Search

Aim and Objectives: This study aimed to evaluate the effectiveness of insulin degludec/insulin aspart (IDegAsp) in uncontrolled type 2 diabetes mellitus (T2DM) patients in clinical practice settings. Materials and Methods: This study includes a retrospective analysis of uncontrolled T2DM patients on oral antidiabetic drugs and/or insulin (basal, bolus, or premix) and initiated on IDegAsp and in a subgroup of patients who switched from insulin glargine to IDegAsp. Clinical endpoints were mean change in glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), postprandial plasma glucose (PPG), and % point in range (PIR) before and after treatment with IDegAsp. Descriptive statistics were applied to analyze the data, and statistical significance was set at P ≤ 0.05. Results: A total of 540 patients with T2DM were initiated on IDegAsp, among which 85 switched from insulin glargine (U100/300) to IDegAsp. In 6 months, overall, the mean change in glycemic variables HbA1c, FPG, and PPG was –0.3%, –21 mg/dL, and –36 mg/dL, and among those who switched from insulin glargine to IDegAsp, it was –0.4%, –18 mg/dL, and –49 mg/dL, respectively, and the difference was statistically significant (P < 0.05). Self-monitored blood glucose, 1 month before and from 4 to 6 months after initiation of IDegAsp was assessed in overall 43 patients. The % PIR before breakfast and before dinner (BBF+BD) was 68% and 69% (95% CI –4.413 to 4.902) respectively. Furthermore, among those who switched from insulin glargine to IDegAsp (n = 25), BBF + BD increased from 67% to 77% (95% CI –10.35 to 10.65). Conclusion: Our results show clinically significant improvements in glycemic variables and PIR in patients treated with IDegAsp and especially in patients who switched from insulin glargine (U100/300) to IDegAsp.

Back ground: The research was carried out with the aim of detecting instances of second-line antiretroviral therapy (ART) failure and exploring the potential of third-line ART treatment for individuals with HIV, incorporating the utilization of HIV viral load (VL) testing. Beginning in 2016-17, individuals living with HIV are directed to government ART centers and ART plus centers for treatment. Patients who have experienced treatment failure with second-line therapy and have been exposed to multiple NRTIs, in accordance with the Indian National ART Guidelines, are referred to the SACEP Clinic for further evaluation. If deemed eligible according to the Indian National 3rd Line ART Guidelines, these patients are enrolled and followed up for the initiation of 3rd Line ART at our center. Throughout the duration of the study, a collective of 55 individuals diagnosed with Human Immunodeficiency Virus (HIV) were identified as potentially experiencing a lack of efficacy with regards to their secondary line antiretroviral therapy (ART). Two patients in the cohort were diagnosed with both HIV and multi drug resistant tuberculosis (MDR-TB). Method: Fifty-four and a half percent of the patient sample was classified as being in WHO stage I, while 32.8% were categorized as being in stage II, and the remaining 12.7% were identified as being in WHO stage IV. Fifty-five patients who were suspected of experiencing second-line treatment failure were transitioned to third-line antiretroviral therapy. Results: All 55 patients underwent VL follow-up, with 53 of them attaining viral suppression within a median period of 6 months. However, two patients were unable to achieve viral suppression. Conclusion: However, this study describes HIV-positive patients who need third-line ART due to probable second-line ART failure.

Abstract As the world grapples with the relentless challenges posed by diseases like malaria, the advent of sophisticated computational tools has emerged as a beacon of hope in the quest for effective treatments. In this study we delve into the strategies behind computational tools encompassing virtual screening, molecular docking, artificial intelligence (AI), and machine learning (ML). We assess their effectiveness and contribution to the progress of malaria treatment. The convergence of these computational strategies, coupled with the ever-increasing power of computing systems, has ushered in a new era of drug discovery, holding immense promise for the eradication of malaria. Scientific contribution Computational tools remain pivotal in drug design and development. They provide a platform for researchers to explore various treatment options and save both time and money in the drug development pipeline. It is imperative to assess computational techniques and monitor their effectiveness in disease control. In this study we examine renown computational tools that have been employed in the battle against malaria, the benefits and challenges these tools have presented, and the potential they hold in the future eradication of the disease.

Introduction: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are cardioprotective, and canagliflozin (CANA), an SGLT2i, has been shown to improve perfusion, AMPK signaling, and oxidative stress in chronically ischemic myocardium. The aim of this study is to determine the effects of CANA in nonischemic myocardium on coronary collateralization, oxidative stress, and other molecular pathways determined by proteomic profiling. Methods: Yorkshire swine underwent placement of an ameroid constrictor to the left circumflex artery. Two weeks later, pigs received no drug (CON, n = 8) or 300 mg CANA daily (n = 8). Treatment continued for five weeks, followed by tissue harvest of nonischemic myocardium. Results: CANA was associated with decreased capillary density (p = 0.05) compared to CON, without changes in arteriolar density. Reduced capillary density did not correlate with reduced perfusion. Oxidative stress was reduced with CANA (22 % decrease). In the CANA group, there was a trend towards increased p-eNOS and eNOS, without a change in p-eNOS/eNOS ratio, p-Akt, Akt, and p-Akt/Akt ratio. There was no change in p-ERK1/2, but a decrease in total ERK1/2 and increase in p-ERK1/2/ERK1/2 ratio. There were no changes in expression of p-AMPK, AMPK, with a trend towards increased ratio of p-AMPK/AMPK. Proteomics analysis identified 2819 common proteins, of which 120 were upregulated and 425 were downregulated with CANA. Pathway analysis demonstrated wide regulation of metabolic proteins. Conclusions: The effects of CANA on myocardial perfusion and AMPK signaling in chronically ischemic myocardium are not found in nonischemic territory, despite attenuation of oxidative stress. Metabolic proteins are widely regulated in nonischemic myocardium with CANA.

A genome-wide association study of cardiac magnetic resonance-derived left ventricular mass index including 43,000 UK Biobank participants reveals 12 associations (11 novel), implicating genes involved in cardiac contractility and cardiomyopathy.

Intra-annual density fluctuation (IADF) refers to anatomical changes in the tree ring caused by a sudden change in wood density triggered by a combination of climate variations and various biotic and abiotic influences. To reveal the occurrence of IADFs, we analyze the growth rings of Himalayan cedar (Cedrus deodara) growing over the Kullu region, Himachal Pradesh, western Himalaya. Using 30 increment cores, we precisely dated and developed a 214-year-long tree-ring chronology extending back to AD 1808. The tree–growth–climate relationship using ring-width chronology and observed climate data revealed that cool and moist condition provides favorable condition for Himalayan cedar tree growth. Delving deeper into wood anatomy of growth rings, we revealed the frequent occurrences of IADFs in both earlywood (IADFe) and latewood (IADFl). The formation of IADFs in earlywood (IADFe) is related to the reduced precipitation from April to July, causing moisture stress in the soil and surrounding climate. However, wetter conditions in the late growing season, mainly August–October, activated the formation of IADFs in latewood (IADFl). The study revealed several IADF years in earlywood and latewood, such as 1901, 1902, 1903, 1914, 1915, 1919, 1920, 1923, 1925, 1943, 1958, 1959 and 1937, 1955, 1956, 1988, respectively. These IADF years corresponded with unusual climatic fluctuations that severely affected apple production, the major cash crop in the region. The analyses demonstrated that the IADF chronology of Himalayan cedar would be a valuable proxy to understand abrupt and unusual climatic fluctuations from a long-term perspective for the data-scarce western Himalayan region.

Heart failure is a major cause of cardiovascular morbidity and mortality. Here, the authors report results of a genome-wide association study meta-analysis, characterizing the role of common genetic variants in heart failure, finding overlap with common cardiovascular risk factors and imaging measures of cardiac structure/function.

Rhabdomyomatous mesenchymal hamartomas (RMH) are congenital benign skin masses that often present at birth and predominate in the head and neck. Superficially, masses appear to have a normal epidermal construct. Histologically, masses contain interspersed skeletal muscle fibers that may be associated with various mesenchymal elements such as adipose tissue, blood vessels, pilosebaceous units, and peripheral nerves. This case describes a 4-day-old male with an RMH of the left nare. Surgical resection as well as future cosmetic reconstruction associated with the patient's altered nasal anatomy is discussed.

The UN Development Program has set forth a roster of sustainable development goals (SDGs) for eradicating hunger and poverty with other consequential targets also to be achieved by 2030. Agroecological production strategies can help accomplish about half of these goals, especially SDG #2 (zero hunger) and SDG #12 (action for climate), utilizing biological processes and potentials that already exist in crop plants and in the soil systems they grow in. These potentials are not mobilized by chemical-dependent practices that create hazards for the environment and human health. An agroecological strategy, the System of Rice Intensification (SRI), has demonstrated that it can raise rice production by 25–50%, and in some cases more than 50% while lowering production costs and raising farmer incomes. Higher yield is achieved by using 25–50% less water, and SRI practices reduce net emission of greenhouse gases from paddy fields, while reducing crops’ vulnerability to the hazards of climate change. The advantages of SRI methods are being extended also to crops beyond rice, like wheat, millet, and sugarcane. SRI practices contribute to achieving other SDGs beyond reducing hunger and poverty. Government initiatives plus investments by donors can extend research and extension for SRI and other agroecological methodologies that enable growers to help achieve multiple SDGs in the next decade.

Hyperglycemia is a common complication in critically ill patients. It is associated with an increased length of hospital stay, infection, and mortality rate. Hence, management of hyperglycemia in critical care settings is important. A literature search from inception till July 2019 using relevant keywords (hyperglycemia and critical illness) was performed with Medline (PubMed), and all the pertinent articles were selected to extract the literature describing the management of hyperglycemia in critically ill patients. Extensive evidence is available, which conclusively demonstrates that hyperglycemia is a marker of severity of illness in critically ill patients. Studies support the use of intensive insulin therapy in critically ill patients both with and without diabetes mellitus (DM). Glycemic variability and hypoglycemia contribute to the worsening condition. Hence, it is important to use the tools that monitor glycemic variability and hypoglycemia in critical care setting. In addition, consideration should be given for an insulin therapy, which lowers the glycemic variability and avoids hypoglycemia. While using insulins, nutrition plays an important role. Evidence supports the use of enteral nutrition over parenteral nutrition due to the low risk of infections and mortality. A transition from intravenous to subcutaneous (SC) insulin is required in certain patients for whom SC basal–bolus insulin therapy is preferred over a sliding-scale insulin regimen. Appropriate glycemic target and determining glycemic threshold for initiating insulin therapy are essential for the management of hyperglycemia in critically ill patients. Moreover, continuous blood glucose monitoring and appropriate medical nutrition therapy improve the patient outcomes.

Abstract Aims The HERMES (HEart failure Molecular Epidemiology for Therapeutic targetS) consortium aims to identify the genomic and molecular basis of heart failure. Methods and results The consortium currently includes 51 studies from 11 countries, including 68 157 heart failure cases and 949 888 controls, with data on heart failure events and prognosis. All studies collected biological samples and performed genome‐wide genotyping of common genetic variants. The enrolment of subjects into participating studies ranged from 1948 to the present day, and the median follow‐up following heart failure diagnosis ranged from 2 to 116 months. Forty‐nine of 51 individual studies enrolled participants of both sexes; in these studies, participants with heart failure were predominantly male (34–90%). The mean age at diagnosis or ascertainment across all studies ranged from 54 to 84 years. Based on the aggregate sample, we estimated 80% power to genetic variant associations with risk of heart failure with an odds ratio of ≥1.10 for common variants (allele frequency ≥ 0.05) and ≥1.20 for low‐frequency variants (allele frequency 0.01–0.05) at P

Objective Posterior fossa decompression is the treatment of choice in type 1 Chiari malformation (CM-1) without bony instability. Although surgical fixation has been recommended by a few authors recently, comparative studies to evaluate these treatment strategies using objective outcome tools are lacking. Methods Seventy-three patients with pure CM-1 (posterior fossa bony decompression [PFBD], n = 21; posterior fossa bony and dural decompression [PFBDD], n = 40; and posterior fixation [PF], n = 12) underwent a postoperative outcome assessment using Chicago Chiari Outcome Score (CCOS). Logistic regression analysis detected predictors of an unfavorable outcome. Results Minimally symptomatic patients generally underwent a PFBD while most of the clinically severe patients underwent a PFBDD (p = 0.049). The mean CCOS score at discharge was highest in the PF (12.0 ± 1.41) and lowest in PFBDD group (10.98 ± 1.73, p = 0.087). Patients with minimal preoperative clinical disease severity (adjusted odds ratio [AOR], 4.58; 95% confidence interval [CI], 1.29–16.31) and PFBDD (AOR, 7.56; 95% CI, 1.70–33.68) represented risks for an unfavorable short-term postoperative outcome. Though long-term outcomes (CCOS) did not differ among the 3 groups (p = 0.615), PFBD group showed the best long-term improvements (mean follow-up CCOS, 13.71 ± 0.95), PFBDD group improved to a comparable degree despite a poorer short-term outcome while PF had the lowest scores. Late deteriorations (n = 3, 4.1%) occurred in the PFBDD group. Conclusion Minimally symptomatic patients and PFBDD predict a poor short-term postoperative outcome. PFBD appears to be a durable procedure while PFBDD group is marred by complications and late deteriorations. PF does not provide any better results than posterior fossa decompression alone in the long run.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease whose diagnosis depends on the presence of combined lower motor neuron (LMN) and upper motor neuron (UMN) degeneration. LMN degeneration assessment is aided by electromyography, whereas no equivalent exists to assess UMN dysfunction. Magnetic resonance imaging (MRI) is primarily used to exclude conditions that mimic ALS. We have identified four different clinical/radiological phenotypes of ALS patients. We hypothesize that these ALS phenotypes arise from distinct pathologic processes that result in unique MRI signatures. To our knowledge, no machine learning (ML)-based data analyses have been performed to stratify different ALS phenotypes using MRI measures. During routine clinical evaluation, we obtained T1-, T2-, PD-weighted, diffusion tensor (DT) brain MRI of 15 neurological controls and 91 ALS patients (UMN-predominant ALS with corticospinal tract CST) hyperintensity, n = 21; UMN-predominant ALS without CST hyperintensity, n = 26; classic ALS, n = 23; and ALS patients with frontotemporal dementia, n = 21). From these images, we obtained 101 white matter (WM) attributes (including DT measures, graph theory measures from DT and fractal dimension (FD) measures using T1-weighted), 10 grey matter (GM) attributes (including FD based measures from T1-weighted), and 10 non-imaging attributes (2 demographic and 8 clinical measures of ALS). We employed classification and regression tree, Random Forest (RF) and also artificial neural network for the classifications. RF algorithm provided the best accuracy (70–94%) in classifying four different phenotypes of ALS patients. WM metrics played a dominant role in classifying different phenotypes when compared to GM or clinical measures. Although WM measures from both right and left hemispheres need to be considered to identify ALS phenotypes, they appear to be differentially affected by the degenerative process. Longitudinal studies can confirm and extend our findings.

Abstract Background Multi-drug resistance (MDR) and extensive-drug resistance (XDR) associated with extended-spectrum beta-lactamases (ESBLs) and carbapenemases in Gram-negative bacteria are global public health concerns. Data on circulating antimicrobial resistance (AMR) genes in Gram-negative bacteria and their correlation with MDR and ESBL phenotypes from Nepal is scarce. Methods A retrospective study was performed investigating the distribution of ESBL and carbapenemase genes and their potential association with ESBL and MDR phenotypes in E. coli, Klebsiella spp., Enterobacter spp. and Acinetobacter spp. isolated in a major tertiary hospital in Kathmandu, Nepal, between 2012 and 2018. Results During this period, the hospital isolated 719 E. coli, 532 Klebsiella spp., 520 Enterobacter spp. and 382 Acinetobacter spp.; 1955/2153 (90.1%) of isolates were MDR and half (1080/2153) were ESBL producers. Upon PCR amplification, bla TEM (1281/1771; 72%), bla CTXM-1 (930/1771; 53%) and bla CTXM-8 (419/1771; 24%) were the most prevalent ESBL genes in the enteric bacilli. Bla OXA and bla OXA-51 were the most common bla OXA family genes in the enteric bacilli (918/1771; 25%) and Acinetobacter spp. (218/382; 57%) respectively. Sixteen percent (342/2153) of all isolates and 20% (357/1771) of enteric bacilli harboured bla NDM-1 and bla KPC carbapenemase genes respectively. Of enteric bacilli, Enterobacter spp. was the most frequently positive for bla KPC gene (201/337; 60%). The presence of each bla CTX-M and bla OXA were significantly associated with non-susceptibility to third generation cephalosporins (OR 14.7, p

Structural changes to the left ventricle are characteristic of dilated cardiomyopathy (DCM), a disease for which many rare genetic variants are known. Here, Pirruccello et al. report GWAS of seven cardiac MRI measurements in the left ventricle and describe shared loci and polygenic association with DCM.

Heart failure is a complex syndrome that is associated with many different underlying risk factors. Here, to increase power, the authors jointly analyse cases of heart failure of different aetiologies in a genome-wide association study and identify 11 loci of which ten had not been previously reported.

Background Genetic studies may help identify causal pathways; therefore, we sought to identify genetic determinants of ideal CVH and their association with CVD outcomes in the multi-population Veteran Administration Million Veteran Program. Methods An ideal health score (IHS) was calculated from 3 clinical factors (blood pressure, total cholesterol, and blood glucose levels) and 3 behavioral factors (smoking status, physical activity, and BMI), ascertained at baseline. Multi-population genome-wide association study (GWAS) was performed on IHS and binary ideal health using linear and logistic regression, respectively. Using the genome-wide significant SNPs from the IHS GWAS, we created a weighted IHS polygenic risk score (PRSIHS) which was used (i) to conduct a phenome-wide association study (PheWAS) of associations between PRSIHS and ICD-9 phenotypes and (ii) to further test for associations with mortality and selected CVD outcomes using logistic and Cox regression and, as an instrumental variable, in Mendelian Randomization. Results The discovery and replication cohorts consisted of 142,404 (119,129 European American (EUR); 16,495 African American (AFR)), and 45,766 (37,646 EUR; 5,366 AFR) participants, respectively. The mean age was 65.8 years (SD = 11.2) and 92.7% were male. Overall, 4.2% exhibited ideal CVH based on the clinical and behavioral factors. In the multi-population meta-analysis, variants at 17 loci were associated with IHS and each had known GWAS associations with multiple components of the IHS. PheWAS analysis in 456,026 participants showed that increased PRSIHS was associated with a lower odds ratio for many CVD outcomes and risk factors. Both IHS and PRSIHS measures of ideal CVH were associated with significantly less CVD outcomes and CVD mortality. Conclusion A set of high interest genetic variants contribute to the presence of ideal CVH in a multi-ethnic cohort of US Veterans. Genetically influenced ideal CVH is associated with lower odds of CVD outcomes and mortality.

The present study examines the entropy generation on Couette flow of a viscous fluid in parallel plates filled with deformable porous medium. The fluid is injected into the porous channel perpendicular to the lower wall with a constant velocity and is sucked out of the upper wall with same velocity .The coupled phenomenon of the fluid flow and solid deformation in the porous medium is taken in to consideration. The exact expressions for the velocity of fluid, solid displacement and temperature distribution are found analytically. The effect of pertinent parameters on the fluid velocity, solid displacement and temperature profiles are discussed in detail. In the deformable porous layer, it is noticed that the velocity of fluid, solid displacement and temperature distribution are decreases with increasing the suction/injection velocity parameter. The results obtained for the present flow characteristic reveal several interesting behaviors that warrant further study on the deformable porous media. Furthermore, the significance of drag and the volume fraction on entropy generation number and Bejan number are discussed with the help of graphs.

Ecologically Himalayan blue pine (Pinus wallichiana A. B. Jackson) is the most sensitive tree-species found across the high mountain ranges of Himalaya with deciphering tree-line for the region. Earlier studies showed the potential of Himalayan blue pine to reconstruct the past climate for extending observational data back to the centuries from orography-dominated Himalaya. However, tree-growth of the blue pine is largely found modulated by temperature in the western Himalayan region. In the present study, we attempted the first time to develop precipitation records using Himalayan blue pine chronology from cold arid Lahaul–Spiti, Himachal Pradesh, India. The blue pine chronology extends back to AD 1578 and showed significant relationship with the climatic variables. The bootstrap correlation analyses revealed previous year December to current year July precipitation plays significant role in tree-growth advancements. The previous year December to current year July (pDcJuly) precipitation has been reconstructed back to the AD 1730 for the Lahaul–Spiti region. The recorded individual and multi-year periods of low and high precipitation are consistent with existing hydro-climatic records from the western Himalaya. The five driest and wettest individual years are 1732, 1737, 1970, 2008, 1785, and 1730, 1771, 1758, 1734, 1736, respectively. The spatial correlation between gridded precipitation and reconstructed pDcJuly precipitation is significant for the region close to the sampling site. The study based on the Himalayan blue pine tree-ring chronology addressed its dendroclimatic utility for the semi-arid Lahaul–Spiti region and would be valuable to understand climatic variability over the past three centuries. The strong resemblance of the species with the Himalayan cedar growth patterns showed its promising viability to develop a network of multispecies for more robust climatic reconstruction in the future.

Background:. Objective evaluation of operative performance is increasingly important in surgical training. Evaluation tools include global rating scales of performance and procedure-specific skills checklists. For unilateral cleft lip repair, the numerous techniques make universal evaluation challenging. Thus, we sought to create a unilateral cleft lip evaluation tool agnostic to specific repair technique. Methods:. Four surgeons with expertise in 3 common cleft lip repair techniques participated in a 3-round Delphi process to generate consensus evaluation points spanning all techniques. Items were categorized as marking the repair, performing the repair, and final result. Two blinded raters then scored videos of simulated cleft lip repairs using both the 21-item novel checklist and the modified Objective Structured Assessment of Technical Skills. Kappa and T values were calculated for both scales to determine level of agreement. Results:. Ten videos of repairs performed by novice residents through experienced craniofacial fellows were scored. Moderate (κ = 0.41–0.60) to substantial (κ = 0.61–0.80) interrater reliability was seen for the majority of questions in both the novel tool and the Objective Structured Assessment of Technical Skills. A single question in the novel tool had almost perfect agreement (κ = 0.81–1.00), 8 had moderate agreement, and 6 had substantial agreement. Poorly scoring questions were discarded from the final 18-item tool. Conclusions:. Despite variations in unilateral cleft lip repair technique, common themes exist that can be used to assess performance and outcome. A universal evaluation tool has potential implications for trainee assessment, surgeon credentialing, and screening for surgical missions.

New diagnostic tests for the etiology of childhood pneumonia are needed. We evaluated the antibody-in-lymphocyte supernatant (ALS) assay to detect immunoglobulin (Ig) G secretion from ex vivo peripheral blood mononuclear cell (PBMC) culture, as a potential diagnostic test for pneumococcal pneumonia. We enrolled 348 children with pneumonia admitted to Patan Hospital, Kathmandu, Nepal between December 2015 and September 2016. PBMCs sampled from participants were incubated for 48 h before harvesting of cell culture supernatant (ALS). We used a fluorescence-based multiplexed immunoassay to measure the concentration of IgG in ALS against five conserved pneumococcal protein antigens. Of children with pneumonia, 68 had a confirmed etiological diagnosis: 12 children had pneumococcal pneumonia (defined as blood or pleural fluid culture-confirmed; or plasma CRP concentration ≥60 mg/l and nasopharyngeal carriage of serotype 1 pneumococci), and 56 children had non-pneumococcal pneumonia. Children with non-pneumococcal pneumonia had either a bacterial pathogen isolated from blood (six children); or C-reactive protein

Abstract The present study envisages the application of multivariate analysis, water utility class and conventional graphical representation to reveal the hidden factor responsible for deterioration of water quality and determine the hydrochemical facies of water sources in Jia-Bharali river basin, North Brahmaputra Plain, India. Fifty groundwater and 35 surface water samples were collected and analyzed for 15 parameters viz pH, TDS, hardness, COD, Ca2+, Mg2+, Na+, K+, Fe, HCO3 −, Cl−, SO4 2−, NO3 −, PO4 3− and F− for a period of 3 hydrological years (2009–2011) in six different seasons (three wet and three dry). The results were evaluated and compared with WHO and BIS water quality standards. Except Fe (> 0.3 mg/L), all parameters were found well within the desirable limit of WHO and BIS for drinking water. Ca2+ and HCO3 − were dominant ions among cations and anions. The piper trilinear diagram classified majority of water samples for both seasons fall in the fields of Ca2+–Mg2+–HCO3 − water type indicating temporary hardness. Varimax factors extracted by principal component analysis indicates anthropogenic (domestic and agricultural runoff) and geogenic influences on the trace elements. Hierarchical cluster analysis grouped water sources into three statistically significant clusters based on the similarity of water quality characteristics. This study illustrates the usefulness of multivariate statistical techniques for analysis and interpretation of complex datasets, and in water quality assessment, identification of pollution sources/factors and understanding temporal/spatial variations in water quality for effective water quality management.

Jennifer Tsai,1 Katherine Brooks,2 Samantha DeAndrade,2 Laura Ucik,3 Stacy Bartlett,1 Oyinkansola Osobamiro,1 Jamila Wynter,2 Gopika Krishna,4 Steven Rougas,1 Paul George1 1Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA; 2Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA; 3Department of Medicine, Montefiore Medical Center, Bronx, NY, USA; 4Department of Obstetrics and Gynecology, Emory University School of Medicine, Atlanta, GA, USA Abstract: Health disparities fall along racial lines, in part, due to structural inequalities limiting health care access. The concept of race is often taught in health professions education with a clear biologic underpinning despite the significant debate in the literature as to whether race is a social or biologic construct. The teaching of race as a biologic construct, however, allows for the simplification of race as a risk factor for disease. As health care providers, it is part of our professional responsibility and duty to patients to think and talk about race in a way that is cognizant of broader historical, political, and cultural literature and context. Openly discussing the topic of race in medicine is not only uncomfortable but also difficult given its controversies and complicated context. In response, we provide several evidence-based steps to guide discussions around race in clinical settings, while also hopefully limiting the use of bias and racism in the practice of medicine. Keywords: racism, racial bias, inequality, health justice

Background: In recent times, high-resolution ultrasound thyroid imaging has paved the way for significant transformation in clinical approach to thyroid nodule. There are several risk stratification systems in thyroid imaging, developed with an aim, not only to reduce the inter-observer variability but also to establish effective communication system. Thyroid image reporting and data system (TIRADS) classification system, which is similar to breast imaging reporting and data system for breast lesion, is the most useful of all. To our knowledge, there is just a handful published research articles available based on Indian population in this regard. In this article, we study the thyroid nodules using high-resolution ultrasound in Indian population and we try to correlate the TIRADS and Bethesda system for reporting thyroid cytopathology. Materials and Methods: This prospective study includes 184 patients studied over a period of 2 years (April 2015–April 2017). Patients having thyroid nodule in B-mode ultrasound and are scheduled to get a fine-needle aspiration cytology (FNAC) done. Bethesda classification of these nodules is tabulated in follow-up period simultaneously. By comparing these data, efficacy of TIRADS in differentiating benign from malignant nodules are assessed finally using accuracy, positive predictive value (PPV), cross-tabulation, and Chi-square tests. Results: Out of the 117 TIRADS 2 nodules, none turned out to be Bethesda IV or higher, which means none of these nodules turned out to be malignant.The risk of malignancy for TIRADS 2, TIRADS 3, TIRADS 4, and TIRADS 5 was 0, 2.2, 38.5, and 77.8%, respectively. The risk of malignancy percentage in our study is similar to those values obtained in other prominent studies. Conclusion: The probability of a particular nodule being malignant can be effectively inferred from the ultrasound-based TIRADS system with a certain level of confidence. Considering our results and other literature reviews, it be can be safely assumed that FNAC can be at least deferred in patients having TIRADS 2 nodules, which contribute to majority of newly detected cases. In our experience, there is a remarkable correlation exists between TIRADS ultrasound classification and Bethesda cytology, especially for benign nodules.

Abstract The sediments in stormwater runoff are recognised as the major sink of the heavy metals and affect the soil quality in the catchment. The runoff sediments are also important in the management of contaminant transport to receiving water bodies. In the present work, stormwater during several major rain events was collected from nine principal locations of Guwahati, India. The solid phase was separated from the liquid phase and was investigated for the total contents of Cd, Co, Cr, Cu, Mn and Zn as well as their distribution among the prominent chemical phases. Sequential extraction procedure was used for the chemical fractionation of the metals that contains five steps. The total metal concentration showed the trend, Cd

The work describes an assessment of the major air pollutants, NO2, SO2, CO, O3, NH3, coarse and fine particulate matter (PM10, PM2.5) in ambient air in and around a 3 million tonne Petroleum Refinery and the possible impacts on a pristine area marked by the presence of the world-famous Kajiranga National Park, a world heritage site and habitat for the most number of one-horned rhinos in the world. The Refinery is at an aerial distance of 20-25 km from the wildlife habitat. The assessment is based on regular monitoring at four stations around the Refinery and one station near the National Park. Heavy rains during June to August influence the pollutant concentrations while at other times of the year, large traffic volume adds to the pollutant concentrations that peak during November to March, the dry months of the year. Correlation analysis by scatter technique is utilised to obtain the enhancement ratios to predict the variations in the concentrations of the pollutants and their spatial distribution. Computation of air quality index (AQI) indicates that the coarse and the fine particulates in the ambient air could be a major hazard to wildlife in the area.

We present a case of an intensely hypermetabolic intracavitary cardiac mass, standardized uptake values max 44.4, that was pathologically proved to be organizing and organized thrombus, negative for tumor. Our patient had previous right atrial mass resection 2 years prior that was pathologically described as either thrombus or infarcted atrial myxoma. She had since been on lifelong controlled anticoagulation; and on routine follow-up imaging, she had recurrent slow growth of a new right atrial mass. During a later hospital admission for chest pain, the mass was evaluated on both transthoracic and transesophageal echo cardiogram, which could not differentiate thrombus vs neoplasm. Cardiac magnetic resonance imaging was equivocal for mass enhancement. The patient underwent fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) evaluation, which revealed intensely hypermetabolic activity within the mass concerning for malignancy, potentially an aggressive tumor. Subsequently, the mass was surgically excised for pathological diagnosis.

Abstract This study was carried out to investigate Arsenic (As) contamination in the alluvial aquifers of the lower Jia Bharali catchment and adjoining areas in Sonitpur district of Assam. Samples were collected twice a year (July and February) for three consecutive years from 50 monitoring wells spread into both older and younger alluvium between the Brahmaputra River towards south and Arunachal foothills towards north. The analytical results show that dissolved As content [both As(III) and As(V)] varies from below detection level (BDL) to 7.39 µg/L with a mean value of 1.92 µg/L and standard deviation of 1.37 µg/L during wet season (July). Thus, it remains within the WHO (2004) prescribed limit (10 µg/L) in the study area in the wet season. During the dry season, the range of variation is higher, from BDL to as much as 13.8 µg/L with a mean value of 2.57 µg/Land standard deviation of 2.23 µg/L. About 78% of the wells show a concentration between 1 and 10 µg/L in both the seasons. However, only one of the wells present in foothills of Arunachal Himalaya was found to have As content higher than the WHO limit in the dry season. Along with total As, examination of concentration levels of other key parameters, viz., Fe, Mn, Ca, Na, K, and Mg with pH and SO4 2− was also carried out. Most of the wells (~92%) showed Fe concentration much higher than the WHO (2004) permissible limit of (0.3 mg/L) particularly during the dry season and it is likely that high Fe concentration was responsible for keeping total As concentration at comparatively low levels. 34% of the samples in the wet seasons and 86% of the samples in the dry seasons have Mn above the permissible limit of 0.1 mg/L.

Abstract Hydroclimatic variability driven by global warming in the climatically vulnerable cold semi-arid to arid northwest (NW) Himalaya is poorly constrained due to paucity of continuous weather records and annually resolved proxies. Applying a network of annually resolved tree-ring-width chronologies from semi-arid region of Kishtwar, Jammu and Kashmir, India, we reconstructed April-May standardized precipitation index extending back to A.D. 1439 (576 years). The reconstructed series is featured by the most conspicuous long-term droughts during the 15th to early 17th centuries followed by a general wetting, with 1984–2014 being the wettest interval in the past 576 years. The data, consistent with other independently developed tree-ring-based hydrological records from cold semi-arid to arid NW Himalaya and Karakoram, point to an increased regional wetting in the recent decades. Such an increased wetting might have led to the anomalous behaviour of glaciers in the NW Himalaya and Karakoram in contrast to the general receding trends in the central and eastern Himalaya.

Objectives: The aim of the study is to compare surrogate markers of cardiovascular disease (CVD) risk, such as adiponectin (APN) levels and low-density lipoprotein (LDL) size, before and after sustained release metformin (Met-SR) therapy in women with polycystic ovarian syndrome (PCOS). Methods: Sixty women with PCOS and sixty age-matched controls in the age group 18–45 years were recruited after obtaining informed consent. Women with PCOS were initiated on Met-SR 1 g orally, which was increased to 1.5 g after 2 weeks and continued up to 24 weeks. Demographic data along with family history of type 2 diabetes mellitus, PCOS, and CVD were collected. Lipid profile plasma APN levels and LDL size were measured before and after therapy in the PCOS group. Data analysis was performed using the GraphPad Prism-5 software. Results: Women with PCOS had greater dyslipidemia, lower APN level and LDL size, and increased lipid accumulating product index as compared to controls. After 6 months of Met-SR therapy, women with PCOS demonstrated significant increase in plasma APN levels and LDL size and significant decrease in weight, waist-hip ratio (WHR), waist circumference (WC), and blood pressure (BP). A significant decrease was observed in body mass index (BMI) in the overweight and obese PCOS subgroups. Conclusion: Met-SR increases LDL size, APN concentration and decreases weight, WC, WHR, and BP in patients with PCOS. Met-SR may have salutary effects on LDL particle size through effects on APN levels in women with PCOS.

Thyroid nodules are prevalent in upto 68% of randomly selected individuals in whom high resolution ultrasound is performed . The majority of nodules are benign. The use of ultrasound coupled with FNAC has dramatically reduced the number of patients who undergo surgery for nodules. The six tier Bethesda scoring system has reduced variability and increased the ability to clinicians to guide patients with thyroid nodules. There is good correlation between cytology and histopathologic outcomes. A significant proportion of patients will however fall into an indeterminate category. The availability of molecular markers enhanced with next generation sequencing technology and the expression classifier are added diagnostic aids that can help in management. However these are not available in many countries and in resource limited settings. A pragmatic approach to the diagnosis of indeterminate nodules includes utilising pre and post test probability, clinical acumen, correlation of ultrasound findings and expert opinion in some settings. Using this approach high risk patients can be appropriately chosen for surgery while relegating patients with lower risk to watchful followup.

Introduction: Hypoglycemia tops the list of hurdles in preventing tight glycemic control in diabetic patients. It is even considered as a cardiovascular risk factor. However, it continues to be a neglected complication with very limited epidemiological data in our country. Aim: To study the self-reported prevalence of hypoglycemia among type 2 diabetic patients and the practices adopted by them during and after the episodes to manage and avert future occurrences. Materials and Methods: It is a questionnaire-based cross-sectional study done using systematic random sampling selecting every 5th patient attending the diabetic Out-Patient (OP) in a tertiary medical college hospital. Results: There were 366 participants with median age of 60 years. Around 96% reported any one symptom of hypoglycemia, but 78% had eaten following the episode and got relieved of the symptoms. Weakness (76.2%) and dizziness (74%) were the most common symptoms reported by the patients. A quarter of them reported having severe attacks requiring somebody's assistance. Most patients resorted to timely meals (85%) to avert future attacks. Patients who took insulin along with oral hypoglycemic agents (OHAs) were at a higher risk (OR = 2.3) for hypoglycemia compared to patients taking only OHAs (P < 0.01). Conclusion: The reported prevalence of hypoglycemia among type 2 diabetes patients is quite high. This finding reiterates the importance of enquiring and educating every diabetic patient about hypoglycemic episodes during every health visit.

Romantic love could be considered as a collection of activities associated with the acquisition and retention of emotions needed to survive and reproduce. These emotions change the individual's behavioural strategies in a way that will increase the likelihood of achieving these goals. Love may be defined as an emergent property of an ancient cocktail of neuropeptides and neurotransmitters. It appears that lust, attachment and attraction appear to be distinct but intertwined processes in the brain each mediated by its own neurotransmitters and circuits. These circuits feed on and reinforce each other. Sexual craving is mediated by testosterone and oestrogen and has the amygdala as an important centre. Attraction is mediated by hormones of stress and reward including dopamine, norepinephrine cortisol and the serotinergic system and has the nucleus accumbens the ventral tegmental area as key mediators.

Background: Type 2 diabetes mellitus (T2DM) and obesity are associated with changes in gut microbiota and characterized by chronic low-grade inflammation. Monocyte chemoattractant protein-1 (MCP-1) and interferon gamma (IFNγ) are proinflammatory cytokines which play an important role in the development of T2DM. We undertook this study to analyze the gut microbiota of T2DM and nondiabetic subjects and to determine the profile of MCP 1 and IFNγ in the same subjects attending a tertiary care center in Chennai, Tamil Nadu, India. Methods: The study included 30 subjects with clinical details. Stool and blood samples were collected from all the subjects. DNA was extracted from fecal samples and polymerase chain reaction was done using fusion primers. Metagenomic analysis was performed using ion torrent sequencing. The reads obtained were in FASTA format and reported as operational taxonomic units. Human MCP 1 and IFNγ enzyme linked immunosorbent assay (ELISA) were performed for 23 serum samples. Results: The study consisted of 30 subjects; 17 were T2DM and 13 were nondiabetics. The gut microbiota among T2DM consisted predominantly of Gram negative bacteria; Escherichia and Prevotella, when compared with the nondiabetic group with predominantly Gram positive organisms suchas Faecalibacterium, Eubacterium, and Bifidobacterium. The mean MCP-1 values in the diabetic group were 232.8 pg/ml and in the nondiabetic group 170.84 pg/ml. IFNγ (mean 385.5 pg/ml) was raised in glycated hemoglobin (HbA1c) group of 6.5–7.5% which was statistically significant. Association of Escherichia with T2DM and association of Bifidobacteria in the nondiabetics were also statistically significant. Conclusion: Escherichia counts were elevated in T2DM with HbA1c of 6.5–8.5% which was statistically significant suggesting that lipopolysaccharides present in the cell wall of Gram-negative bacteria may be responsible for low-grade inflammation as evidenced by elevated MCP-1 and IFNγ levels in T2DM with the same HbA1c levels.

A comprehensive longitudinal understanding of the changing epidemiology of the agents causing bacteraemia and their AMR profiles in key locations is crucial for assessing the progression and magnitude of the global AMR crisis. We performed a retrospective analysis of routine microbiological data from April 1992 to December 2014, studying the time trends of non-Salmonella associated bacteraemia at a single Kathmandu healthcare facility. The distribution of aetiological agents, their antimicrobial susceptibility profiles, and the hospital ward of isolation were assessed. Two hundred twenty-four thousand seven hundred forty-one blood cultures were performed over the study period, of which, 30,353 (13.5%) exhibited growth for non-contaminant bacteria. We observed a significant increasing trend in the proportion of MDR non-Salmonella Enterobacteriaceae (p < 0.001), other Gram-negative organisms (p = 0.006), and Gram-positive organisms (p = 0.006) over time. Additionally, there was an annual increasing trend in the proportion of MDR organisms in bacteria-positive blood cultures originating from patients attending the emergency ward (p = 0.006) and the outpatient department (p = 0.006). This unique dataset demonstrates that community acquired non-Salmonella bacteraemia has become an increasingly important cause of hospital admission in Kathmandu. An increasing burden of bacteraemia associated with MDR organisms in the community underscores the need for preventing the circulation of MDR bacteria within the local population.

Background: There is a high risk of occupational exposure to tuberculosis among healthcare workers in endemic countries. Regular screening for tuberculosis among healthcare workers is not carried out in Nepal. Infection control measures are also not routinely implemented. The aim of this study was to determine the prevalence of active tuberculosis among staff/students at Patan Hospital. Methods: Participants were given a self-administered questionnaire and invited to undergo chest radiography. Cases were scored and reviewed based on predetermined criteria, and presumptive tuberculosis cases were invited to undergo sputum smear and culture. Participants were categorized according to the extent of patient contact and asked about history of tuberculosis medication. Results: Among 560 participants, 76.8% had direct contact with patients. Fifty-eight (10.4%) gave history of cough >2 weeks. Based on symptom history and chest radiography, 20.0% (n=112) cases were reviewed, and 12.5% (n=14) of those reviewed had sputum tested for acid-fast bacilli. One participant had culture-positive tuberculosis. Fifty participants (8.9%) reported tuberculosis in the past, among which 42.0% (n=21) occurred after employment at Patan Hospital and 42.0% before joining Patan Hospital. Security staff, radiology technicians and ward cleaning staff had the highest proportion of cases with a history of tuberculosis.History of tuberculosis medication had no relation with age, sex, education, body mass index and smoking.The incidence rate of tuberculosis at Patan Hospital was 3.6 per 1000 person-years. Conclusions: Overall incidence of tuberculosis among healthcare workers is noteworthy. However, this study suggests when symptomatic tuberculosis occurs in healthcare worker at Patan Hospital, it is diagnosed and there is not a large pool of undiagnosed tuberculosis. Keywords: Health personnel; occupational health; tuberculosis.

Introduction: Lower-extremity ulcers represent the largest group of ulcers presenting to an outpatient department. It is a cumbersome, difficult to treat disease, which causes high morbidity and huge cost for the patient and healthcare system. Current standard treatment includes compression therapy. However, majority of patients need long term treatment with minimal efficacy. Aim of our study is to evaluate efficacy of four layers compressive bandages for the management of chronic venous ulcers. Methods: In Group A, we have prospectively included 20 patients with chronic venous ulcers on lower limbs for four layers hosiery bandage using Velfour bandage. Other 15 patients, Group B, were treated with conventional wound dressing. Velfour and crepe bandage were done once weekly for three weeks. Results: DVT was cause of chronic venous ulcer in 70% patient in group A and in 73.3% in Group B. Majority of patients were having left sided chronic venous ulcers. The mean duration of the ulcers was 15.6 vs 10.86 months (group A vs. group B). At the end of 3rd week, in 55% wounds in Group A were healed except few big and deep wounds remained. Most of these wounds also became smaller with minimal discharge. Size of wounds significantly decreased in Group A vs. Group B patients (0.7±0.81 cm vs. 1.73±0.77 cm, p

Introduction: Hypoglycemia being the rate limiting complication in the attainment of strict glycemic control in diabetes management, in this study, we intended to study the knowledge of its symptoms, target blood levels during treatment and ways of prevention among type 2 diabetes patients attending Outpatient Department (OPD) of a medical college hospital. Materials and Methods: Every fifth patient attending the OPD during the 4 months between March and June 2013 was interviewed using a questionnaire. Results: The study included 366 type 2 diabetic patients, of which 76.5% were females. The target fasting and postprandial blood glucose levels while on treatment was known to 135 (36.9%) and 126 (34.4%) patients, respectively. The common symptoms of hypoglycemia known to the study subjects were dizziness (81.4%), weakness (73.8%), and drowsiness (72.1%). Overall, 242 (66.1%) diabetic patients had good knowledge on hypoglycemia (knowledge of at least three symptoms of hypoglycemia together with at least one precipitating factor and at least one remedial measure). Higher age, illiteracy, low socioeconomic status were associated with poor knowledge whereas treatment with insulin along with oral hypoglycemic agents was associated with good knowledge on hypoglycemia. Sex and duration of disease were not associated with knowledge on hypoglycemia. Conclusion: Although the knowledge on symptoms of hypoglycemia, precipitating factors, remedial measures are high in this study, the target blood levels, complications were known to just a third of them. There is a knowledge gap on important aspects of hypoglycemia among type 2 diabetic patients.