The Out-of-pocket Expenditures Incurred during Neonatal Hospitalization in a Public Hospital in Tamil Nadu - A Cross-Sectional Study.

Background: For effective policy making, it is important to understand out of pocket costs incurred in neonatal admissions in public hospitals. This cross sectional study was conducted with an objective to estimate out of pocket expenses expended on neonates and attenders during neonatal hospitalizations in a tertiary care referral hospital. Material and Methods: The data were collected using a pretested and semi structured questionnaire in 298 neonates during July'2022. Expenditures were reported as median values with interquartile range (IQR) and compared using the Kruskal Wallis test. Result: On analyzing the results, there were no direct medical costs. The median cost spent on food per day, transport during the stay, non medical expenses per day, and total expenses per day were Rs. 300 (IQR 200, 500), Rs. 1000 (500, 1500), Rs. 500 (333, 896), and Rs. 1080 (800, 1533), respectively. Higher expenses were associated with preterm, low birth weight, neonatal seizures, and longer stay (P values <0.001, 0.028, <0.001, and <0.001, respectively). About 9.39% and 1% of the families were found to be catastrophic health expenditures at 10% and 25% threshold levels, respectively. Conclusion: To conclude, all the direct medical costs were borne by the caregiver. However, some non medical and indirect costs are associated with neonatal hospitalizations in public hospitals and cash benefit schemes can offset them.

Data-driven predictions of potential Leishmania vectors in the Americas.

The incidence of vector-borne diseases is rising as deforestation, climate change, and globalization bring humans in contact with arthropods that can transmit pathogens. In particular, incidence of American Cutaneous Leishmaniasis (ACL), a disease caused by parasites transmitted by sandflies, is increasing as previously intact habitats are cleared for agriculture and urban areas, potentially bringing people into contact with vectors and reservoir hosts. Previous evidence has identified dozens of sandfly species that have been infected with and/or transmit Leishmania parasites. However, there is an incomplete understanding of which sandfly species transmit the parasite, complicating efforts to limit disease spread. Here, we apply machine learning models (boosted regression trees) to leverage biological and geographical traits of known sandfly vectors to predict potential vectors. Additionally, we generate trait profiles of confirmed vectors and identify important factors in transmission. Our model performed well with an average out of sample accuracy of 86%. The models predict that synanthropic sandflies living in areas with greater canopy height, less human modification, and within an optimal range of rainfall are more likely to be Leishmania vectors. We also observed that generalist sandflies that are able to inhabit many different ecoregions are more likely to transmit the parasites. Our results suggest that Psychodopygus amazonensis and Nyssomia antunesi are unidentified potential vectors, and should be the focus of sampling and research efforts. Overall, we found that our machine learning approach provides valuable information for Leishmania surveillance and management in an otherwise complex and data sparse system.

What Causes Desmoplastic Reaction in Small Intestinal Neuroendocrine Neoplasms?

PURPOSE OF REVIEW: Mesenteric desmoplasia in small intestinal neuroendocrine neoplasms (SINENs) is associated with increased morbidity and mortality. In this paper, we discuss the development of desmoplasia in SINENs. RECENT FINDINGS: The fibrotic reactions associated with these tumours could be limited to the loco-regional environment of the tumour and/or at distant sites. Mesenteric fibrotic mass forms around a local lymph node. Formation of desmoplasia is mediated by interactions between the neoplastic cells and its microenvironment via number of profibrotic mediators and signalling pathways. Profibrotic molecules that are mainly involved in the desmoplastic reaction include serotonin, TGFß (transforming growth factor ß) and CTGF (connective tissue growth factor), although there is some evidence to suggest that there are a number of other molecules involved in this process. Desmoplasia is a result of autocrine and paracrine effects of multiple molecules and signalling pathways. However, more research is needed to understand these mechanisms and to develop targeted therapy to minimise desmoplasia.

Nailfold capillaroscopy changes associated with anti-RNP antibodies in systemic lupus erythematosus.

Anti-U1RNP antibody is associated with distinct organ involvement in patients with systemic lupus erythematosus (SLE). Nailfold capillaroscopy (NFC) allows non-invasive assessment of microvascular abnormalities in several connective tissue diseases. The objective of this study is to determine the association of anti-U1RNP antibody with microvascular changes by NFC in RNP-positive SLE patients in comparison with RNP-negative SLE patients (negative disease controls) and mixed connective tissue disease (MCTD) cases (positive disease controls). NFC examination was performed in consecutive patients with SLE with or without anti-U1RNP positivity. MCTD patients were recruited as disease controls. Abnormalities noted in the three groups were compared using non-parametric tests. Ordinal logistic or linear regression was used wherever applicable. 81 patients were studied, of whom 28 were diagnosed as RNP-positive SLE (age 30.0 ± 10.37; 26 females), 26 were RNP-negative SLE (age 29.42 ± 9.20; 25 females) and 27 had MCTD (age36.5 ± 9.70; 25 females). RNP-positive SLE patients had more frequent giant capillaries, enlarged capillaries and ramified capillaries as compared to RNP-negative SLE (p = 0.05, < 0.01 and 0.03, respectively). The capillary density was lower in patients with MCTD as compared with patients with RNP-positive SLE (5.11 ± 1.69/mm vs 7.25 ± 1.38/ mm, p < 0.01) and RNP-negative SLE (8.92 ± 1.13/mm, p < 0.01). The reduction in capillary density was less severe in patients with RNP-negative SLE as compared with RNP-positive SLE (OR = 0.1058 [95% CI = 0.02-0.546], p < 0.01) which was independent of the presence of Raynaud's phenomenon, interstitial lung disease and disease duration. Presence of anti-U1RNP antibody is associated with notable patterns of microvascular abnormalities in SLE. These NFC abnormalities are noted more profoundly in patients with MCTD and are less marked in RNP-negative SLE patients.

Duodenal neuroendocrine neoplasms with unexpectedly aggressive behaviour: Challenging the "watch and wait" approach.

The incidence of duodenal neuroendocrine neoplasms has risen over the past decades as a result of the wide availability of endoscopy and associated expertise. Although it is considered that tumour size greater than 10 mm, higher tumour grade and/or location in relation to the ampulla of Vater represent the main risk factors for local or distant metastases, we describe two cases of well differentiated grade 1 and grade 2 neuroendocrine tumours, which measured < 10 mm at the time of diagnosis but had an aggressive course during follow-up. Furthermore, we also summarise the available therapeutic strategies for the management of small, low grade, non-functioning, non-ampullary duodenal neuroendocrine neoplasms.

Middle ear neuroendocrine tumours: Insight into their pathogenesis, diagnosis and management.

Recent advances in the diagnosis of neuroendocrine tumours (NETs) have led to the identification of NETs in unusual locations. NETs originating in the middle ear have been reported in a number of case reports with differing terminologies, where they were variously referred to as middle ear adenomas or middle ear carcinoids. In this report, we describe two cases of middle ear NETs with locally advanced disease and with distant metastases, respectively. The embryological origin, pathogenesis and histopathological characteristics, including immunohistochemical markers, are discussed aiming to clarify the terminology of these tumours. Functional imaging modalities (eg, 68 Ga-DOTATATE positron emission tomography/computed tomography/magnetic resonance imaging) play a pivotal role in the diagnosis, staging and determining the optimal systemic therapy in managing NETs of the middle ear. In addition, surgical, local and systemic therapeutic modalities are discussed, including the management option of long-acting somatostatin analogue therapy and targeted radionuclide therapy for somatostatin receptor-positive well-differentiated middle ear NETs.

Fabrication of Nd3+ and Yb3+ doped NIR emitting nano fluorescent probe: A candidate for bioimaging applications.

The intentional design of rare earth doped luminescent architecture exhibits unique optical properties and it can be considered as a promising and potential probe for optical imaging applications. Calcium fluoride (CaF2) nanoparticles doped with optimum concentration of Nd3+ and Yb3+ as sensitizer and activator, respectively, were synthesized by wet precipitation method and characterized by x-ray diffraction (XRD) and photoluminescence. In spite of the fact that the energy transfer takes place from Nd3+ to Yb3+, the luminescence intensity was found to be weak due to the lattice defects generated from the doping of trivalent cations (Nd3+ and Yb3+) for divalent host cations (Ca2+). These defect centres were tailored via charge compensation approach by co-doping Na+ ion and by optimizing its concentration and heat treatment duration. CaF2 doped with 5 mol% Nd3+, 3 mol% Yb3+ and 4 mol% Na+ after heat treatment for 2 h exhibited significantly enhanced emission intensity and life time. The ex vivo fluorescence imaging experiment was done at various thickness of chicken breast tissue. The maximum theoretical depth penetration of the NIR light was calculated and the value is 14 mm. The fabricated phosphor can serve as contrast agent for deep tissue near infrared (NIR) light imaging.

Expectant versus immediate delivery in women with PPROM between 34 and 35+6 weeks: A Retrospective cohort.

CONTEXT: Studies comparing the efficacy of expectant management (EM) and immediate delivery (ID) in the management of women with preterm prelabor rupture of membranes (PPROM) between 34 and 35+6 weeks have not been done in a developing country. Although large multicentric studies show better outcomes with EM, the economic implications have not been studied. AIMS: This study compared women with PPROM between 34 and 35 +6 weeks, managed expectantly with women who were delivered immediately. SETTINGS AND DESIGN: Large tertiary center and retrospective cohort. METHODS AND MATERIALS: Data of 206 women with PPROM between 34 and 35+6 weeks managed with immediate delivery in the years 2014 and 2015 were compared with seventy-five women with PPROM managed expectantly in the years 2016 and 2017. STATISTICAL ANALYSIS USED: Data was summarized using mean standard deviation (SD) or median interquartile range for continuous variables and frequency and percentage for categorical variables. Continuous variables were compared using independent t-test and categorical variables were compared using Chi-square statistics. RESULTS: Neonatal sepsis was seen in 1/75 (1.3%) in the group managed expectantly and 12/206 (5.8%) in the ID group (P = 0.109). Respiratory distress was seen in 3/75 (4%) in the group managed expectantly and 22/206 (10.7%) with ID (P = 0.08). Chorioamnionitis was similar in both groups. Cesarean rate was 17.3% with expectant management and 28% with ID (P = 0.065). The mean hospital bill was ₹.33,494/- in the ED group and ₹.27,079/- in the ID group (P < 0.001). CONCLUSIONS: Expectant management was more expensive.

The effects of N95 mask and face shield on speech perception among healthcare workers in the coronavirus disease 2019 pandemic scenario.

OBJECTIVE: The current circumstances of the coronavirus disease 2019 pandemic necessitate the use of personal protective equipment in hospitals. N95 masks and face shields are being used as personal protective equipment to protect from aerosol-related spread of infection. Personal protective equipment, however, hampers communication. This study aimed to assess the effect of using an N95 mask and face shield on speech perception among healthcare workers with normal hearing. METHODS: Twenty healthcare workers were recruited for the study. Pure tone audiometry was conducted to ensure normal hearing. Speech reception threshold and speech discrimination score were obtained, first without using personal protective equipment and then repeated with the audiologist wearing an N95 mask and face shield. RESULTS: A statistically significant increase in speech reception threshold (mean of 12.4 dB) and decrease in speech discrimination score (mean of 7 per cent) was found while using the personal protective equipment. CONCLUSION: Use of personal protective equipment significantly impairs speech perception. Alternate communication strategies should be developed for effective communication.

Acceptability and outcomes of foreskin preservation for phimosis: An Indian perspective.

AIM: Understanding the Indian perspective, effectiveness, and acceptability of prepuce conservation in children with phimosis. Circumcision is performed and recommended far too often for nonphysiological phimosis. Will a less radical approach be acceptable in the subcontinent? METHOD: A two-arm study with the first arm as KAP (knowledge, attitude, and practice) study (n = 502). The second arm recruited deserving boys (n = 47) with symptomatic phimosis (see inclusion criteria). Betamethasone ointment was applied twice daily over the foreskin and gently massaged to stretch the phimotic band. Those who failed were offered lateral preputioplasty or circumcision. Religious beliefs influence attitude and practice and these were looked at with subgroup analysis. RESULTS: Most (85%) knew that circumcision was not the only treatment for phimosis. Though many parents (93%) knew the importance of foreskin cleanliness, few practiced it. The success of the steroid application was 81% (n = 38/47). Eight underwent preputioplasty. Minor discomfort as morbidity was noted. All parents were able to completely retract the foreskin of their children by the end of one month and were happy about the cosmetic result. CONCLUSIONS: KAP data on foreskin health is not available in the subcontinent, and this is a landmark study. Religious belief and community identity play a strong role in decisions related to foreskin preservation. Prepuce hygiene and knowledge about the usefulness of the foreskin is poor. The combination of medical and surgical methods of conserving the prepuce was effective. A high rate of success and the non-mutilating cosmetic result of prepuce preservation were acceptable to these parents.

Sertraline as a promising antifungal agent: inhibition of growth and biofilm of Candida auris with special focus on the mechanism of action in vitro.

AIM: The aim of this present study was to investigate the antifungal mechanism of sertraline against Candida auris (C. auris) and its effect on biofilm formation. METHODS AND RESULTS: Sertraline, a repurposing drug with a history of human use for the treatment of depression was screened against three different isolates of C. auris, and was found to possess efficient antifungal activity. The antifungal activity of sertraline was further confirmed by killing kinetics assay and post-antifungal effect (PAFE). Sertraline inhibited C. auris yeast to hyphae conversion and further the inhibition of biofilm formation showed 71% inhibition upon treatment. Cell damage caused due to C. auris after treatment with sertraline was observed using SEM and cell membrane damage was ascertained using flow cytometry by Propidium Iodide (PI) uptake assay. The results of sorbitol protection assay and ergosterol effect assay suggested that sertraline did not affect the cell wall and did not act by binding to membrane ergosterol. The mechanism of action of sertraline against C. auris was understood through in silico docking studies that revealed the binding nature of sertraline to the sterol 14 alpha demethylase which is involved in ergosterol biosynthesis. Ergosterol that was quantified from treated cells showed a 5·5-fold decrease in ergosterol production. CONCLUSION: Sertraline displayed promising antifungal activity against C. auris involved in candidiasis infection and the mechanism of action was predicted. SIGNIFICANCE AND IMPACT OF THIS STUDY: The results of this study can encourage for the development of new antifungal agents and can be promising antifungal agent against C. auris infection.

A prospective observational study of the follow-up of medical management of early pregnancy failure.

BACKGROUND: Medical termination for missed miscarriage with the use of 800 µg of vaginal misoprostol as a single agent is recommended as a cheap option before 14 weeks of gestation in developing countries. A few studies have looked at its efficacy. METHODS: A prospective, observational study was done on women having medical termination with up to three doses of 800 µg vaginal misoprostol at 12 hourly intervals. The number of women who needed check curettage was collected. Ultrasound findings if done were collated. Follow-up was done telephonically at the end of first week, fourth week and sixth week. RESULTS: The cohort comprised 145 women. The primary outcome was the need for curettage after expulsion of products following medical management and this was 49/145 (37.8%) of women. The induction expulsion interval was 36 hours. The mean endometrial thickness of the 113/145 women who had an ultrasound was 11 mm. The mean endometrial thickness in women who had check curettage was 18 mm. Persistent spotting was the only significant symptom at follow-up. Resumption of cycle at the end of the sixth week was seen in 105/132 (80.15%) of women who were followed up. CONCLUSION: Findings of our study showed the check curettage rate of 37.8%. However, the regime which we used, that is, 800 µg vaginal misoprostol at 12 hourly intervals had a long induction to expulsion interval of 36 hours. In all, 80% of women resumed normal cycles at the end of the sixth week. No significant complications were noted on follow-up.

Sequential drug delivery for liver diseases.

The liver performs critical physiological functions such as metabolism/detoxification and blood homeostasis/biliary excretion. A high degree of blood access means that a drug's resident time in any cell is relatively short. This short drug exposure to cells requires local sequential delivery of multiple drugs for optimal efficacy, potency, and safety. The high metabolism and excretion of drugs also impose both technical challenges and opportunities to sequential drug delivery. This review provides an overview of the sequential events in liver regeneration and the related liver diseases. Using selected examples of liver cancer, hepatitis B viral infection, fatty liver diseases, and drug-induced liver injury, we highlight efforts made for the sequential delivery of small and macromolecular drugs through different biomaterials, cells, and microdevice-based delivery platforms that allow fast delivery kinetics and rapid drug switching. As this is a nascent area of development, we extrapolate and compare the results with other sequential drug delivery studies to suggest possible application in liver diseases, wherever appropriate.

Effect of Native and Acetylated Dietary Resistant Starches on Intestinal Fermentative Capacity of Normal and Stunted Children in Southern India.

The health benefits of dietary amylase resistant starch (RS) arise from intestinal microbial fermentation and generation of short chain fatty acids (SCFA). We compared the intestinal fermentative capability of stunted and nonstunted ('healthy') children in southern India using two types of RS: high amylose maize starch (HAMS) and acetylated HAMS (HAMSA). Twenty children (10 stunted and 10 healthy) aged 2 to 5 years were fed biscuits containing HAMS (10 g/day) for two weeks followed by a 2-week washout and then HAMSA biscuits (10 g/day) for 2 weeks. Fecal samples were collected at 3-4 day intervals and pH and SCFA analyzed. At entry, stunted children had lower SCFA concentrations compared to healthy children. Both types of RS led to a significant decrease in fecal pH and increase in fecal acetate and propionate in both healthy and stunted children. However, while HAMS increased fecal butyrate in both groups of children, HAMSA increased butyrate in healthy but not stunted children. Furthermore, healthy children showed a significantly greater increase than stunted children in both acetate and butyrate when fed either RS. No adverse effects were reported with either RS. Stunted children have impaired capacity to ferment certain types of RS which has implications for choice of RS in formulations aimed at improving microbial function in stunted children.

Clinically important microbial diversity and its antibiotic resistance pattern towards various drugs.

BACKGROUND: Increased use of antibiotics in poultry leads to the development of antimicrobial resistance among the commensal bacterium of broiler chickens. OBJECTIVE: In this study, we aimed at studying the effect of periodic administration of therapeutic antibiotics against the bacterial diversity in poultry litters collected from broiler chickens. METHODS: Poultry litters were collected randomly at regular intervals after administration of antibiotics (1st, 12th and 22nd day) to the chicken. Bedding material without litters served as control. Phenotypic observations showed that there is a difference in the bacterial richness isolated at regular intervals. A total of 32 bacteria were isolated from poultry letters and are grouped into ten different genus. Isolated bacterial species were further confirmed by16S rRNA sequencing. RESULTS: Antibiotic susceptibility profile of isolated bacterial species exhibited strong resistance towards 13 selected antibiotics. These results substantiate that administration of antibiotics leads to the alterations in bacterial diversity and development of antimicrobial resistance among the commensal bacteria of poultry litter. CONCLUSION: This high selection pressure of therapeutic antibiotics may lead to species selection and development of antibiotic resistance among bacterial population. Development of such species selection may access the human and other organisms via food chain and can cause severe health defects.

Assessment of two immunoassays for detection of IgM antibodies to scrub typhus using a serum panel.

Laboratory tests are necessary for diagnosis of scrub typhus (ST) especially in the absence of the distinctive eschar. Performance of an ELISA and ICT (immunochromatography) to detect IgM antibodies to scrub typhus was assessed using a panel of 346 sera chosen from healthy individuals, those with scrub typhus and scrub-typhus like illness. A sensitivity of 98.7% for ST IgM ICT and 97.4% for ST IgM ELISA was observed while specificity was 96.3% for ICT and 95.9% for ELISA. As excellent concordance (98.8%) was noted between the two assays, IgM ICT can be used for rapid diagnosis of scrub typhus. Abbreviations: ST IgM ELISA: Scrub typhus IgM ELISA; ST IgM ICT: Scrub Typhus IgM Immunochromatography, Rapid diagnostic test: RDT.

Ultrasound-guided Fine-needle Aspiration Cytology along with Clinical and Radiological Features in Predicting Thyroid Malignancy in Nodules ≥1 cm.

AIMS AND OBJECTIVES: The aim of the study is to examine the adequacy and accuracy of ultrasound-guided fine-needle aspiration cytology (US-FNAC) in thyroid nodules ≥1 cm and to analyze the clinical, sonological, and cytological features in predicting thyroid malignancy. MATERIALS AND METHODS: US-FNAC was done on 290 patients from December 2013 to December 2014 by the radiologist. The Thyroid Imaging Reporting and Data System (TIRADS) was used to record the sonological features. FNAC samples were reported by a dedicated cytopathologist. Accuracy was calculated by comparing US-FNAC, clinical features and ultrasound (US) features for those who had final histopathology till April 2017. RESULTS: The adequacy of US-FNAC in this study was 80.2%. Thyroidectomy was performed in 128/290 (44.1%). The sensitivity and specificity of US-FNAC in this study is 83.9 and 76.3%, respectively, with a positive predictive value of 85.2%, negative predictive value of 74.4%, and an accuracy of 81% in predicting malignancy in thyroid nodules ≥1 cm. The malignancy rate in benign FNAC sample was 25% (10/40), and was 69% (8/13) in those with a follicular lesion of undetermined significance (FLUS). Around 80% of benign and 89% of FLUS had follicular variant of papillary carcinoma of thyroid (FVPTC). US-FNAC, a high TIRADS score, and US features such as marked hypoechogenicity, taller than wide, irregular margins, microcalcification, and clinical features, such as hard in consistency and significant cervical lymph nodes, were important in predicting malignancy (P < 0.001). CONCLUSIONS: The accuracy of US-FNAC in this study is 81%. The US-FNAC, a high TIRADS score, a hard thyroid nodule, and significant cervical lymph nodes are important in predicting malignancy. The accuracy rate in benign and atypia undetermined significance categories needs to improve in this study. Further research to help in decreasing false negative rates of FVPTC will help in increasing the accuracy of US-FNAC in the present study.

Giant honey bee (Apis dorsata) sting and acute limb ischemia: a case report and review of the literature.

BACKGROUND: Clinically significant manifestations of Hymenopteran envenomation is increasingly recognized in Sri Lanka. These clinical manifestations range from localized allergic reactions to end-organ failure and thrombotic-episodes. We report a case of 65 year old male who developed acute lower limb ischaemia after a sting of the hymenopteran Apis dorsata. CASE PRESENTATION: A 65 year old male with hypertension and hyperlipidaemia presented with envenomation from an attack of a swarm of A. dorsata. He subsequently developed acute limb ischaemia following an acute femoral thrombus and made a complete recovery with anticoagulation and surgical-embolectomy. CONCLUSIONS: This case adds to the spectrum of thrombotic manifestations of Hymenopteran venom highlighting the requirement for close monitoring and clinical vigilance in these patients.