Impact on Cognitive Improvement Following Burr Hole Evacuation of Chronic Subdural Hematoma: A Prospective Observational Study

Objective:

Patients of Chronic subdural haematoma can present with only subtle cognitive impairment without any motor deficit. It is hence imperative for the treating clinician to be aware of this entity. The aim of the study was to identify any statistically significant improvement of cognitive functions following burr hole evacuation of Chronic SDH especially in the elderly patients.

Methods and Material:

A Prospective observational study of 30 patients of CSDH, from Jan 2015 to Dec 2016 was done at a tertiary level Armed Forces Hospital. The study had 23 male, 07 female, with age ranging from 7-85 years. The cognitive function of each patient was assessed at admission and 24 hours after surgery by MMSE. Radiological confirmation was done by CT head. Standard two burr holes were made and hematoma evacuated. The clinical, cognitive assessment and radiological data were collected and analysed.

Results:

There was no statistical significance preoperatively between age and pre operative cognitive impairment, headache, hemiparesis, dysarthria (P>0.05). We however found a statistically significant improvement postoperatively in cognitive impairment, headache (P= 0.00), motor deficit (P=0.01) and dysarthria (P=0.046).

Conclusion:

The clinical features of dementia and other neurodegenerative disorders simulate CSDH in the geriatric population. These patients should have early neuroimaging and prompt surgical intervention to alleviate cognitive deficits.

Cerebral pilocytic astrocytoma with spontaneous intratumoral haemorrhage in the elderly - a rare entity

Pilocytic astrocytomas (PA) are histologically are low-grade tumours, commonly found in the paediatric and young adult population. Although cases of adult and elderly pilocytic astrocytomas are described in the literature, they are quite uncommon. The rate of PAs with spontaneous bleeding is very less, with a high occurrence in children than in adults, moreover, that is in cerebellar PAs. Cerebral PAs with intratumoral haemorrhage in the older age group is extremely rare. We present a case of a 60-year female presenting with acute neurological compromise resulting from an acutely haemorrhagic Left temporal pilocytic astrocytoma. She was managed surgically with evacuation of tumoral haemorrhages, as well as resection of the tumour. Postoperatively the patient made a remarkable recovery.

Lessons Learned from a Migratory Intradural Extramedullary Schwannoma: A Case Report with Review of the Literature

BACKGROUND

Migratory tumors of the spinal cord are rare and can present as a missing tumor intraoperatively. This can lead to unnecessary abandonment of surgery or unnecessary laminectomies.

CASE DESCRIPTION

We present a case of migratory intradural extramedullary tumor of the spine, which was missing intraoperatively. The surgery was abandoned, and on reimaging the tumor was found to have migrated. Here we summarize a review of the literature of such cases and the lessons we learned from our experience, emphasizing the measures to prevent tumor displacement and the importance of intraoperative imaging.

CONCLUSIONS

Migratory schwannoma should be suspected in case of a missing lesion. Intraoperative ultrasonography and myelography use should be definitely considered where facility for intraoperative magnetic resonance imaging is not available. Preventive measures should be taken to avoid tumor migration in all routine cases of intradural extramedullary lesions.

Guidelines for training in cardiovascular magnetic resonance (CMR)

These "Guidelines for training in Cardiovascular Magnetic Resonance" were developed by the Certification Committee of the Society for Cardiovascular Magnetic Resonance (SCMR) and approved by the SCMR Board of Trustees.

Acute Renal Failure Amongst Children in a Tropical Environment

The pathogenetic factors leading to acute renal failure (ARF) in 223 children between the ages of 20 days and 14 years were studied. Diarrhoeal diseases were responsible for ARF in 49.8%, acute glomerulonephritis in 34.1%, drug induced intravascular hemolysis in glucose -6-phosphate dehydrogenase deficiency in 4.5%, snake bite in 4%, hemolytic uremic syndrome in 2.2%, and miscellaneous causes in 5.4%. Dialysis was instituted in 178 children and the others were treated conservatively. Renal histology in 39 out of 76 children who presented with an acute nephritic illness revealed acute endocapillary proliferative glomerulonephritis in 27 and crescentic glomerulonephritis in 12. The histology in 79 out of 147 remaining patients showed acute tubular necrosis in 64, acute cortical necrosis in 13, and acute interstitial nephritis in 2. Overall mortality was 27.4%. This high incidence of ARF due to infective diarrhoeas and dysentery reflects poor socio-economic and hygienic conditions, inadequate facilities in rural areas, delays in seeking medical advice, and lack of knowledge about fluid and electrolyte therapy amongst the staff.

Cystic meningioma: unusual entity with review of literature

Cystic meningioma is a relatively rare condition, radiological appearance of the cystic-solid components of the mass may create a diagnostic dilemma. The presence of a cyst is not a common imaging feature and this makes it difficult to differentiate it from hemangioblastoma, craniopharyngioma, metastasis and gliomas. Cystic meningiomas are present more commonly in children. We present a 60 year old male who presented with seizures and frontal lobe signs. The lesion was suspected as glioma however, postoperative histopathological examination demonstrated as meningioma. Patient showed remarkable recovery after surgery. Complete cyst resection should be considered if it is technically feasible and safe.

Unscreened older men diagnosed with prostate cancer are at increased risk of aggressive disease

BACKGROUND

To evaluate the relationship between PSA testing history and high-risk disease among older men diagnosed with prostate cancer.

METHODS

Records from 1993 to 2014 were reviewed for men who underwent radiotherapy for prostate cancer at age 75 years or older. Patients were classified into one of four groups based on PSA-testing history: (1) no PSA testing; (2) incomplete/ineffective PSA testing; (3) PSA testing; or (4) cannot be determined. Outcomes of interest were National Comprehensive Cancer Network (NCCN) risk group (that is, low, intermediate or high risk) and biopsy grade at diagnosis. Multivariable logistic regression was used to determine the association between PSA testing history and high-risk cancer.

RESULTS

PSA-testing history was available in 274 (94.5%) of 290 subjects meeting study criteria. In total, 148 men (54.0%) underwent PSA testing with follow-up biopsy, 72 (26.3%) underwent PSA testing without appropriate follow-up, and 54 men (19.7%) did not undergo PSA testing. Patients who underwent PSA testing were significantly less likely to be diagnosed with NCCN high-risk cancer (23.0% vs 51.6%, P<0.001). On multivariable analysis, men with no/incomplete PSA testing had more than three-fold increased odds of high-risk disease at diagnosis (odds ratio 3.39, 95% confidence interval 1.96-5.87, P<0.001) as compared to the tested population.

CONCLUSIONS

Older men who underwent no PSA testing or incomplete testing were significantly more likely to be diagnosed with high-risk prostate cancer than those who were previously screened. It is reasonable to consider screening in healthy older men likely to benefit from early detection and treatment.

A 10-Year united network for organ sharing review of mortality and risk factors in young children awaiting liver transplantation

Young children < 2 years of age with chronic end-stage liver disease (YC2) are a uniquely vulnerable group listed for liver transplantation, characterized by a predominance of biliary atresia (BA). To investigate wait-list mortality, associated risk factors, and outcomes of YC2, we evaluated United Network for Organ Sharing registry data from April 2003 to March 2013 for YC2 listed for deceased donor transplant (BA = 994; other chronic liver disease [CLD] = 221). Overall, wait-list mortality among YC2 was 12.4% and posttransplant mortality was 8%, accounting for an overall postlisting mortality of 19.6%. YC2 demonstrated 12.2%, 18.7%, and 20.6% wait-list mortality by 90, 180, and 270 days, respectively. YC2 with CLD demonstrated significantly higher wait-list mortality compared with BA among YC2 (23.9% versus 9.8%; P < 0.05). Multivariate analyses revealed that listing Pediatric End-Stage Liver Disease [PELD] > 21 (hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.6-6.5), lack of exception (HR, 5.8; 95% CI, 2.8-11.8), listing height < 60.6 cm (HR, 2.1; 95% CI, 1.4-3.1), listing weight  > 10 kg (HR, 3.8; 95% CI, 1.5-9.2), and initial creatinine > 0.5 (HR, 6.8; 95% CI, 3.4-13.5) were independent risk factors for YC2 wait-list mortality (P < 0.005 for all). Adjusting for all variables, the risk of death among CLD patients was 2 (95% CI, 1.3-3.1) times greater than patients with BA + surgery (presumed Kasai). Furthermore, the risk of death in BA without surgery was 1.9 (95% CI, 1‐3.4) times greater than BA with presumed Kasai. Our data highlight unacceptably high wait-list and early post-liver transplant mortality in YC2 not predicted by PELD and suggest key risk factors deserving of further study in this age group. Liver Transplantation 22 1584-1592 2016 AASLD.

Novel mutations in typical and atypical genetic loci through exome sequencing in autosomal recessive cerebellar ataxia families

Nearly a thousand mutations mapping to 60 different loci have been identified in cerebellar ataxias. However, almost 50% of the cases remain genetically uncharacterized and there is a difference in prevalence as well as in the phenotypic spectrum of ataxia among various geographical regions. This poses a challenge for setting up a genetic panel for screening ataxia. In our ataxic cohort of 1014 families, 61% are genetically uncharacterized (UC). We investigated the potential of whole exome sequencing in conjunction with homozygosity mapping (HM) to delineate the genetic defects in three uncharacterized families with recessive inheritance each manifesting some unusual phenotype: (i) infantile onset ataxia with hearing loss (IOAH), (ii) Juvenile onset cerebellar ataxia with seizures (JCS) and (iii) Friedreich ataxia-like (FA-like). We identified a novel missense mutation in c10orf2 in the family with IOAH, compound heterozygous mutations in CLN6 in the family with JCS and a homozygous frame-shift mutation in SACS in the FA-like patient. Phenotypes observed in our families were concordant with reported phenotypes of known mutations in the same genes thus obviating the need for functional validation. Our study revealed novel variations in three genes, c10orf2, CLN6, and SACS, that have so far not been reported in India. This study also demonstrates the utility of whole exome screening in clinics for early diagnosis.

Impact of body mass index on thyroid functions in Indian children

OBJECTIVE

There is controversy about the relation of thyroid functions and body mass index. The present study was aimed to assess the relationship between thyroid function and body mass index in Indian school children.

DESIGN

Population survey.

PATIENTS

Data were collected from 25 schools in 19 cities across five different geographical zones of India. Children, who consented, were evaluated for anthropometry and blood tests. Children were categorized as overweight and obese based on standard BMI criteria.

MEASUREMENTS

Serum samples were analysed for free T3, free T4, TSH and anti-TPO antibodies.

RESULTS

A total of 13,691 children in the age group of 5-18 years formed the study population. The mean age and mean BMI were 11·9 ± 3·0 years and 18·48 ± 3·89 kg/m² respectively. Among these, 2119 (15·5%) children were overweight and 536 (3·9%) were obese. Subclinical hypothyroidism was present in 943 (6·9%) children.FT3 and TSH levels increased and FT4 levels decreased with increasing BMI in euthyroid boys and girls. Prevalence of SCH was significantly higher in obese/overweight children (9·0%, vs 6·5%; P = 0·034) as compared with normal BMI children.

CONCLUSIONS

Serum FT3 and TSH were positively while FT4 was negatively associated with BMI in apparently healthy euthyroid children.

Comparing hand hygiene measures in a neonatal ICU: a randomized crossover trial

OBJECTIVE

To compare plain soap, alcohol hand rub and iodophors as hand hygiene measures in a neonatal intensive care unit (NICU).

DESIGN

Randomized, crossover, three-armed, controlled trial with blinded outcome measurement.

SETTING

Level III NICU.

PARTICIPANTS

35 NICU nurses.

INTERVENTION

Participants were assigned to plain soap hand washing, alcohol hand rub and povidone-iodine hand scrub by a random cross-over design. Interventions were preceded by 14-day neutral periods. Cultures from hands were taken before and after each hand-hygiene use, prior to 5 patient-care activities.

MAIN OUTCOME MEASURE

The primary outcome was mean post-hygiene colony forming unit count (CFU-C).

RESULTS

There were differences between soap, alcohol and povidone groups vis a vis posthygiene CFUC [median: 60, 8 and 10.5, respectively (P<0.001)], absolute reduction in CFU-C [median: 15, 100 and 40, respectively (P<0.001)], percent reduction in CFUC [median: 33.3, 92 and 87, respectively (P<0.001)] and proportion with low CFU-C [47%, 71% and 72%, respectively (P<0.001)]. Alcohol [Adjusted OR 3.2 (95% CI 1.9, 5.3)], povidone-iodine [AOR 3.1 (95% CI 1.8, 5.3)] and high prehygiene CFU-C (>300) [AOR 0.18 (95% CI 0.1, 0.3)] were independently associated with low CFU-C.

CONCLUSION

After a 2 minute hand wash at entry into NICU, alcohol hand rub and povidone-iodine scrub are superior to plain soap hand wash for subsequent decontamination of hands of nurses working in NICU.

Glutamic acid decarboxylase (anti-GAD) & tissue transglutaminase (anti-TTG) antibodies in patients with thyroid autoimmunity

BACKGROUND & OBJECTIVES

Several autoimmune disorders have been reported to be associated with autoimmune thyroiditis and may coexist with other organ-specific autoantibodies. The aim of the present study was to evaluate the presence of tissue transglutaminase (anti-TTG) and glutamic acid decarboxylase (anti-GAD) antibodies in patients suffering from autoimmune thyroiditis as diagnosed by anti-thyroid peroxidase (anti-TPO) antibodies, which may indicate high risk for developing celiac disease or type 1 diabetes mellitus.

METHODS

Five thousand children and 2800 adults were screening as part of a general health examination done on a voluntary basis in four different parts of Delhi. A total of 577 subjects positive for anti-TPO antibody constituted the cases. Equal number of age and sex matched anti-TPO antibody negative controls were randomly selected from the same cohort to form paired case control study. The cases and controls were further divided into two groups as follows: group-1 (children and adolescent <18 yr), group-2 (adults >18 yr). Serum samples of cases and controls were analysed for thyroid function test (FT3, FT4, and TSH), anti-TTG and anti-GAD antibodies.

RESULTS

A total of 1154 subjects (577 cases and 577 controls) were included in this study. Hypothyroidism was present in 40.2 per cent (232) cases compared to only 4.7 per cent (27) in controls (P<0.001). Anti-TTG and anti-GAD antibodies were present in 6.9 and 12.5 per cent subjects among cases compared to 3.5 per cent (P=0.015) and 4.3 per cent (P=0.001) in controls, respectively. Only anti-GAD antibody were significantly positive in cases among children and adolescents (P =0.0044) and adult (P=0.001) compared to controls. Levels of anti-TTG and anti-GAD antibodies increased with increasing titre of anti-TPO antibody.

INTERPRETATION & CONCLUSIONS

Our findings showed high positivity of anti-GAD and anti-TTG antibodies among subjects with thyroid autoimmunity. It is, therefore, important to have high clinical index of suspicion for celiac disease or type 1 diabetes mellitus in patients with autoimmune thyroiditis.

Bone health in healthy Indian population aged 50 years and above

One thousand six hundred healthy subjects aged more than 50 years, residing in Delhi, were evaluated for bone mineral metabolic parameters. High prevalence of osteoporosis (35.1% subjects) was observed in this population. Bone mineral density (BMD) correlated positively with body mass index (BMI) and negatively with PTH levels. No correlation was observed with serum 25(OH)D levels.

INTRODUCTION

To assess the bone health status in elderly Indians and compare peripheral DXA (pDXA) with central DXA in evaluation of osteoporosis.

METHODS

The study involved 1,600 healthy subjects more than 50 years of age residing in Delhi, India, who underwent anthropometric, biochemical, and hormonal evaluation. BMD was measured by DXA at lumbar spine, hip, and distal radius; and by pDXA at forearm and calcaneum.

RESULTS

Seven hundred ninety-two males and 808 postmenopausal females, with a mean age of 57.67 ± 9.46 years were evaluated. Osteoporosis was present in 35.1% subjects (M-24.6%, F-42.5%) and osteopenia in 49.5% (M-54.3%, F-44.9%). Prevalence of osteoporosis increased with age in females, but not in males. BMD at all sites, except distal radius, was positively correlated with BMI (r=0.037, p=0.14). Total body BMD was negatively correlated with alkaline phosphatase (r= -0.184, p<0.00001) and PTH levels (r= -0.099, p<0.00001), respectively. No significant correlation was observed between serum 25(OH)D levels and BMD at any site. BMD at forearm and calcaneum, measured using pDXA, showed strong positive correlation with BMD measured by central DXA. pDXA had sensitivity of 88%, specificity of 55%, and negative and positive predictive values of 89% and 52%, respectively, at T-score -2.5 at peripheral sites compared to central DXA.

CONCLUSIONS

A high prevalence of osteoporosis was observed in elderly Indian subjects. pDXA has high negative predictive value, making it a useful tool in population screening for osteoporosis.

Vitamin D status in healthy Indians aged 50 years and above

INTRODUCTION

There is widespread prevalence of vitamin D deficiency from new-born to infancy, childhood and adult male and females (non-pregnant, pregnant and lactating). However, there is limited information of the vitamin D status in elderly Indians.

MATERIAL AND METHODS

The study was carried in 1346 healthy subjects more than 50 years of age residing in Delhi, India. These subjects, who were divided in two groups: Group-1 (50-< 65 years) and Group-2 (> or = 65 years), underwent anthropometric, biochemical and hormonal evaluation for vitamin D status Bone mineral density was measured by dual X-ray absorptiometry.

RESULTS

There were 643 males and 703 females, with a mean age of 58.0 +/- 9.5 years (range 50-84 years). Vitamin D deficiency [VDD, serum 25(OH)D levels < 20 ng/ml) was present in 1228 (91.2%) and Vitamin D insufficiency [VDI, serum 25(OH)D levels 20-< 30 ng/ml] in 92 (6.8%). There was no significant difference in prevalence of either VDD or VDI between two age groups and sexes. Serum 25(OH)D levels were negatively correlated with PTH levels (r -0.027, p <0.00001) and BMI (r -0.128, p 0.05). Prevalence of secondary hyperparathyroidism increased from 14.1% to 43.1% from VDI to severe VDD. PTH levels started rising at vitamin D level < 30 ng/ml. However, more than 50% of subjects with severe VDD had PTH levels within normal range. High prevalence of osteopenia (50.2%) and osteoporosis (31.2%) was observed in this population.

CONCLUSION

Hypovitaminosis D is universal above the age of 50 years in north India. Absence of a PTH response was observed in more than 50% of individuals with VDD, the cause of which merits further evaluation. Normal bone mass was observed in only 18.6% of study subjects.

Reference intervals of serum lipid profile in healthy Indian school children and adolescents

OBJECTIVE

To develop age and sex specific reference intervals of serum lipid parameters in healthy Indian children in the age group of 6-17 years.

PARTICIPANTS

Study subjects were selected from the schools of Delhi. Children with BMI either in overweight or obese category were excluded to generate reference intervals. The final analysis included 3076 children with BMI in normal range for age.

RESULTS

The mean±SD, 3rd, 10th, 25th, 50th, 75th, 90th and 97th centile values of lipid parameters are presented. All these parameters were significantly higher in girls than in boys. About 89.2% subjects had total cholesterol in acceptable range while 9.1% had borderline elevated and 1.5% had elevated TC. Optimal serum triglyceride levels were seen in 45.1% subjects while optimal levels of HDL cholesterol were seen in 0.3% subjects only.

CONCLUSIONS

Reference intervals of serum lipid parameters for healthy Indian children (6-17 years) are presented.