Unravelling the utility of modern sulfonylureas from cardiovascular outcome trials and landmark trials: expert opinion from an international panel

AIM

The primary objective of this review is to develop practice-based expert group opinions on the cardiovascular (CV) safety and utility of modern sulfonylureas (SUs) in cardiovascular outcome trials (CVOTs).

BACKGROUND

The United States Food and Drug Administration issued new guidance to the pharmaceutical industry in 2008 regarding the development of new antihyperglycemic drugs. The guidance expanded the scope for the approval of novel antihyperglycemic drugs by mandating CVOTs for safety. A few long-term CVOTs on dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors have been completed, while others are ongoing. SUs, which constitute one of the key antihyperglycemic agents used for the management of type 2 diabetes mellitus (T2DM), have been used as comparator agents in several CVOTs. However, the need for CVOTs on modern SUs remains debatable. In this context, a multinational group of endocrinologists convened for a meeting and discussed the need for CVOTs of modern SUs to evaluate their utility in the management of patients with T2DM. At the meeting, CVOTs of modern SUs conducted to date and the hypotheses derived from the results of these trials were discussed.

REVIEW RESULTS

The expert group analyzed the key trials emphasizing the CV safety of modern SUs and also reviewed the results of various CVOTs in which modern SUs were used as comparators. Based on literature evidence and individual clinical insights, the expert group opined that modern SUs are cardiosafe and that since they have been used as comparators in other CVOTs, CVOTs of SUs are not required.

CONCLUSION

Modern SUs can be considered a cardiosafe option for the management of patients with diabetes mellitus and CV disease; thus CVOTs among individuals with T2DM are not required.

Career in Obstetrics and Gynecology; to be or Not to be: A Study of Intern Doctors in a Nepalese Medical College

Aims: To find the preference of career in Obstetrics and Gynecology among interns at the end of internship and factors influencing this choice. Methods: A semistructured questionnaire was distributed to interns at the end of a one year rotatory internship. Demographic factors and clinical exposure in Obstetrics and Gynecology (ObGyn) were assessed using chi-square test and attitudinal factors were measured using 5 point Likerts scale. This was compared with interns choosing other subjects. Mean score on Likerts scale was compared with independent t-test. Logistic regression analysis was used to predict independent factors affecting career choice in ObGyn. Results: Out of 174 interns, 22 (12.6%) chose ObGyn as the first career choice. Female gender (OR=1.46), urban residence (OR=1.21) and having a doctor in the family (OR=1.22) were factors associated with choosing ObGyn. Social commitment (p=0.027), high income potential (p=0.000), focus on urgent care (p= 0.000), gratifying practice (p=0.043) and short postgraduate training (p=0.000) were attitudinal factors related to this choice. Conclusions: Though ObGyn is a popular choice, students tend to change minds against it throughout medical school, influenced by various experiences. Department of ObGyn has a major responsibility to develop role models and encouraging mentors so that students choose ObsGyn with interest and do not regret the choice till the end of medical school.

Reproductive Health Issues and Depression in Wives of Labor Migrant Workers

BACKGROUND

Young Nepalese men have been forced to migrate to other countries in search of better opportunities. Wives of these migrant workers are in a vulnerable state and face various problems. The aim of this study wasto assess the prevalence of reproductive health problems and depression in this sub-population and to compare it with women living together with their husbands.

METHODS

This is a hospital based case control study where depression and reproductive health problems including gender based violence were compared between wives of migrant workers and women living with their husbands. Structured questionnaire was used to assess reproductive symptomatology and Becks depression Inventory-II was used to measure level of depression.

RESULTS

During the study period, 38.65% (2193) of all women were wives of migrant workers. India was the country where most 34.6% (73) men migrated. Mean duration of migration was 51.96 months (SD= 63.27). Moderate to severe depression was present in 42.6% (90) of wives of migrant workers and 80.09% of these women experienced some form of gender based violence. Reproductive tract symptoms and gender based violence and depression were significantly more present in these women (p<0.000).

CONCLUSIONS

Depression and reproductive health problems weremore prevalent in wives of labor migrant workers than in women living with their husbands. The physical and mental health needs of this sub-population warrants screening strategies and preventive measures.

Periodontal Antibodies and All-Cause and Cardiovascular Disease Mortality

Periodontitis is positively linked to cardiovascular disease (CVD), diabetes, cancer, and increased mortality. Empirically derived clusters of IgG antibodies against 19 selected periodontal microorganisms have been associated with hyperglycemia. We further investigated associations between these serum IgG antibody clusters and all-cause and CVD mortality in a representative US population. Participants free of CVD and cancer and aged ≥40 y at baseline (N = 6,491) from the Third National Health and Nutrition Examination Survey (1988 to 1994) were followed up until December 31, 2011. Antibodies were categorized into 4 clusters: red-green, orange-red, yellow-orange, and orange-blue. Over a 23-y follow-up, 2,702 deaths occurred, including 810 CVD-related deaths. In fully adjusted Cox proportional hazard models, the red-green cluster was positively associated with all-cause mortality (tertile 3 vs. tertile 1: hazard ratio [HR] = 1.43, 95% CI = 1.08 to 1.90, P = 0.015). The yellow-orange cluster was inversely associated with all-cause mortality (tertile 3 vs. tertile 1: HR = 0.78, 95% CI = 0.63 to 0.97, P = 0.028) and CVD mortality (tertile 2 vs. tertile 1: HR = 0.57, 95% CI = 0.42 to 0.77, P = 0.005). The orange-blue cluster (composed of antibodies against Eubacterium nodatum and Actinomyces naeslundii) was inversely associated with all-cause mortality (tertile 3 vs. tertile 1: HR = 0.65, 95% CI = 0.55 to 0.78, P < 0.0001) and CVD mortality (tertile 3 vs. tertile 1: HR = 0.65, 95% CI = 0.47 to 0.88, P = 0.007). These antibodies could predict prognosis or be potential intervention targets to prevent systemic effects of periodontal disease if further studies establish a causal relationship.

Dosimetric evaluation of 4D-CBCT reconstructed by Simultaneous Motion Estimation and Image Reconstruction (SMEIR) for carbon ion therapy of lung cancer

PURPOSE

Motion management is critical for the efficacy of carbon ion therapy for moving targets such as lung tumors. We evaluated the feasibility of using four-dimensional cone beam computed tomography (4D-CBCT) reconstructed by Simultaneous Motion Estimation and Image Reconstruction (SMEIR) for dose calculation and accumulation in carbon ion treatment of lung cancer.

METHODS

Motion-compensated 4D-CBCT images were reconstructed with the SMEIR algorithm to capture the most updated anatomy and motion with an updated interphase motion model on the treatment day. Projections of all CBCT phases were simulated from the planning 4D-CT by the ray tracing technique. Treatment planning and dose calculation were performed with a GPU-based Monte Carlo dose calculation software for carbon ion therapy. The treatment plan was optimized on the average computed tomography (CT) to obtain optimal intensity of the carbon ions. From the optimized plan, dose distributions on individual phases of 4D-CT and 4D-CBCT were calculated by the Monte Carlo-based dose engine. Dose accumulation was performed on 4D-CBCT images using deformable vector fields (DVF) generated by SMEIR. The accumulated planning target volume (PTV) dose based on 4D-CBCT was then compared to the accumulated dose calculated on 4D-CT, where the DVFs between different phases were obtained by the demons deformable registration algorithm.

RESULTS

Dose value histograms (DVH) as well as absolute deviations of the maximum dose ( Δ D max ), mean dose ( Δ D mean ), and dose coverage metrics ( Δ V 95 % and Δ V 100 % ) for PTV were quantitatively evaluated for the two sets of plans. Good agreement was found between the 4D-CT and 4D-CBCT-based PTV-DVH curves. The average values of Δ D max , Δ D mean , Δ V 95 % , and Δ V 100 % calculated between the 4D-CT and SMEIR-4D-CBCT-based plans were 1.91 % , 3.55 % , 2.12%, and 1.15 % , respectively, for the PTVs of ten patient case studies.

CONCLUSIONS

Based on these results, SMEIR-reconstructed 4D-CBCTs can potentially be used for motion estimation, dose evaluation, and adaptive treatment planning in lung cancer carbon ion therapy.

Serum IgG Antibodies against Periodontal Microbes and Cancer Mortality

INTRODUCTION

Periodontitis is a chronic inflammatory condition initiated by microorganisms and is positively linked to systemic conditions such as cancer, cardiovascular disease, and diabetes mellitus.

OBJECTIVES

To prospectively investigate associations between empirically derived clusters of IgG antibodies against 19 selected periodontal microorganisms and cancer mortality in a representative sample of the US population.

METHODS

We evaluated 6,491 participants aged ≥40 y from the Third National Health and Nutrition Examination Survey (1988 to 1994), who had complete data on IgG antibody titers against 19 selected periodontal microorganisms and were free of cardiovascular disease and cancer. In a prior study, antibodies were categorized into 4 mutually exclusive groups via cluster analysis: red-green, orange-red, yellow-orange, and orange-blue. Cluster scores were estimated by summing z scores of the antibody titers making up each cluster. Participants were followed up to death until December 31, 2011. Cox proportional hazard models were applied to estimate hazard ratios (HRs) and 95% CIs for all-cancer mortality by tertiles of cluster scores.

RESULTS

During follow-up for a median of 15.9 y, there were 2,702 deaths (31.3%), including 631 cancer-related deaths (8.1%). After adjusting for multiple confounders, the orange-blue cluster was inversely associated with cancer mortality (tertile 2 vs. tertile 1: HR = 0.67, 95% CI = 0.54 to 0.84; tertile 3 vs tertile 1: HR = 0.62, 95% CI = 0.46 to 0.84). The association between the yellow-orange cluster and all-cancer mortality was also inverse but not significant, and the orange-red cluster and the red-green cluster were not associated with all-cancer mortality.

CONCLUSIONS

Antibodies against Eubacterium nodatum and Actinomyces naeslundii may be novel predictors of cancer mortality. If further studies establish a causal relationship between these antibodies and cancer mortality, they could be targets to prevent possible systemic effects of periodontal disease with potential interventions to raise their levels.

KNOWLEDGE TRANSFER STATEMENT

Periodontal antibodies against Eubacterium nodatum and Actinomyces naeslundii were inversely associated with cancer mortality among adults followed up for an average of 16 y. Periodontal antibodies may predict cancer mortality.

Diversity of Root Canal Morphology in Mandibular First Premolar

Background Mandibular first premolars have been reported to have complex anatomical aberration making them one of the most difficult teeth to manage endodontically. Objective To determine the root canal anatomy of mandibular first premolar in a Nepalese population using decalcification and clearing technique. Method One hundred and fifty extracted mandibular first premolars were collected from Nepalese population. Access cavities were prepared on the occlusal surface of each tooth. Teeth were decalcified by immerging in 5% nitric acid, dehydrated in ethyl alcohol and made transparent using methyl salicylate. Methylene blue dye was injected through access cavity and canal anatomy were observed and classified according to Vertucci's classification. Result The average length of mandibular first premolar was 20.43mm. One rooted teeth were 96% and two rooted were 4%. Vertucci's type I canal configuration was most prevalent (72%) followed by type V (18.6%), type III (3.3%), type II (2.6%) and type IV (2.6%). An unusual configuration was found in one tooth. Isthmus and apical deltas were found in 8.6%) and 14.6% of the cases respectively. Conclusion Type I canal configuration were the most frequently observed root canal configuration in mandibular first premolar followed by type V configuration. Such variation in root canal anatomy should be taken into consideration to ensure successful endodontic therapy of these teeth.

Assessing the Temporal Effects of Squash vein yellowing virus Infection on Settling and Feeding Behavior of Bemisia tabaci (MEAM1) (Hemiptera: Aleyrodidae)

Insect vector behavior and biology can be affected by pathogen-induced changes in the physiology and morphology of the host plant. Herein, we examined the temporal effects of Squash vein yellowing virus (family Potyviridae, genus Ipomovirus) infection on the settling, oviposition preference, and feeding behavior of its whitefly vector, Bemisia tabaci (Gennadius) Middle East-Asia Minor 1 (MEAM1), formerly known as B. tabaci biotype B. Settling and oviposition behavioral choice assays were conducted on pairs of infected and mock-inoculated watermelon (Citrullus lanatus (Thunb) Matsum and Nakai) (Cucurbitales: Cucurbitaceae) at 5-6 days post inoculation (DPI) and 10-12 DPI. Electropenetrography, or electrical penetration graph (both abbreviated EPG), was used to assess differences in feeding behaviors of whitefly on mock-inoculated, 5-6 and 10-12 DPI infected watermelon plants. Whiteflies showed no preference in settling or oviposition on the infected and mock-inoculated plants at 5-6 DPI. However, at 10-12 DPI, whiteflies initially settled on infected plants but then preference of settling shifted to mock-inoculated plants after 8 h. Only at 10-12 DPI, females laid significantly more eggs on mock-inoculated plants than infected plants. EPG revealed no differences in whitefly feeding behaviors among mock-inoculated, 5-6 DPI infected and 10-12 DPI infected plants. The results highlighted the need to examine plant disease progression and its effect on vector behavior and performance, which could play a crucial role in Squash vein yellowing virus spread.

Safety, Efficacy and Acceptability of Early First Trimester Abortion using Oral Mifepristone and Sublingual Misoprostol

BACKGROUND

With the legalization of medical abortion in Nepal, mifepristone-misoprostol combination via different routes has been widely used for early abortion. This study aims to evaluate the efficacy and acceptability of 200 milligrams mifepristone orally followed by 800 micrograms sublingual misoprostol in outpatient setting.

METHODS

It was an open-label prospective study conducted in outpatient department of a tertiary hospital over a period of 13 months. Clients upto nine weeks of pregnancy were enrolled. 200 milligrams of mifepristone orally followed by 800 micrograms of misoprostol sublingually 36 to 48 hours later were prescribed. They were followed up in 14 days sonologically or verbally through telephone. Side effects and satisfaction to the regimen were assessed through acceptability questionnaire. Mann-Whitney U test was used for analyzing categorical data.

RESULTS

A total of 47 clients were enrolled. The mean age and gestational age were 29.38 years (SD+5.914) and 6.2 weeks (SD+1.28) respectively. The commonest indications for termination were completed family and unwanted pregnancy (40.4% each). The average duration of bleeding was 5.76 days (SD +3.61). Abdominal cramping was the most common side effect (95.7%). The least acceptable parameter was the bleeding time (80.9%). For 97.9% clients, the adverse effects were acceptable. The overall success rate of the regimen was 87.2%.

CONCLUSIONS

With a comparable success rate to vaginal use, home based sublingual use of misoprostol in low resource settings offers an acceptable and cost effective alternative for medical abortion upto nine weeks of pregnancy. Lesser gestational age is a useful predictor for successful abortion.

Outcome of Surgical Resection of Craniopharyngioma:Single Center 12 Years' Experience

Background Craniopharyngiomas (CPs) are rare epithelial tumors arising from the Rathke's pouch remnant located along the path of the craniopharyngeal duct accounting for 1.2-4% of all primary intracranial brain tumors, the primary treatment of which is surgery. Objective Whether radical surgical resection or partial resection followed by radiotherapy is a topic of debate. We presented our 12 years single center experience on surgical resection of craniopharyngioma. Method This was a descriptive cross-sectional study conducted among forty-five patients who underwent transcranial resection of craniopharyngioma during a period of 12 years. Data were collected from medical record archives. Glassgow outcome score (GOS), electrolyte imbalance and visual complications were assessed as outcome measure. GOS > 3 was considered favorable while score ≤ 3 was considered unfavorable. Recurrence of tumors were analyzed. Result Out of 45 patients, 28 patients were male with male to female ration of 1.64. Mean age was 32.22±16.42 years. Supra-sellar craniopharyngioma were the most common location. Gross total resection was accomplished in 32 patients (71.1%) while subtotal resection among 13 patients (28.9%). Post-operative Diabetes Insipidus was developed among 35 patients (77.7%). Adamantinomatous craniopharyngioma was the most common histopathological type. Postoperative MRI with contrast was repeated to ascertain the completeness of resection. All patient with subtotal resection received radiotherapy. Follow up period ranged from 3 months to 8 years with mean of 4.2 years. Favorable outcome (GOS>3) was seen among 41 patients while unfavorable among 4 patients. Recurrence seen among 4 patients (8.9%). Overall mortality was 4 (8.8%). Conclusion Gross total excision of craniopharyngioma has a favorable outcome with acceptable morbidity.

Evaluation of Clinical Characteristics and Outcomes of Obstetric Patients Admitted to Intensive Care Unit

Introduction: The need for critical care support and admission to intensive care unit (ICU) in obstetric population is infrequent. The proportion ranges from 0.1 to 8.5%. Yet, obstetric admissions to ICU and mortality continue to have a significant impact on overall maternal health care. The study of epidemiology and predictors of obstetric admissions to ICU will prove a useful proxy for better understanding maternal near miss events and mortality. Methods: This was a case control study reviewing all the obstetric cases admitted to ICU over a study period of five years. The individual files were recovered from the record section and data pertaining to referral status, demographics, clinical profile and ICU information were retrieved. The ICU data comprised of the length of ICU stay, indications for admission, interventions required, and outcomes. The data were then compared to historical controls. Results: A total of 80 patients were admitted to ICU accounting for 0.84% of total deliveries and 4.6% of total ICU admissions. Mean age was 24.84 years, mean gestational age was 32.33 weeks, and mean blood loss was 707.27 ml. Hypertensive disorder of pregnancy followed by obstetric hemorrhage were the most common indications. Lower gestational age, increased blood loss, emergency cesarean sections, and surgical interventions were noteworthy risk factors for ICU admissions. There was a mortality rate of 5%. Conclusion: Hypertensive disorders account for the most number of admissions to ICU followed by obstetric hemorrhage. Lower gestational age, increased blood loss and emergency cesarean section are notable risk factors for ICU admission.

Post-Operative Pain and Associated Factors in Patients Undergoing Single Visit Root Canal Treatment on Teeth with Vital Pulp

Background Pain after root canal therapy is unwanted yet common experience for the patient and unpleasant for the dentist so it is always desirable to predict such pain. Objective To evaluate the frequency, intensity and associated factors of post-operative pain after single visit endodontic therapy on teeth with vital pulps. Method A total of 418 single visit root canal treatments were performed on patients of age 18 years and above by two endodontists. Canals were shaped with rotary ProTaper files. After the canal preparation, the canals were obturated, using lateral compaction technique, with ProTaper universal gutta-percha and AH-Plus sealer. Independent factors were recorded during the treatment and characteristics of postoperative pain were later surveyed through questionnaires. The severity of pain was recorded on a visual analogue scale (VAS) of 0-5. The data were analyzed using logistic regression models. Result The prevalence of post-operative pain within first six hours after treatment was high (79.2%) which decreased to 22% at the end of 72 hours however majority (70%) of the patients had mild to moderate pain (VAS 1-2). The factors that significantly influenced post-obturation pain experience were: gender (OR=0.55, 95%CI=0.32- 0.93; p=0.03), tooth type (OR-0.67; 95% CI=10.56-0.81, p=0.00), history of preoperative pain (OR=1.26; 95% CI= 1.04-1.51; p=0.02) and number of canals (OR=2.03; 95% CI=1.40-2.95; p=0.00). Conclusion The prevalence of some level of post -operative pain after single visit root canal therapy was high and was significantly influenced by female gender, increased number of canals, posterior tooth type and positive history of pre-operative pain.

Clinical Outcome following Intra-articular Triamcinolone Injection in Osteoarthritic Knee at the Community: A Randomized Double Blind Placebo Controlled Trial

Background Knee pain is one of the common complaints patients present with in any community based health camps and Osteoarthritis of knee is a usual diagnosis. Injecting a long acting steroid is a common practice to alleviate the symptoms of osteoarthritic knee. Objective To evaluate the clinical outcome of injecting Triamcinolone acetenoid in osteoarthritis of knee in a community set up over a randomized double-blind placebo control trial. Method A prospective, randomized, double blind, placebo control trial was carried out in community after obtaining the ethical clearance from the IRC. Patients with clinically diagnosed osteoarthritis of knee were injected either Triamcinolone or Placebo after recording the baseline scores of the knee by Knee injury and Osteoarthritis Outcome Score (KOOS) - Physical Function Short form (KOOS-PS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Visual Analogue Scale (VAS). The same tools were used at two, six and at twelve weeks post injection to evaluate the functional outcome and pain. Result One hundred and seventeen patients were available for analysis among which, 55(48.7%) patients received Triamcinolone and 58(51.3%) received placebo. The baseline status of knees of two groups was comparable at the start of study. There was significant pain relief in the group receiving Triamcinolone at two and six week but not in twelve weeks. Group receiving placebo had pain relief only for first two weeks. Functional outcome was significantly improved compared to baseline in both the groups until six weeks however, in the triamcinolone group, it was significant until twelve weeks. No major complications were noted. Conclusion Intra-articular injection of Triamcinolone acetenoid is effective in symptoms control and improving functional outcome in clinically diagnosed osteoarthritis of knees in community set up during health camps.

Iterative reconstruction with boundary detection for carbon ion computed tomography

In heavy ion radiation therapy, improving the accuracy in range prediction of the ions inside the patient's body has become essential. Accurate localization of the Bragg peak provides greater conformity of the tumor while sparing healthy tissues. We investigated the use of carbon ions directly for computed tomography (carbon CT) to create the relative stopping power map of a patient's body. The Geant4 toolkit was used to perform a Monte Carlo simulation of the carbon ion trajectories, to study their lateral and angular deflections and the most likely paths, using a water phantom. Geant4 was used to create carbonCT projections of a contrast and spatial resolution phantom, with a cone beam of 430 MeV/u carbon ions. The contrast phantom consisted of cranial bone, lung material, and PMMA inserts while the spatial resolution phantom contained bone and lung material inserts with line pair (lp) densities ranging from 1.67 lp cm^-1 through 5 lp cm^-1. First, the positions of each carbon ion on the rear and front trackers were used for an approximate reconstruction of the phantom. The phantom boundary was extracted from this approximate reconstruction, by using the position as well as angle information from the four tracking detectors, resulting in the entry and exit locations of the individual ions on the phantom surface. Subsequent reconstruction was performed by the iterative algebraic reconstruction technique coupled with total variation minimization (ART-TV) assuming straight line trajectories for the ions inside the phantom. The influence of number of projections was studied with reconstruction from five different sets of projections: 15, 30, 45, 60 and 90. Additionally, the effect of number of ions on the image quality was investigated by reducing the number of ions/projection while keeping the total number of projections at 60. An estimation of carbon ion range using the carbonCT image resulted in improved range prediction compared to the range calculated using a calibration curve.

Ectopic Pregnancy Following Interval Tubal Sterilization

Introduction:  Tubal sterilization is a highly effective method of permanent contraception. However, pregnancy can still occur following a successful procedure. Published literatures report a failure rate of 0.13-1.3% and 15-33% of such pregnancies are likely to be ectopic. Case report: A 33 years para three lady with prior history of tubal ligation presented with generalized abdominal pain and several episodes of vomiting. Bimanual examination revealed a soft and mobile mass of 2 x 3 cm in right adnexa. Urine pregnancy test was positive and ultrasonogram showed a heterogeneous mass of 3.4 x 3.3 cm in right adnexa with empty uterine cavity. Culdocentesis resulted in aspiration of frank non-clotting blood. She then underwent emergency laparotomy with bilateral salpingectomy for ruptured ectopic pregnancy. Conclusion: Ectopic pregnancy after tubal sterilization though rare is not entirely impossible. All women who are offered this procedure should always be educated about its failure rate. And in women presenting with acute abdomen, a prior history of tubal sterilization doesn't preclude the possibility of ectopic pregnancy.

Responses of Aphid Vectors of Potato leaf roll virus to Potato Varieties

Potato leaf roll virus (PLRV) can reduce tuber yield and quality in potato. Green peach aphid (Myzus persicae [Sulzer]) and potato aphid (Macrosiphum euphorbiae [Thomas]) are the two most important potato-colonizing PLRV vectors in the Pacific Northwest. We compared My. persicae and Ma. euphorbiae densities and PLRV incidences among potato varieties in the field to clarify the relationships between aphid abundance and PLRV incidence in plants. Aphids were sampled weekly over three years in the potato varieties Russet Burbank, Ranger Russet, and Russet Norkotah in a replicated field trial. In all years, My. persicae was more abundant than Ma. euphorbiae, representing at least 97% of samples. My. persicae densities did not differ among potato varieties across years; very low numbers of Ma. euphorbiae precluded such statistical comparisons for this species. PLRV infection did not differ significantly among potato varieties, although the percent of PLRV-infected plants differed among years when all varieties were combined (46% in 2013, 29% in 2011, 13% in 2012). For Ranger Russet and Russet Norkotah, PLRV incidence was positively correlated with aphid abundance as well as proportion of PLRV-positive aphids. In Russet Burbank, only aphid abundance was positively correlated with PLRV infection. Our results suggest that the three most commonly grown potato varieties in our region do not differ in their susceptibility to PLRV infection, and that aphid density was a consistent indicator of the risk of infection by this virus across varieties. Both of these findings can be used to hone PLRV monitoring and modeling efforts.

Host-Mediated Effects of Semipersistently Transmitted Squash Vein Yellowing Virus on Sweetpotato Whitefly (Hemiptera: Aleyrodidae) Behavior and Fitness

Plant viruses may indirectly affect insect vector behavior and fitness via a shared host plant. Here, we evaluated the host-mediated effects of Squash vein yellowing virus (SqVYV) on the behavior and fitness of its whitefly vector, Bemisia tabaci (Gennadius) Middle East-Asia Minor 1, formerly biotype B. Alighting, settling, and oviposition behavioral assays were conducted on infected and mock-inoculated squash (Cucurbita pepo L.) and watermelon [Citrullus lanatus (Thunb) Matsum and Nakai] plants. Developmental time of immature stages, adult longevity, and fecundity were measured on infected and mock-inoculated squash plants. For adult longevity and fecundity, whiteflies were reared on infected and mock-inoculated squash plants to determine the effects of nymphal rearing host on the adult stage. More whiteflies alighted and remained settled on infected squash than on mock-inoculated squash 0.25, 1, 8, and 24 h after release. No such initial preference was observed on watermelon plants, but by 8 h after release, more whiteflies were found on mock-inoculated watermelon plants than on infected plants. Whiteflies laid approximately six times more eggs on mock-inoculated watermelon than on infected watermelon; however, no differences were observed on squash. Development from egg to adult emergence was 3 d shorter on infected than mock-inoculated squash plants. Females lived 25% longer and had higher fecundity on infected squash plants than on mock-inoculated plants, regardless of infection status of the rearing host. The host-mediated effects of SqVYV infection on whitefly behavior differ on two cucurbit host plants, suggesting the potential for more rapid spread of the virus within watermelon fields.

Fetal Ascites Mimicking Maternal Ovarian Tumor: A Rare Cause of Obstructed Labour

Fetal ascites has been diagnosed more frequently these days because of routine ultrasound scanning in pregnancy. However as a cause of dystocia in labour, it is very rare. Twenty four years second gravida of 28 weeks 6 days of gestation presented to labour room with preterm obstructed labour. Abdominal examination revealed less readily palpable fetal parts and distantly localized fetal heart sounds. An urgent ultrasound showed huge maternal ovarian cyst. She then underwent emergency cesarean section; delivered a male baby with grossly distended abdomen. However, the ovaries were normal looking. Routine antenatal ultrasounds help in identifying maternal and congenital fetal anomalies. They also guide in planning the most appropriate management. Whenever fetal ascites is diagnosed antenatally, possibility of dystocia in labour should be kept in mind.

Displaced Intra-Articular Calcaneal Fractures: Evaluation of Clinical and Radiological Outcome Following Open Reduction and Internal Fixation with Locking Branched Calcaneal Plate

Background Calcaneal fractures are common, but are difficult to manage. Immediate concern is soft tissue problems, while long term concern is pain as a sequelae of subtalar arthritis. A consensus has not been reached in the management of calcaneal fractures. Objective This study aims to evaluate clinical and radiological outcomes of the patients managed with open reduction and internal fixation with Calcaneal Locking Plates for the displaced intra-articular calcaneal fractures presenting in Dhulikhel Hospital, Kathmandu University Hospital. Method This was a prospective study, conducted on displaced intra articular calcaneal fractures from January 2014 through December 2016. The patients underwent open reduction and internal fixation with Locking Branched Calcaneal Plates through the extensile lateral approach. Post-operatively, ankle was mobilized after two weeks. Weight bearing was started after 12 weeks. Patients were evaluated clinically with Maryland foot score and radiologically with measurements of Boehler's and Gissane angle. Result Twenty-two cases of calcaneal fractures managed with open reduction and internal fixation with Locking Branched Calcaneal Plates were available for final evaluation. Seventeen of the enrolled patients were males in their third decade of life. On average, calcaneal fractures were operated on seven days after the injury. Sanders Type II were seen in 68.2% of the cases and Sanders Type III were in 31.8%. Mean follow-up duration was 21.5 months. The average Maryland foot score was 77.27. Seventeen cases (77.13%) had good, four cases (18.2%) had fair, and one case (5.5%) had poor outcome score. There was statistically significant improvement in Boehler's and Gissane angle across all enrolled patients. Conclusion Displaced intra-articular calcaneal fractures treated operatively with open reduction and internal fixation with Locking Branched Calcaneal Plates through the extended lateral approach, with proper planning of operation and surgical techniques in soft tissue handling, results in good clinical as well as radiological outcomes.

Fluoroscopy Guided Percutaneous Transpedicular Biopsy for Thoracic and Lumbar Vertebral Body Lesion: Technique and Safety in 23 Consecutive Cases

Background Though some vertebral lesions have typical imaging findings, histological/ microbiological evidence are required for definitive diagnosis and management, specially for tumor and infective lesions so that wrong diagnosis and wrong treatment can be avoided. Conventionally, open biopsy methods are used. With availability of CT scan, MRI, percutaneous transpedicular vertebral biopsy has now become popular as a minimally invasive technique for biopsy of vertebral lesion.Objective To describes technique and to analyzes safety and feasibility of percutaneous transpedicular vertebral biopsy with fluoroscopy guidance for thoracic and lumbar vertebral body lesions.Method Twenty three patients who underwent percutaneous transpedicular vertebral biopsy under fluoroscopy guidance were retrospectively evaluated for demographic data, indication for biopsy, anatomical locations, histological/microbiological diagnosis, complications and final outcome of treatment. True positive, true negative, false positive and false negative cases were defined.Result There were 17 males and 6 female patients of mean age 47 (range 22-73 years). Biopsies were performed in 17 dorsal and six lumbar vertebral bodies. Adequate sample were obtained in all cases. Seventeen patients (12: tubercular pathology, 1: primary tumor, 3: metastasis, 1: osteoporotic fracture) had definitive histological/ microbiological diagnosis. Four patients had no granuloma and tumor. Two had histological features of chronic non specific inflammation. True positive cases were 17, true negative were four and false negative case were two. Overall accuracy was 92%. One patient developed small hematoma at biopsy site.Conclusion Fluoroscopy guided percutaneous transpedicular biopsy of is a safe procedure with high adequacy and accuracy and low complication rate for thoracic and lumbar vertebral body lesion.

Study of Clinical Variables Affecting Long Term Outcome after Microdisectomy for Lumbar Disc Herniation

Background Outcome of lumbar disc herniation are influenced by various clinical, socioeconomic and psychological factors. In the absence of provision of medical insurances, worker’s compensation and sick leave, predictors for outcome after lumbar disc herniation surgery will be different in Nepalese population.Objective To evaluate different clinical variables that can affect outcome after lumbar disc herniation surgery.Method Among 88 patients who underwent microdisectomy for lumbar disc herniation, 63 patients (43 male, 20 female) with follow up at least six months were retrospectively evaluated for clinical variables which can affect Oswestry disability index (ODI) score, its interpretation and Mcnab classification of post operative outcome.Result Average age of patients was 42.54±8.60 years. Mean follow up period was 34.89±23.80 months (range 6 -111 months). Thirty four patients had follow up period > 24 months. Mean ODI score before surgery and at final follow up was 37.87±8.76 vs 7.78±7.7; (p=0.00). Success rate was 90.47% (change in ODI score at least by 10), 93.65% (ODI score interpretation <40%), and 85.71%. (Mcnab outcome excellent and good). Significant correlation was found between age and ODI at final follow up but not with duration of symptoms. Male, non alcoholic, low level of education, numbness as a predominant symptom, disc at L4-L5 were significantly associated with better ODI at final follow up. For ODI score interpretation, gender, smoking habit, presence of leg pain as a predominant symptom were statistically significant factors whereas smoking and drinking habit, level of education, occupation, back pain and numbness as predominant pre-operative symptom, types of disc in MRI were significantly related to Mcnab outcome. There was 9.5% peri- or post-operative complications and recurrence in seven patients.Conclusion Age, gender, smoking and drinking habit, level of education, occupation, types of disc in MRI are important variables for ODI score, ODI score interpretation and Mcnab outcome.

Step towards Formulating a Maximum Surgical Blood Ordering Schedule in Obstetrics and Gynecology

Introduction: Blood transfusion is an essential part of perioperative care in surgeries in obstetrics and gynecology. A tendency of over ordering of blood imposes additional workload to the blood bank and extra cost to the laboratory and patients. Maximum surgical blood ordering schedule (MSBOS) is a guide which helps in the decision of ordering and transfusing blood which reduces blood wastage. This study was done with the aim of evaluating the blood ordering and utilization patterns in obstetric and gynecologic surgeries and formulation of MSBOS for these procedures for the institute.   Methods: This is a cross-sectional, hospital based study conducted for the duration of three months. All patients undergoing major and minor surgeries at the department were included. Crossmatch to transfusion ratio (C/T), transfusion probability (%T), transfusion index (TI) and MSBOS were calculated for each procedure.   Results: Total 309 surgeries were performed in the department during the study period of three months. Most common surgery was emergency cesarean section (n=164, 53.1%) followed by abdominal hysterectomy (n=43, 13.9%). Utilization of crossmatched blood was 22.51%. Overall transfusion rate for all surgeries was 3.88%. Overall C/T ratio, %T, and TI were 4.44, 9.83 and 0.27 respectively which elicited indiscriminate ordering of blood.   Conclusion: Over ordering and under utilization of blood were seen in this audit. Blood ordering patterns need to change in order to minimize over ordering of blood which may prevent abuse of the system. MSBOS maybe an useful tool in this institute as it allows optimum blood usage for surgeries.

Cross-Sectional Analysis of Alcohol Intake and Serum Antibodies to Oral Microorganisms

The objective of this study was to evaluate the relation between alcohol intake and groups of periodontal antibody titers among individuals with normal glucose tolerance (NGT), prediabetes and diabetes. This was a cross-sectional analysis of the National Health and Nutrition Examination Survey III (NHANES III) 1988–1994 data, among individuals 40 y and older with information on alcohol intake and serum immunoglobulin G (IgG) antibody data against 19 oral microorganisms. Participants were excluded if they did not have teeth, reported that they were taking insulin, or having gestational diabetes. The sample size for this analysis was 3,219. Periodontal antibodies were grouped into four clusters using cluster analysis: Orange-Red, Red-Green, Yellow- Orange, and Orange-Blue. Cluster scores were computed for each individual by summing z-scores of standardized log-transformed IgG titers of antibodies against periodontal microorganisms making up each respective cluster. Each cluster score was modeled as an outcome. Alcohol consumption was assessed in g/day using self-reported number of days of drinking in the past 12 mo and the average number of drinks consumed per day on days when they drank. Overall, alcohol intake was positively associated with periodontal antibodies of the Orange-Red cluster (P. melaninogenica, P. intermedia, P. nigrescens, and P. gingivalis), and inversely associated with the Yellow-Orange cluster (S. intermedius, S. oralis, S. mutans, F. nucleatum, P. micra, C. ochracea) after multivariable adjustment. The association between alcohol intake and the Orange-Red cluster was strongest among individuals with diabetes; this relation was seen among individuals with and without periodontal damage. The Orange-Red cluster was positively associated with periodontal damage among individuals with diabetes. Alcohol intake was not associated with any antibody cluster among individuals with NGT or prediabetes. The effect of alcohol intake on periodontal disease may be greater among individuals with diabetes but this finding needs to be confirmed in prospective studies.

Knowledge Transfer Statement: The results of this study can be used by clinicians when treating patients with periodontal disease and diabetes.

Combined Sonography

We report the results of a joint thyroid clinic with a consultant surgeon and consultant radiologist to offer “triple assessment” for patients on a single visit. All new referrals from September 2011 to December 2013 were reviewed. Among 228 patients referred, 163 patients underwent ultrasonography (US) on the same visit and 66 fine needle aspiration cytology (FNAC) studies (57 under US guidance) were done. One hundred ninety-eight (87%) patients made a single visit to the clinic for diagnosis. One hundred twenty-five were discharged or referred elsewhere after the visit and 21 underwent surgery; the remaining 52 patients were followed up. There were 7 thyroid cancers and 2 lymphomas diagnosed. We have concluded that the joint ultrasound-surgery clinic provided an effective outpatient thyroid service with fewer hospital visits.