigen sequences. We describe this approach, including the bioinformatics method and experimental model to verify their function that can be further broadened for personalized neoantigen prediction and testing for the generation of anticancer vaccines against high-risk pediatric leukemias.

Background The primary aim was to investigate outcome of the decision making on duration of injection intervals between injection visits over the first 2 years of a treat and extend regimen. Method Consecutive patients receiving Aflibercept for treatment naive neovascular age-related macular degeneration between 01.01.2016 and 15.07.2017 were identified from our departmental register. Retrospective data collected on all visits over 24 months were classified into three groups: (A) Without Interval Decision Events (IDE)" Injection only" (B) IDE resulting in injection intervals of 5 weeks. The primary outcome was number of successful IDE relative to the total visits in Group C. Successful decision making was defined as absence of worsening of visual acuity (>5 L) or central retinal thickness (>50 microns) at the subsequent visit. Secondary visual and anatomical outcomes at 24 months were also evaluated. Results Data from 56 eyes of 50 patients were included in the study. Visual acuity improved by +7.11 L at 24 months. Forty one patients with unilateral therapy made 721 visits: 280 visits (38.8%) were group A; 164 visits (22.8%) were group B and 277 visits (38.4%) were group C. Average interval in Group C was 8.9 weeks (range 5-15). The success rate of extension was 95.31% (264/277 visits). Conclusion These metrics for evaluating the decision making aspect of disease activity monitoring may be useful for monitoring performance and have given us a more realistic view and expectations of what can be achieved using this regime to optimise the timing of injections.

Background: Most children with recurrent metastatic solid tumors have high mortality rates. Recent studies have shown that proteasome inhibition leads to effective tumor killing in cells that have acquired treatment resistance and metastatic properties. Objective: The purpose of this study was to test the potential of Carfilzomib (CFZ), a proteasome inhibitor, in refractory pediatric solid tumors which is currently unknown. Methods: A panel of pediatric solid tumor cell lines, including neuroblastoma, Ewing’s sarcoma, osteosarcoma, rhabdomyosarcoma and atypical teratoid rhabdoid tumor (ATRT), was used to evaluate the cytotoxic and proteasomal inhibitory effects of CFZ. A drug scheduling experiment was performed to determine the optimal dose and time to obtain effective cell killing. Combination studies of CFZ with chemotherapeutic drugs of different classes were performed to determine the extent of synergy. Results: CFZ showed effective cytotoxicity against all cell lines tested (mean IC50 = 7nM, range = 1-20nM) and activity in a fluorophore-tagged cell-based proteasome assay. Drug scheduling experiments showed that the minimum exposure of 4-8 hours/day is needed for effective cumulative killing. CFZ, when combined with chemotherapeutic drugs of different classes, synergistically enhanced the extent of cell death. Conclusions: CFZ showed cytotoxic activity against all the solid pediatric cancer cell lines tested. This study provides initial in vitro data on the potential of CFZ to treat pediatric solid tumors and supports further investigations into the components of drug scheduling, biological correlates and drug combinations for future early phase clinical trials in children.

In recent years, the electronic sharing of digital images faces a major threat to security, as the existing image transmission infrastructure is mainly based on the trust of third parties. At the same time, the available solutions are placed on the cloud based centralized data center, which is expensive, requires large storage area, and security issues regarding the transmission of data over the network. So, it is needed to develop an image management system which enables sharing and storing of digital images effectively. This paper develops novel multiple share creation schemes with block technology for secure image management (MSCCBT-SIM) systems. The MSCCBT-SIM model allows the user to create consensus with no dependencies on central authorities. It involves an MSC which involves share creation and share encryption using emperor penguin optimizer based ElGamal public key cryptosystem (EPO-EPKC). In addition, the blockchain is used as a distributed data storage mechanism to generate a ledger for permitting access to the user and prevent third party access to the encrypted shares. The application of blockchain technology and MSC techniques helps to achieve decentralization, highly reliable, inexpensive, and secure transmission and storage of digital images. In order to validate the effective performance of the MSCCBT-SIM model, a series of simulations take place and investigated the results interms of different measures. The experimental results ensured the better performance of the MSCCBT-SIM model with the superior PSNR of 57.09 dB whereas the HOCE-ECC, GO-ECC, PSO-ECC, and CS-ECC methods offered a lower PSNR of 53.08 dB, 52.91 dB, 52.65 dB, and 50.51 dB respectively.

Isolated systolic hypertension is the most common hemodynamic form of hypertension in the elderly. With a rapidly aging population, the prevalence of hypertension, particularly isolated systolic hypertension, is increasing steadily. Isolated systolic hypertension is associated with substantial mortality and morbidity, particularly of cerebrovascular disease. It is a rapidly growing public health concern and its management continues to remain a challenge to practicing physicians. Recent studies like the Systolic Blood Pressure Intervention Trial (SPRINT) and Heart Outcomes Prevention Evaluation (HOPE)-3 have implications for antihypertensive therapy in general and for the management of isolated systolic hypertension in particular. Keywords: Hypertension, Cardiovascular disease, Isolated Systolic Hypertension, Essential hypertension

Both PLMA and SLIPA were easy to insert (100% success) and ventilate with maximum sealing pressure of 30cm H2o (P = 0.4) with no muscle relaxant. No significant difference (P = 0.265) in intubation time between PLMA and ETT were observed in the study. A significant SpO2 change (P = 0.804, 0.561, 0.657, 0.248, 0.561) measured Pre op, Pre intubation, lmt, 3 mt and 5mts after intubation and there were no significant EtCO2 changes (P =0.861, 0.251, 0.44) measured after intubation was observed. Blood staining in 1/25 cases with PLMA and 2/25 cases with ETT with a P value of 0.561was seen.

Background: Breast milk reduces morbidity and mortality in infants admitted to neonatal intensive care unit (NICU). Objectives: We determined predictors of procuring mother's own milk (MOM) among N...

AIM To identify the baseline demographic and clinical characteristics associated with diabetes-related distress (DRD) and factors associated with improvement in DRD after initiating use of the FreeStyle Libre (FSL) in people living with type 1 diabetes (T1D). METHODS The study was performed using baseline and follow-up data from the Association of British Clinical Diabetologists nationwide audit of people with diabetes who initiated use of the FSL in the United Kingdom. DRD was assessed using the two-item diabetes-related distress scale (DDS; defined as the average of the two-item score ≥3). People living with T1D were categorized into two groups: those with high DRD, defined as an average DDS score ≥3 and those with lower DRD, defined as a DDS score

We describe the rationale, aims and objectives and the methodology of data collection for the ABCD nationwide audit of individuals admitted to hospital with coronavirus (SARS-CoV-2; COVID-19) and diabetes. The audit was inspired and undertaken by the urgent need to understand the clinical course of COVID-19 in patients with diabetes admitted to hospital in the UK during the pandemic. We wished to understand the clinical behaviour of diabetes per se, post hospital admission and the factors with may be associated with admission to the Intensive Care Unit (ICU) and death due to COVID-19. This was a clinically-led audit. We used existing infrastructure and expertise to collect data using an electronic tool specifically designed and piloted by the steering group members. The clinical variables were chosen to fulfil the main aim of this audit as stated above, and factors influencing the clinical course of COVID-19 in individuals with both type 1 and type 2 diabetes at the time of admission to hospital and during the whole length of stay, until discharge or death from COVID-19. The data collected so far represent a large, multicentre audit with more than 3,500 admissions during the pandemic. We plan to continue collecting additional data and publish ongoing reports of interest to diabetes clinicians with the aim of enhancing knowledge and understanding and thereby improving clinical care of, and outcomes for, people with diabetes who are admitted to hospital with COVID-19 in the UK.

Background/Objective Newborn infant skin is functional but immature, and diapering products can play a significant role in infant diapered skin health. Previous work demonstrated a regimen consisting of a diaper with an emollient and apertures on the inner liner (topsheet) with an acidic, pH‐buffered wipe (Regimen A) lowered newborn skin pH and reduced the enzymatic activity on skin post‐stool cleaning versus a regimen without these features (Regimen B). This study extends these findings to determine the impact of Regimen A on diaper area erythema severity over a 2‐week use period. Methods This IRB‐approved, blinded, randomized, crossover study enrolled newborn infants >7 days and ≤8 weeks. Participants exclusively used two unique diaper and wipe combinations, Regimen A and Regimen B (non‐emollient, non‐aperture containing topsheet and wipe with limited buffering capacity), each for 14 days and preceded by a 3‐day washout regimen. Results Diapered skin pH was reduced during Regimen A use to values similar to that of a non‐diapered control site (chest), while use of Regimen B was associated with a more alkaline skin pH. Regimen A resulted in significantly fewer severe erythema episodes. At the site of highest erythema, the perianal space, the average erythema score was significantly lower and more newborns were free of erythema while using Regimen A vs. Regimen B (P

No in vivo human studies have examined the prevalence of Alzheimer’s disease (AD) neuropathology in individuals with alcohol-use disorder (AUD), although recent research suggests that a relationship between the two exists. Therefore, this study used Pittsburgh Compound-B ([11C]PiB) PET imaging to test the hypothesis that AUD is associated with greater brain amyloid (Aβ) burden in middle-aged adults compared to healthy controls. Twenty healthy participants (14M and 6F) and 19 individuals with AUD (15M and 4F), all aged 40–65 years, underwent clinical assessment, MRI, neurocognitive testing, and positron emission tomography (PET) imaging. Global [11C]PiB standard uptake value ratios (SUVRs), cortical thickness, gray matter volumes (GMVs), and neurocognitive function in subjects with AUD were compared to healthy controls. These measures were selected because they are considered markers of risk for future AD and other types of neurocognitive dysfunction. The results of this study showed no significant differences in % global Aβ positivity or subthreshold Aβ loads between AUD and controls. However, relative to controls, we observed a significant 6.1% lower cortical thickness in both AD-signature regions and in regions not typically associated with AD, lower GMV in the hippocampus, and lower performance on tests of attention as well as immediate and delayed memory in individuals with AUD. This suggest that Aβ accumulation is not greater in middle-aged individuals with AUD. However, other markers of neurodegeneration, such as impaired memory, cortical thinning, and reduced hippocampal GMV, are present. Further studies are needed to elucidate the patterns and temporal staging of AUD-related pathophysiology and cognitive impairment. Imaging β-amyloid in middle age alcoholics as a mechanism that increases their risk for Alzheimer’s disease; Registration Number: NCT03746366.

BACKGROUND Sepsis is a potentially life threatening medical emergency. It should be diagnosed at the earliest and treated effectively to prevent mortality. Therefore, there is a need for parameters which are simple, reliable and cost effective which help in predicting the prognosis and help in managing the patient with sepsis more efficaciously. METHODS A total of seventy patients, 42 male and 28 female patients, over a period of one year, who fulfilled the inclusion and exclusion criteria was included in the study. In this study various clinical variables and biochemical markers including serum lactate dehydrogenase (LDH) were compared among survivor and non–survivor groups and analysed. RESULTS In this study out of 70 patients, 36 patients [51.4 %] expired. Various clinical variables and biochemical markers including serum LDH [on day 1 & day 3], were compared among survivor and non–survivor groups and analysed. Pulse rate, mean arterial pressure (MAP), total leucocyte count, renal function test (RFT), liver function test (LFT), day 3 LDH levels and requirement of ventilator support showed statistically significant difference among the survivor and non-survivor groups. CONCLUSIONS Despite the recent medical advances, sepsis is a multiorgan disease with significant mortality. Hence, we need simple and effective parameters which are essential in assessing the prognosis and in guiding the treatment protocols. This study focused on simple clinical and biochemical parameters with special reference to LDH, which helped us in predicting the mortality. KEYWORDS Markers, Serum LDH, Sepsis, Survival

Purpose: To describe the magnitude and spectrum of abnormal ocular findings other than retinopathy of prematurity (ROP) detected during an ROP telescreening programme. Methods: Retrospective review of the records of all premature babies screened for ROP from August 2015 to December 2019. Results: A total 9105 babies were screened during the study period with total 17,075 imaging sessions. Non-ROP ocular abnormalities were seen in 566 eyes of 383 babies (4.2%) including 207 male (54%) and 176 female babies (46%). Posterior segment abnormalities were seen in 88.2% babies (338/383) with haemorrhage being the most common (77%, 295/383). Anterior segment pathologies were seen in 12% babies (46/383) with congenital cataract being the most common pathology requiring surgical intervention. Other findings included globe abnormalities in 0.8% babies (3/383), adnexal disorders in 0.5% babies (2/383) and squint in 0.3% babies (1/383). Rare life-threatening conditions such as retinoblastoma and lipaemia retinalis were also detected. Eighty-seven babies (22.7%) were diagnosed with referral-warranted non-ROP pathologies, with an overall prevalence of 1% (87/9105). Prompt surgical intervention was advised for 7.3% babies (28/383), 3.4% babies (13/383) were treated medically and 4.2% babies (16/383) needed visual rehabilitation for non-amenable pathologies. Conclusion: This is the largest study describing the magnitude and spectrum of neonatal ocular pathologies other than ROP in a cohort of premature babies. Digital imaging has a significant impact on early detection and timely intervention for various vision as well as life-threatening non-ROP pathologies, which would have been missed or delayed otherwise.

BACKGROUND Cluster headache is an unusual but particularly painful and crippling primary headache disorder with a prevalence of 1 in 1000 making study of the disease process a difficult task to master. These headaches are always unilateral characterised by recurrent short-lasting attacks of 15 - 180 minutes associated with ipsilateral autonomic signs. The diagnosis is mainly clinical, and it continues to be managed sub optimally as the chance of coming across such a condition is few and far between. This study was conducted to determine the incidence of cluster headache in a hospital population and study its association with age, gender and triggers. METHODS This is a cross sectional study of a total of 100 patients attending our Otorhinolaryngology department from June 2017 to June 2018 at Sri Muthukumaran Medical College Hospital & Research Centre with primary complaints of headache. Prior ethical committee clearance was obtained. Patients with chronic debilitating illness, chronic rhino sinusitis, headache following trauma or the presence of fever or any other acute illness were excluded from this study. The results were interpreted using Statistical Package for Social Sciences (SPSS) version 17. RESULTS Out of the total number of 100 patients with headache, only one patient, a 40-yearold male was diagnosed with cluster headache. CONCLUSIONS Hence, we conclude that the incidence of cluster headache in the total of 100 patients is only 1 % which makes it a quite rare condition. Diagnosis is clinical, hence effective history taking is mandatory. KEY WORDS Cluster Headache, Primary Headache, Trigeminal Autonomic Cephalgia, Cluster Attacks

Study objective To evaluate a surveillance protocol in managing the risk of hepatitis B virus (HBV) reactivation among lymphoma patients with resolved HBV infection receiving rituximab. Design Prospective, single-arm study. Setting National Cancer Centre, Singapore. Patients Lymphoma patients with resolved HBV infection and scheduled to receive rituximab-based treatment. Intervention Close monitoring of HBV DNA levels, ie. every 4-6 weeks during rituximab treatment, every 6-8 weeks in the first year post-treatment, and every 3-4 months in the second year post-treatment. Measurements The efficacy of the surveillance protocol was examined by evaluating the rates of reactivation-related events. Feasibility was evaluated based on patient adherence. An economic analysis using a cost-minimization approach was conducted to compare the costs between the surveillance protocol and universal prophylaxis with entecavir 0.5 mg daily up to 1 year after cessation of rituximab. Main results A total of 66 patients provided analyzable data with a follow-up period of 966.6 months. No hepatitis flare or reactivation-related events were detected. The median adherence rate to the surveillance protocol was 90.5%. Cost savings of US$946.40 per patient over the entire surveillance period were achieved if the surveillance protocol was adopted and was most affected by changes in prophylaxis duration and the cost of antiviral prophylaxis. Conclusions The surveillance protocol is an effective, feasible and cost-saving strategy to manage HBV reactivation among lymphoma patients with resolved HBV infection receiving rituximab.

Precipitable water vapor (PWV) plays an important role in understanding the atmosphere and weather. The advancement in Global Navigation Satellite System (GNSS) technology provides the possibility of computing PWV in near real time. In this study, the PWV was computed using the Zenith Tropospheric Delay (ZTD) from Global Positioning System (GPS) data for two International GNSS Service (IGS) stations (IISC & HYDE) for monsoon period (June–September) of 2014 and 2015. The GPS-derived PWV has been validated with reference to radiosonde data and University NAVSTAR Consortium (UNAVCO) PWV products. The coefficient of determination between GPS-derived PWV and radiosonde PWV is 0.73–0.83 for IISC station and 0.76–0.91 for HYDE station. For IISC station, the coefficient of determination between GPS-derived PWV and UNAVCO-derived PWV is 0.80–0.89. Also, in this study, GPS-derived PWV for IISC station has been compared with the rainfall events of Indian National Satellite System (INSAT-3D). From the analysis, we observed a direct relation between PWV and rainfall events from Hydro Estimator Method (HEM), INSAT Multi spectral Rainfall (IMR) products of INSAT-3D. This study highlights the satellite-based observations from GNSS and INSAT satellite for regional weather forecasting in near real time.

The objective was to ascertain factors among deliveries complicated by shoulder dystocia (SD) and neonatal brachial plexus palsy (NBPP).At 11 hospitals, deliveries complicated by SD were identified. The inclusion criteria were vaginal delivery of non-anomalous, singleton at 34-42 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for NBPP.Of the 62,939 individuals who delivered vaginally, 1,134 (1.8%) had SD and met other inclusion criteria. Among the analytic cohort, 74 (6.5%) had NBPP. The factor known before delivery which was associated with NBPP was diabetes (aOR = 3.87; 95% CI = 2.13-7.01). After delivery, the three factors associated with NBPP were: (1) birthweight of at least 4000 g (aOR = 1.83; 95% CI = 1.05-3.20); (2) calling for help during the SD (aOR = 4.09, 95% CI = 2.29-7.30), and (3) the duration of SD ≥120 sec (aOR = 2.47, 95% CI = 1.30-4.69). The AUC under the ROC curve for these independent factors was 0.79 (95% CI = 0.77 - 0.82).Few factors were identified that were associated with NBPP after SD, but they could not reliably predict which neonates will experience the complication.

Objective While it is generally considered that patients with diabetes mellitus (DM) have more distal peripheral arterial disease (PAD), there is little information on how individual vessels are affected. The aim of this study was to adapt Bollinger's scoring system for lower limb angiograms (DSAs) to include the distal and planter vessels. The reliability of this extension was tested and was used to compare the distribution of disease in two cohorts of patients with and without DM. Methods Patients who had undergone DSA ± angioplasty for PAD at a single centre between September 2010 and April 2014 were identified. Twenty-five patients' images were reviewed by four clinicians and scored using an extended version of the Bollinger score. A total of 153 patients with DM were matched, for age, sex, ethnicity, smoking, and hypertension, with 153 patients without DM. The infrainguinal vessels were divided into 16 arterial segments, including plantar vessels, and scored using the Bollinger score. The score ranges from 0 to 15. Fifteen represents an arterial segment with more than 50% of its length occluded. Interobserver reliability was tested using interclass correlation (ICC) and Cohen's kappa coefficient. Results The ICC demonstrated good agreement between observers (0.76 [0.72–0.79]) with good internal consistency (Cronbach's alpha 0.93). When the Bollinger scores were categorised, the results were weaker, Cohen's kappa ranged from 0.39 (standard error 0.033) to 0.54 (0.030). Patients with DM had a higher burden of disease in the anterior tibial and posterior tibial arteries with relative sparing of the peroneal artery and no difference in the plantar vessels. Conclusion It has been demonstrated that the Bollinger score can be extended to include the distal vessels. This amended scoring system can be used to compare the burden of distal disease in patients with PAD. How the score relates to clinical presentation and outcomes needs further investigation.

A previously healthy 27-year-old gravida 1, para 0 woman is admitted with preterm labor and loss of fluids at 28 weeks’ gestation. She receives antenatal steroids and obstetric ultrasonography shows bilateral cerebral ventriculomegaly and an absent stomach bubble. Before admission, her pregnancy had been uneventful and findings on early anomaly screening ultrasonography at 19 weeks’ gestation are normal. Serologic tests for maternal group B Streptococcus , cytomegalovirus, toxoplasma, and Treponema all have negative findings. The fetal tracing becomes non-reassuring and the neonate is born via emergency cesarean delivery. The neonate has apnea, hypotonia, and bradycardia at birth and does not respond to face mask ventilation. He undergoes intubation by 5 minutes after birth, with improvement in his heart rate, but he remains limp without any spontaneous breathing. His Apgar scores are 1, 2, and 3 at 1, 5, and 10 minutes after birth, respectively. Arterial and venous cord blood gases are 7.29 pH and 7.36 pH. Initial examination shows a preterm infant with appropriate weight, length, and head circumference for age, decorticate posturing, hypotonia of the lower extremities, …

Introduction Traumatic bronchial injury (TBI) is uncommon, difficult to diagnose and often missed. The incidence of TBI among blunt trauma patients is estimated to be around 0.5–2%. Bronchoplastic surgery is indicated in most cases to repair the tracheobronchial airway and preserve lung capacity. There is limited existing literature addressing the management of this condition in view of its rarity. The comprehensive management and outcomes of these patients are discussed. Methods The case notes of all patients who presented with persistent lung collapse due to trauma since July 2017 were reviewed retrospectively. Those patients requiring surgical intervention were included in the review. The mode of injury, clinical, radiological and bronchoscopy findings, concurrent injuries, type of surgery, length of stay (LOS) and operative outcomes were reviewed. Results Out of 11 patients who presented with persistent lung collapse post-blunt trauma, four (36%) were found to have structural bronchial disruption. All of them underwent successful repair of the injured bronchus, without the need of a pneumonectomy. The other seven patients were successfully treated conservatively. Conclusion The repair of the injured bronchus is essential in improving respiratory function and to prevent a pneumonectomy. Routine bronchoscopic evaluation should be performed for all suspected airway injuries as recommended in our management algorithm. Delayed presentations should not hinder urgent referral to thoracic centers for tracheobronchial reconstruction.

Introduction: Skin interventions have been implemented to reduce neonatal mortality, demonstrating the skin’s role in neonatal innate immunity. We examined the impact of birthweight and environmental conditions on skin integrity in infants receiving oil massage in rural Nepal. Methods: In a community-based cluster randomized controlled trial, 991 premature and full-term infants were grouped by birthweight as: (1) 920–1,560 g, (2) 1,570–2,450 g, (3) 2,460–2,990 g, and (4) 3,000–4,050 g and by high or low heat index (HI). Skin integrity was measured as erythema, rash, dryness, pH, protein concentration, and transepidermal water loss (TEWL). Results: Skin pH was higher for the smallest (group 1) than the largest infants (group 4) and higher for group 2 than 3 and 4. Arm and leg rash differed for all 4 groups, with the least amount of rash for the smallest babies. Erythema was lower for group 1 than all others. The lower day 1 values for pH, TEWL and protein at high versus low HI remained lower over 28 days. The pH reduction was faster at high HI. Erythema (arm, leg) was more severe at high HI. Rash severity was greater at high HI for arms and legs every day. Conclusions: Birthweight influenced the skin response to oil massage. The smallest infants had the lowermost skin irritation, suggesting diminished ability to mount an inflammatory response. High HI may be protective for premature infants in low resource settings.

Background Coronavirus disease 2019(COVID-19) pandemic is recognized as a major threat to human health in 2020. As the disease is new and spreading quickly, the scientific community is reporting new information daily to address this issue. The public is well informed and is ready to adopt the protective and preventive measures suggested by the authorities. Aim & objective This study is aimed at understanding the perception towards the pandemic using the Health Belief Model (HBM) approach, preparedness measures adopted, opinion and confidence towards various Governmental activities and control measures. Methods and material A Cross-sectional survey was conducted among adults across the Kerala state using modified WHO Cosmo protocol and questionnaires implemented through google forms in late April during the preparedness phase of the disease. Statistical analysis The results were explained using descriptive and Binary Logistic Regression analysis using SPSS version 22. Results Among the 680 participants, 675 (99.3%) were aware about COVID-19 and 598 (88%) had good knowledge. Behavioural change was observed in 638 (93.8%) and variables in Health Belief Model showed a significant association with behavioural change. Conclusions Most people living across Kerala approached the COVID-19 pandemic in a similar manner, irrespective of age, education, or relation to the healthcare field. Perceptions of the community as explained by Health Belief Model was greatly influenced by the primary health care approach by the government and for the subsequent behavioural change.

Neurotrophic tyrosine receptor kinase gene fusions (NTRK) are oncogenic drivers present at a low frequency in most tumour types (80%) in a small number of rare tumours (e.g., infantile fibrosarcoma [IFS]) and considered mutually exclusive with other common oncogenic drivers. Health Canada recently approved two tyrosine receptor kinase (TRK) inhibitors, larotrectinib (for adults and children) and entrectinib (for adults), for the treatment of solid tumours harbouring NTRK gene fusions. In Phase I/II trials, these TRK inhibitors have demonstrated promising overall response rates and tolerability in patients with TRK fusion cancer who have exhausted other treatment options. In these studies, children appear to have similar responses and tolerability to adults. In this report, we provide a Canadian consensus on when and how to test for NTRK gene fusions and when to consider treatment with a TRK inhibitor for pediatric patients with solid tumours. We focus on three pediatric tumour types: non-rhabdomyosarcoma soft tissue sarcoma/unspecified spindle cell tumours including IFS, differentiated thyroid carcinoma, and glioma. We also propose a tumour-agnostic consensus based on the probability of the tumour harbouring an NTRK gene fusion. For children with locally advanced or metastatic TRK fusion cancer who have either failed upfront therapy or lack satisfactory treatment options, TRK inhibitor therapy should be considered.

We report the two cases who presented with sudden decreased vision and sub-internal limiting membrane (ILM) hemorrhage without a history of Valsalva maneuver, trauma, or hematological disorders. Multimodal imaging revealed the features suggestive of polypoidal choroidal vasculopathy (PCV) in addition to the sub-ILM hemorrhage. A provisional diagnosis of sub-ILM hemorrhage secondary to PCV was made and was treated with intravitreal Bevacizumab injection. Treatment resulted in the improved visual acuity along with the resolution of the sub-ILM hemorrhage. These cases highlight the possibility of isolated sub-ILM hemorrhage as a presenting fundus finding in PCV, which is previously unreported. This report also highlights the importance of multimodal imaging in diagnosing chorioretinal disorders with unusual presentation.

PURPOSE To report a case of idiopathic full-thickness macular hole in a young boy, which was managed surgically with good visual and anatomical outcomes. METHOD Single case report. RESULTS An 8-year-old boy presented for defective vision in the left eye noticed for the past 2 weeks with best-corrected visual acuity of 6/24. A large full-thickness macular hole was diagnosed clinically and was confirmed on optical coherence tomography. There was no clinical or tomographic findings suggestive of trauma or retinal degeneration. After observation for 8 weeks, the patient underwent macular hole surgery in the left eye including internal limiting membrane peeling and C3F8 gas tamponade. Intraoperatively abnormally tight vitreoretinal adherence was noted during the induction of posterior vitreous detachment. Optical coherence tomography at 1 month after surgery showed decrease in the size of macular hole suggestive of incomplete closure. Repeat optical coherence tomography at 3 months showed closed macular hole with mild foveal thinning and ellipsoid zone discontinuity with best-corrected visual acuity improving to 6/18. The tomographic features and best-corrected visual acuity remained stable at 6-month follow-up. CONCLUSION We hereby report the first case, to the best of our knowledge, of a truly idiopathic full-thickness macular hole in an 8-year-old boy. Surgical treatment offers the best outcomes in these cases and should be considered at the earliest without waiting for spontaneous closure unlike in the case of traumatic full-thickness macular hole.

Mutations in the CBL gene were first identified in adults with various myeloid malignancies. Some patients with juvenile myelomonocytic leukemia (JMML) were also noted to harbor mutations in CBL, but were found to have generally less aggressive disease courses compared to patients with other forms of Ras pathway-mutant JMML. Importantly, and in contrast to most reports in adults, the majority of CBL mutations in JMML patients are germline with acquired uniparental disomy occurring in affected marrow cells. Here, we systematically studied a large cohort of 33 JMML patients with CBL mutations and found that this disease is highly diverse in presentation and overall outcome. Moreover, we discovered somatically acquired CBL mutations in 15% of pediatric patients who presented with more aggressive disease. Neither clinical features nor methylation profiling were able to distinguish patients with somatic CBL mutations from those with germline CBL mutations, highlighting the need for germline testing. Overall, we demonstrate that disease courses are quite heterogeneous even among patients with germline CBL mutations. Prospective clinical trials are warranted to find ideal treatment strategies for this diverse cohort of patients.

Background: Artificial intelligence is gaining traction in automated medical imaging analysis. Development of more accurate magnetic resonance imaging (MRI) predictors of successful clinical outcomes is necessary to better define indications for surgery, improve clinical outcomes with targeted minimally invasive and endoscopic procedures, and realize cost savings by avoiding more invasive spine care. Objective: To demonstrate the ability for deep learning neural network models to identify features in MRI DICOM datasets that represent varying intensities or severities of common spinal pathologies and injuries and to demonstrate the feasibility of generating automated verbal MRI reports comparable to those produced by reading radiologists. Methods: A 3-dimensional (3D) anatomical model of the lumbar spine was fitted to each of the patient9s MRIs by a team of technicians. MRI T1, T2, sagittal, axial, and transverse reconstruction image series were used to train segmentation models by the intersection of the 3D model through these image sequences. Class definitions were extracted from the radiologist report for the central canal: (0) no disc bulge/protrusion/canal stenosis, (1) disc bulge without canal stenosis, (2) disc bulge resulting in canal stenosis, and (3) disc herniation/protrusion/extrusion resulting in canal stenosis. Both the left and right neural foramina were assessed with either (0) neural foraminal stenosis absent, or (1) neural foramina stenosis present. Reporting criteria for the pathologies at each disc level and, when available, the grading of severity were extracted, and a natural language processing model was used to generate a verbal and written report. These data were then used to train a set of very deep convolutional neural network models, optimizing for minimal binary cross-entropy for each classification. Results: The initial prediction validation of the implemented deep learning algorithm was done on 20% of the dataset, which was not used for artificial intelligence training. Of the 17,800 total disc locations for which MRI images and radiology reports were available, 14,720 were used to train the model, and 3560 were used to validate against. The convergence of validation accuracy achieved with the deep learning algorithm for the foraminal stenosis detector was 81% (sensitivity = 72.4.4%, specificity = 83.1%) after 25 complete iterations through the entire training dataset (epoch). The accuracy was 86.2% (sensitivity = 91.1%, specificity = 82.5%) for the central stenosis detector and 85.2% (sensitivity = 81.8%, specificity = 87.4%) for the disc herniation detector. Conclusions: Deep learning algorithms may be used for routine reporting in spine MRI. There was a minimal disparity among accuracy, sensitivity, and specificity, indicating that the data were not overfitted to the training set. We concluded that variability in the training data tends to reduce overfitting and overtraining as the deep neural network models learn to focus on the common pathologies. Future studies should demonstrate the accuracy of deep neural network models and the predictive value of favorable clinical outcomes with intervention and surgery. Level of Evidence: 3. Clinical Relevance: Feasibility, clinical teaching, and evaluation study.

Even though pregnant women are more prone to have severe COVID 19, few studies have been conducted on their protective behaviours against this disease in our country during the COVID-19 pandemic. Fear of getting COVID infection may prevent antenatal women from visiting hospitals for routine antenatal checkups and utilization of telemedicine may be an alternative to get connected with their health care providers during the pandemic. Aims: To evaluate the protective behaviour adopted by pregnant women during the COVID pandemic and their utilization of teleconsultation for antenatal care. Methods: A cross- sectional study was conducted among pregnant women attending three selected hospitals in Trivandrum District in Kerala during May to August 2020. The data was collected from a random sample of 252 pregnant women registered in these hospitals using a self-administered semi-structured questionnaire. Results: Around 89% of pregnant women had adopted good practice to protect themselves against the COVID 19. About 94% wore a mask whenever they went outside. About 72% completely avoided crowded place. About 72% had rated themselves to have good or very good knowledge regarding protective measures of COVID 19. Among the pregnant women, 61(24.2%) missed their scheduled antenatal visit once, 32(12.7%) missed twice and 8(3.2% missed three or more times during the pandemic period. Half of the pregnant women utilized telemedicine facility during the pandemic to stay connected with their doctors. But 31% were not aware of telemedicine facility in hospitals, while 1.6% does not have an internet access. Higher age group, current employment status and area of residence was found to be associated with poor practice. Conclusions: Nearly 89% pregnant women adopted good protective measures against COVID19. Measures need to be taken to improve the availability of telemedicine facility in hospitals for antenatal women and to improve awareness about it among public which may help the antenatal women to stay connected with their health care providers during this pandemic.

Background: Identifying pain generators in multilevel lumbar degenerative disc disease is not trivial but is crucial for lasting symptom relief with the targeted endoscopic spinal decompression surgery. Artificial intelligence (AI) applications of deep learning neural networks to the analysis of routine lumbar MRI scans could help the primary care and endoscopic specialist physician to compare the radiologist9s report with a review of endoscopic clinical outcomes. Objective: To analyze and compare the probability of predicting successful outcome with lumbar spinal endoscopy by using the radiologist9s MRI grading and interpretation of the radiologic image with a novel AI deep learning neural network (Multus Radbot™) as independent prognosticators. Methods: The location and severity of foraminal stenosis were analyzed using comparative ordinal grading by the radiologist, and a contiguous grading by the AI network in patients suffering from lateral recess and foraminal stenosis due to lumbar herniated disc. The compressive pathology definitions were extracted from the radiologist lumbar MRI reports from 65 patients with a total of 383 levels for the central canal – (0) no disc bulge/protrusion/canal stenosis, (1) disc bulge without canal stenosis, (2) disc bulge resulting in canal stenosis, and (3) disc herniation/protrusion/extrusion resulting in canal stenosis. Both neural foramina were assessed with either – (0) neural foraminal stenosis absent, or (1) neural foramina are stenosis present. Reporting criteria for the pathologies at each disc level and, when available, the grading of severity were extracted and assigned into two categories: “Normal,” and “Stenosis.” Clinical outcomes were graded using dichotomized modified Macnab criteria considering Excellent and Good results as “Improved,” and Fair and Poor outcomes as “Not Improved.” Binary logistic regression analysis was used to predict the probability of the AI- and radiologist grading of stenosis at the 88 foraminal decompression sites to result in “Improved” outcomes. Results: The average age of the 65 patients was 62.7 +/- 12.7 years. They consisted of 51 (54.3%) males and 43 (45.7%) females. At an average final follow-up of 57.4 +/- 12.57, Macnab outcome analysis showed that 86.4% of the 88 foraminal decompressions resulted in Excellent and Good (Improved) clinical outcomes. The stenosis grading by the radiologist showed an average severity score of 4.71 +/- 2.626, and the average AI severity grading was 5.65 +/- 3.73. Logit regression probability analysis of the two independent prognosticators showed that both the grading by the radiologist (86.2%; odds ratio 1.264) and the AI grading (86.4%; odds ratio 1.267) were nearly equally predictive of a successful outcome with the endoscopic decompression. Conclusions: Deep learning algorithms are capable of identifying lumbar foraminal compression due to herniated disc. The treatment outcome was correlated to the decompression of the directly visualized corresponding pathology during the lumbar endoscopy. This research should be extended to other validated pain generators in the lumbar spine. Level of Evidence: 3. Clinical Relevance: Validity, clinical teaching, evaluation study.

An estimated 3.5 million interstate migrant workers have become an indispensable part of Kerala’s economy. The state also offers the highest wages for migrant workers for jobs in the unorganised sector in the entire Indian subcontinent. Further, the state has evolved several measures for the inclusion of the workers and was able to effectively respond to their distress during the national lockdown. This paper examines labour migration to Kerala, key measures by the government to promote the social security of the workers and the state’s response to the distress of migrant workers during lockdown, by synthesising the available secondary evidence. The welfare measures as well as interventions initiated by the state are exemplary and promising given the intent and provisions. However, some of them do not appear to have consideration of the grassroots requirements and implementation mechanisms to enhance access. As a result, the policy intent and substantial investments have not yielded the expected results. The state’s effective response to the distress of workers during the lockdown emanates from its overall disaster preparedness and resilience achieved from confronting with two consecutive state-wide natural disasters and a public health emergency in the immediate past. While the government has played a strategic role through policy imperative and ensuring a synergistic response, the data presented by the state indicate a much larger but invisible role played by the employers and civil society in providing food and shelter to workers.

Background Positron emission tomography studies have demonstrated less dopamine D2/3 receptor availability and blunted psychostimulant-induced dopamine release in cocaine-dependent subjects (CDSs). No studies in CDSs have reported the in vivo status of D2/3 and dopamine release in the cortex. Basic and functional imaging studies suggest a role for prefrontal cortical dopaminergic abnormalities in impaired executive function and relapse in cocaine dependence. We used [11C]FLB 457 positron emission tomography and amphetamine to measure cortical D2/3 receptors and dopamine release in CDSs. Methods [11C]FLB 457 and positron emission tomography were used to measure D2/3 receptor binding potential in cortical regions of interest in recently abstinent CDSs (n = 24) and healthy control subjects (n = 36) both before and after 0.5 mg kg−1 of oral d-amphetamine. Binding potential relative to nondisplaceable uptake (BPND) and binding potential relative to total plasma concentration (BPP) were derived using an arterial input function-based kinetic analysis. Cortical dopamine release in regions of interest was measured as the change in BPND and BPP after amphetamine. Results Baseline D2/3 receptor availability (BPP and BPND) and amphetamine-induced dopamine release (ΔBPND and ΔBPP) were significantly lower in the cortical regions in CDSs compared with healthy control subjects. Fewer D2/3 receptors and less dopamine release in CDSs were not associated with performance on working memory and attention tasks. Conclusions The results of this study suggest that deficits in dopamine D2/3 transmission involve the cortex in cocaine dependence. Further studies to understand the clinical relevance of these findings are warranted.

Aim: To describe the multimodal imaging findings of pigmented paravenous retinochoroidal atrophy. Methods: A 23-year-old female presented to us for a routine ocular examination. She had a best-corrected visual acuity of 6/6 in both eyes. Anterior segment examination was unremarkable. Fundus examination showed pigmentary changes along the retinal vasculature extending from mid periphery to post-equatorial retina suggesting a diagnosis of pigmented paravenous retinochoroidal atrophy. Swept-source optical coherence tomography of the macula showed choriocapillaris thinning at the mid periphery whereas coherence tomography angiography at the mid periphery showed a relatively normal choriocapillaris vasculature in the early stage of the disease. Conclusion: A relatively normal choriocapillaris structure was seen on ocular coherence tomography angiography which could have been due to a milder form of the disease in a young patient.

Objective: The influence of tuberculosis (TB)-immune reconstitution inflammatory syndrome (IRIS) on TB treatment outcomes and its risk factors were investigated among people with human immunodeficiency virus (HIV) and co-infected with TB. Methods: Newly diagnosed, culture-confirmed, pulmonary TB patients with HIV and enrolled in a clinical trial (NCT00933790) were retrospectively analysed for IRIS occurrence. Risk factors and TB outcomes (up to 18 months after initiation of anti-TB treatment [ATT]) were compared between people who experienced IRIS (IRIS group) and those who did not (non-IRIS group). Results: TB-IRIS occurred in 82 of 292 (28%) participants. Significant baseline risk factors predisposing to TB-IRIS occurrence in univariate analysis were: lower CD4+ T-cell count, CD4/CD8 ratio, haemoglobin levels, presence of extra-pulmonary TB focus, and higher HIV viral load; the last two retained significance in the multivariate analysis. After 2 months of ATT commencement, sputum smear conversion was documented in 45 of 80 (56.2%) vs. 124 of 194 (63.9%) (p = 0.23), culture conversion was in 75 of 80 (93.7%) vs. 178 of 194 (91.7%) (p = 0.57) and the median decline in viral load (log10copies/mm3) was 2.7 in the IRIS vs. 1.1 in the non-IRIS groups (p

This paper introduces the PSCORE, which aggregates nine personal characteristics of chief executive officers (CEOs), to signal the quality of earnings. The PSCORE is a composite score based on publicly available data on CEOs. The study reports strong positive relationships between the PSCORE and two different proxies for earnings quality, (1) discretionary accruals and (2) financial statement errors, measured by deviations of the first digits of figures reported in financial statements from those expected by Benford’s Law. Further analyses indicate that the relationships between the PSCORE and the proxies for earnings quality become more pronounced when CEOs have high equity-based compensation incentives. The findings have some implications for practitioners.

ObjectiveTo examine the relationship between neonatal inflammatory cytokines and perinatal stroke using a systems biology approach analyzing serum and blood-spot cytokines from 47 patients.MethodsThis was a population-based, controlled cohort study with prospective and retrospective case ascertainment. Participants were recruited through the Alberta Perinatal Stroke Project. Stroke was classified as neonatal arterial ischemic stroke (NAIS), arterial presumed perinatal ischemic stroke (APPIS), or periventricular venous infarction (PVI). Biosamples were stored blood spots (retrospective) and acute serum (prospective). Controls had comparable gestational and maternal ages. Sixty-five cytokines were measured (Luminex). Hierarchical clustering analysis was performed to create heat maps. The Fisher linear discriminant analysis was used to create projection models to determine discriminatory boundaries between stroke types and controls.ResultsA total of 197 participants were analyzed (27 with NAIS, 8 with APPIS, 12 with PVI, 150 controls). Cytokines were quantifiable with quality control measures satisfied (standards testing, decay analysis). Linear discriminant analysis had high accuracy in using cytokine profiles to separate groups. Profiles in participants with PVI and controls were similar. NAIS separation was accurate (sensitivity 77%, specificity 97%). APPIS mapping was also distinguishable from NAIS (sensitivity 86%, specificity 99%). Classification tree analysis generated similar diagnostic accuracy.ConclusionsUnique inflammatory biomarker signatures are associated with specific perinatal stroke diseases. Findings support an acquired pathophysiology and suggest the possibility that at-risk pregnancies might be identified to develop prevention strategies.Classification of evidenceThis study provides Class III evidence that differences in acute neonatal serum cytokine profiles can discriminate between patients with specific perinatal stroke diseases and controls.

OBJECTIVE The FreeStyle Libre (FSL) flash glucose-monitoring device was made available on the U.K. National Health Service (NHS) drug tariff in 2017. This study aims to explore the U.K. real-world experience of FSL and the impact on glycemic control, hypoglycemia, diabetes-related distress, and hospital admissions. RESEARCH DESIGN AND METHODS Clinicians from 102 NHS hospitals in the U.K. submitted FSL user data, collected during routine clinical care, to a secure web-based tool held within the NHS N3 network. The t and Mann-Whitney U tests were used to compare the baseline and follow-up HbA1c and other baseline demographic characteristics. Linear regression analysis was used to identify predictors of change in HbA1c following the use of FSL. Within-person variations of HbA1c were calculated using . RESULTS Data were available for 10,370 FSL users (97% with type 1 diabetes), age 38.0 (±18.8) years, 51% female, diabetes duration 16.0 (±49.9) years, and BMI of 25.2 (±16.5) kg/m2 (mean [±SD]). FSL users demonstrated a −5.2 mmol/mol change in HbA1c, reducing from 67.5 (±20.9) mmol/mol (8.3%) at baseline to 62.3 (±18.5) mmol/mol (7.8%) after 7.5 (interquartile range 3.4–7.8) months of follow-up (n = 3,182) (P < 0.0001). HbA1c reduction was greater in those with initial HbA1c ≥69.5 mmol/mol (>8.5%), reducing from 85.5 (±16.1) mmol/mol (10%) to 73.1 (±15.8) mmol/mol (8.8%) (P < 0.0001). The baseline Gold score (score for hypoglycemic unawareness) was 2.7 (±1.8) and reduced to 2.4 (±1.7) (P < 0.0001) at follow-up. A total of 53% of those with a Gold score of ≥4 at baseline had a score CONCLUSIONS We show that the use of FSL was associated with significantly improved glycemic control and hypoglycemia awareness and a reduction in hospital admissions.

To evaluate the effects of gestational age (GA) and postnatal age on skin barrier integrity by comparing premature infants at full-term corrected age with infants born at term. Parallel comparison of chest skin in 36 premature infants with 39 full-term infants using daily measures of transepidermal water loss (TEWL), skin pH, erythema and rash, over 2 weeks. Chest skin pH was significantly lower for premature infants, indicating that acid mantle formation had occurred in the premature versus full-term infants. Chest TEWL was significantly higher for premature versus full-term infants over 2 weeks, suggesting that even 7–8 weeks after birth, skin integrity is poorer in premature infants. Skin barrier properties of premature infants at adjusted full-term age differ from full-term infants, suggesting that epidermal barrier development depends on GA and time from birth. These maturational differences may influence premature infant response to topical agents.

PurposeSocial loafing is a key inhibitor in group-based student learning and is a key challenge in administering group-based assessments in higher education. This study examines differences in the effects of antecedents of social loafing (disruptive behaviour, social disconnectedness and apathy) on work quality by comparing student-created and instructor-created groups. The study also investigates how group members' efforts to “pick up the slack” of social loafers in the two kinds of groups moderate the effect of antecedents of social loafing on work quality.Design/methodology/approachPost-graduate students from two different sessions of the Marketing Management unit participated in the study: 95 students from session 1 and 90 students from session 2. One session represented student-created groups and the other session represented instructor-created groups. Each group consisted of five students. Partial Least Square (PLS) estimation using SmartPLS was used to assess the direct and interaction effects.FindingsThe results indicate differences in the effects of the antecedents of social loafing such as apathy and disruptive behaviour on work quality for both student-created and instructor-created groups. Social disconnectedness was found to have no significant effect on work quality. Interestingly, the study found significant differences in the effects of “pick up the slack” on the work quality of student-created and instructor-created groups. Members of student-created groups who picked up the slack of social loafers improved the work quality for unit assessment. This effect was not significant for instructor-created groups.Originality/valueExtant literature on social loafing predominantly focusses on its effect on students' work quality and educational achievement. This study contributes to the literature by investigating how the student-created and instructor-created group members' efforts to pick up the slack of social loafers moderate the effects of the antecedents of social loafing on work quality.

New findings What is the topic of this review? Hypoglycaemia is a commonly cited barrier to exercise in type 1 diabetes mellitus (T1D). Knowledge of approaches to prevent or manage exercise-induced hypoglycaemia can support patients to exercise and help clinicians to give advice. This review presents evidence-based strategies to prevent exercise-induced hypoglycaemia in T1D. What advances does it highlight? This review highlights approaches that can be used before, during and after exercise to mitigate the risk of hypoglycaemia. The approaches include the timing of exercise, the type of exercise, adjustments to insulin and carbohydrate, use of novel technology and education. Abstract Exercise is a key component for the management of type 1 diabetes mellitus (T1D) and is associated with reduced risk of cardiovascular disease, decreased daily insulin requirements and improved quality of life. Owing to these benefits, people with T1D are recommended to undertake regular physical activity, 150 min per week for adults and 60 min per day for children and adolescents. Despite the recommendations, many people do not meet these targets. One of the commonly cited barriers to exercise is fear of hypoglycaemia along with limited knowledge of effective preventative strategies. Hypoglycaemia can be difficult to predict, and symptoms are often masked during exercise or stress of competition. For athletes with T1D, hypoglycaemia can also limit sporting success. Hypoglycaemia before an event increases the risks of hypoglycaemia during competition and can reduce performance. To avoid hypoglycaemia, people with T1D may avoid exercise altogether or consume excessive amounts of carbohydrates, which mitigates many of the health benefits of exercise. Increased understanding of approaches to prevent or manage hypoglycaemia is therefore important to help increase levels of physical activity in people with T1D and to support athletes with T1D to compete at the highest level. This review outlines the prevalence of exercise-related hypoglycaemia, its underlying physiology and the strategies that can be used to prevent and manage exercise-induced hypoglycaemia in T1D. Our hope is that this knowledge will be used by people with T1D and their clinicians to find individual approaches to manage exercise-related hypoglycaemia.

Rotator cuff and tuberosity avulsions in growing age group are rare injuries with concerns about delayed diagnosis and physeal damages. We report in a 14-year boy with isolated greater tuberosity apophyseal separation that was initially overlooked and presented later with displacements and supraspinatus/infraspinatus weakness. The fracture geometry and proximity of physis did not favour an arthroscopic procedure. Open reduction was performed and stabilised by an extraosseos construct in the form of fibre tapes, interval closure and screw post. The proximal humeral epiphysis united by eight weeks without alteration in physis and had an excellent modified UCLA outcome score of 35 in thirteen months follow up. Knowledge on the physeal anatomy, mechanism of injury and astute clinical examination of shoulder are of paramount importance to adequately manage pediatric cuff injuries. The extraosseous method is an effective alternate when the transosseous physis sparing fixation methods are limited.

Background/Objectives Diaper dermatitis is one of the most frequent skin conditions affecting infants and is associated with elevated skin pH, exposure to urine and feces, and increased fecal protease and lipase activity, resulting in stratum corneum barrier damage and increased risk of infection. The study aim was to determine the impact of two diaper and wipe regimens on newborn infant skin pH and residual enzyme activity after stool cleaning. Methods Two diaper and wipe regimens were compared in a randomized, single‐blinded crossover study. Regimen A paired an emollient‐containing diaper with an acidic, pH‐buffered wipe. Regimen B was a non‐emollient diaper and wipe with limited buffering capacity. A 3‐day washout period preceded each 3‐day regimen use period. Skin pH at the perianal/buttocks interface (PBI), genital region, and undiapered chest control were measured at baseline and day 3. Skin swabs were collected for residual enzyme activity after a stool cleaning event. Results Diapered skin pH at the PBI was similar to undiapered skin after 3 days of use for Regimen A, while PBI pH for Regimen B was elevated versus control. PBI pH was lower for Regimen A versus Regimen B. After a stool cleaning, PBI skin pH for Regimen A was lower immediately and had lower residual enzyme activity versus Regimen B (P

OBJECTIVE: An imbalance between neuropeptides that promote stress and resilience, such as corticotrophin-releasing factor (CRF) and nociceptin, has been postulated to underlie relapse in addiction. The objective of this study was to develop a paradigm to image the in vivo interaction between stress-promoting neuropeptides and nociceptin receptors (NOP) in humans. METHODS: [(11)C]NOP-1A PET was used to measure the binding to NOP receptors at baseline (BASE) and following an intravenous hydrocortisone challenge (POST-CORT) in 19 healthy controls. Hydrocortisone was used as a challenge because in microdialysis studies it has been shown to increase CRF release in extrahypothalamic brain regions such as the amygdala. [(11)C]NOP-1A total distribution volume (V(T)) in eleven regions (ROIs) were measured using a two-tissue compartment kinetic analysis. The primary outcome measure was hydrocortisone-induced ΔV(T) calculated as (V(T POST-CORT) - V(T BASE)) / V(T BASE). RESULTS: Hydrocortisone led to an acute increase in plasma cortisol levels. Regional [(11)C]NOP-1A V(T) was on average 11 to 16% higher in the POST-CORT compared to BASE condition (linear mixed model, condition, p = 0.005; region, p < 0.001, condition*region, p < 0.001). Independent t-tests in all ROIs were statistically significant and survived multiple comparison correction. Hydrocortisone-induced ΔV(T) was significantly negatively correlated with baseline V(T) in several ROIs. CONCLUSIONS: Hydrocortisone administration increases NOP receptor availability. Increased NOP in response to elevated cortisol might suggest a compensatory mechanism in the brain to counteract CRF/stress. The [(11)C]NOP-1A and hydrocortisone imaging paradigm should allow for the examination of interactions between stress-promoting neuropeptides and NOP in addictive disorders. (In Vivo Imaging of Corticotropin-releasing Factor - Nociceptin Receptor Interactions, https://clinicaltrials.gov/ct2/show/NCT03302416 ClinicalTrials.gov Identifier: )

Objectives This report aims to provide clear recommendations and practical guidance from a panel of UK retinal experts on an aflibercept treat-and-extend (T&E) pathway that can be implemented in clinical practice. These recommendations may help service providers across the NHS intending to implement a T&E approach, with the aim of effectively addressing the capacity and resource issues putting strain on UK neovascular age-related macular degeneration (nAMD) services while promoting patients’ best interests throughout. Methods Two structured roundtable meetings of retinal specialists were held in London, UK on 7 December 2018 and 1 March 2019. These meetings were organised and funded by Bayer. Results The panel provided recommendations for an aflibercept T&E pathway and developed specific criteria based on visual acuity, retinal morphology and optical coherence tomography imaging to guide reduction, maintenance and extension of injection intervals. They also discussed the extension of treatment intervals by 2- or 4-week adjustments to a maximum treatment interval of 16 weeks, the management of retinal fluid and the stopping of treatment. Conclusions The long-term benefits of implementing a T&E pathway may include superior visual outcomes compared with a pro re nata (PRN; as needed) protocol, and a lower treatment burden compared with a fixed protocol, which is likely to improve service capacity. Furthermore, the predictable nature of a T&E approach compared with a PRN service may aid capacity planning for the future nAMD treatment demand.