Reporting Practices of Serum Protein Electrophoresis in Pakistan - a Multicenter Survey.

BACKGROUND: Serum Protein Electrophoresis (SPE) is crucial for the diagnosis and follow-up of monoclonal gammopathy (MG), as it helps to separate and identify these paraproteins. Currently, Pakistan lacks standardized guidelines for SPE reporting and analytical performance. This survey aims to analyze reporting variations from Consultant Chemical Pathologists in Pakistani laboratories. METHODS: This cross-sectional survey was conducted by the section of Chemical Pathology, Department of Pathology and Laboratory Medicine, at Aga Khan University Hospital, Karachi. A previously validated and published tool was used with some modifications to assess analytical techniques, reporting patterns, and interpretations provided with SPE by different laboratories. Frequency and percentages were calculated for each response and descriptive results were also evaluated. Differences between laboratories were also assessed qualitatively. RESULTS: Out of the eight laboratories contacted, seven participated in the survey, yielding a response rate of 87.5%. Immunofixation Electrophoresis (IFE) was used by all labs for serum immunotyping. All labs reported a new small abnormal band in patients with no known monoclonal gammopathy or with a known M-protein. Variations were found in terminologies used to label paraprotein, terminologies used to report normal and pathological SPE patterns, electrophoretic technique, methods for quantifying paraprotein in the gamma region on SPE and for albumin quantification. Similarly, the number of decimal places reported, reporting of multiple monoclonal proteins and small paraprotein in the beta region or monoclonal proteins less than 1 g/L, approach for screening, number of fractions reported in gamma region and reporting of interferences were also not standardized and var-iations were noticed. CONCLUSIONS: Our survey highlighted variations in practices of SPE reporting. These differences in laboratory practices could result in inconsistent test results, which could adversely affect patient care.

Cancer Chemoresistance; Recent Challenges and Future Considerations.

Cancer remains one of the serious health hazards and major causes of human mortality across the world. Despite the development of many typical antineoplastic drugs and introduction of novel targeted agents, chemoresistance constitutes a major challenge in the effective therapeutic management of cancer. Drug inactivation, efflux of anticancer agents, modification of target sites, enhanced repair of DNA damage, apoptosis failure and induction of epithelial-mesenchymal transition are the principal mechanisms of cancer chemoresistance. Moreover, epigenetics, cell signaling, tumor heterogeneity, stem cells, microRNAs, endoplasmic reticulum, tumor microenvironment and exosomes have also been implicated in the multifaceted phenomenon of anticancer drug resistance. The tendency of resistance is either intrinsically possessed or subsequently acquired by cancerous cells. From clinical oncology standpoint, therapeutic failure and tumor progression are the most probable consequences of cancer chemoresistance. Combination therapy can help to overcome the issue of drug resistance, and therefore, the development of such treatment regimens is recommended for counteracting the emergence and dissemination of cancer chemoresistance. This chapter outlines the current knowledge on underlying mechanisms, contributory biological factors and likely consequences of cancer chemoresistance. Besides, prognostic biomarkers, diagnostic methods and potential approaches to overcome the emergence of antineoplastic drug resistance have also been described.

Arthroscopic removal of a solitary osteochondroma interfering with the podotrochlear apparatus in a foal.

OBJECTIVE: To report the diagnostics, surgical treatment, and outcome of a juvenile foal with solitary osteochondroma (SO) interfering with the podotrochlear apparatus. STUDY DESIGN: Case report ANIMAL: One 36-day-old Arabian colt. METHODS: Clinical, radiographic, ultrasonographic, computed tomographic, and histopathologic examinations were required to characterize and treat an SO located at the palmar aspect of the diaphysis of the second phalanx of the left forelimb. This SO caused severe distal interphalangeal joint (DIPJ) inflammation, marked interference with the podotrochlear apparatus, and associated lameness. RESULTS: Despite the small size of the foal's foot, complete resection of the SO was possible via palmar DIPJ arthroscopy by using motorized equipment. Full resolution of the lameness was achieved within 3 months of surgery. CONCLUSION: Atypical SO located on the palmar aspect of the second phalanx can cause marked nonseptic inflammation of the DIPJ and interference with the podotrochlear apparatus and should be considered among the differential diagnoses for severe lameness in juvenile foals. Arthroscopic resection of the SO led to an excellent outcome.

Successful management of ivermectin-induced blindness in an African lion (Panthera leo) by intravenous administration of a lipid emulsion.

BACKGROUND: Ivermectin is widely used in veterinary practice for the treatment of ecto- and endo-parasites. In wildlife, an extra-label use this parasiticide is sometimes associated with toxicity. Different treatment regimens have been used in ivermectin toxicosis. The present report describes a successful reversal of ivermectin toxicity by intravenous administration of a commercially available lipid emulsion in a captive African lion (Panthera leo). CASE PRESENTATION: A 2-year old captive African lion (Panthera leo) weighing ~130 kg was presented with acute neurological impairment and bilateral blindness that had developed 24 h after ivermectin exposure. The animal was treated with a commercially available lipid emulsion along with supportive therapy and experienced complete recovery. CONCLUSION: To our knowledge, this is the first case report of the use of lipid emulsion in the management of ivermectin induced blindness in an African lion and it appears that intravenous lipid emulsion may be an effective therapy in ivermectin toxicity in lions. Further testing in expanded clinical trials is clearly warranted.

Artificial Intelligence - Perception of Clinical Laboratories' Technical Staff a Nationwide Multicentre Survey in Pakistan.

Introduction: As Artificial Intelligence (AI) technology continues to assimilate into various industries, there is a huge scope in the healthcare industry specifically in clinical laboratories. The perspective of the laboratory professionals can give valuable insight on the ideal path to take for AI implementation. Methods: The study utilized a cross-sectional survey design and was conducted at the section of Chemical Pathology, Department of Pathology and Laboratory Medicine, the Aga Khan University (AKU), Karachi, Pakistan in collaboration with Consultant Pathologists of 9 clinical laboratories associated with teaching hospitals across Pakistan from October-November 2023. The survey was for a duration of 2 weeks and was circulated to all working laboratory technical staff after informed consent. Results: A total of 351 responses were received, of which 342 (male=146, female=196) responses were recorded after exclusion. Respondents ranged from technologists, faculty, residents, and coordinators, and were from different sections (chemical pathology, microbiology, haematology, histopathology, POCT). Out of the total 312 (91.2%) of respondents stated that they were at least somewhat familiar with AI technology. Experts in AI were only 2.0% (n=7) of all respondents, but 90% (n=6) of these were < 30 years old. 76.3% (n=261) of the respondents felt the need to implement more AI technology in the laboratories, with time saving (26.1%) and improving performances of tests (17.7%) cited to be the greatest benefits of AI. Security concerns (n=144) and a fear of decreasing personal touch (n=143) were the main concerns of the respondents while the younger employees had an increased fear of losing their jobs. 76.3% were in favour of an increase in AI usage in the laboratories. Conclusion: This study highlights a favourable perspective among laboratory professionals, acknowledging the potential of AI to enhance both the efficiency and quality of laboratory practices. However, it underscores the importance of addressing their concerns in the thoughtful implementation of this emerging technology.

Worm control practices used by Thoroughbred horse managers in Australia: A national survey.

This study assessed worm control practices used by Australian Thoroughbred farm managers with an online questionnaire survey. The questionnaire comprised 52 questions (close-ended: 44; open-ended: 8) about farm demography and general husbandry practices, farm managers' knowledge of gastrointestinal nematodes (GIN) and their importance, diagnosis, worm control strategies and anthelmintics, anthelmintic resistance (AR) and grazing management. Following the pilot survey, the link for the questionnaire survey was sent to all (n = 657) registered members of the Thoroughbred Breeders Australia on 12th April 2020. The response rate for the questionnaire was 18.5% (122 of 675). The farm managers reported a good understanding of GIN and their importance in different age groups of horses as most respondents (70% of 122) perceived worm-related illness to be more important in young (i.e., foals, weanlings and yearlings) than adult (> 3 years old) horses. Although most respondents (93%, 113 of 122) used anthelmintics prophylactically to control GIN, only 15% (18 of 122) observed worm-related illness in their horses. Just under 40% of respondents were performing faecal egg counts, with less than 20% using the results of faecal egg counts to guide deworming decisions. The interval-based deworming strategy was the most common method (≥55% of 122 respondents) to control GIN in all age groups of horses. Macrocyclic lactones were the first choice of anthelmintics for all age groups of horses. Although the majority of respondents (88%, 107 of 122) perceived resistance in GIN against commonly used anthelmintics as an important issue in managing worms in horses, only 29% assessed the efficacy of anthelmintics and 91% (111 of 122) were unaware of AR on their properties. Grazing management practices, such as manure removal, were more frequently performed on smaller paddocks (<0.20 ha: 58%) than on larger paddocks (>0.20 ha: 18%). Multiple correspondence analyses showed that the likelihood of suboptimal worm control practices on small farms (n = ≤50 horses) was greater than that of medium (n = 51-100) and large (n = >100) farms. This study provides insights into the demography of Thoroughbred farms in Australia, husbandry practices used by stud managers and their knowledge about worms, control options and AR concerns, thereby paving the way for taking any initiatives to address the problem of AR in GIN of Australian Thoroughbred horses.

Understanding temporal and spatial distribution of intestinal nematodes of horses using faecal egg counts and DNA metabarcoding.

This study reports the spatial and temporal distribution of ascarid and strongylid nematodes in Thoroughbred horses by age category across different climatic zones in Australia over an 18-month period. Faecal samples (n = 2046) from individual horses were analysed using the modified McMaster technique for faecal egg counts (FECs). Strongylids were identified using PCR-directed next-generation sequencing of the second internal transcribed spacer (ITS-2) of the nuclear ribosomal DNA. Yearlings had the highest prevalence (82%) of strongyle eggs followed by weanlings (79%), foals (58%), wet mares (49%) and dry mares (46%). For Parascaris spp., foals had the highest prevalence (35%) followed by weanlings (21%) and yearlings (10%). The highest mean FECs for Parascaris spp. were observed in foals (525 eggs per gram [EPG] of faeces) while those for strongyles were in yearlings (962 EPG). Among horses that were classified as adults at the time of sampling, 77% (860 of 1119) of mares were low (i.e., <250 EPG) strongyle egg-shedders. Mean strongyle FEC counts were highest in the Mediterranean (818 EPG) followed by summer (599 EPG), winter (442 EPG), and non-seasonal (413 EPG) rainfall zones. Twenty-six nematode species were detected, with Cylicostephanus longibursatus (26.5%), Cylicocyclus nassatus (23.7%) and Coronocyclus coronatus (20.5%) being the most frequently detected species. Their richness and relative abundance varied with horse age, season and climatic zone. In addition, Strongylus equinus and Triodontophorus spp. (T. brevicauda and T. serratus) were also detected. This comprehensive study elucidates spatial (climatic zone) and temporal (i.e., seasonal) trends in prevalence and burdens of intestinal nematodes in Australian horses using non-invasive conventional and molecular methods. The information presented in this study is crucial for developing integrated management strategies to control horse parasites in farmed horses.

A national survey of anthelmintic resistance in ascarid and strongylid nematodes in Australian Thoroughbred horses.

This study quantified the extent of anthelmintic resistance (AR) in ascarid and strongylid nematodes against commonly used anthelmintics in Australian Thoroughbred horses. Faecal egg count reduction tests (FECRTs, n = 86) and egg reappearance period (ERP) tests were conducted on 22 farms across Australia. Faecal egg counts (FECs) were determined using the modified McMaster technique, and percent faecal egg count reduction (%FECR) was calculated using the Bayesian hierarchical model and hybrid Frequentist/Bayesian analysis method. The results were interpreted using old (published in 1992) and new (2023) research guidelines of the World Association for the Advancement of Veterinary Parasitology (WAAVP). The species composition of strongylid nematodes was detected utilising a DNA-metabarcoding method using pre- and post-treatment samples. Resistance was observed in strongylid nematodes to commonly used single-active and combination anthelmintics, including ivermectin (IVM %FECR range: 82%-92%; 95% lower credible interval (LCI) range: 80%-90%), abamectin (ABM: 73%-92%; 65%-88%), moxidectin (MOX: 89%-91%; 84%-89%), oxfendazole (OFZ: 0%-56%; 0%-31%) and its combination with pyrantel (OFZ + PYR: 0%-82%; 0%-78%). Resistance in Parascaris spp. was observed to IVM (10%-43%; 0%-36%), ABM (0%; 0%) and MOX (0%; 0%). When the new thresholds recommended by the WAAVP were used, AR was detected in six additional FECRTs for strongylids and three more tests for Parascaris spp., introducing resistance to OFZ and OFZ + PYR in the latter. Shortened ERPs (4-6 weeks) of strongylids were observed in 31 FECRTs in which AR was not detected at 2 weeks post-treatment for all the anthelmintics tested. Among cyathostomins, Cylicocyclus nassatus, Cylicostephanus longibursatus and Coronocyclus coronatus were the most prevalent species at 2 weeks post-treatment, whereas the main species appearing at five weeks following treatments with macrocyclic lactones were Cylicocyclus nassatus, Cylicostephanus longibursatus and Cylicocyclus ashworthi. After treatment with OFZ + PYR, the latter three, plus Coronocyclus coronatus and Cyathostomum catinatum, were detected at 5 weeks post-treatment. Overall, the study highlights the prevalence of AR in both ascarids and strongylid nematodes against commonly used anthelmintic products to control worms in Australian horses. The results indicate that ML combination products provided acceptable efficacy at 2 weeks. However, ERP calculations suggest that products work less effectively than previously measured. It is suggested to regularly monitor the efficacy of the anthelmintics and consider changing the worm control practices to better manage worms and AR in Australian horses.

Biological implications of long-term anthelmintic treatment: what else besides resistance are we selecting for?

Long-term intensive use of anthelmintics for parasite control of livestock, companion animals, and humans has resulted in widespread anthelmintic resistance, a problem of great socioeconomic significance. But anthelmintic therapy may also select for other biological traits, which could have implications for anthelmintic performance. Here, we highlight recent examples of changing parasite dynamics following anthelmintic administration, which do not fit the definition of anthelmintic resistance. We also consider other possible examples in which anthelmintic resistance has clearly established, but where coselection for other biological traits may have also occurred. We offer suggestions for collecting more information and gaining a better understanding of these phenomena. Finally, we propose research questions that require further investigation and make suggestions to help address these knowledge gaps.

Synthesis and analytical characterization of Ca-BTC metal organic framework.

Metal Organic framework (MOF) has been a class of great interest during the past few years owing to its decidedly applicative, easily synthesized and improved characteristics. Ca-BTC MOF is synthesized by Hydrothermal technique and reported for the first time. Its structural morphology was analyzed using XRD, SEM, and EDS, showing the tetragonal crystal structure having grain size of 24.92 nm and purity of sample respectively. FTIR, Raman Spectroscopy ensures the metal organic framework between Calcium and the tri-carboxylic group. Photoluminescence measures the energy gap of 3.792 eV, showing approximately the semiconducting behavior of synthesized material. Zeta potential having value of -13.5 mV confirms the instability having good microbial activity and conductivity i.e 0.290 mS/cm which reveals important insights into its electrical properties.

Assessment of worm control practices recommended by equine veterinarians in Australia.

This study aimed to assess Australian veterinarians' knowledge, perceptions and treatment strategies for worm control in horses with an online questionnaire. The questionnaire comprised 64 questions covering various aspects of: (i) veterinary practice; (ii) the veterinarian's knowledge of gastrointestinal nematodes (GINs) and the importance of parasites in different age groups of horses; (iii) the diagnosis and control of worms; (iv) anthelmintics and anthelmintic resistance (AR); (v) grazing management; and (vi) the means of communication and the discussion between veterinarians and their clients regarding worm control. Following a pilot survey, a link for the questionnaire survey was sent to all (n = 1,148) registered members of Equine Veterinarians Australia in April 2020. The response rate for the questionnaire was 10% (118 of 1,148). The findings of this study illustrate veterinarians' good understanding of aspects of equine parasites, including control. However, respondents mainly recommended frequent, interval-based prophylactic deworming in young horses, and only 40% (96 of 239) diagnosed GIN infections based on faecal egg count (FEC) results in all age groups of horses. Furthermore, only 27% (88 of 330) of the respondents made deworming decisions based on FECs. Most of the respondents recommended macrocyclic lactones (MLs) for all age groups of horses (71%, 481 of 677), and the most frequently used method to calculate the dose of anthelmintics was by estimating the weight of animals visually (53%, 63 of 118). Although the majority of respondents (97%, 115 of 118) perceived AR to be a critical issue in managing worms in horses, 58% (67 of 118) of them were unaware of the status of AR on their clients' properties. Forty-two percent (50 of 118) of the respondents perceived the presence of AR in worms, including pinworms (16%), strongylins (15%), species of Draschia and Habronema (6%), Strongyloides westeri (2%) and tapeworms (1%). Twenty-seven percent (32 of 118) of the respondents rarely discussed equine worm control practices with their clients. This study provides insights into the perception and worm control practices recommended by Australian veterinarians to manage equine parasites. The findings highlight the importance of continued education and awareness of AR, and the use of non-chemical methods as well as consideration of the legislation of prescription-only use of anthelmintics based on FECs to achieve sustainable control of GINs in Australian horses.

Prevalence and diversity of ascarid and strongylid nematodes in Australian Thoroughbred horses using next-generation sequencing and bioinformatic tools.

The study presents the results of a cross-sectional survey to describe the epidemiology of ascarid and strongylid nematodes in horses, the impact of diverse climatic conditions on parasite diversity and the levels of faecal egg shedding in different age groups of managed Thoroughbred horses. Individual faecal samples (n = 1377) collected from 62 Thoroughbred farms across four climatic zones in Australia were analysed using the modified McMaster technique for faecal egg counts (FECs) and strongylid nematodes were identified utilising PCR-directed next-generation sequencing (NGS) of the second internal transcribed spacer of the nuclear ribosomal DNA (ITS-2). Across all age groups, the prevalence of ascarid and strongylid nematodes was 12% (95% confidence interval 10-14%) and 72% (70-74%), respectively. Based on strongylid FECs, yearlings had the highest prevalence (89%) followed by weanlings (83%), foals (79%), wet mares (61%), dry mares (59%) and stallions (54%). However, for Parascaris spp., foals had the highest prevalence (46%) followed by weanlings (32%) and yearlings (13%). The highest mean FECs for Parascaris spp. were observed in foals (418 eggs per gram [EPG] of faeces) while those for strongylids were in yearlings (1002 EPG). Of the adult horses (mares and stallions), 67% (489 of 729) and 11% (77 of 729) were low (i.e., ≤250 EPG) and moderate (i.e., 251-500 EPG) strongylid egg-shedders, respectively. Strongylid egg shedding varied across climatic zones, with the highest mean FECs in the summer rainfall (723 EPG) followed by non-seasonal rainfall (629 EPG), winter rainfall (613 EPG), and Mediterranean (606 EPG) rainfall zones. Twenty-three nematode species were detected using NGS, with Cylicostephanus longibursatus (28%), Cylicocyclus nassatus (23%) and Coronocyclus coronatus (23%), being the most abundant species. Three species of Strongylus (i.e., S. vulgaris, S. equinus and S. edentatus) were also detected. The nemabiome composition, species richness and relative abundance varied within horse age and between climatic zones. These empirical findings provide a comprehensive understanding of the prevalence of parasites within horse populations and the multifaceted factors that influence their occurrence, thereby allowing for the formulation of tailored strategies aimed at parasite control in domestic horses.

Egg reappearance periods of anthelmintics against equine cyathostomins: The state of play revisited.

Cyathostomins are the most common and highly prevalent parasites of horses worldwide. Historically, the control of cyathostomins has mainly relied on the routine use of anthelmintic products. Increasing reports on anthelmintic resistance (AR) in cyathostomins are concerning. A potential method proposed for detecting emerging AR in cyathostomins has been estimating the egg reappearance period (ERP). This paper reviews the data available for the ERP of cyathostomins against the three major classes of anthelmintics, macrocyclic lactones, tetrahydropyrimidines, and benzimidazoles. Published peer-reviewed original research articles were obtained from three databases (PubMed, CAB Direct and Web of Science) and were evaluated for their inclusion in a systematic review. Subsets of articles were then subjected to a review of ERP data. A total of 54 (of 134) studies published between 1972 and 2022 met the criteria for inclusion in the systematic review. Until the beginning of 2022, there was no agreed definition of the ERP; eight definitions of ERP were identified in the literature, complicating the comparison between studies. Additionally, potential risk factors for the shortening of the ERP, including previous anthelmintic use and climate, were frequently not described. Reports of shortened ERP for moxidectin and ivermectin are frequent: 20 studies that used comparable ERP definitions reported shortened moxidectin and ivermectin ERPs of 35 and 28 days, respectively. It is unclear whether the ERPs of these anthelmintics reduced to such levels are due to the development of AR or some biological factors related to horses, cyathostomin species, and/or the environment. The ERPs for other anthelmintics, such as fenbendazole and pyrantel, were frequently not reported due to established resistance against these drugs. Future research in horses is required to understand the mechanism(s) behind the shortening of ERP for cyathostomins. Based on this systematic review, we propose recommendations for future ERP studies.

Molecular diagnostics for gastrointestinal helminths in equids: Past, present and future.

This review is aimed to (i) appraise the literature on the use of molecular techniques for the detection, quantification and differentiation of gastrointestinal helminths (GIH) of equids, (ii) identify the knowledge gaps and, (iii) discuss diagnostic prospects in equine parasitology. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews, we retrieved 54 studies (horses: 50/54; donkeys and zebras: 4/54) from four databases. Polymerase chain reaction (PCR) was employed in all of the studies whereas PCR amplicons were sequenced in only 18 of them. Other techniques used (including modifications of PCR) were reverse line blot, quantitative (q)PCR, restriction fragment length polymorphism, nested-PCR, PCR-directed next-generation sequencing, Southern blotting, single strand conformation polymorphism, PCR-enzyme linked immunosorbent assay, matrix-assisted laser desorption/ionisation-time of flight and random amplification of polymorphic DNA. Most of the studies (53/54) used nuclear ribosomal RNA (including the internal transcribed spacers, intergenic spacer, 5.8 S, 18 S, 28 S and 12 S) as target loci while cytochrome c oxidase subunit 1 and random genomic regions were targeted in only three and one studies, respectively. Overall, to date, the majority of molecular studies have focused on the diagnosis and identification of GIHs of equids (i.e. species of Anoplocephala, Craterostomum, cyathostomins, Oesophagodontus, Parascaris, Strongylus, Strongyloides and Triodontophorus), with a recent shift towards investigations on anthelmintic resistance and the use of high-throughput nemabiome metabarcoding. With the increasing reports of anthelmintic resistance in equid GIHs, it is crucial to develop and apply techniques such as advanced metabarcoding for surveillance of parasite populations in order to gain detailed insights into their diversity and sustainable control. To the best of our knowledge, this is the first systematic review that evaluates molecular investigations published on the diagnosis and quantification of equid GIHs and provides useful insights into important knowledge gaps and future research directions in equid molecular parasitology.

La0.3Sr0.2Mn0.1Zn0.4 oxide-Sm0.2Ce0.8O1.9 (LSMZ-SDC) nanocomposite cathode for low temperature SOFCs.

Nanocomposite based cathode materials compatible for low temperature solid oxide fuel cells (LTSOFCs) are being developed. In pursuit of compatible cathode, this research aims to synthesis and investigation nanocomposite La0.3Sr0.2Mn0.1Zn0.4 oxide-Sm0.2Ce0.8O1.9 (LSMZ-SDC) based system. The material was synthesized through wet chemical method and investigated for oxide-ceria composite based electrolyte LTSOFCs. Electrical property was studied by AC electrochemical impedance spectroscopy (EIS). The microstructure, thermal properties, and elemental analysis of the samples were characterized by TGA/DSC, XRD, SEM, respectively. The AC conductivity of cathode was obtained for 2.4 Scm(-1) at 550 degrees C in air. This cathode is compatible with ceria-based composite electrolytes and has improved the stability of the material in SOFC cathode environment.

Ultrasound-guided injection technique of the equine cervical nerve roots.

Radiculopathy in horses is often a diagnosis of exclusion because of the non-specific clinical signs related to neck pain and possible forelimb lameness. There are no reported treatment options in the equine veterinary literature. The purpose of the study was to describe an ultrasound-guided injection of the cervical nerve root C3 to C8, to evaluate accuracy, time and safety and to anticipate possible complications on clinical cases. Under general anesthesia and with ultrasound guidance, five horses were injected from C3 to C8 with 1.5mL mix of contrast and latex. Immediately after euthanasia, the necks were taken for CT examination and then dissection was performed 3 days later. Data regarding the accuracy of injection, the presence of injectate in the nerve root, vertebral vessel or vertebral canal were recorded from both CT and dissection. The time of injection and ability to visualize the nerve root prior to injection were also recorded. Out of 60 intended injections, 55 (CT images) and 57 (dissection) led to injectate deposited within the target zone with direct contact between contrast/latex and cervical nerve roots noted in 76.4% and 73.7%, respectively. Presence of contrast/latex injectate within nerves (≤11%), vertebral vessels (<4%) and canal (<4%) were rarely encountered. No variation on success rate or safety noted based on the site of injection. The technique described has excellent accuracy, with injectate deposition in direct contact (≈75%) or close vicinity (≈25%) of C3-C8 cervical nerve roots. Injectate diffusion is likely to further improve success rate. Rare presence of injectate within nerve/sheath, vertebral vessels/canal along with diffusion warrants caution when performing this procedure in clinical cases.

Development of a virtual classroom for pre-analytical phase of laboratory medicine for undergraduate medical students using the Delphi technique.

BACKGROUND: Amongst the pre-analytical, analytical, and post-analytical phase of laboratory testing, pre-analytical phase is the most error-prone. Knowledge gaps in understanding of pre-analytical factors are identified in the clinical years amongst undergraduate students due to lack of formal teaching modules on the pre-analytical phase. This study was conducted to seek experts' consensus in Clinical Chemistry on learning objectives and contents using the Delphi technique with an aim to develop an asynchronous virtual classroom for teaching pre-analytical factors of laboratory testing. METHODS: A mixed method study was conducted at the Aga Khan University. A questionnaire comprising of 16 learning objectives and their associated triggers was developed on Google Docs for developing the case vignettes. A four-point Likert Scale, which included strongly agree, agree, disagree and strongly disagree, was utilized for the learning objectives. An open-ended question was included for experts to suggest new items for inclusion. A cut off of at least 75% agreement was set to establish consensus on each item. A total of 17 Chemical Pathology faculty from 13 institutions across Pakistan were invited to participate in the first round of Delphi. Similar method of response was used in round two to establish consensus on the newly identified items suggested by the faculty in round 1. Later, the agreed-upon objectives and triggers were used to develop interactive scenarios over Moodle to concurrently test and teach medical students in a nonchalant manner. RESULTS: A total of 17 responses were received in Round 1 of the Delphi process (response rate = 100%), while 12 responses were received in Round 2 (response rate = 71%). In round 1, all 16 learning objectives reached the required consensus (≥ 75%) with no additional learning objectives suggested by the experts. Out of 75 triggers in round 1, 61 (81.3%) reached the consensus to be included while 39 were additionally suggested. In 2nd round, 17 out of 39 newly suggested triggers met the desired consensus. 14 triggers did not reach the consensus after two rounds, and were therefore eliminated. The virtual classroom developed using the agreed-upon learning objectives and triggers consisted of 20 items with a total score of 31 marks. The questions included multiple choice questions, fill in the blanks, drag and drop sequences and read-and-answer comprehensions. Specific learning points were included after each item and graphs and pictures were included for a vibrant experience. CONCLUSION: We developed an effective and interactive virtual session with expert consensus on the pre-analytical phase of laboratory testing for undergraduate medical students which can be used for medical technologist, graduate students and fellows in Chemical Pathology.

Docking study of chloroquine and hydroxychloroquine interaction with RNA binding domain of nucleocapsid phospho-protein - an in silico insight into the comparative efficacy of repurposing antiviral drugs.

Recent outbreak of novel Coronavirus disease () pandemic around the world is associated with severe acute respiratory syndrome. The death toll associated with the pandemic is increasing day by day. SARS-CoV-2 is an enveloped virus and its N terminal domain (NTD) of Nucleocapsid protein (N protein) binds to the viral (+) sense RNA and results in virus ribonucleoprotien complex, essential for the virus replication. The N protein is composed of a serine-rich linker region sandwiched between NTD and C terminal (CTD). These terminals play a role in viral entry and its processing post entry. The NTD of SARS-CoV-2 N protein forms orthorhombic crystals and binds to the viral genome. Therefore, there is always a quest to target RNA binding domain of nucleocapsid phosphoprotein (NTD-N-protein which in turn may help in controlling diseases caused by SARS-CoV-2 in humans. The role of Chloroquine and Hydroxychloroquine as potential treatments for is still under debate globally because of some side effects associated with it. This study involves the In silico interactions of Chloroquine and Hydroxychloroquine with the NTD-N-protein of SARS-CoV-2. With the help of various computational methods, we have explored the potential role of both of these antiviral drugs for the treatment of patients by comparing the efficacy of both of the drugs to bind to NTD-N-protein. In our research Hydroxychloroquine exhibited potential inhibitory effects of NTD-N-protein with binding energy -7.28 kcal/mol than Chloroquine (-6.30 kcal/mol) at SARS-CoV-2 receptor recognition of susceptible cells. The outcomes of this research strongly appeal for in vivo trials of Hydroxychloroquine for the patients infected with . Furthermore, the recommended doses of Hydroxychloroquine may reduce the chances of catching to the healthcare workers and staff who are in contact with or delivering direct care to coronavirus patients as long as they have not been diagnosed with . We further hypothesize that the comparative NTD-N-protein -drug docking interactions may help to understand the comparative efficacy of other candidate repurposing drugs until discovery of a proper vaccine.Communicated by Ramaswamy H. Sarma.

The Long-Term Characteristics of Immunity Conferred by COVID-19 Using Antibody Tests.

Introduction Since December 2019, more than 184 Million cases and 3.97 Million COVID-19 related deaths have been reported around the world. Since these statistics are laboratory-based confirmed cases, the true burden of disease may be underestimated. Many populations like those who are regularly visiting health care facilities and those with end-stage renal disease (ESRD) for visiting dialysis units, patients with malignancies, on regular chemo and radiotherapy, and healthcare workers (HCW) are considered high risk for nosocomial COVID-19 re-infections. Objective To understand the long-term behaviour and protective efficacy of already formed anti-SARS-CoV-2 antibody against spike-S protein and nucleocapsid antigen in different populations keeping in view their risk of re-exposure and re-infection is high. To delineate seropositivity with respect to age, gender, and other co-morbidities like diabetes mellitus (DM), hypertension (HTN), and chronic kidney disease (CKD)/ESRD as well as the general population. Methodology During the study, 480 cases of COVID-19 with a post-exposure antibody reactive were followed. These patients were followed on telemedicine for the development of reinfection symptoms and persistence of antibody response. Around 115 patients agreed for regular monitoring of their immunity against the COVID-19 virus through testing through the anti-SARS-CoV-2 antibody test. The rest of the patients were followed on telemedicine until the date of development of any re-infection, but none reported to have typical symptoms of COVID-19 along with positive polymerase chain reaction (PCR). Results Among 115 patients, the mean age was 42.44 + 15.755 years. 61.7% of patients were males and 66.1% were non-health workers while 26.1% of patients had DM/HTN or both. Among these patients, 76.5% had mild/no symptoms and antibodies were found present among 51.3% patients for 3-6 months. Only 2.6% of patients were re-infected. Significant association (p<0.05) of age was found with re-infection while insignificant association (p>0.05) of sex, co-morbidities, profession, symptoms, and persistence of antibodies with re-infection. Conclusion The study concluded that natural immune response was adequate to protect against reinfection as long as more than 9 months. It was more pronounced among patients with ESRD and those with severe disease. Surprisingly, among patients with haematological malignancies, either there was no seropositivity or a very weak positive antibody response. All other malignancies had similar seropositivity behaviour compared to the general population or other co-morbidity like DM, HTN, and coronary artery disease (CAD).

Clinical Utility of Protein Induced by Vitamin K Absence-II in Patients with Hepatocellular Carcinoma.

OBJECTIVE: Despite moderate sensitivity, alpha fetoprotein (AFP) is widely used in screening and prognostication for hepatocellular carcinoma (HCC). The objective of the current study was to assess clinical utility of Prothrombin induced by Vitamin K absence-II (PIVKAII) in addition to AFP in patients with HCC. METHODS: We retrospectively reviewed 244 patients with documented AFP, PIVKA II and dynamic imaging of the liver. Using ROC curves, cutoff values for AFP and PIVKAII for HCC detection, tumor grade and microvascular invasion (MVI) were assessed. In patients who underwent liver transplantation (LT) for HCC, survival was determined using Kaplan Meier curves. RESULTS: The median PIVKAII in healthy living donors was 28.6mAU/ml (15.9-55). In cirrhotics, the sensitivity of an AFP cutoff of 7.6 ng/ml or PIVKAII  cutoff of 250 mAU/ml for HCC detection was 91.7% (176/192) and specificity was 62.9%(68/108) (p <0.0001). In patients with HCC, PIVKAII values were significantly elevated with tumor size > 5 cm (P < 0.0001), tumor nodules > 3(P=0.01), and macrovascular invasion(p <0.0001).  The high risk group (patients with AFP ≥ 40 ng/ml + PIVKAII ≥ 350 mAU/ml), had a sensitivity of (23/33) 69.6% and specificity of (22/22)100% for MVI (P <0.001). The estimated 3 year RFS after LT in the low risk group (AFP.