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Tackles a variety of issues concerning patients dying in hospitals in Great Britain. Concerns over the quality of hospital care; Establishment of integrated care pathways for terminal care; Factors that need to be considered in terminal care.

Background Ledipasvir and sofosbuvir is a well-tolerated regimen with high sustained virological response ( SVR) rates in pre-liver transplant patients infected with chronic hepatitis C virus ( HCV), but data in liver transplant recipients outside of clinical trials is limited. Aim To address this knowledge gap and assess SVR rates without the use of ribavirin in liver transplant recipients Methods This is a retrospective study examining the treatment of 75 post-liver transplant recipients with ledipasvir and sofosbuvir without ribavirin. Differences between SVR cohorts and predictors of SVR were analysed in an intention-to-treat ( ITT) fashion. Results A total of 408 genotype 1, HCV patients were treated with ledipasvir/sofosbuvir from October 2014 to August 2015 at our centre. Seventy-three patients were post-liver transplant and were treated with a median of 2.9 years from transplant. Ledipasvir/sofosbuvir achieved an SVR12 of 95.9%. African Americans made up 28.8% of the cohort. Sixty-three per cent of patients were treated previously, including 13.7% of patients previously treated with direct-acting antivirals. Only 2.7% had recurrent allograft cirrhosis, and the majority (90.4%) was on calcineurin inhibitor based immunosuppressive therapy. Approximately 82% of patients had chronic kidney disease ( CKD) stage 2 or 3. In univariate logistic regression, only detectable week 8 viral load was predictive of failure to achieve SVR. Conclusion Our data confirm excellent SVR outcomes and favourable safety and tolerability profiles with ledipasvir/sofosbuvir without ribavirin in post-liver transplant recipients infected with HCV, despite treatment guidelines to use ribavirin. [ABSTRACT FROM AUTHOR]

Aims and Objectives: Spontaneous rupture of ureter is a rare entity; we present one such case managed successfully using Appendix. Materials and Methods: One and half years male child presented with necrotizing fascitis-right thigh. Debridement for necrotising fascitis was performed and was discharged on next day. Almost after three weeks he presented with gradual distention of abdomen, constipation since 5 days. Initially USG later CT-IVP revealed large right sided retroperitoneal cystic fluid filled mass extending up to diaphragmatic level and displacing right kidney medially; we initially managed conservatively by right retroperitoneal tube drain; but it continuously kept draining almost 700cc of fluid/day, so after 10 days we tried cystoscopic retrograde stenting of right ureter which failed and then we explored the patient on the same day; it revealed complete transection of right upper half of ureter with fibroadhesive retroperitoneum. Direct end to end anastomosis of ureter was not possible hence we replaced the gap by using Appendix. Result: Post op recovery was uneventful. This case was managed successfully. Conclusion: -Spontaneous rupture of ureter is a rare entity, its possibility must be acknowledged. Primary spontaneous rupture of ureter is unknown; no such case has been reported occurring in an otherwise healthy individual. When direct end to end anastomosis is not possible significant gap between two transected ends of ureter can be managed successfully by replacing Appendix. [ABSTRACT FROM AUTHOR]

Aims: The creation of continent catheterizable stoma for management of neurogenic bladder and faecal incontinence is established technique. Large numbers of patients who have bladder and bowel incontinence need both the stomas which can be created simultaneously by using appendix. Materials and Methods: Five patients presented to us with neurogenic bladder and faecal incontinence, all were operated cases of meningomyelocoele. Our procedure includes splitting of appendix followed by creating MACEstoma with the stump of appendix and Mitrofanoff's stoma with the rest of appendix. Thus in patients with neurogenic bladder and faecal incontinence only appendix can be used for creation of both Malone's and Mitrofanoff's stoma simultaneously. Resuls: Results of all the cases were satisfactory in terms of dryness and continence. There was no regurgitation of emema fluid or faecal matter. Conclusion: Using appendix for creating both Malone's and Mitrofanoff's stoma simultaneously is technically simple. In many studies it was found that creation of antireflux mechanism is not required. Thus both the stomas created with appendix fulfills all the criteria for perfect continent urinary stoma and ACE. [ABSTRACT FROM AUTHOR]

Aims: A long term (upto 30 yrs) follow up of 100 cases of Hydrocephalus treated with shunt. To assess life span, morbidity and quality of life. Materials and Methods: A series of about 100 cases of Hydrocephalus-primary and secondary to meningomylocele and meningitis treated with variety of shunts like Upadhe's or Chhabra's with different methods like Ventriculoatrial and ventriculoperitoneal in the past 30 years. Survey of complications and frequency of shunt revisions done. A long term follow up of those alive or responded has been done. They have been assessed for outcome of the treatment, quality of life with the parameters like state of physical and mental health, education, occupation, marriage and there role in family and society. Also survey of incidence of NTD in the family. Results: The benefits of treatment depended on the age of presentation, methods of shunt and number of revisions required. The quality of life depended on the success of treatment, parent counseling and social support patient received. Conclusion: Message of this presentation is that a long term follow up study of any congenital malformation should in addition to routine physical assessment include the quality of life and the family and social support. [ABSTRACT FROM AUTHOR]

Aims: Small series of four cases of duodenal diaphragm with varied presentation. Materials and Methods. Case I, a 3 and ½ year old male child presented with history of haematemesis once & intermittent bilious vomiting. Past history of surgery for malrotation of gut in neonatal period. On per abdominal examination epigasric fullness with visible peristalsis was noted. Baium meal showed huge dilatation of duodenal loop. On laparotomy duodenal diaphragm with eccentric hole was found. Case II, a 2 year old female child presented with h/o bilious vomiting off & on since birth with failure to thrive. Barium meal showed gross dilatation of duodenum upto right iliac fossa. On laparotomy duodenal diaphragm was present in its 4th part. Case III, a 2 year old male presented with nonbilious vomiting since birth. On laparotomy preampullary duodenal diaphragm with hole present. CaseIV, a 1 month old male presented with non-bilious vomiting since 4 days. X-ray shows grossly dialated stomach with paucity of gas distally. During surgery preampullary duodenal diaphragm was found. Result: 2 cases presented with bilious vomiting off and on while 2 cases presented with non-bilious vomiting and all had uneventful recovery after surgery. Conclusion: Four cases of duodenal diaphragm presented at different age groups with different signs and symptoms with different operative findings. [ABSTRACT FROM AUTHOR]

Aims and Objectives: Study of urinary tract abnormalities associated with anorectal malformations in 100 cases of ARM. Materials and Methods: 100 cases of anorectal malformations presented to us were scanned retrospectively and their association with urinary tract abnormalities was studied. Various urological problems----recto-urethral/vesical fistulas, vesico-ureteric reflux, undescended testis, hypospadias, megaureters, duplex, crossed fused ectopia, renal dysfunction and rare presentation of superior vesical fissure with ARM , ano-urethro-cutaneous fistula etc were taken into consideration. Sex wise variation for association of urinary abnormalities was studied. Incidence of urinary tract abnormalities in -high, intermediate, low types of anorectal malformations was studied. All the cases were managed successfully as per associated urinary abnormalities. Results: Post op recovery was uneventful, all the reported cases were managed successfully. Conclusion: Urinary tract abnormalities associated with anorectal malformations are more common in males. Urinary tract abnormalities are more common in high type of anorectal malformations and are rarely associated with low type of anorectal malformations. After recto-urethral fistula, vesico-ureteric reflux is the most common urinary tract abnormality associated with anorectal malformations. With proper follow up and timely evaluation, these cases can be managed successfully. [ABSTRACT FROM AUTHOR]

Searches for dark matter axions involve the use of microwave resonant cavities operating in a strong magnetic field. Detector sensitivity is directly related to the cavity quality factor, which is limited, until recently, to the use of non-superconducting metals by the presence of the external magnetic field. In this paper, we present a cavity of novel design whose quality factor is not affected by a magnetic field. It is based on a photonic structure by the use of sapphire rods. The quality factor at cryogenic temperature is in excess of 5 × 105 for a selected mode. [ABSTRACT FROM AUTHOR]

Newly arrived refugees and asylum seekers are faced with many difficulties in accessing effective health care when settling in Australia. Cultural, language and financial constraints, lack of awareness of available services, and lack of health provider understanding of the complex health concerns of refugees can all contribute to limiting access to health care. Understanding the complexities of a new health care system under these circumstances and finding a regular health provider may be difficult. In some cases there may be a fundamental distrust of government services. The different levels of health entitlements by visa category and (for some) detention on arrival in Australia may further complicate the provision and use of health services for providers and patients. Children are particularly at risk of suboptimal health care due to the impact of these factors combined with the effect of resettlement stresses on parents’ ability to care for their children. Unaccompanied and separated children, and those in detention experience additional challenges in accessing care. This article aims to increase awareness among health professionals caring for refugee children of the challenges faced by this group in accessing and receiving effective health care in Australia. Particular consideration is given to the issues of equity, rights of asylum seekers, communication and cultural sensitivities in health care provision, and addressing barriers to health care. The aim of the paper is to alert practitioners to the complex issues surrounding the delivery of health care to refugee children and provide realistic recommendations to guide practice. [ABSTRACT FROM AUTHOR]

The realization and characterization of a high quality factor resonator composed of two hollow-dielectric cylinders with its pseudo-TM 030 mode resonating at 10.9 GHz frequency is discussed. The quality factor was measured at the temperatures 300 K and 4 K obtaining Q 300 K = (150 , 000 ± 2 , 000) and Q 4 K = (720 , 000 ± 10 , 000) respectively, the latter corresponding to a gain of one order of magnitude with respect to a traditional copper cylindrical-cavity with the corresponding TM 010 mode resonating at the same frequency. The implications to dark-matter axion-searches with cavity experiments are discussed showing that the gain in quality factor is not spoiled by a reduced geometrical coupling C 030 of the cavity mode to the axion field. This reduction effect is estimated to be at most 20%. Numerical simulations show that frequency tuning of several hundreds MHz is feasible. [ABSTRACT FROM AUTHOR]

The potential of photon-magnon hybrid systems as building blocks for quantum information science has been widely demonstrated, and it is still the focus of much research. We leverage the strengths of this unique heterogeneous physical system in the field of precision physics beyond the standard model, where the sensitivity to the so-called "invisibles" is currently being boosted by quantum technologies. Here, we demonstrate that quanta of spin waves, induced by effective magnetic fields, can be detected in a large frequency band using a hybrid system as transducer. This result can be applied to the search of cosmological signals related, for example, to cold Dark Matter, which may directly interact with magnons. Our model of the transducer is based on a second-quantisation two-oscillators hybrid system, it matches the observations, and can be easily extended to thoroughly describe future large-scale ferromagnetic haloscopes. Precision magnetometry has emerged as a sensitive means to probe spin dynamics at a fundamental level. Here, a broadband a photon-magnon hybrid system is demonstrated, capable of detecting quanta of magentisation induced by tiny effective magnetic fields [ABSTRACT FROM AUTHOR]

Esophageal varices (EV) in liver cirrhosis carry high mortality risks. Traditional endoscopy, which is costly and subjective, prompts a shift towards machine learning (ML). This review critically evaluates ML applications in predicting bleeding risks and grading EV in patients with liver cirrhosis. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic review of studies using ML to predict the risk of variceal bleeding and/or grade EV in liver disease patients. Data extraction and bias assessment followed the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies) checklist and PROBAST (Prediction model Risk Of Bias Assessment Tool) tool, respectively. Due to the heterogeneity of the study, a meta-analysis was not feasible; instead, descriptive statistics summarized the findings. Twelve studies were included, highlighting the use of various ML models such as extreme gradient boosting, artificial neural networks, and convolutional neural networks. These studies demonstrated high predictive accuracy, with some models achieving area under the curve values above 99%. However, significant heterogeneity was noted in input variables, methodologies, and outcome measures. Moreover, a substantial portion of the studies exhibited unclear or high risk of bias, mainly due to insufficient participant numbers, unclear handling of missing data, and a lack of detailed reporting on endoscopic procedures. ML models show significant promise in predicting the risk of variceal bleeding and grading EV in patients with cirrhosis, potentially reducing the need for invasive procedures. Nonetheless, the current literature reveals considerable heterogeneity and methodological limitations, including high or unclear risks of bias. Future research should focus on larger, prospective trials and the standardization of ML assessment criteria to confirm these models' practical utility in clinical settings., (© 2024 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

We introduce a portable dual-comb spectrometer operating in the visible spectral region for atmospheric monitoring of NO 2 , a pollution gas of major importance. Dual-comb spectroscopy, combining key advantages of fast, broadband and accurate measurements, has been established in the infrared as a method for the investigation of atmospheric gases with kilometer-scale absorption path lengths. With the presented dual-comb spectrometer centered at 517 nm, we make use of the strong absorption cross section of NO 2 in this spectral region. In combination with a multi-pass approach through the atmosphere, we achieve an interaction path length of almost a kilometer while achieving both advanced spatial resolution (90 m) and a detection sensitivity of 5 ppb. The demonstrated temporal resolution of one minute outperforms the standard chemiluminescence-based NO 2 detector that is commercially available and used in this experiment, by a factor of three.

Purpose: The objective of this study was to determine if standardization improves adolescent idiopathic scoliosis (AIS) surgery outcomes and whether it is transferrable between institutions., Methods: A retrospective review was conducted of AIS patients operated between 2009 and 2021 at two institutions (IA and IB). Each institution consisted of a non-standardized (NST) and standardized group (ST). In 2015, surgeons changed institutions (IA- > IB). Reproducibility was determined between institutions. Median and interquartile ranges (IQR), Kruskal-Wallis, and χ 2 tests were used., Results: 500 consecutive AIS patients were included. Age (p = 0.06), body mass index (p = 0.74), preoperative Cobb angle (p = 0.53), and levels fused (p = 0.94) were similar between institutions. IA-ST and IB-ST had lower blood loss (p < 0.001) and shorter surgical time (p < 0.001). IB-ST had significantly shorter hospital stay (p < 0.001) and transfusion rate (p = 0.007) than IB-NST. Standardized protocols in IB-ST reduced costs by 18.7%, significantly lowering hospital costs from $74,794.05 in IB-NST to $60,778.60 for IB-ST (p < 0.001). Annual analysis of surgical time revealed while implementation of standardized protocols decreased operative time within IA, when surgeons transitioned to IB, and upon standardization, IB operative time values decreased once again, and continued to decrease annually. Additions to standardized protocol in IB temporarily affected the operative time, before stabilizing., Conclusion: Surgeon-led standardized AIS approach and streamlined surgical steps improve outcomes and efficiency, is transferrable between institutions, and adjusts to additional protocol changes., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Here, we present a frequency tuning mechanism for microwave cavities designed for axion dark matter searches and show that it provides a range of at least 200 MHz for the fundamental mode TM010 resonant at ∼10 GHz. The apparatus is based on a clamshell cavity, with the two semi-cells held together at a fixed joint while the other side opens to tune the frequency of the resonant modes. Measurements of the cavity frequencies and quality factor were taken at liquid helium temperature as the aperture was increased incrementally to ∼2°. We show that the frequency shift is approximately linear with respect to the angle of aperture with no mode crossings present for an aperture less than 2°. Furthermore, the form factor and quality factor of the TM010 mode remain relatively constant throughout the tuning as predicted by simulation., (© 2023 Author(s). All article content, except where otherwise noted, is licensed under a Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).)

This narrative review aims to clarify the role of breast and gynecological risk-reduction surgery in BRCA mutation carriers. We examine the indications, contraindications, complications, technical aspects, timing, economic impact, ethical issues, and prognostic benefits of the most common prophylactic surgical options from the perspectives of a breast surgeon and a gynecologist. A comprehensive literature review was conducted using the PubMed/Medline, Scopus, and EMBASE databases. The databases were explored from their inceptions to August 2022. Three independent reviewers screened the items and selected those most relevant to this review's scope. BRCA1/2 mutation carriers are significantly more likely to develop breast, ovarian, and serous endometrial cancer. Because of the Angelina effect, there has been a significant increase in bilateral risk-reducing mastectomy (BRRM) since 2013. BRRM and risk-reducing salpingo-oophorectomy (RRSO) significantly reduce the risk of developing breast and ovarian cancer. RRSO has significant side effects, including an impact on fertility and early menopause (i.e., vasomotor symptoms, cardiovascular disease, osteoporosis, cognitive impairment, and sexual dysfunction). Hormonal therapy can help with these symptoms. Because of the lower risk of developing breast cancer in the residual mammary gland tissue after BRRM, estrogen-only treatments have an advantage over an estrogen/progesterone combined treatment. Risk-reducing hysterectomy allows for estrogen-only treatments and lowers the risk of endometrial cancer. Although prophylactic surgery reduces the cancer risk, it has disadvantages associated with early menopause. A multidisciplinary team must carefully inform the woman who chooses this path of the broad spectrum of implications, from cancer risk reduction to hormonal therapies.

Study Design: Retrospective review., Objective: The objective of this study was to evaluate and compare distribution of hospital and operating room charges and outcomes during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) patients by high-volume (HV) and standard-volume (SV) surgeons at one institution and examine potential cost savings., Summary of Background Data: Increased surgical volume has been associated with improved perioperative outcomes after spinal deformity correction. However, there is a lack of information on how this may affect hospital costs., Methods: Retrospective study of AIS patients undergoing posterior spinal fusion between 2013 and 2019. Demographic, x-ray, chart review and hospital costs were collected and compared between HV surgeons (≥50 AIS cases/y) and SV surgeons (<50/y). Comparative analyses were computed using Wilcoxon rank-sum, Kruskal-Wallis, and the Fisher exact tests. Average values with corresponding minimum-maximum rages were reported., Results: A total of 407 patients (HV: 232, SV: 175) operated by 4 surgeons (1 HV, 3 SV). Radiographic parameters were similar between the groups. HV surgeons had significantly lower estimated blood loss (385.3 vs. 655.6 mL, P <0.001), fewer intraoperative transfusions (10.8% vs. 25.1%, P <0.001), shorter surgery time (221.6 vs. 324.9 min, P <0.001), and lower radiation from intraoperative fluoroscopy (4.4 vs. 6.4 mGy, P <0.001). HV patients had a significantly lower length of stay (4.3 vs. 5.3, P <0.001) and complication rate (0.4% vs. 4%, P =0.04).HV surgeons had significantly lower total costs ($61,716.24 vs. $72,745.93, P <0.001). This included lower transfusion costs ( P <0.001), operative time costs ( P <0.001), screw costs ( P <0.001), hospital stay costs ( P <0.001), and costs associated with 30-day emergency department returns ( P <0.001)., Conclusion: HV surgeons had significantly lower operative times, lower estimated blood loss and transfusion rates and lower perioperative complications requiring readmission or return to emergency department resulting in lower health care costs., Level of Evidence: Level III., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

In this paper, we will describe the characterization of an RF amplification chain based on a traveling wave parametric amplifier. The detection chain is meant to be used for dark matter axion searches, and thus, it is coupled to a high Q microwave resonant cavity. A system noise temperature T sys = (3.3 ± 0.1) K is measured at a frequency of 10.77 GHz, using a novel calibration scheme, allowing for measurement of T sys exactly at the cavity output port.

Variations in the shape of foramen magnum can affect the normal anatomy of vital structures passing through it. Therefore, it is of interest to evaluate the various shapes of foramen magnum by using CT scans performed in patients of Indian population to establish clinical correlation. A total of 314 CT images of human skull base obtained from the Department of Radio-diagnosis, Geetanjali Medical College and Hospital, Udaipur, Rajasthan were used in the present study. All the patients' CT scans were observed to determine the shape of foramen magnum. They were classified into one of the following shapes: Oval, round, tetragonal, egg shaped, hexagonal, pentagonal and irregular. The shapes of the foramen magnum in CT scans were oval in 39.09%, round in 22.61%, tetragonal in 12.10%, hexagonal in 10.51%, irregular in 7.96%, pentagonal in 5.41% and egg shaped in 1.59% CT images. Data shows that it is easy to operate at the base of skull in case of round, oval and hexagonal shape foramen magnum, as the working space is more in these shapes., (© 2022 Biomedical Informatics.)

Introduction: Presently the leprosy program has no defined surveillance protocols for patients who complete the fixed duration multidrug therapy and are released from treatment (RFT). Hence, the information about the post-RFT events in these patients is sparse and qualitative and quantitative data regarding their health care requirements is missing. During the DermLep survey carried out by the Indian Association of Dermatologists,Venereologists and Leprologists (IADVL), a number of patients presented to dermatologists during the post RFT period for a variety of symptoms. This paper analyses the events in these patients during the post RFT period., Results: Out of a total of 3701 leprosy patients who presented to 201 dermatologists across India during the DermLep survey, 708 (26.2%) were in the post RFT period (488 males; 220 females). Of these, 21% were PB and 79% MB patients as per their treatment records. Majority were in the age group of 31-59 years (55.5%); however, a significant proportion of them (20.7%) were elderly (>60 years). Majority of the patients (45.5%) presented within the first year of RFT with variable symptoms; 28% were between 1-5 years, 5.5% between 5-10 years; and 11.0% presented more than 10 years after RFT. Most common presenting complaint being persistent skin lesions as perceived by patients in 21.2%, followed by neuritis in 14.5%; trophic ulcers in 13.8%; deformities in 67 (11.8%); lepra reactions in 66 (11.6%); and recurrence of original symptoms in 6.7%., Conclusion: The DermLep Surve y highlights the importance of 'post RFT' patients as an important subset of leprosy patients who visit dermatologists for various health related issues. The most common complaints in this subset were active/persistent skin lesions, lepra reactions and neuritis. In these patients, who are a sub-group of 'persons affected with leprosy' the disease related issues can persist for many years post RFT. Hence, it is important to provide services in the programme to monitor and manage these complications for the prevention of impairments, disability and the related social issues., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Dermatology Online Journal.)

Study Design: Multicenter retrospective review., Objective: This study aims to address major postoperative complications associated with Scheuermann kyphosis (SK) when compared with adolescent idiopathic scoliosis (AIS) in a large population matched by demographic characteristics, levels fused and operative technique., Summary of Background Data: Prior studies have found that SK patients are 3.86 times more likely to experience major postoperative complications than in AIS. Historically, however, these studies have often had populations that were significantly different between the two groups in terms of disease severity, demographics, and small sample sizes., Methods: AIS patients were compared to SK patients between 2006 and 2018 contemporaneously. All surgeries were conducted by six surgeons among two institutions. Complications and revisions were calculated. A sub-analysis comparing SK and AIS patients by age, sex, and levels-fused in one-to-one matched pairs was performed as well as a sub-analysis matched by levels fused only in one-to-one matched pairs., Results: One thousand three hundred twenty two patients were reviewed (1222 AIS; 100 SK). There were 52 (4.3%) complications in the AIS group compared with 20 (20%) complications in the SK group (P < 0.001), with infections and revisions consisting of the majority of complication rates in both cohorts.When matched by age, sex, and levels fused, there were eight complications in the AIS group and 11 in the SK group (P = 0.63), with infection and revision rates being similar, (P = 0.29) and (P = 0.26) respectively.When matched by levels fused only, EBL, operative time and complication rates remained similar (P > 0.05)., Conclusion: Contrary to previously published literature, our analyses indicate that in a matched population, postoperative complication rates (i.e., infection and revision rates) are not significantly different between SK and AIS patients.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Inflammatory bowel disease (IBD) is a chronic relapsing and remitting condition. The COVID-19 pandemic has severely disrupted provision of medical care across the world. IBD clinical nurse specialists (CNSs) played a pivotal role in the care of children with IBD during the pandemic national lockdown and in the recovery phase. This article aims to look at the impact of COVID-19 on the paediatric IBD service in one children's hospital and the effect on the IBD CNSs' workload., Method: A retrospective review of clinical notes and the service's IBD database from January 2019 to September 2020., Results: There was a significant increase in the number of email and telephone contacts to the IBD CNS team during lockdown. There was an increase in virtual clinics, and an increase in new IBD patients coming to the service, but a reduction in the number of face-to-face consultant clinics., Conclusion: COVID-19 has disrupted medical services to children with IBD and led to a reduction in face-to-face activities but has also led to a significant increase in virtual activities. CNSs have taken up a wider role to cover patient care during a time of both medical and nursing redeployment.

Background: Intestinal pseudo obstruction both acute and chronic is an uncommon severe motility disorder that affect both children and adults, can lead to significant morbidity burden and have no standard management strategy. Prucalopride a highly selective serotonin receptor agonist is an effective laxative with reported extra colon action. We aim to report our experience in children with acute and chronic intestinal pseudo obstruction who responded to prucalopride and systemically review the use of prucalopride in intestinal pseudo obstruction., Methods: A report of clinical experience and systemic review of the relevant medical databases to identify the outcome of usage of prucalopride in patients with acute and chronic intestinal pseudo obstruction. Studies meeting the selection criteria were reviewed including abstract only and case reports., Results: All reported cases showed clinical response to prucalopride. There were three full text, two abstracts only and three case reports all reporting clinical improvement with prucalopride., Conclusion: Prucalopride appears to show promising results in children and adults with acute and chronic intestinal pseudo obstruction., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

Introduction: Dermatologists in India are trained and qualified to treat leprosy and there is evidence to suggest that they are involved in the diagnosis and management of a significant number of leprosy patients in the country. The present study evaluated the access to quality leprosy services at their clinics and hospitals to understand the extent of their role in providing comprehensive care to people affected by leprosy and how it can be organized further., Methods: The DermLep Study was a pan-India questionnaire-based survey carried out to evaluate the role that dermatologists play in leprosy management in the country. It included as part-2 of the survey, 11 questions on the access of the dermatologist to various quality leprosy services available at the clinic or institution including skin smears, skin biopsy, multidrug therapy (MDT) blister packs, basic physiotherapy services, and reporting to the national program (NLEP)., Results: The dermatologists who participated in the survey included 101 private practitioners and 100 working in Government or private medical institutions. The key findings of the survey were that 78% of the participating dermatologists still encounter leprosy patients frequently in their clinics; 81.0% of them had access to skin smears; and 93.4% to skin biopsy. The World Health Organization (WHO) MDT regimen was followed by 79.0% of the dermatologists in the study, majority of whom were those working in medical colleges (88%); however overall, 87.4% extended the regimen beyond the fixed duration, mostly on a case to case basis. Thalidomide was available for 61.1% of them to treat type 2 reactions. Basic physiotherapy services were available with 70.2% of dermatologists surveyed; 58.9% dermatologists had access to MCR footwear; and RCS facility access known to 45.5% of them. About 83.5% of the dermatologists working in institutions were reporting their leprosy cases to the NLEP, whereas from a high percentage (71.4%) of dermatologists in private practice, cases were not captured in routine under NLEP., Conclusion: Dermatologists in India have the clinical skill, expertise, and access to most of the basic services, including skin smear and skin biopsy facilities needed to provide comprehensive care to leprosy patients in post-elimination era of integration of leprosy services. While dermatologists are already managing leprosy patients both at medical institutes and private clinics across India, their "structured" involvement at all levels in the national program will facilitate improved reporting and cataloging of cases seen by them. It will also elevate standards of leprosy care; create an effective public-private partnership and disease expertise; and assist develop a comprehensive, patient-tailored approach in the leprosy program in India., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Dermatology Online Journal.)

Introduction: There is evidence to suggest that there is a mismatch between the number of reported cases of leprosy in India and the number of actual cases in the country. One reason could be that many patients are diagnosed and treated outside the NLEP network and dermatologists may be managing some of these patients not captured by official statistics. To estimate these missing numbers, the DermLep survey was carried out to study the number and profile of leprosy patients seen by dermatologists and their significance., Methodology: The DermLep survey was a questionnaire-based study to be filled in by participating dermatologists from all over India, both in private practice and in medical institutions. Participating dermatologists provided information on old and new leprosy patients seen in their clinic over a 3-month period., Results: Total of 201 dermatologists from 20 states of India participated in the survey. 3701 leprosy patients (M: F ratio 2.1:1) were seen. Of them 46.62% (n = 1680) were new; 22.89% (n = 825) were under-treatment; and 19.65% (n = 708) were post RFT patients. Children <15 years constituted 4.29%, while elderly >60 years were 22.21%. As per WHO classification, MB were 73.36% and PB 28.46%. Of all patients 30.91% had lepra reactions, with T2R being more frequent. While 23.58% of all patients in the survey had G2D; in new patients 17.79%; and in post RFT patients 37% had G2D. Among the 1680 new cases seen, 59% were reported to NLEP by the dermatologists and 41% remained unreported mainly by the private dermatologists, among whom for 20% of the cases they mentioned "no access to register". Source of MDT was WHO-MDT in 60.09% of new cases and for rest of 39.91% it was private pharmacies where private dermatologists had no access to MDT blister packs., Conclusion: This survey suggests that a good number of new-untreated leprosy patients, treatment defaulters and post RFT cases are managed by dermatologists in India. About 40% of the new patients managed mainly by private dermatologists are not being reported to NLEP for various reasons, and these constitute the "missing numbers" from government statistics. If extrapolated to the large of number of practicing dermatologists in India, these numbers could be very significant. The high percentage of G2D noted in patients surveyed (23.58%) and post RFT patient issues observed need special attention. There is a need to develop access for dermatologists to confidentially report leprosy patients treated at their clinics to the NLEP., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Dermatology Online Journal.)

Background: The number of Australians dying each year is predicted to double in the next 25 years and there is an urgent need to establish sustainable models for providing high quality end-of-life care. An innovative community care model (Bupa Palliative Care Choices Program or BPCCP) was developed and piloted with the purpose of supporting patients in achieving their choices surrounding end-of-life care., Aims: This study evaluates whether BPCCP patients were more likely to die in their place of choice compared with patients receiving standard care. Additional aims were evaluating patient and carer satisfaction and insurer cost., Methods: This prospective, comparative cohort study comprises a clinical chart audit and survey of patient and carer experience., Results: More BPCCP participants preferred to die at home (53% vs 31%). A lower proportion of BPCCP patients died in acute hospitals (10% vs 19%) and more of this cohort died at home (46% vs 26%). In both cohorts, nearly 90% of patients were able to die in their preferred location. Patient and carer satisfaction with the programme was very high in the small cohort who responded to the survey. There was a decrease in average claims spend per patient enrolled in the programme during the first 12-month period of implementation compared with historical claims spend for inpatients only., Conclusions: This evaluation of an innovative community palliative care intervention indicates that the extra services available to patients support the choice of dying at home and the ability to do so while generating claims cost efficiencies., (© 2019 Royal Australasian College of Physicians.)

Background: Endometriosis is complex, but identifying the novel biomarkers, inflammatory molecules, and genetic links holds the key to the enhanced detection, prediction and treatment of both endometriosis and endometriosis related malignant neoplasia. Here we review the literature relating to the specific molecular mechanism(s) mediating tumorigenesis arising within endometriosis., Methods: Guidance (e.g. Cochrane) and published studies were identified. The Published studies were identified through PubMed using the systematic review methods filter, and the authors' topic knowledge. These data were reviewed to identify key and relevant articles to create a comprehensive review article to explore the molecular fingerprint associated with in endometriosis-driven tumorigenesis., Results: An important focus is the link between C3aR1, PGR, ER1, SOX-17 and other relevant gene expression profiles and endometriosis-driven tumorigenesis. Further studies should also focus on the combined use of CA-125 with HE-4, and the role for OVA1/MIA as clinically relevant diagnostic biomarkers in the prediction of endometriosis-driven tumorigenesis., Conclusions: Elucidating endometriosis' molecular fingerprint is to understand the molecular mechanisms that drive the endometriosis-associated malignant phenotype. A better understanding of the predictive roles of these genes and the value of the biomarker proteins will allow for the derivation of unique molecular treatment algorithms to better serve our patients., Competing Interests: Conflicts of Interest: The authors declare no conflicts of interest.

We report a case of a school-age child with symptomatic distal oesophageal spasm (DES), clinical dysphagia and typical feature in high-resolution oesophageal manometry secondary to eosinophilic oesophagitis (EoE). His symptoms resolved with normalisation of oesophageal manometry after standard treatment of EoE. DES is mainly an adult disorder and rarely affect children; to the best of our knowledge, this is the first reported case in a child that document full recovery after treating the underlying EoE., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Azathioprine is widely used for the maintenance of remission in children with inflammatory bowel disease (IBD). Measuring thiopurine metabolites 6-thioguanine (6-TGN) and 6-methyl-mercaptopurine (6-MMP) can aid in optimizing treatment and preventing toxicity. We report a proactive approach combining early metabolite measurements with IBD activity index to achieve optimal azathioprine dosing., Methods: The reporting of azathioprine dosing, IBD activity indexes and thiopurine metabolites was evaluated retrospectively in 40 children with IBD. Additional treatments and the effect of azathioprine on blood counts were also examined., Results: Forty children (40% female) with IBD (26 Crohn's disease, 12 ulcerative colitis, and 2 unclassified IBD), mean age 12.2±3.4 years, were included in the study. The mean azathioprine dose was 1.3±0.4 mg/kg; mean 6-TGN level was 280±151 pmol/8 × 10 8 red blood cells (RBC) and mean 6-MMP level 1022±1007 pmol/8 × 10 8 RBC. Disease activity index (Crohn's and ulcerative colitis, pediatric specific) at the time of metabolite measurement was 6.5±8. Twenty-eight children did not require azathioprine dose adjustment, while it was increased in 12. Data from children with azathioprine monotherapy were analyzed separately and the results were similar., Conclusion: Timely measurement of thiopurine metabolites and clinical assessment can provide a powerful tool to optimize azathioprine dosing and reduce serious adverse effects in children with IBD., Competing Interests: Conflict of Interest: None

Background: Palm oil (PO) is used in infant formulas in order to achieve palmitic acid (PA) levels similar to those in human milk. PA in PO is esterified predominantly at the SN-1,3 position of triacylglycerol (TAG), and infant formulas are now available in which a greater proportion of PA is in the SN-2 position (typical configuration in human milk). As there are some concerns about the use of PO, we aimed to review literature on health effects of PO and SN-2-palmitate in infant formulas., Methods: PubMed and Cochrane Database of Systematic Reviews were systematically searched for relevant studies on possible beneficial effects or harms of either PO or SN-2-palmitate in infant formula on various health outcomes., Results: We identified 12 relevant studies using PO and 21 studies using SN-2-palmitate. Published studies have variable methodology, subject characteristics, and some are underpowered for the key outcomes. PO is associated with harder stools and SN-2-palmitate use may lead to softer stool consistency. Bone effects seem to be short-lasting. For some outcomes (infant colic, faecal microbiota, lipid metabolism), the number of studies is very limited and summary evidence inconclusive. Growth of infants is not influenced. There are no studies published on the effect on markers of later diseases., Conclusions: There is insufficient evidence to suggest that PO should be avoided as a source of fat in infant formulas for health reasons. Inclusion of high SN-2-palmitate fat blend in infant formulas may have short-term effects on stool consistency but cannot be considered essential.

Background & Aims: Children on home parenteral nutrition and their parents not only engage with complex nutritional issues but also have to manage difficult social and financial problems with social and clinical support that may not always meet their needs. Baxter's HPN-QOL questionnaire, assesses the QOL of adult patients treated with HPN, and has been developed rigorously using standard guidelines, measuring various dimensions of QOL. Our aim was to use this tool to explore how HPN influences the QOL of paediatric patients., Methods: The HPN-QOL questionnaire was modified to suit a paediatric HPN population. Data on demographics, aetiology of intestinal failure and duration of HPN were collected from a departmental database. Quality-of-Life grading of functional and symptom scales, HPN specific items and overall QOL Numerical Rating Scales were determined., Results: Fourteen out of 17 families returned the completed questionnaires. QOL was significantly impaired by increased dependency regarding items of daily living such as eating, dressing, washing, and mobility, but was not affected in the domains of school attendance, general fatigue, pain and body image. There were no significant differences in QOL when patients with and without enterostomy were compared. Patients felt well supported by the hospital nutrition team in managing logistics related to HPN., Conclusions: QOL in HPN patients was not significantly affected by the medical aspects of care. This descriptive study highlights the need for further integration of medical and social care in order to support families of children receiving HPN as QOL was impaired in relation to activities of daily living and social functioning., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

The need for successful management of posterior urethral valves always captivates the minds of pediatric surgeons. Its success, however, depends on several factors ranging from prenatal preservation of upper tracts to postoperative pharmacological compliance. Regardless of measures available, some cases do not respond and progress to end stage. The management depends on several issues ranging from age and severity at presentation to long-term follow-up and prevention of secondary renal damage and managing valve bladder syndrome. This article is based on a consensus to the set of questionnaires, prepared by research section of Indian Association of Paediatric Surgeons and discussed by experienced pediatric surgeons based in different institutions in the country. Standard operating procedures for conducting a voiding cystourethrogram and cystoscopy were formulated. Age-wise contrast dosage was calculated for ready reference. Current evidence from literature was also reviewed and included to complete the topic., Competing Interests: There are no conflicts of interest.