Diagnostic accuracy of autofluorescence-Raman spectroscopy for surgical margin assessment during Mohs micrographic surgery of basal cell carcinoma.

BACKGROUND: Autofluorescence (AF) - Raman spectroscopy is a technology that can detect residual basal cell carcinoma (BCC) on the resection margin of fresh surgically excised tissue specimens. The technology does not require tissue fixation, staining, labelling, or sectioning, and provides quantitative diagnosis maps of the surgical margins in 30 minutes. OBJECTIVES: To determine the accuracy of the AF-Raman instrument to detect incomplete excisions of BCC during Mohs micrographic surgery, using histology as reference standard. METHODS: Skin layers from 130 patients undergoing Mohs surgery at the Nottingham University Hospitals NHS Trust (September 2022 to July 2023) were investigated with the AF-Raman instrument. The layers were measured fresh, immediately after excision. The AF-Raman results and the intra-operative assessment by Mohs surgeons were compared to a post-operative consensus-derived reference produced by three dermatopathologists. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULTS: The AF-Raman analysis was successfully completed for 125 out of the 130 layers. The AF-Raman analysis covered 91% of the specimen surface area on average, with the lowest being 87% for eyelid and the highest being 94% for forehead specimens. The AF-Raman instrument identified positive margins in 24 out of 36 BCC-positive cases, resulting in a 67% sensitivity (95% confidence intervals (CI): 49%-82%) and negative margins in 65 out of 89 BCC-negative cases, resulting in a 73% specificity (95% CI 63%-82%). Only one out of the 12 false negative cases was caused by misclassification by the AF-Raman algorithm. The other 11 false negatives cases were produced because no valid Raman signal was recorded at the location of the residual BCC due to either occlusion by blood or poor contact between tissue and cassette window. The intra-operative diagnosis by Mohs surgeons identified positive margins in 31 out of 36 BCC-positive cases, 86% sensitivity (95% CI: 70%-95%), and negative margins in 79 out of 89 BCC-negative cases, 89% specificity (95% CI: 81%-95%). CONCLUSIONS: This study shows that the AF-Raman instrument has potential for intra-operative microscopic assessment of surgical margins in surgery of BCC. Further improvements are required for tissue processing to ensure complete coverage of the surgical specimens. ClinicalTrials.gov ID NCT03482622.

Diagnosis of tumors during tissue-conserving surgery with integrated autofluorescence and Raman scattering microscopy.

Tissue-conserving surgery is used increasingly in cancer treatment. However, one of the main challenges in this type of surgery is the detection of tumor margins. Histopathology based on tissue sectioning and staining has been the gold standard for cancer diagnosis for more than a century. However, its use during tissue-conserving surgery is limited by time-consuming tissue preparation steps (1-2 h) and the diagnostic variability inherent in subjective image interpretation. Here, we demonstrate an integrated optical technique based on tissue autofluorescence imaging (high sensitivity and high speed but low specificity) and Raman scattering (high sensitivity and high specificity but low speed) that can overcome these limitations. Automated segmentation of autofluorescence images was used to select and prioritize the sampling points for Raman spectroscopy, which then was used to establish the diagnosis based on a spectral classification model (100% sensitivity, 92% specificity per spectrum). This automated sampling strategy allowed objective diagnosis of basal cell carcinoma in skin tissue samples excised during Mohs micrographic surgery faster than frozen section histopathology, and one or two orders of magnitude faster than previous techniques based on infrared or Raman microscopy. We also show that this technique can diagnose the presence or absence of tumors in unsectioned tissue layers, thus eliminating the need for tissue sectioning. This study demonstrates the potential of this technique to provide a rapid and objective intraoperative method to spare healthy tissue and reduce unnecessary surgery by determining whether tumor cells have been removed.

Prevalence of VKORC1 and CYP2C9 gene polymorphisms in Indian population and its effect on warfarin response.

OBJECTIVES: The clinical effectiveness of Warfarin is established. Patients require different warfarin dosages to achieve the target therapeutic anticoagulation. The variability of Warfarin dosage is largely genetically determined, and it can be partly explained by the C1173T and G-1639A polymorphisms of vitamin K epoxide reductase complex subunit 1 (VKORC1) which is its target and *2 and *3 allele of Cytochrome P-450 (CYP) 2C9 [CYP2C9] enzyme which metabolizes to its inactive form. Aim of the present study was to determine the prevalence of these variant alleles known to influence the warfarin dose and correlate genotypes with the average INR as well as mean dose of Warfarin required to maintain INR, in the Indian population. METHODS: Study population included 100 healthy individuals and 83 patients operated for Aortic or Mitral Valve replacement and prescribed warfarin thereafter. Of these 83 patients records of INR for the period of six months and mean maintenance dose (stable therapeutic dose) of warfarin required to maintain INR were available for 26 patients. For the remaining patients, apart from their demographic data only maintenance dose was available. Genotyping of above mentioned polymorphisms was carried out by using PCR-based restriction digestion method. RESULTS: Although less as compared to wild type alleles, the variant alleles of CYP2C9*2 and *3 as well as of VKORC1 polymorphisms (C1173T and G-1639A) were observed in our study population. Mean maintenance dose (mg/day) of Warfarin was in the decreasing order of patients as compared to the wild type genotypes for all above mentioned polymorphisms. The decrease in the dose was in the order of heterozygotes for CYP2C9*2 to CYP2C9*3 to C1173T and G-1639A of VKORC1 (P<0.001). There was significant correlation (r=0.51, P<0.001) observed between the dose estimated by pharmacogenetic algorithm of Sconce et al (2005) and actual stable therapeutic dose. INR was high for mutant variants (3.8 to 4) after first dose suggesting that they require decreased mean daily dose of Warfarin. CONCLUSION: In the present study the effect of CYP2C9*2, *3, and VKORC1 (C1173T and G-1639A) genotypes on warfarin dose was observed. However, the genotyping has not been incorporated into daily practice. Perhaps more practical approach would be for clinicians to take genotype information into consideration along with other factors when dosing warfarin.

Use of a temporary forearm tourniquet for intravenous regional anaesthesia: a randomised controlled trial.

BACKGROUND AND OBJECTIVE: To investigate the effect of a temporary, additional mid-forearm tourniquet on the quality of intravenous regional anaesthesia. METHODS: Fifty patients undergoing hand and wrist surgery under intravenous regional anaesthesia (Bier's block) were randomised to receive a temporary mid-forearm tourniquet for 8 min during and after administration of local anaesthetic or to a control group (no tourniquet). The dose of prilocaine was standardised. Onset of block was assessed by response to pinprick in ulnar, radial and median nerve distributions of the hand. Quality of intraoperative anaesthesia was assessed using response to forceps pinch, visual analogue score (VAS) for pain and requirement for supplemental infiltration anaesthesia. Post-operative pain was assessed using VAS. RESULTS: There was no difference between the groups with respect to intraoperative pain VAS (P = 0.19) or post-operative pain VAS (P = 0.69). More patients in the temporary tourniquet group were numb to pinprick testing in the three nerve distributions of the hand at 4 and 8 min after injection of local anaesthetic (P = 0.038). There was no difference in the requirement for supplemental infiltration of local anaesthetic between the groups. CONCLUSION: Our results suggest that a temporary mid-forearm tourniquet might speed the onset of intravenous regional anaesthesia. Although the advantage is lost by the time surgery starts, the technique might permit the use of a smaller dose of local anaesthetic and may have safety advantages by more rapid movement of anaesthetic out of the venous bed. The technique merits further investigation.

Graph NLU enabled question answering system.

With a huge amount of information being stored as structured data, there is an increasing need for retrieving exact answers to questions from tables. Answering natural language questions on structured data usually involves semantic parsing of query to a machine understandable format which is then used to retrieve information from the database. Training semantic parsers for domain specific tasks is a tedious job and does not guarantee accurate results. In this paper, we used conversational analytics tool to create the user interface and to get the required entities and intents from the query thus avoiding the traditional semantic parsing approach. We then make use of Knowledge Graph for querying in structured data domain. Knowledge graphs can be easily leveraged for question answering systems, to use them as the database. We extract appropriate answers for different types of queries which have been illustrated in the Results section.

Morphological and genetic variation in populations of Sitana/ marudhamneydhal/ and the validity of Sitana attenboroughii/.

Dewlap morphology and body ratios are two of the main morphological characters used in delimiting Sitana spp. It becomes a statistical limitation when small samples are used in species descriptions, as outliers can be picked to be described as a distinct species. Genetic data has been used to support the distinctness of a species in Sitana. However, species with shallow genetic divergence becomes a problem if not thoroughly examined. We examine and report our findings on morphological and genetic differences in two populations of Sitana marudhamneydhal and one population of S. attenboroughii. The shallow genetic divergence and overlapping morphology shows that Sitana attenboroughii is a junior synonym of Sitana marudhamneydhal.

Clinical integration of fast Raman spectroscopy for Mohs micrographic surgery of basal cell carcinoma.

We present the first clinical integration of a prototype device based on integrated auto-fluorescence imaging and Raman spectroscopy (Fast Raman device) for intra-operative assessment of surgical margins during Mohs micrographic surgery of basal cell carcinoma (BCC). Fresh skin specimens from 112 patients were used to optimise the tissue pre-processing and the Fast Raman algorithms to enable an analysis of complete Mohs layers within 30 minutes. The optimisation allowed >95% of the resection surface area to be investigated (including the deep and epidermal margins). The Fast Raman device was then used to analyse skin layers excised from the most relevant anatomical sites (nose, temple, eyelid, cheek, forehead, eyebrow and lip) and to detect the three main types of BCC (nodular, superficial and infiltrative). These results suggest that the Fast Raman technique is a promising tool to provide an objective diagnosis "tumour clear yes/no" during Mohs surgery of BCC. This clinical integration study is a key step towards a larger scale diagnosis test accuracy study to reliably determine the sensitivity and specificity in a clinical setting.

In vitro anti-inflammatory and skin protective properties of Virgin coconut oil.

Virgin coconut oil (VCO) has been traditionally used as moisturizer since centuries by people in the tropical region. Clinical studies have revealed that VCO improves the symptoms of skin disorders by moisturizing and soothing the skin. However, the mechanistic action of VCO and its benefits on skin has not been elucidated in vitro. The cytotoxicity (CTC50) of VCO was 706.53 ± 2.1 and 787.15 ± 1.1 µg/mL in THP-1 (Human monocytes) and HaCaT (Human keratinocytes) cells respectively. VCO inhibited TNF-α (62.34 ± 3.2 %), IFN-γ (42.66 ± 2.9 %), IL-6 (52.07 ± 2.0 %), IL-8 (53.98 ± 1.8 %) and IL-5 (51.57 ± 2.6 %) respectively in THP-1 cells. Involucrin (INV) and filaggrin (FLG) content increased by 47.53 ± 2.1 % and 40.45 ± 1.2 % respectively in HaCaT cells. VCO increased the expression of Aquaporin-3 (AQP3), involucrin (INV) and filaggrin (FLG) and showed moderate UV protection in HaCaT cells. In vitro skin irritation studies in Reconstructed human epidermis (RHE) and NIH3T3 cells showed that VCO is a non skin irritant (IC50 > 1000 µg/mL) and non phototoxic (PIF < 2). Our study demonstrated the anti inflammatory activity of VCO by suppressing inflammatory markers and protecting the skin by enhancing skin barrier function. This is the first report on anti-inflammatory and skin protective benefits of VCO in vitro. Overall, the results warrant the use of VCO in skin care formulations.