DLTN-LOSP: A Novel Deep-Linear-Transition-Network-Based Resource Allocation Model with the Logic Overhead Security Protocol for Cloud Systems.

Cloud organizations now face a challenge in managing the enormous volume of data and various resources in the cloud due to the rapid growth of the virtualized environment with many service users, ranging from small business owners to large corporations. The performance of cloud computing may suffer from ineffective resource management. As a result, resources must be distributed fairly among various stakeholders without sacrificing the organization's profitability or the satisfaction of its customers. A customer's request cannot be put on hold indefinitely just because the necessary resources are not available on the board. Therefore, a novel cloud resource allocation model incorporating security management is developed in this paper. Here, the Deep Linear Transition Network (DLTN) mechanism is developed for effectively allocating resources to cloud systems. Then, an Adaptive Mongoose Optimization Algorithm (AMOA) is deployed to compute the beamforming solution for reward prediction, which supports the process of resource allocation. Moreover, the Logic Overhead Security Protocol (LOSP) is implemented to ensure secured resource management in the cloud system, where Burrows-Abadi-Needham (BAN) logic is used to predict the agreement logic. During the results analysis, the performance of the proposed DLTN-LOSP model is validated and compared using different metrics such as makespan, processing time, and utilization rate. For system validation and testing, 100 to 500 resources are used in this study, and the results achieved a make-up of 2.3% and a utilization rate of 13 percent. Moreover, the obtained results confirm the superiority of the proposed framework, with better performance outcomes.

Knock-out of vasotocin reduces reproductive success in female zebrafish, Danio rerio.

The vertebrate nonapeptide vasotocin/vasopressin is evolutionarily highly conserved and acts as neuromodulator and endocrine/paracrine signaling molecule. Circumstantial and mechanistic evidence from pharmacological manipulations of the vasotocin system in several teleost fishes suggest sex- and species-specific reproductive roles of vasotocin. While effects of vasotocin on teleost reproductive physiology involve both courtship behaviors and the regulation of the hypothalamic-pituitary-gonadal (HPG) axes, comprehensive studies investigating behavioral and physiological reproductive consequences of genetic ablation of vasotocin in a genetically tractable fish model, such as the zebrafish, are currently lacking. Here, we report the generation of homozygous CRISPR/Cas9-based vasotocin gene knock-out zebrafish. Breeding pairs of vasotocin knock-out fish produce significantly fewer fertilized eggs per clutch compared to wildtype fish, an effect coincident with reduced female quivering courtship behavior. Crossbreeding experiments reveal that this reproductive phenotype is entirely female-dependent, as vasotocin-deficient males reproduce normally when paired with female wild-type fish. Histological analyses of vasotocin knock-out ovaries revealed an overall reduction in oocytes and differential distribution of oocyte maturation stages, demonstrating that the reproductive phenotype is linked to oocyte maturation and release. Ovarian hormone quantification and gene expression analysis in mutant fish indicated reduced synthesis of Prostaglandin F2α, a hormone involved in ovarian maturation, egg release and regulation of female courtship behavior in some cyprinids. However, acute injection of vasotocin did not rescue the female mutant reproductive phenotype, suggesting a contribution of organizational effects of vasotocin. Together, this study provides further support for emerging roles of vasotocin in female teleost reproduction in an important teleost model species.

Biological therapy for severe asthma - Indian perspectives and challenges.

Asthma is a complex and heterogeneous disease. Severe asthma makes up only a minority of asthma patients encountered in clinical settings but accounts for substantial healthcare utilisation in terms of manpower as well as economic allocation. The availability of monoclonal antibodies has a major impact on severe asthmatics and has provided excellent clinical results in properly selected patients. The discovery of new molecules might present uncertainties to clinicians as to the best agent to institute in an individual patient. The practice scenario in India is unique when it comes to the commercial availability of monoclonal antibodies, patient attitudes, and allocation of the healthcare budget. The present review dissects and summarises the available monoclonal antibodies for asthma treatment in India, the perspectives of Indian patients on biological therapy, and the challenges encountered by patients and physicians in this regard. We provide practical suggestions for utilising monoclonal antibodies and deciding on the optimal agent for a given patient.

Hospitalisation outcomes in pneumococcal-vaccinated versus -unvaccinated patients with exacerbation of COPD: results from the HOPE COPD Study.

Background: Infectious exacerbations are crucial events that dictate the natural course of COPD patients. Pneumococcal vaccination has been shown to decrease incidence of community-acquired pneumonia in COPD patients. There is a paucity of data on outcomes of hospitalisation in pneumococcal-vaccinated COPD patients in comparison with unvaccinated subjects. The objectives of the present study were to evaluate the difference in hospitalisation outcomes in pneumococcal-vaccinated versus -unvaccinated COPD subjects hospitalised with acute exacerbation. Methods: This was a prospective analytical study on 120 subjects hospitalised with acute COPD exacerbation. 60 patients with prior pneumococcal vaccination and 60 unvaccinated patients were recruited. Outcomes of hospitalisation such as mortality rate, need for assisted ventilation, length of hospital stay, need for intensive care unit (ICU) care and length of ICU stay were collected and compared between two groups with appropriate statistical tools. Results: 60% of unvaccinated patients (36 out of 60) required assisted ventilation, whereas only 43.3% of vaccinated subjects (26 out of 60) needed assisted ventilation (p-value of 0.04). Most of the secondary outcomes were better in the vaccinated group. The mean±SD length of ICU stay in the vaccinated group was 0.67±1.11 days compared to 1.77±1.89 days in the unvaccinated group. The mean±SD length of hospital stay was 4.50±1.64 days and 5.47±2.03 days in the vaccinated and unvaccinated group, respectively (p-value of 0.005). Conclusions: COPD patients who have received prior pneumococcal vaccination have better outcomes when they are hospitalised for an acute exacerbation. Pneumococcal vaccination may be recommended for all patients with COPD who are at risk of hospitalisation with acute exacerbation.

Pneumothorax ex vacuo: Three cases of an uncommon entity.

Pneumothorax is a frequently encountered entity in pulmonary practice and can be primary or secondary. Traumatic and iatrogenic causes also account for a minority of cases presenting to the chest physician. The most common therapeutic intervention done is a tube thoracostomy in all but the mildest of cases. Pneumothorax ex vacuo is a distinctly uncommon entity that differs considerably from the rest of the pneumothorax cases in its pathogenesis, clinical manifestations, radiological findings, and management. Pneumothorax in this entity results from the sucking in of air into the pleural space caused by an exaggerated negative intrapleural pressure, which is most frequently secondary to acute lobar collapse. Symptoms attributable to pneumothorax per se are distinctly mild and the vital aspect of treatment is to relieve the bronchial obstruction. Tube thoracostomy fails to relieve the pneumothorax in such cases and should be avoided. We share three cases of pneumothorax ex vacuo encountered in our institution and alert clinicians of the presentation, radiology, and management of this uncommon condition.

Health service approaches to providing care for people who seek treatment for obesity: identifying challenges and ways forward.

OBJECTIVE: This paper aims to identify challenges in current health service approaches to providing optimal care for people who seek treatment for obesity. Type of program or service: Health service management of obesity in Australia Methods: Drawing on lived experience, clinical and academic perspectives, and available evidence, we reflect on the current state of the healthcare system to support people seeking treatment for obesity. We suggest actions to enable effective, acceptable and equitable care for this group of people. RESULTS: Identified challenges include the complexity of care required to adequately manage obesity, existing service capability and capacity, and high out-of-pocket patient costs. LESSONS LEARNT: To address these challenges, a comprehensive response is required at all levels of the healthcare system. As a starting point, we propose eight areas of action: partner with people living with obesity; eliminate weight stigma; increase healthcare professional education, guidelines and resources; establish clear referral pathways and working partnerships; scale services to meet demand; ensure flexible and accessible service delivery; implement changes to the Medicare Benefits Schedule to increase service provision and pursue opportunities for subsidised medicines.

Reproductive roles of the vasopressin/oxytocin neuropeptide family in teleost fishes.

The vertebrate nonapeptide families arginine vasopressin (AVP) and oxytocin (OXT) are considered to have evolved from a single vasopressin-like peptide present in invertebrates and termed arginine vasotocin in early vertebrate evolution. Unprecedented genome sequence availability has more recently allowed new insight into the evolution of nonapeptides and especially their receptor families in the context of whole genome duplications. In bony fish, nonapeptide homologues of AVP termed arginine vasotocin (Avp) and an OXT family peptide (Oxt) originally termed isotocin have been characterized. While reproductive roles of both nonapeptide families have historically been studied in several vertebrates, their roles in teleost reproduction remain much less understood. Taking advantage of novel genome resources and associated technological advances such as genetic modifications in fish models, we here critically review the current state of knowledge regarding the roles of nonapeptide systems in teleost reproduction. We further discuss sources of plasticity of the conserved nonapeptide systems in the context of diverse reproductive phenotypes observed in teleost fishes. Given the dual roles of preoptic area (POA) synthesized Avp and Oxt as neuromodulators and endocrine/paracrine factors, we focus on known roles of both peptides on reproductive behaviour and the regulation of the hypothalamic-pituitary-gonadal axis. Emphasis is placed on the identification of a gonadal nonapeptide system that plays critical roles in both steroidogenesis and gamete maturation. We conclude by highlighting key research gaps including a call for translational studies linking new mechanistic understanding of nonapeptide regulated physiology in the context of aquaculture, conservation biology and ecotoxicology.

Inhaled corticosteroids and risk of tuberculosis-How bad is the risk?

Inhaled corticosteroids (ICS) have a central role in the management of obstructive airway diseases. Use of ICS in asthma and chronic obstructive pulmonary disease (COPD) is associated with a small but clear increase in incidence of pneumonia and tuberculosis. Since ICS use in obstructive airway diseases has beneficial effects with regard to symptoms, lung function, quality of life and exacerbations, denying the benefit of ICS solely based on this small elevated risk of pneumonias and tuberculosis is not justified. The present article attempts to elucidate mechanisms contributing to the increased risk, assesses the magnitude and risk factors of tuberculosis in patients using ICS and provides practical suggestions for practising clinicians.

A successful salvage story: Uveitis with nontuberculous mycobacterial infection in a patient on secukinumab.

The reported occurrence of ocular infections with nontuberculous mycobacterial (NTM) infections has been increasing in the past few decades. NTM are known to cause intraocular infections as well as infections of the ocular appendages and are often recalcitrant to medical therapy. Uveal involvement due to NTM is rare and most reported cases have predisposing factors such as cataract surgery or immunocompromised states. Diagnosis and treatment pose challenge due to difficulty in procuring sufficient clinical material to obtain microbial diagnosis and inadequate response to medical therapy. The clinical challenge is further heightened in the presence of an underlying rheumatologic disease that is known to cause uveitis. We share the case of a young gentleman with ankylosing spondylitis who was being treated with secukinumab with good response to joint symptoms. He developed sudden onset uveitis which was diagnosed to be due to NTM infection based on aqueous humor polymerase chain reaction studies. He had a good clinical response to an empirical anti-mycobacterial regime with the restoration of vision. This report narrates the first case of NTM uveitis secondary to secukinumab therapy.

Acceptance and results of therapy with omalizumab in real world Kerala setting: reports from the ARTWORK study, Kerala, South India.

OBJECTIVE: Despite the availability of effective medications, only a minority of asthma patients achieve guideline defined asthma control. Treatment success depends on patient concurrence to the prescribed drug and adherence to treatment. It is therefore crucial to identify the patient preferences as well as attitudes towards asthma medications. Omalizumab is recommended as a preferred option in step 5 of asthma therapy. There have been few studies to address patient perspectives on omalizumab therapy in India. METHODS: This was a retrospective study. Patients with inadequate asthma control were considered for the study. Systematic evaluation was done to identify and correct modifiable factors that can worsen asthma control. Patients with persisting poor asthma control who were deemed suitable to receive this agent were evaluated with their attitudes toward acceptance or refusal and the reasons for opting out were noted. The patients who received omalizumab were followed up to determine the results of treatment and duration of adherence to therapy. RESULTS: Thirty-five patients out of 51 patients chose to avoid this drug. The reasons for opting out included erroneous perception of optimal asthma control, cost of therapy, and concern about adverse effects. Patients took omalizumab for a median duration of 6 months. Improved asthma control and decreased frequency of exacerbation was noted in all patients which persisted during the 6-month follow-up. CONCLUSIONS: The majority of patients needing step 5 therapy opt out of omalizumab. Cost of drug, duration of therapy and erroneous perception of good asthma control account for refusing treatment. Omalizumab affords excellent clinical benefits to patients who receive it, and the benefits extend beyond the duration of therapy.

Improving the yield of diagnostic medical thoracoscopy for undiagnosed exudative pleural effusions using a rigid diagnostic algorithm.

Background: Establishing the etiology of exudative pleural effusions in the setting of an unrewarding pleural fluid analysis often requires biopsies from the parietal pleura. However, it may be noted that diagnosis such as pulmonary embolism and connective tissue diseases can result in an exudative pleural effusion where a pleural biopsy can yield nonspecific results. Medical thoracoscopy (MT) is a minimally invasive procedure performed under local anesthesia or moderate sedation with excellent yield and favorable safety profile. We analyzed the diagnostic yield of MT for exudative pleural effusions after employing a rigid diagnostic algorithm. The study was undertaken to ascertain the yield of MT in establishing the diagnosis in diagnosis of exudative pleural effusions, to find out the relative contribution of pleural tuberculosis (TB) as a cause of undiagnosed exudative pleural effusion, to describe the etiology of undiagnosed exudative pleural effusion in patients undergoing MT and to determine the correlation between pleural fluid adenosine deaminase (ADA) levels and TB pleuritis in patients undergoing MT. Methods: This was a retrospective study. Patients with undiagnosed exudative pleural effusion were included in the study. MT was performed with semirigid thoracoscope (Olympus LTF 160) under local anesthesia and conscious sedation. Gross appearance and ADA level of pleural fluid were noted. Pleural biopsy material was subjected to histopathology examination and culture for mycobacteria along with cartridge-based nucleic acid amplification test for TB. The yield of MT for establishing the etiology of pleural effusion and the relative contribution of tuberculous pleuritis as a cause of undiagnosed pleural effusion was ascertained. Correlation of pleural fluid ADA levels was done with a final diagnosis of TB pleuritis in patients undergoing MT. Results: Twenty-five patients with undiagnosed exudative pleural effusion underwent thoracoscopy of which 16 were male and 9 were female. MT was able to establish the diagnosis in all cases, providing a diagnostic yield of 100%. Histopathological examination of biopsy specimens yielded a diagnosis of malignant involvement of pleura in 10 patients and granulomatous pleuritis consistent with TB in 14 patients. Pleural TB contributed to 60% of undiagnosed pleural effusions in the present study. The mean ADA value among those who turned positive was 56.338 and 35.300 among those who turned negative using genexpert, which was found to be statistically significant. A value of 31 IU/L showed a sensitivity of 93.3% and specificity of 99.8% and hence can be taken as a cut off value for the diagnosis of pleural TB based on receiver-operating characteristic analysis. Conclusion: TB contributed to 60% of undiagnosed exudative pleural effusions in the present study. MT had 100% yield in the diagnosis of undiagnosed exudative effusions. Pleural fluid ADA levels may help in differentiating TB versus malignant effusion.

Weight stigma and obesity-related policies: A systematic review of the state of the literature.

Weight stigma is an important issue colliding with obesity-related policies; both have population health and social impacts. Our aim was to conduct a systematic review of the peer-reviewed literature that combined the concepts of stigma, obesity, and policy. We searched PsycINFO, Medline, Scopus, and Google Scholar for peer-reviewed articles amalgamating terms relevant to stigma, obesity, and policy. Of 3219 records identified, 47 were included in the narrative synthesis. Two key types of studies emerged: studies investigating factors associated with support for obesity-related policies and those exploring policy implementation and evaluation. We found that support for nonstigmatizing obesity-related policies was higher when obesity was attributed as an environmental rather than individual problem. An undercurrent theme suggested that views that blame individuals for their obesity were associated with support for punitive policies for people living in larger bodies. Real-world policies often implicitly condoned stigma through poor language choice and conflicting discourse. Our findings inform recommendations for policy makers that broader socioecological stigma-reduction approaches are needed to fully address the issue of weight stigma in obesity-related policies. Efforts are needed in the research and policy sectors to understand how to improve the design and support of nonstigmatizing obesity-related policies.

Expecting the unexpected - Primary mediastinal large B cell lymphoma presenting as huge lung parenchymal mass.

The first possibility considered in the etiology of large lung masses is neoplastic lesions. The differential diagnoses of these masses include bronchogenic carcinoma, pulmonary sarcoma, primitive neuroectodermal tumor etc. Primary or secondary pulmonary parenchymal lymphomas presenting as large mass is distinctly rare. We share the case of a young lady who presented with a large left lung mass almost entirely replacing the left lung parenchyma, with associated intrathoracic lymphadenopathy. On evaluation she was proved to have primary mediastinal large B-cell lymphoma. Treatment with an aggressive chemotherapy regimen led to complete remission of the parenchymal and nodal disease. The uncommon radiological presentation and the excellent therapeutic response despite huge tumor load merit clinical attention.

Xanthogranulomatous pleuritis - An unusual presentation of tuberculosis.

In pulmonary practice, pleural effusion is a commonly encountered entity and has various etiologies. Pleural effusions in postpartum women can be an incidental self-limiting finding. The presence of systemic or respiratory symptoms, however, calls for prompt etiological workup and targeted therapy. Tuberculous pleuritis and lupus-related pleural disease are well known to flare up in the postpartum period. We describe the case of a young healthcare worker with no previous comorbidities who presented with fever, breathlessness, and chest pain 2 weeks after an uneventful confinement. Chest radiograph revealed moderate left-sided pleural effusion. Pleural fluid analysis was biochemically consistent with tubercular effusion. Pleural biopsy histological examination showed features of xanthomatous pleuritis and Cartridge based nucleic acid amplification test (CB-NAAT) showed evidence of Mycobacterium tuberculosis(MTB). She was initiated on antitubercular medicines to which she responded well with the resolution of clinical symptoms and pleural collection. This is the first case report describing an association of xanthogranulomatous pleuritis with tuberculosis.

Food Co-Operatives: A Potential Community-Based Strategy to Improve Fruit and Vegetable Intake in Australia.

Only 5% of Australian children and adults eat enough fruit and vegetables. Two common barriers are high cost and limited access. Food co-operatives ('co-ops') may have the potential to reduce these barriers. We conducted a scoping analysis of food co-ops in the Sydney region to describe their characteristics and objectives. We also conducted a survey of members and non-members of co-ops to assess their fruit and vegetable intake using validated questions. Fifteen food co-ops were identified in the Sydney region and the most common objective was to provide cheap affordable produce. Most co-ops (61%) were in areas of high socio-economic status (SES). Members of food co-ops had a higher vegetable intake than non-members [mean difference (MD) = 0.54 serves/daily; 95% confidence interval (CI) of 0.15 to 0.93] and were also more likely to meet the recommendations for fruit and vegetable intake [odds ratio (OR) = 4.77 (95% CI = 1.15, 19.86)]. Implications of this study are that if food co-ops can be implemented on a wider scale, they hold potential for improving fruit and vegetable intakes.

Product of Investigator Global Assessment and Body Surface Area (IGAxBSA): A practice-friendly alternative to the Eczema Area and Severity Index to assess atopic dermatitis severity in children.

BACKGROUND: Accurately documenting pediatric atopic dermatitis (AD) severity is important, but research tools, such as Eczema Area and Severity Index (EASI), are too time consuming for clinical settings. Product of the Physician Global Assessment and affected percentage of body surface area (PGA×BSA) is a new, rapid measure of psoriasis severity. OBJECTIVE: To evaluate an Investigator Global Assessment and body surface area product (IGA×BSA) as an easy-to-use severity measure for pediatric AD. METHODS: Patient-reported and objective disease severity measures were collected from 195 caretaker/child dyads (child age range, 5-17 years) with almost clear (Validated Investigator Global Assessment for AD [vIGA] of 1) to severe (vIGA of 4) AD. Data were assessed with Spearman coefficients and plots. Severity strata were proposed by using an anchoring approach based on the EASI. RESULTS: IGA×BSA correlates better with the EASI than IGA alone (r = 0.924 vs r = 0.757, P < .001). Bland-Altman plot indicates high and consistent agreement between IGA×BSA and the EASI. Suggested severity strata for IGA×BSA are 0-30, mild; 30.1-130, moderate; and 130.1-400, severe (κ = 0.760). LIMITATIONS: The patient cohort was predominantly from the midwestern United States. CONCLUSIONS: IGA×BSA (using the vIGA) is a simple measure that correlates well with the EASI in patients with mild to severe pediatric AD. Future work is needed to affirm reliability across IGA scales and responsiveness to change.

Standard baseline data collections in obesity management clinics: A Delphi study with recommendations from an expert panel.

We aimed to develop an expert consensus on standardizing data collections in specialist obesity management clinics in Australia. A panel of 16 experts participated in a structured consensus-driven Delphi process to reach agreement on a minimum set of baseline patient data collections for consideration in specialist obesity services. The panel included surgeons, clinicians, allied health professionals (dietician, exercise physiologist, psychologist), a bariatric nurse and obesity researchers. We produced a recommended list of core and useful data items that should comprise the baseline patient data set. Consensus was achieved for recommended measures of demographic, anthropometric, biochemical, weight-loss history, medication, medical history and comorbidity data items using a 70% agreement threshold. In this iterative process, there was also consideration of specific data items for patients referred for bariatric surgery. We present the first expert panel consensus on recommendations for a minimum and standard set of baseline patient data collections in obesity management services in Australia. These may be relevant to other countries with similar obesity management service models. Implementation of these recommendations should facilitate data pooling for clinical audits and research collaborations across clinics seeking to improve the quality of specialist obesity care.