Provision of smoking cessation support for patients following a diagnosis of cancer in Ireland.

There is growing evidence that smoking cessation (SC) improves outcomes following diagnosis of cancer. Notwithstanding adverse outcomes, a significant number of those diagnosed with cancer continue to smoke. Our objective was to document the SC services provided for patients with cancer by specialist adult cancer hospitals across Ireland, a country with a stated tobacco endgame goal. A cross-sectional survey based on recent national clinical guidelines was used to determine SC care delivery across eight adult cancer specialist hospitals, and one specialist radiotherapy centre. Qualtrics was used. The response rate was 88.9% with data reported from seven cancer hospitals and one specialist radiotherapy centre, all indicating they had some SC related provision (100%). Stop smoking medications were provided to cancer inpatients in two hospitals, at outpatients and attending day ward services in one hospital. Smokers with cancer were referred automatically to the SC service in two hospitals at diagnosis. While stop smoking medications were available 24 h a day in five hospitals, most did not stock all three (Nicotine Replacement Therapy, Bupropion, Varenicline). One hospital advised they had data on uptake of SC services for smokers with cancer but were unable to provide detail. There is considerable variation in SC information and services provided to cancer patients across adult cancer specialist centres in Ireland, reflecting the suboptimal practice of smoking cessation for patients with cancer found in the limited international audits. Such audits are essential to demonstrate service gaps and provide a baseline for service improvement.

Development of a model to investigate the effects of prolonged ischaemia on the muscles of mastication of male Sprague Dawley rats.

OBJECTIVE: The aims of this study were to develop a novel rodent model of masticatory muscle ischaemia via unilateral ligation of the external carotid artery (ECA), and to undertake a preliminary investigation to characterize its downstream effects on mechanosensitivity and cellular features of the masseter and temporalis muscles. DESIGN: The right ECA of 18 male Sprague-Dawley rats was ligated under general anaesthesia. Mechanical detection thresholds (MDTs) at the masseter and temporalis bilaterally were measured immediately before ECA ligation and after euthanasia at 10-, 20-, and 35-days (n = 6 rats/timepoint). Tissue samples from both muscles and sides were harvested for histological analyses and for assessing changes in the expression of markers of hypoxia and muscle degeneration (Hif-1α, VegfA, and Fbxo32) via real time PCR. Data were analyzed using mixed effect models and non-parametric tests. Statistical significance was set at p < 0.05. RESULTS: MDTs were higher in the right than left hemiface (p = 0.009) after 20 days. Histological changes indicative of muscle degeneration and fibrosis were observed in the right muscles. Hif-1α, VegfA, and Fbxo32 were more highly expressed in the masseter than temporalis muscles (all p < 0.05). Hif-1α and, VegfA did not change significantly with time in all muscles (all p > 0.05). Fbxo32 expression gradually increased in the right masseter (p = 0.024) and left temporalis (p = 0.05). CONCLUSIONS: ECA ligation in rats induced hyposensitivity in the homolateral hemiface after 20 days accompanied by tissue degenerative changes. Our findings support the use of this model to study pathophysiologic mechanisms of masticatory muscle ischaemia in larger investigations.

Analysis of Perception of Students and Faculty on Case Based Early Clinical Exposure in First Year Medical Students.

Early clinical exposure (ECE) is a novel strategy for medical colleges to bridge the gap between basic and clinical sciences. There are few studies that explain student's and faculty's perspective on ECE. This study compares the ECE models (Case-based and Video-based case) in terms of benefits and challenges. This cross-over comparative study with 120 medical students of MBBS Batch 2019 and 8 facilitators was conducted in Government medical college, Pali, Rajasthan, India from September 2020 to March 2021. Entire batch was divided into two groups. In a hospital environment, one group was taught by an actual case (patient) of a specific topic, while another group was taught in a classroom setting by a video-based case. The students' and faculty's perspectives on Case-Based Early Clinical Exposure (CBECE) were documented using a pre-tested questionnaire and evaluated on a Likert scale. Finally, both groups were given assessment questions and the process was repeated in the following session of case based early clinical exposure, but with switched groups. Majority of the students (98.3%) agreed CBECE as more effective for attentiveness, retention, correlation of clinical knowledge with theoretical knowledge and communication. Most of the students (43.0%) believed that learning is limited due to lack of repeatability as compare with video-based case. Most of the facilitators found CBECE as effective tool for the development of attitude and communication skills of the students. CBECE can be implemented with limited sessions for sensitization of students about health care setup, importance of empathetic behavior, communication skill and better correlation of preclinical subjects in the context of disease.

A Nationwide Survey of Educational Resource Utilization and Perception Among Internal Medicine Residents.

BACKGROUND: New virtual resources ("novel resources") have been incorporated into medical education. No recent large studies about their use and perception among internal medicine (IM) residents exist. OBJECTIVE: Characterize the use and perceived helpfulness of educational resources. DESIGN: Nationwide survey from December 2019 to March 2020. PARTICIPANTS: IM residents in the USA. MAIN MEASURES: Residents were surveyed on their use and their perceived helpfulness of resources for both attaining general medical knowledge and for point-of-care (POC) learning. Traditional resources included board review resources, clinical experience, digital clinical resources (e.g., UpToDate), journal articles, pocket references, professional guidelines, textbooks, and residency curricula. Novel resources included Twitter, video streaming platforms (e.g., YouTube), online blogs, podcasts, and Wikipedia. KEY RESULTS: We had 662 respondents from 55 residency programs across 26 states. On average, residents used 9 total resources (7 traditional and 2 novel). Digital clinical resources and clinical experience were used by all residents and found helpful by the highest percentage of residents (96% and 94%, respectively). Journal articles were next (used by 90%), followed by board review resources and residency curricula (both used by 85%). Their perceived helpfulness varied, from 90% for board review resources, to 66% for journal articles and 64% for residency curricula, the lowest perceived helpfulness of any traditional resource. Podcasts and video streaming platforms were used as frequently as textbooks (58-59%), but were rated as helpful more frequently (75% and 82% vs 66%, respectively). CONCLUSIONS: Digital clinical resources, video streaming platforms, and podcasts were perceived as helpful, underscoring the importance of ensuring their integration into medical education to complement clinical experience and other traditional resources which remain highly valued by residents. IMPORTANCE: Our findings can inform residency programs as they transition to virtual curricula in the wake of the COVID-19 pandemic.

Intrapatient viral diversity and treatment outcome in patients with genotype 3a hepatitis C virus infection on sofosbuvir-containing regimens.

Treatment with the direct-acting antiviral agent (DAA) sofosbuvir (SOF), an NS5B inhibitor, and velpatasvir (VEL), an NS5A inhibitor, demonstrates viral cure rates of ≥95% in hepatitis C virus (HCV) genotypes (GT) 1-6. Here, we investigated intrapatient HCV diversity in NS5A and NS5B using Shannon entropy to examine the relationship between viral diversity and treatment outcome. At baseline, HCV diversity was lowest in patients infected with HCV GT3 as compared to the other GTs, and viral diversity was greater in NS5A than NS5B (P < .0001). Treatment outcome with SOF/VEL or the comparator regimen of SOF with ribavirin (RBV) was not correlated with baseline diversity. However, among persons treated with SOF/VEL, a decrease in diversity from baseline was observed at relapse in the majority virologic failures, consistent with a viral bottleneck event at relapse. In contrast, an increase in diversity was observed in 27% of SOF+RBV virologic failures. We investigated whether the increase in diversity was due to an increase in the transition rate, one mode of potential RBV-mediated mutagenesis; however, we found no evidence of this mechanism. Overall, we did not observe that viral diversity at baseline influenced treatment outcome, but the diversity changes observed at relapse can improve our understanding of RBV viral suppression in vivo.

Airway changes following labor and delivery in preeclamptic parturients: a prospective case control study.

BACKGROUND: Preeclampsia is associated with greater narrowing of the airway than normal pregnancy, but it is not known if these changes worsen during labor and delivery. The aim of the study was to evaluate the airway during and after labor in women with or without preeclampsia. METHODS: Twenty-five normal and 25 severely preeclamptic pregnant women in early labor were recruited in this single-center, prospective, case-control study. Airway assessment was performed (a) before active labor (b) within one hour of delivery and (c) 24-48 h postpartum. The Mallampati grade was the primary outcome. Sonographic measurements of tongue thickness, anterior neck soft tissue at the level of the hyoid bone and the vocal cords, thyromental distance, and neck circumference, were secondary outcomes. RESULTS: The Mallampati score increased from the pre-labor to the post-labor period in both preeclamptic and normotensive patients (P=0.001 and P=0.002 respectively). A significant difference in tissue thickness at the hyoid level was observed between preeclamptic and normotensive patients pre-labor (P=0.035), post-labor (P=0.05) and postpartum (P=0.05). There was no significant difference in thyromental distance or neck circumference between groups at any time. The total duration of labor and a Mallampati change by one grade correlated (Spearman correlation coefficient 0.473). CONCLUSION: Airway sonography may provide useful bedside anatomical information for prediction of difficult laryngoscopy. The change in airway dimensions and the Mallampati score during labor may persist for 48 h postpartum in both groups. Those with prolonged labor are more susceptible to changes in airway dimensions.

Current Treatment Approaches to HCC with a Special Consideration to Transplantation.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths worldwide. The mainstay of treatment of HCC has been both resectional and transplantation surgery. It is well known that, in selected, optimized patients, hepatectomy for HCC may be an option, even in patients with underlying cirrhosis. Resectable patients with early HCC and underlying liver disease are however increasingly being considered for transplantation because of potential for better disease-free survival and resolution of underlying liver disease, although this approach is limited by the availability of donor livers, especially in resectable patients. Outcomes following liver transplantation improved dramatically for patients with HCC following the implementation of the Milan criteria in the late 1990s. Ever since, the rather restrictive nature of the Milan criteria has been challenged with good outcomes. There has also been an increase in the donor pool with marginal donors including organs retrieved following cardiac death being used. Even so, patients still continue to die while waiting for a liver transplant. In order to reduce this attrition, bridging techniques and methods for downstaging disease have evolved. Additionally new techniques for organ preservation have increased the prospect of this potentially curative procedure being available for a greater number of patients.

Profile of fatal Streptococcal bacteraemia at a tertiary care Indian hospital.

Streptococcus pyogenes causes mild to acutely life-threatening diseases. Herein, we report our experience with five cases of fatal bacteraemia due to various groups of Streptococci, three of them due to Group G Streptococcus and one case each due to Group A Streptococcus and Group F Streptococcus. The peculiarity of all these cases was the rapidity of deaths occurring in these patients despite all the strains being sensitive to Penicillin. Hence, timely intervention in all suspected cases is strongly advocated. All isolates of beta-haemolytic Streptococci should be identified up till the species level and antimicrobial susceptibility be performed so that proper and early management can be done.

Vpx-containing dendritic cell vaccine induces CTLs and reactivates latent HIV-1 in vitro.

Eradication of human immunodeficiency virus-1 (HIV-1) from an infected individual requires a means of inducing production of virus from latently infected cells and stimulating an immune response against the infected cells. We report the development of lentiviral vectors that transduce dendritic cells (DCs) to both induce production of virus from latently infected cells and stimulate antigen-specific cytotoxic T lymphocytes (CTLs). The vectors package Vpx, a lentiviral accessory protein that counteracts the SAMHD1-mediated block to DC transduction, allowing for long-term expression of vector-encoded proteins. The vectors encode influenza or HIV-1-derived epitopes fused via a self-cleaving peptide to CD40L that releases the peptide into the endoplasmic reticulum for entry into the antigen presentation pathway. Expression of CD40L caused transduced DCs to mature and produce Th1-skewing cytokines. The DCs presented antigen to CD8 T cells, enhancing antigen-specific CTLs. Coculture of the transduced DCs with latently infected cells induced high-level virus production, an effect that was mediated by tumor necrosis factor alpha. The ability of a DC vaccine to reactivate latent HIV-1 and stimulate an adaptive immune response provide a means to reduce the size of the latent reservoir in patients. This strategy can also be applied to develop DC vaccines for other diseases.

Effect of oral-transmucosal midazolam sedation on anxiety levels of 3-4 years old children during a Class II restorative procedure.

AIM: A double-blind randomized control trial was conducted to assess the effect of oral-transmucosal midazolam sedation on changes in anxiety levels of precooperative children during a Class II amalgam restorative procedure. METHODOLOGY: A sample of 40 healthy, American Society of Anesthesiologists I, children aged 3-4 years having at least one carious primary mandibular molar requiring a Class II amalgam restoration with no previous dental history were randomly divided into experimental and control groups comprising of 20 children each. The children in the experimental group (Group I) received 0.5 mg/kg body weight of midazolam mixed in strawberry syrup and those in the control group (Group II) received the same syrup mixed in saline, 15 min prior to the restorative procedure. Routine nonpharmacological behavior management techniques were used in both groups. The anxiety levels were recorded using Venham's anxiety scale at the start and end of each procedural step. RESULTS: There was a significant (P < 0.001) reduction in the anxiety levels of children in the experimental group on entry into the operatory compared with the control group. Introduction of each fear evoking stimuli showed a somewhat similar increase in anxiety levels in the two groups. In spite of a similar trend, the anxiety levels remained much lower in Group I than in Group II. CONCLUSION: Midazolam in conjunction with behavior management is more helpful in relaxing the child initially than behavior management alone, thus increasing the chances of successful and easy accomplishment of further treatment steps.

Characterization of modified pearl millet (Pennisetum typhoides) starch.

Pearl millet starch (Pennisetum typhoides) was isolated and subjected to hydrothermal, acidic and enzymatic modifications. Native and various modified starches were characterized in terms of yield, moisture, protein, ash, bulk density, swelling power, solubility, colour, sediment volume, gel consistency, water binding capacity, pasting properties, freeze thaw stability and paste clarity. Hydrothermal modification (HTMS) caused an increase in swelling power and solubility. L value was higher for acid and enzymatically modified starches (EMS). A significant reduction (p ≤ 0.05) in sediment volume and water binding capacity was observed for acid modified starch (AMS) and EMS. Peak viscosity values declined for all modifications. However, EMS and AMS showed an improved freeze-thaw stability and paste clarity.

Beta-hemolytic streptococcal infections in trauma patients.

PURPOSE: ß-hemolytic streptococci (ßHS) causes a diverse array of human infections. The molecular epidemiology of ß-hemolytic streptococcal infections in trauma patients has not been studied. This study reports the molecular and clinical epidemiology of ß-hemolytic streptococcal infections at a level 1 trauma centre of India. METHODS: A total of 117 isolates of ßHS were recovered from clinical samples of trauma patients. The isolates were identified to species level and subjected to antimicrobial susceptibility testing. Polymerase chain reaction (PCR) assay was done to detect exotoxin virulence genes. The M protein gene (emm gene) types of GAS strains were ascertained by sequencing. RESULTS: Group A Streptococcus (GAS) was the most common isolate (64 %), followed by group G Streptococcus (23 %). A large proportion of GAS produced speB (99 %), smeZ (91 %), speF (95 %) and speG (87 %). smeZ was produced by 22 % of GGS. A total of 25 different emm types/subtypes were seen in GAS, with emm 11 being the most common. Resistance to tetracycline (69 %) and erythromycin (33 %) was commonly seen in GAS. CONCLUSIONS: ß-hemolytic streptococcal infections in Indian trauma patients are caused by GAS and non-GAS strains alike. A high diversity of emm types was seen in GAS isolates, with high macrolide and tetracycline resistance. SpeA was less commonly seen in Indian GAS isolates. There was no association between disease severity and exotoxin gene production.

Evaluation of baseline structural factors for predicting glaucomatous visual-field progression using optical coherence tomography, scanning laser polarimetry and confocal scanning laser ophthalmoscopy.

PURPOSE: The objective of this study is to assess whether baseline optic nerve head (ONH) topography and retinal nerve fiber layer thickness (RNFLT) are predictive of glaucomatous visual-field progression in glaucoma suspect (GS) and glaucomatous eyes, and to calculate the level of risk associated with each of these parameters. METHODS: Participants with ≥28 months of follow-up were recruited from the longitudinal Advanced Imaging for Glaucoma Study. All eyes underwent standard automated perimetry (SAP), confocal scanning laser ophthalmoscopy (CSLO), time-domain optical coherence tomography (TDOCT), and scanning laser polarimetry using enhanced corneal compensation (SLPECC) every 6 months. Visual-field progression was assessed using pointwise linear-regression analysis of SAP sensitivity values (progressor) and defined as significant sensitivity loss of >1 dB/year at ≥2 adjacent test locations in the same hemifield at P<0.01. Cox proportional hazard ratios (HR) were calculated to determine the predictive ability of baseline ONH and RNFL parameters for SAP progression using univariate and multivariate models. RESULTS: Seventy-three eyes of 73 patients (43 GS and 30 glaucoma, mean age 63.2±9.5 years) were enrolled (mean follow-up 51.5±11.3 months). Four of 43 GS (9.3%) and 6 of 30 (20%) glaucomatous eyes demonstrated progression. Mean time to progression was 50.8±11.4 months. Using multivariate models, abnormal CSLO temporal-inferior Moorfields classification (HR=3.76, 95% confidence interval (CI): 1.02-6.80, P=0.04), SLPECC inferior RNFLT (per -1 µm, HR=1.38, 95% CI: 1.02-2.2, P=0.02), and TDOCT inferior RNFLT (per -1 µm, HR=1.11, 95% CI: 1.04-1.2, P=0.001) had significant HRs for SAP progression. CONCLUSION: Abnormal baseline ONH topography and reduced inferior RNFL are predictive of SAP progression in GS and glaucomatous eyes.

Detection of progressive macular thickness loss using optical coherence tomography in glaucoma suspect and glaucomatous eyes.

AIMS: To examine the rate of macular thickness loss using time-domain optical coherence tomography (OCT) in functionally progressing versus non-progressing eyes, determined by standard automated perimetry (SAP). METHODS: Glaucoma suspects (GS) and glaucomatous (G) eyes underwent SAP and OCT imaging every 6 months. Functional progression was determined using pointwise linear regression, defined as 2 contiguous locations losing ≥1.0 dB/year at P<1.0% in the same hemifield. The annual rate of macular thickness loss was calculated from inner and outer regions of the macular map. RESULTS: 72 eyes (43 GS and 29G) with ≥30 months of follow-up were enrolled. Fourteen eyes demonstrated SAP progression. The annual rate of macular thickness loss (µm/year) in progressing eyes was faster (all P<0.05) than non-progressing eyes in temporal outer (-1.90±2.97 vs 0.33±2.77), nasal inner (-1.70±2.66 vs 0.14±2.76), superior inner (-2.15±4.57 vs 0.51±2.99), temporal inner quadrants (-2.58±5.05 vs -0.38±2.34), and the average of inner macular quadrants (-1.84±2.90 vs 0.03±2.10). The rate of loss in the nasal inner (P=0.02) and temporal outer (P=0.02) macular regions was associated with optic disc haemorrhage. CONCLUSIONS: Eyes with SAP progression have significantly greater rates of macular thickness loss consistent with glaucomatous retinal ganglion cell atrophy, as compared with non-progressing eyes.