Dyslipidemia and heart failure: current evidence and perspectives of use of statins.

Heart failure (HF) is a condition with growing morbidity and mortality. Dyslipidemia in HF is not concentrated around hypercholesterolemia as in coronary artery disease. As a corollary, the robust benefits seen with statins across the spectrum of CAD have not been replicated in HF. Multiple potential pleiotropic effects of statins include anti-inflammatory, antioxidant, endothelial stabilization, antiapoptotic, anti-thrombotic, and modulation of the autonomic system apart from lipid lowering. These benevolent actions need to be counterbalanced with the potential derangement of ubiquinone, selenoprotein and endotoxin pathways. While small randomized and non-randomized studies demonstrated a multitude of benefits in clinical and surrogate endpoints, two large RCTs failed to demonstrate unequivocal benefits. However, multiple large meta-analyses do demonstrate definite improvement in clinical endpoints including death and heart failure hospitalization. The clinical likelihood of benefit was higher in younger patients with less advanced HF and use of lipophilic statins.

Growth Characteristics of Female Radiation/Clinical Oncologists in South Asia: Assessment of Gender Neutrality and Leadership Position.

AIM: To evaluate the temporal growth pattern of female radiation/clinical oncologists (FRCOs) and, if applicable, predict the gender neutrality in different countries of South Asia. MATERIALS AND METHODS: South Asia is composed of Afghanistan, Bhutan, Maldives, Bangladesh, India, Nepal, Pakistan and Sri Lanka. The growth pattern of FRCOs in the latter five countries having radiation oncology facilities was evaluated from respective national registration data. Based on the average annual differential growth rate, together with the already existing female and male radiation/clinical oncologists (MRCOs), the cumulative numbers of FRCOs and MRCOs were forecasted for the next 10 years. The data regarding FRCOs in a leadership position were also calculated from different sources. RESULTS: The total number of radiation/clinical oncologists in the region was 4074, of which 91.8% were in India, because of its vast population. The overall number of FRCOs and MRCOs stood at 1370 and 2704, with a 1:2 female:male ratio. The average incremental annual growth of FRCOs in India was the highest (12.7 persons/year) and Nepal was the lowest (0.4 persons/year), with no data from Pakistan. If the current growth rate is sustained, Indian gender neutrality will be achieved by 2027-2030. In other countries, gender neutrality is unlikely to be achieved in the near future. With regards to leadership positions, 56-77 radiation oncology departments in India, one each in Bangladesh and Sri Lanka are headed by FRCOs, whereas Nepal and Pakistan have none. CONCLUSIONS: With the current growth rate of FRCOs and MRCOs, India will achieve gender parity within a decade; however, the rest of the countries will not achieve this in the near future. Analysis of radiation/clinical oncologists' registration data with their respective national bodies revealed an encouraging growth in the number of FRCOs as against their male counterparts in the last 5 years, compared with previous decades, especially in Bangladesh, Sri Lanka and India. Sri Lanka show high gender neutrality and adopted a multi-tasking and holistic approach of clinical oncology practices as also seen in Scandinavian countries. Such practice may be helpful to improve gender equality in radiation/clinical oncology practice for the other countries in the South Asian region.

Ischemic and Bleeding Profile of Patients on Dual Antiplatelet Therapy beyond 1 Year of Index Acute Coronary Syndrome / Percutaneous Intervention.

Dual antiplatelet treatment (DAPT) is the cornerstone of the management and prophylaxis of acute coronary syndrome (ACS). However, the associated risk of bleeding with the usage of DAPT and risk of thrombosis with stoppage of the drug makes it a challenging task to take appropriate decisions regarding the choice and duration of DAPT. The present study is aimed to tackle these challenges and to analyze whether prolonged dual antiplatelet therapy carries more risk of bleeding or a higher risk of thrombosis is present with discontinuation of the same. MATERIAL: In this study, a total of 235 cases of confirmed myocardial infarction, unstable angina, or those who underwent percutaneous intervention were included. After 1 year, the number of patients on DAPT, the type of antiplatelets they were using were observed, their ischemic risk was calculated using DAPT score, and bleeding risk was calculated using PRECISE-DAPT score. Bleeding events were assessed using BARC classification. OBSERVATION: Out of 235 patients, the majority of the patients were males (78.7%). Only 7.2% of the patients had bleeding since the start of the drugs. The majority (5% out of 7.2%) of bleeding episodes were clinically insignificant. 163 (69%) patients were on Dual antiplatelet therapy after 1 year. Out of which 115 were appropriately taking DAPT as per their DAPT score. Patients with high bleeding risk (PRECISE DAPT score ≥25) were 89, out of which 38 (53.2%) patients were taking SAPT, appropriate for their bleeding risk. While 112 (68.7%) were taking prolonged DAPT, appropriate for PRECISE-DAPT risk. CONCLUSION: The majority of patients remained on DAPT following discharge for more than 1 year after ACS. This suggests that treating physicians prioritizes ischemic risk reduction over bleeding risk in patients with ACS, according to the patient's risk profile.

Comparison of Hearing Result and Graft Uptake Rate between Temporalis Fascia and Tragal Cartilage in Endoscopic Myringoplasty.

Background There are different methods to repair the perforation of the tympanic membrane. Recently cartilage has been used for the repair and results are comparable to temporalis fascia. For surgical procedure endoscope had added good assistance in middle ear surgery. Though the one hand technique the image quality and results are on par with the use of a microscope. Objective To compare the graft uptake rate and hearing results between temporalis fascia and tragal cartilage in endoscopic myringoplasty. Method This is a prospective, longitudinal study conducted among 50 patients who underwent endoscopic myringoplasty using temporalis fascia and tragal cartilage with 25 patients in each group. The hearing was assessed by comparing pre with post-operative ABG (Air bone gap) and ABG closure in speech frequencies (500Hz, 1 KHz, 2 KHz, 4 KHz). The status of graft and hearing results was evaluated on 6 months of follow up in both the groups. Result Out of total 25 patients enrolled for study in both (temporalis fascia and cartilage) groups, 23 (92%) patients in each group had graft uptaken. The audiological gain in the temporalis fascia group was 11.37±0.32 dB whereas in the tragal cartilage group it was 14.56±1.22dB. The audiological gain between the two groups did not show any statistically significant (p = 0.765). However, the pre and post-operative hearing difference was statistically significant in both temporalis fascia and tragal cartilage group. Conclusion Tragal cartilage has similar graft uptake rate and hearing gain when compared with temporalis fascia in endoscopic myringoplasty. Hence, tragal cartilage can be used for myringoplasty whenever required without any fear of deterioration in hearing.

Refractive and Binocular Vision Status and Associated Asthenopia among Clinical Microscopists.

Background Clinical microscopists are at a greater risk of developing binocular vision anomalies and asthenopia. Objective To assess the refractive and binocular vision status and to explore the association between the presence of asthenopic symptoms and microscopy work among clinical microscopists working at medical laboratory department. Method This cross-sectional study involved 37 clinical microscopists working at medical laboratory department of Dhulikhel Hospital, Nepal. The study was conducted from January to December 2013. Only those participants who had been using microscope for at least a year were enrolled in this study. Each participant underwent distance visual acuity (VA) assessment, refractions, and orthoptic evaluation, including measurement of distance and near phoria, near point of convergence (NPC), near point of accommodation (NPA), positive fusional vergence (PFV), adduction, and calculation of accommodation convergence/accommodation (AC/A) ratio. The tear test was also carried out in each subject. Information about use of glasses, microscopy work (duration, and time spent per day in microscope), and visual symptoms associated with the use of microscope such as eye strain, headache, double vision, and near vision were collected. Result The mean age of the clinical microscopists was 29 ± 5.7 years. The prevalence of refractive error was 56.76% and the mean spherical equivalent (SE) refractive error was -0.77 ± 0.86 D. Refractive error had neither correlation with microscopy work and asthenopic symptoms associated with it, and nor with binocular vision parametersNPC, AA and AC/A ratio. However, there was a positive association between asthenopic symptoms and microscopy work. There was statistically significant difference between symptomatic and asymptomatic subjects for binocular vision parameters, including NPC, AA and positive fusional vergence (PFV) for near. Conclusion Microscopy work has an impact on near binocular vision. Asthenopic symptoms bear a positive association with microscopy work. Refractive error has no significant correlation with either microscopy works or associated asthenopic symptoms.

Knowledge and Attitude on Eye Donation among Undergraduate Medical Students of Kathmandu University School of Medical Sciences, Nepal.

Background Corneal blindness accounts for a significant proportion of avoidable visual impairment in developing countries. Eye donation is voluntary and awareness in undergraduate medical students being a future practitioner in any field are expected to be linked to patients during death in hospitals. Objective To assess the awareness of medical students on eye donation at Kathmandu University School of Medical Sciences (KUSMS). Method This was a cross-sectional study conducted among undergraduate medical students of KUSMS. Students' responses were recorded using a predesigned, pretested, semistructured questionnaire inquiring knowledge and attitude of eye donation, sources of information, their willingness to donate eyes as well as the reasons for donating/ not donating eyes. Result Less than half of the medical students (45.6%) were aware of eye donation only after death. Newspapers (72.2%) were the major source of information. The final year medical students were more aware (Average knowledge score = 11.56 ± 2.05) than their juniors. 80.7% of the students were willing to donate their eyes. The adjudged reasons for willingness to donate were that eye donation is a noble work and pleasure in helping a blind person while the reasons for unwillingness to donate were lack of awareness followed by family objection to eye donation. Conclusion Future medical practitioners possessed satisfactory knowledge about eye donation. Educating this cadre of human resources to sensitize them towards the need for eye donation would be a crucial step towards reducing the global burden of corneal blindness.

Prevalence, Extent, and Severity of Oral Health Impacts Among Adults in Rural Karnataka, India.

INTRODUCTION: Oral health affects quality of life. Many studies have investigated the factors associated with oral health-related quality of life (OHRQoL). Little is known about OHRQoL of adults living in rural and remote areas of India, where many have lower levels of education and limited availability of oral health care services. OBJECTIVES: To determine the prevalence, extent, and severity of OHRQoL impacts associated with psychosocial factors, functional dentition, and patterns of dental visits among rural Indian adults between the ages of 35 and 54 y. METHODS: A cross-sectional study was conducted with a multistage stratified sampling strategy targeting 35- to 54-year-olds. Interviews and oral examinations were performed to collect data on sociodemographic variables, Oral Health Impact Profile-14 (OHIP-14), patterns of dental visits, stress, tobacco and alcohol use, and dentition status. Univariate, bivariate, and multivariable analyses were done to determine the factors associated with prevalence, extent, and severity of OHIP-14 using SAS version 9.3. RESULTS: There were 873 participants. Prevalence, extent, and severity of OHIP-14 were 13.4%, 0.5 (0.4-0.7), and 11.8 (11.2-12.5), respectively. The OHIP-14 impacts reported were not severe and mostly affected physical functioning. Levels of education, income, and number of functional teeth (FT) were inversely associated and last dental visit within the previous year was positively associated with prevalence, extent, and severity of OHIP-14. The prevalence of 1 or more oral health impacts was nearly 13% among rural middle-aged adults in India. CONCLUSIONS: Low socioeconomic conditions, dental visits, and FT ≤19 were positively associated with prevalence, extent, and severity of oral health impacts. KNOWLEDGE TRANSFER STATEMENT: This article provides data regarding OHRQoL of people in rural areas of a developing country. The study was intended to determine the factors associated with OHRQoL in rural people who are less educated and living in areas with minimal oral health care facilities. The findings of this study could potentially facilitate further research and health promotional activities for rural people of developing countries.

Robust Simultaneous and Proportional Myoelectric Control Scheme for Individuals with Transradial Amputations.

Commercial myoelectric prostheses need to be accurate and clinically viable to be successful. This study proposed a simultaneous and proportional control scheme with frequency division technique (SPEC-FDT) to address limitations in current myoelectric prosthesis control, specifically to address non-stationaries such as contraction level variations and unintended activations. Twenty able-bodied participants (14 males and 6 females, age 23.4 ± 3.0) and four individuals with transradial amputations performed wrist movements (flexion/extension, rotations and combined movements) in two degrees-of freedom virtual tasks. The SPEC-FDT had a completion rate (CR)>90% for both control and clinical participants which was significantly higher than the conventional technique (CR=68%). Our results showed that SPEC-FDT is highly accurate for both able-bodied and clinical participants and provides a robust myoelectric control scheme allowing for increased prosthetic hand functions.

Universal Neonatal Hearing Screening: An Experience at Tertiary Care Hospital.

Background Hearing loss among neonates is one of the important health issue in pediatric population which may remain unnoticed until the child reaches a certain age. The importance of universal early screening, diagnosis and intervention in reducing the negative impact of congenital hearing loss has been described all over the world. Objective To observe the outcome of hearing screening by Automated Auditory Brainstem Response (AABR) in newborns delivered in Dhulikhel Hospital and neonates admitted in an intensive care unit (NICU) of Dhulikhel Hospital. Method A prospective study was done in neonates who were born at Dhulikhel Hospital, Kathmandu University Hospital from February 15th, 2017 to October 30th, 2019. AABR was used for their hearing assessment within 24 hours of birth and again at about 6 weeks of age in those neonates who failed the initial test. All the neonates admitted in NICU were studied regarding the risk factors based on Joint committee on Infant Hearing. Those who failed the test for the second time were referred for detailed audiological diagnostic work up. Result The screening rate was 92.6% of the total deliveries. A total of 5517 neonates comprising of 2800 males and 2717 females were screened from total deliveries of 5956 neonates in the study period. Among them, NICU (sick) babies were 422 (7.7%) and well babies were 5095 (92.3%). Out of them, 1675 failed the test in the first screening and 374 failed in the second screening. So, the total number of referred babies in second screening was 6.7% (374) out of 5517 screened. Amongst them, well babies were 6.59% (336), out of 5095 screened and sick babies were 9% (38) out of 422 screened. Low birth weight and prematurity were found to be the commonest risk factor present among them, followed by the use of ototoxic medications, hyperbilirubinemia and prolonged use of mechanical ventilation. Conclusion Automated Auditory Brainstem Response (AABR) is a very useful tool for hearing screening which should preferably be done in all the neonates where possible. It should be done within one month of life and those with confirmed hearing loss should receive early appropriate intervention for better hearing in future.

Toxoplasma gondii tissue cyst formation and density of tissue cysts in shoulders of pigs 7 and 14 days after feeding infected mice tissues.

Among the meat sources of Toxoplasma gondii, pork is considered important in the epidemiology of toxoplasmosis in the USA. How soon after infection T. gondii forms tissue cysts in pork is unknown. In the present study, eight serologically negative ˜3 months old pigs were fed mouse tissues infected with VEG (Type III) strain of T. gondii and euthanized 7 (4 pigs) and 14 days (4 pigs) post-inoculation (p.i.). Meat from the right shoulder of each pig was bioassayed in mice for T. gondii tissue cysts by peptic digestion. From each pig, the shoulder muscle was cut at random spots into 5 g, 10 g and 50 g portions. Extreme care was taken to use different scalpels and forceps to minimize cross contamination among 17 samples (6 replicates of each 5 g and 10 g portions and 5 replicates of 50 g). From the four pigs euthanized at 7 days p.i., a composite of ˜200 g of leftover meat from each shoulder was bioassayed in cats and their feces were tested for oocyst excretion. All eight pigs developed T. gondii antibodies (modified agglutination test, MAT, 1: 80 or higher) and viable T. gondii was isolated from shoulder meat of each pig. All four cats fed pork from excreted T. gondii oocysts. The density of T. gondii, based on mouse infectivity, varied within 5-50 g samples each pig, and between pigs within the same group, day 7 versus day 14 p.i. There were no significant differences in mouse bioassay results obtained with day 7 versus day 14 infected pigs. Overall, the rate of isolation of T. gondii increased with sample size of meat bioassayed. Results demonstrate that tissue cysts are formed early in infection and they are unevenly distributed.

Factors Affecting Recanalisation after Optimal Management of Deep Vein Thrombosis; A single institution based study.

Background Presence of recanalisation will favour for better physiological recovery after medical management of Deep Vein Thrombosis (DVT) along with lesser chances of post thrombotic syndrome. Rate of recanalisation is varied and can range from 43-57% and the factors that affect recanalisation are still a dilemma. Objective To know the factors for recanalisation following Deep Vein Thrombosis. Method This is a single institution based retrospective-prospective analytical study encompassing all ultrasonologically diagnosed cases of Deep Vein Thrombosis in adults from January 2015 to November 2017. All the cases were admitted with oral warfarin bridged by Heparin/ Enoxaparin and were discharged once International Normalization Ratio was in therapeutic range. The patients were followed up for three months with minimal of three outpatient followup. Best finding in the doppler ultrasonography (done by Acuson P500, Seimens) in relation to recanalisation was taken for the study. Result There were 67 cases of Deep Vein Thrombosis. Of these cases male to female ratio was 0.91. The mean age was 48.07. Most common extent was up to common femoral vein (47.8%) followed by upto popliteal vein (40.3%). Remaining 11.9% had extension upto iliac veins. There was no recanalisation in 2 cases (3%). Partial recanalisation was seen in 23 cases (34.3%) while complete recanalisation was seen in 42 cases (62.7%). Recanalisation is more in DVT involving popliteal vein while it decreases as the extension goes up. In contrast to 79.4% complete recanalisation in popliteal vein, that in common femoral vein is 62.5% while in iliac vein is only 37.5%. Mean age in no recanalisation group is much younger than partial or complete recanalisation groups. Conclusion Recanalisation following Deep Vein Thrombosis distal to popliteal vein is more than that in proximal Deep Vein Thrombosis. The information on recanalization can be considered to use to decide upon the duration of medical management of Deep Vein Thrombosis.

Exploring the Magnetoelectric Coupling at the Composite Interfaces of FE/FM/FE Heterostructures.

Multiferroic materials have attracted considerable attention as possible candidates for a wide variety of future microelectronic and memory devices, although robust magnetoelectric (ME) coupling between electric and magnetic orders at room temperature still remains difficult to achieve. In order to obtain robust ME coupling at room temperature, we studied the Pb(Fe0.5Nb0.5)O3/Ni0.65Zn0.35Fe2O4/Pb(Fe0.5Nb0.5)O3 (PFN/NZFO/PFN) trilayer structure as a representative FE/FM/FE system. We report the ferroelectric, magnetic and ME properties of PFN/NZFO/PFN trilayer nanoscale heterostructure having dimensions 70/20/70 nm, at room temperature. The presence of only (00l) reflection of PFN and NZFO in the X-ray diffraction (XRD) patterns and electron diffraction patterns in Transmission Electron Microscopy (TEM) confirm the epitaxial growth of multilayer heterostructure. The distribution of the ferroelectric loop area in a wide area has been studied, suggesting that spatial variability of ferroelectric switching behavior is low, and film growth is of high quality. The ferroelectric and magnetic phase transitions of these heterostructures have been found at ~575 K and ~650 K, respectively which are well above room temperature. These nanostructures exhibit low loss tangent, large saturation polarization (Ps ~ 38 µC/cm2) and magnetization (Ms ~ 48 emu/cm3) with strong ME coupling at room temperature revealing them as potential candidates for nanoscale multifunctional and spintronics device applications.

Does a facilitated pathway improve access to dental services for homeless and disadvantaged adults?

Access to dental care is poorer for people experiencing homelessness and disadvantage due to barriers such as lengthy waiting lists, lack of transport, lack of information and fear of authorities and treatment. This study aimed to evaluate a system integration model for oral health care for clients of homeless services in Brisbane, Australia. This model aimed to provide a facilitated access pathway between homeless community organisations and a public dental service to improve access to dental care. Participants were adult (≥18 years) clients Brisbane homeless community organisations. Those who participated in the intervention evaluation completed a questionnaire, had their oral health screened and followed up for feedback at their dental appointment. Seventy-six clients of community organisations in Brisbane participated in the intervention and its evaluation. Fear was a barrier to accessing dental services for 23% (n = 18). Attendance to the subsequent appointments at the public dental clinic was high, with 85% (n = 64) attending their first appointment. A higher proportion of participants who had surgical and prosthodontic treatment needs at the screening did not attend their appointment compared to those with other needs. Overall the model piloted in this study had positive outcomes; with high attendance rates to the dental facility and positive experiences by participants.

A low gradient junction technique of craniospinal irradiation using volumetric-modulated arc therapy and its advantages over the conventional therapy.

A technique using volumetric-modulated arc therapy (VMAT) fields for craniospinal irradiation with low dose gradients at the field junction was tested for its sensitivity to positional inaccuracy. It was compared against the conventional three-dimensional (3D) conformal radiotherapy in terms of dose uniformity at the junction. Treatment plans generated for ten patients who received craniospinal irradiation (35Gy in 21 fractions) by VMAT technique at our centre were included in this study. For these patients, 3D conformal radiotherapy plans were also generated in addition to the VMAT treatment plans. Intentional shifting of the cranial field in the superior and then in the inferior directions was done, creating a gap or overlap between the fields. Consequent changes in dose distributions in these two plans to positional inaccuracies were studied. The 3D conformal radiotherapy plans showed large dose variations at the junction due to positional shifts as compared to the VMAT plans. With a 5mm superior shift of the cranial field isocentre creating a gap between the cranial and spinal fields, the magnitudes of under-dosing were 13.9±3.6Gy and 4.8±2.0Gy for 3D conformal radiotherapy and VMAT respectively. When the cranial field was moved by 5mm inferiorly creating an overlap between the fields, overdose to the effects of 10.3±4.0Gy and 4.9±1.3Gy were observed for the 3D conformal radiotherapy plans and VMAT plans respectively. The VMAT technique is insensitive to longitudinal setup errors (1-3mm) in patients because of the existence of low dose gradients at the junction between fields. This is unlike the 3D conformal radiotherapy plans which have steep dose gradients at the field edges and thus are highly sensitive to setup errors. Such an advantage for VMAT circumvents the need for dose feathering often practiced with the 3D conformal radiotherapy technique and makes the technique simpler to follow.

Pattern and Prevalence of Refractive Error and Secondary Visual Impairment in Patients Attending a Tertiary Hospital in Dhulikhel, Nepal.

Background Uncorrected refractive error is one of the most important causes of visual impairment worldwide. Objective To ascertain the pattern and prevalence of refractive error and secondary visual impairment in subjects attending Ophthalmology department. Method A prospective hospital-based study was designed where presenting visual acuity, age of presentation, refractive status, best corrected visual acuity and status of visual impairment were assessed in participants, ages ranging from 3-39 years presenting to the Ophthalmology department of Dhulikhel Hospital, Kathmandu University Hospital. History of use of spectacle was noted and participants were categorized into different visual impairment categories as per their presenting visual acuity. Result Out of a total of 4500 total clients examined during the study period, 388 (8.62%) had refractive error where 219 (56.44%) were females and 169 (43.56%) were males. Mean age at presentation was 22.70±7.69 years (range, 3-39 years). Astigmatism was the most common subtype seen in 373 eyes (48.06%), followed by myopia (366 eyes, 47.16%) and hypermetropia (31 eyes, 4.0%). Only 40.50% subjects who required refractive correction were using spectacle. 62.37% (242 clients) had some of visual impairment during their presentation. There was statistically significant improvement in visual acuity after refractive correction (p=0.00). Conclusion Uncorrected refractive error is one of the most important causes of visual impairment. Lack of awareness, infrequent ocular examination and lack of community or preschool vision screening were the main causes for the late presentation and significant visual impairment associated with the condition. Social stigma, economical limitation and negative counseling and attitudes about spectacle wear were primary factors behind the unsatisfactory spectacle use.

Oral health impacts of medications used to treat mental illness.

BACKGROUND: Many psychotropic medications affect oral health. This review identified oral side effects for antidepressant, antipsychotic, anticonvulsant, antianxiety and sedative drugs that are recommended in Australia for the management of common mental illnesses and provides recommendations to manage these side-effects. METHODS: The Australian Therapeutic Guidelines and the Australian Medicines Handbook were searched for medications used to treat common mental health conditions. For each medication, the generic name, class, and drug company reported side-effects were extracted from the online Monthly Index of Medical Specialties (eMIMs) and UpToDate databases. Meyler's Side Effect of Drugs Encyclopaedia was used to identify additional oral adverse reactions to these medications. RESULTS: Fifty-seven drugs were identified: 23 antidepressants, 22 antipsychotics or mood stabilisers, and 12 anxiolytic or sedative medications. Xerostomia (91%) the most commonly reported side effect among all classes of medications of the 28 identified symptoms. Other commonly reported adverse effects included dysguesia (65%) for antidepressants, and tardive dyskinesia (94%) or increased salivation (78%) for antipsychotic medications. CONCLUSIONS: While xerostomia has often been reported as a common adverse effect of psychotropic drugs, this review has identified additional side effects including dysguesia from antidepressants and tardive dyskinesia and increased salivation from antipsychotics. Clinicians should consider oral consequences of psychotropic medication in addition to other side-effects when prescribing. For antidepressants, this would mean choosing duloxetine, agomelatine and any of the serotonin re-uptake inhibitors except sertraline. In the case of antipsychotics and mood stabilisers, atypical agents have less oral side effects than older alternatives.

Isolation of viable Toxoplasma gondii, molecular characterization, and seroprevalence in elk (Cervus canadensis) in Pennsylvania, USA.

Toxoplasmosis is a worldwide zoonosis. The ingestion of uncooked/undercooked meat and consumption of water contaminated with Toxoplasma gondii oocysts excreted by felids are the main modes of transmission of this parasite. T. gondii has been reported in multiple cervid species; however, little is known of the parasite in North American elk (Cervus canadensis). In the present study, antibodies to T. gondii were detected in serum of wild elk from Pennsylvania collected during 2013-2016 by the modified agglutination test (MAT, cut-off 1:25); 221 of 317 (69.7%) had MAT titers of 1:25 in 19, 1:50 in 28, 1:100 in 34, and 1:200 or higher in 140. Thus most (44.1%) elk had relatively high titers. Seroprevalence was slightly higher in males (76.9%) than females (67.5%, not statistically significant, Chi-square tests, P<0.0001) and was higher in adults (76.5%) than yearlings (46.4%, Odds ratio 3.82; 95% CL 1.72-8.47; P=0.001) or calves (21.7%, Odds ratio 12.58; 95% CL 4.51-35.10; P<0.0001). Annual seroprevalence was relatively stable throughout the period tested and ranged from 66.6% to 72.2%. Of the 101 elk harvested in 2016, hearts were bioassayed from 20 elk and tongues were bioassayed from 56; all tongue samples were negative. Viable T. gondii was isolated from hearts of two female elk, one of these was a seronegative adult and the other was a calf with no serum available for testing. Both T. gondii isolates were cultivated in cell culture and DNA derived from tachyzoites was characterized using the PCR-RFLP markers including SAG1, SAG2 (5'- 3'SAG2 and altSAG2), SAG3, BTUB, GRA6, c22-8, c29-2, L358, PK1, and Apico. One isolate belongs to ToxoDB PCR-RFLP genotype #2 and the other is genotype #5. Both genotypes are frequently identified in animals in North America.

Epithelioid sarcomas: How important is loco-regional control?

AIMS: To investigate the impact of the method of treatment on the oncological outcomes in patients with epithelioid sarcomas managed at two international speciality sarcoma centres. METHODS: The databases of two centres were used to identify patients treated for epithelioid sarcomas between 1985 and 2012. Patient, tumor, treatment and outcome data was collected. RESULTS: There were 36 males and 18 females with a mean age of 38.3 years (range 9-79). Of 49 patients who were treated surgically, limb salvage surgery was carried out in 38 patients (78%) and limb amputation in 11 (22%). Of 49 total patients who underwent surgery for ES, 48 (98%) with ES had negative margin resection and 24 (49%) received (neo) adjuvant radiotherapy. Regional lymph node metastases developed in 5 (13%) patients. The five-year risk of local recurrence was 14%. The overall survival rate at five and ten years was 70% and 66% respectively. In multivariate analysis of patients with localized disease and negative margins, survival and risk of metastases was worse in those treated by amputation. CONCLUSION: This series has shown that although the rate of local recurrence is not influenced by the type of surgery, the risk of metastases is higher following amputation. This finding is likely due to patients with larger, deeper and more locally advanced tumors requiring amputation. However, we could not prove that immediate amputation was likely to affect overall survival.