Comparison of Bone-Patellar Tendon-Bone Graft, Semitendinosus-Gracilis Graft and Semitendinosus-Gracilis with Preserved Tibial Insertion Graft in Anterior Cruciate Ligament Reconstruction in Sports Persons

Introduction

Bone-patellar tendon-bone (BPTB) and semitendinosus-gracilis (STG) are the commonest grafts used for ACL reconstruction. However even after having been debated for years, there is no consensus about the ideal graft. Moreover, the literature is deficient about STG graft with preserved tibial insertion (STGPI) which preserves the proprioception. Our aim is to compare the outcome of BPTB, free STG and STGPI grafts after ACL reconstruction in professional sports persons. We compared the outcome in terms of mechanical stability, functional outcome, return to sports activity and degenerative changes.

Material and Methods

Professional sports persons aged between 16-50 years operated for ACL tear using BPTB, free STG and STGPI grafts with minimum follow-up of two years were identified from hospital records. Patients with associated knee injuries were excluded. Patients, divided in three groups according to graft used, were compared in terms of mechanical stability (arthrometric examination KT-1000 score), functional outcome (Lysholm Score), return to sports activity (Tegner score and difference in thigh circumference) and degenerative changes (KL grading).

Results

BPTB graft group was found to be better than free STG and STGPI graft groups in terms of KT-1000 score. There was no statistically significant difference among the groups in terms of Lysholm score, Tegner score, difference in thigh circumference and KL grading.

Conclusion

BPTB graft is better than free STG and STGPI grafts in terms of knee stability. When compared for patient reported outcome, return to sports activity, osteoarthritic changes and graft failure there is no significant difference among the three types of grafts.

A new approach for identifying positional isomers of glycans cleaved from monoclonal antibodies

Glycosylation patterns in monoclonal antibodies (mAbs) can vary significantly between different host cell types, and these differences may affect mAbs safety, efficacy, and immunogenicity. Recent studies have demonstrated that glycan isomers with the terminal galactose position on either the Man α1-3 arm or the Man α1-6 arm have an impact on the effector functions and dynamic structure of mAbs. The development of a robust method to distinguish positional isomers of glycans is thus critical to guarantee mAb quality. In this work, we apply high-resolution ion mobility combined with cryogenic infrared spectroscopy to distinguish isomeric glycans with different terminal galactose positions, using G1F as an example. Selective enzymatic synthesis of the G1(α1-6)F isomer allows us to assign the peaks in the arrival-time distributions and the infrared spectra to their respective isomeric forms. Moreover, we demonstrate the impact of the host cell line (CHO and HEK-293) on the IgG G1F gycan profile at the isomer level. This work illustrates the potential of our approach for glycan analysis of mAbs.

POS0805 TREATMENT OF GIANT CELL ARTERITIS WITH TOCILIZUMAB: A RETROSPECTIVE COHORT STUDY OF 119 PATIENTS

Background:

Giant cell arteritis (GCA) is an inflammatory condition of medium- and large-sized arteries. Prospective clinical trials have demonstrated the efficacy of tocilizumab (TCZ) for treatment of patients with GCA (1). However, there is a limited data on the use of TCZ in routine clinical practice.

Objectives:

To evaluate the efficacy and safety of TCZ in a retrospective cohort study of patients with GCA treated with TCZ.

Methods:

Patients with GCA treated with TCZ at 4 clinical centers of a single tertiary care institution (2000-2020) were identified. The diagnosis of GCA was confirmed by at least one of the following modalities: 1. Arterial biopsy 2. Large vessel imaging 3. Clinical diagnosis of GCA meeting ACR classification criteria and established by a rheumatologist. Patient demographics, clinical presentation, laboratory studies, treatment course and adverse events were abstracted from the medical record; only patients with at least 6 months of follow-up after TCZ initiation were included. Kaplan-Meier methods were used to estimate time to TCZ discontinuation and time to first relapse after TCZ discontinuation. Poisson regression models were used to compare relapse rates before and after TCZ initiation.

Results:

The study cohort included 119 patients [61% female; mean (SD) age at GCA diagnosis 70.3 (8.2) years]. The majority of patients (89%) had a biopsy-proven and/or imaging-based diagnosis of GCA, while 13 (11%) had a clinical diagnosis of GCA. In addition to glucocorticoids, 40 (34%) patients received other immunosuppressive agents prior to TCZ. The method of initial TCZ administration was subcutaneous (162mg/ml) weekly in 48 (41%), subcutaneous every other week in 20 (17%), monthly 4mg/kg infusions in 34 (29%), monthly 8mg/kg infusions in 14 (12%) and non-standard dosing in 3 remaining patients. The median (IQR) duration from GCA diagnosis to TCZ initiation was 4.8 (1.2-22.0) months and the median (IQR) duration of TCZ treatment was 18 (11-28) months. The mean (SD) dose of prednisone at TCZ initiation was 31 (19) mg/day and was reduced to a mean (SD) dose of 3.9 (6.7) mg/day at TCZ discontinuation/last follow-up visit. The relapse rate per year decreased 43% from 0.77 to 0.44 after the initiation of TCZ (RR=0.57; 95% CI: 0.44-0.75; p<0.001). The mean (SD) ESR and CRP decreased from 22 (20) mm/hour to 6 (9.2) mm/hour and from 19.1 (25) mg/L to 5.4 (16.6) mg/L, respectively from TCZ initiation to TCZ discontinuation/last follow-up visit. At 2 years of follow-up, 67% of patients had discontinued glucocorticoids. At last follow up, 46 patients had discontinued TCZ, only 14 of which were due to adverse events. The median time to TCZ discontinuation was 2.9 years. Only 17% (95%CI: 10-24%) had discontinued by 1 year after TCZ initiation and 38% (95% CI: 26-47%) had discontinued by 2 years. The most common adverse events were infections and cytopenias. While on TCZ, 1 patient developed new onset vision loss related to GCA and 1 patient, without history of diverticulitis, had bowel perforation. Among those discontinuing TCZ, 61% had relapsed at least once by 1 year after TCZ discontinuation.

Conclusion:

In this large single institution cohort of patients with GCA, TCZ use resulted in a significantly reduced relapse rate and reduction in glucocorticoid dosage. Overall, patients tolerated long-term use with only 12% discontinuing due to adverse events. However, over half of patients stopping TCZ had a subsequent flare; highlighting ongoing use may be required beyond two years in several patients with GCA to maintain remission.

References:

[1]Stone JH, et al. Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med. 2017 Jul 27;377(4):317-328. doi: 10.1056/NEJMoa1613849. PMID: 28745999.

[2]Calderón-Goercke M, et al. Tocilizumab in giant cell arteritis. Observational, open-label multicenter study of 134 patients in clinical practice. Semin Arthritis Rheum. 2019 Aug;49(1):126-135. doi: 10.1016/j.semarthrit.2019.01.003. Epub 2019 Jan 5. PMID: 30655091.

Disclosure of Interests:

Jigisha Rakholiya: None declared, Matthew Koster: None declared, Hannah Langenfeld: None declared, Cynthia S. Crowson: None declared, Andy Abril: None declared, Pankaj Bansal: None declared, Lester Mertz: None declared, Alicia Rodriguez-Pla: None declared, Rahul Sehgal: None declared, Benjamin Wang: None declared, Kenneth J Warrington Grant/research support from: Research support: Kiniksa, Eli Lilly

Protein kinase TgCDPK7 regulates vesicular trafficking and phospholipid synthesis in Toxoplasma gondii

Apicomplexan parasites are causative agents of major human diseases. Calcium Dependent Protein Kinases (CDPKs) are crucial components for the intracellular development of apicomplexan parasites and are thus considered attractive drug targets. CDPK7 is an atypical member of this family, which initial characterization suggested to be critical for intracellular development of both Apicomplexa Plasmodium falciparum and Toxoplasma gondii. However, the mechanisms via which it regulates parasite replication have remained unknown. We performed quantitative phosphoproteomics of T. gondii lacking TgCDPK7 to identify its parasitic targets. Our analysis lead to the identification of several putative TgCDPK7 substrates implicated in critical processes like phospholipid (PL) synthesis and vesicular trafficking. Strikingly, phosphorylation of TgRab11a via TgCDPK7 was critical for parasite intracellular development and protein trafficking. Lipidomic analysis combined with biochemical and cellular studies confirmed that TgCDPK7 regulates phosphatidylethanolamine (PE) levels in T. gondii. These studies provide novel insights into the regulation of these processes that are critical for parasite development by TgCDPK7.

In this study, we demonstrate that protein kinase TgCDPK7 regulates cellular processes like vesicular trafficking and the synthesis of phospholipids, which are critical for the development of the parasite Toxoplasma gondii. It regulates the localization of a small GTPase TgRab11a by phosphorylating it at a specific site, which is critical for trafficking of important parasite proteins and is important for parasite division. TgCDPK7 may regulate key enzymes involved biogenesis of phosphatidylethanolamine, which may contribute to the synthesis of this important phospholipid. These and other studies shed light on a novel signaling pathway in apicomplexan parasite Toxoplasma gondii.

A Cross-sectional Study to Assess Psychiatric Co-morbidity among Patients of Migraine and Other Headaches

Introduction: Migraine is the most common cause of vascular headache with a one-year prevalence as high as 6-14.3%. Having various pathophysiological theories, it occurs in much co-morbidity with several medical as well as psychiatric disorders like mood disorders, phobia, anxiety spectrum, etc. Migraine, especially when co-morbid with psychiatric illness stands markedly burdensome economically, diagnostically, therapeutically and prognostically. Hence, needs even further research. Aim: To study patients with migraine versus other types of headache and to study psychiatric co-morbidity among patients with migraine. Materials and Methods: This cross-sectional study was conducted on total 100 patients presenting with headache, meeting the criteria were taken up for the study and divided into two groups. Patients meeting International Headache Society (IHS) criteria for migraine were enrolled under group A and patients suffering from headache other than migraine under group B. Having subjected to detailed history and evaluation, patients were subjected to Symptom checklist-80, Hamilton’s Anxiety Rating Scale (HARS) and Montgomery Asberg Depression Rating Scale (MADRS), International Classification of Diseases (ICD)-10 criteria. The data so collected was subjected to statistical analysis and association of psychiatric morbidity with migraine patients was assessed. Results: Patients with migraine (group A) and among those too, patients having psychiatric morbidity had significantly (p<0.01) longer duration of illness (≥8 years), more frequent attacks ≥5 attacks per month and had longer duration of each attack >24 hours compared to the other groups. Patients having migraine had significantly (p<0.01) higher psychiatric morbidity, more SCL-80 symptoms (mean score 83.05); more depressive symptoms (mean MADRS score was 31.9±9.2) and more anxiety with the mean Hamilton Anxiety score was 23.3 than in patients without psychiatric morbidity. Conclusion: A thorough evaluation of psychiatric disorders in migraine is important so as to propose a non segregated model of care to direct the burden and deterioration associated with psychiatric co-morbidity in migraine.

Practical consensus recommendations for gestational breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to manage gestational breast cancer.

Defective Proventriculus Regulates Cell Specification in the Gastric Region of Drosophila Intestine

The gastrointestinal tract in metazoans consists of diverse epithelial cells with distinct cell morphology and physiological functions. The development and homeostasis of gastrointestinal epithelia involve spatiotemporal regulation by many signaling pathways, essential to confer their region-specific function and identity. The adult Drosophila midgut and the mammalian intestine share a high degree of conservation between such signaling pathways. Due to availability of sophisticated techniques for genetic manipulation, Drosophila is an excellent model to study mechanisms of tissue homeostasis regulation in a regionally defined manner. The gastric region located in the Drosophila middle-midgut coincides with the region containing fewest number of stem cells. It is also known as the copper cell (CC) region since it is composed of specialized groups of acid-secreting CCs, along with interstitial cells and enteroendocrine cells. The generation and maintenance of these cell populations are determined by the bone morphogenic protein-like Decapentaplegic (Dpp) signaling pathway. The morphogenic gradient of the Dpp signaling activity induces differential expression of specific transcription factors labial (lab) and defective proventriculus (dve), which are required for the generation of various cell types specific to this region. In this study, we investigated the role of Dve in regulation of tissue homeostasis in the CC region. Our studies reveal that ectopic expression of dve in stem cells suppresses their self-renewal throughout the intestine. We further demonstrate that Dve is not required for generation of CCs. Higher levels of Dve can alter cell specification by inhibition of cut expression, which in turn prevents CC formation during homeostasis.

Embelin modulates metabolic endotoxemia and associated obesity in high fat diet fed C57BL/6 mice

The present study was designed to investigate the effect of embelin in metabolic endotoxemia (ME) mediated inflammation and associated obesity in high fat diet (HFD)-fed C57BL/6 mice. The molecular docking of embelin confirms its binding with the toll-like receptor-4 (TLR-4). In vivo study, mice were treated with HFD for 8 weeks to induce ME mediated inflammation and associated obesity. Further, mice were treated with embelin (50 and 100 mg/kg/day, p.o.) and orlistat (10 mg/kg/day, p.o.) from 5th to 8th week along with HFD to improve associated changes. After 8 weeks, mice were euthanized and assessed for body weight, body mass index (BMI), fat pad weights (mesenteric, retroperitoneal, and epididymal), intestinal permeability, TLR-4, tumor necrosis factor-α, interleukin-6, lipopolysaccharide, and serum lipid levels followed by histopathological analysis of liver and adipose tissues. Embelin significantly decreased the body weight, BMI, serum lipid levels, ME, and inflammation manifested by above parameters. Further, results of histopathological study showed that embelin restored the vacuolization, inflammation, one side shifting of nucleus in liver tissue, and decreased adipocyte cells size in adipose tissue in HFD-fed mice. Thus, our findings provide the strong evidence first time that embelin could modulate ME, mediate inflammation, and consequently reduce body weight gain, BMI, and serum lipid levels in HFD-fed mice.

Using SLIM-Based IMS-IMS Together with Cryogenic Infrared Spectroscopy for Glycan Analysis

The isomeric heterogeneity of glycans poses a great challenge for their analysis. While combining ion mobility spectrometry (IMS) with tandem mass spectrometry is a powerful means for identifying and characterizing glycans, it has difficulty distinguishing the subtlest differences between isomers. Cryogenic infrared spectroscopy provides an additional dimension for glycan identification that is extremely sensitive to their structure. Our approach to glycan analysis combines ultrahigh-resolution IMS-IMS using structures for lossless ion manipulation (SLIM) with cryogenic infrared spectroscopy. We present here the design of a SLIM board containing a series of on-board traps in which we perform collision-induced dissociation (CID) at pressures in the millibar range. We characterize the on-board CID process by comparing the fragments generated from a pentapeptide to those obtained on a commercial tandem mass spectrometer. We then apply our new technique to study the mobility and vibrational spectra of CID fragments from two human milk oligosaccharides. Comparison of both the fragment drift times and IR spectra with those of suitable reference compounds allows us to identify their specific isomeric form, including the anomericity of the glycosidic linkage, demonstrating the power of this tool for glycan analysis.

Isolation of lupenone (18-Lupen-3-one) from Roscoea purpurea root extract

Background: Endangered plant “Kakoli” is important component of Ashtwarga group of plants and anti-aging Ayurvedic preparations. Due to limited supply of original plant, official substitutes and common adulterants are being used by drug manufacturers. There is a need to identify a marker compound that could differentiate original plant from substitutes and common adulterants. Objective: To isolate and characterize the marker compound from roots of this plant. Material and methods: The extract of plant root was prepared in methanol and marker compound was isolated from methanol extract through column chromatography by using silica gel (60–120 mesh size) in glass column (1000mm x 50mm). The compound was obtained in fractions numbered 990-1550 and isolated by cutting and pooling of TLC plate of compound having Rf = 0.52 by the use of mobile phase toluene: ethyl acetate: formic acid (9.5: 0.5: 0.1 v/v/v). Compound was characterized by using IR, NMR, Mass and UV spectroscopy. Results: The methanol extract was blackish brown in color and showed the presence of alkaloids, terpenoids, phytosterols, flavonoids, phenolics and amino acid. The isolated compound was found to be colorless terpenoid needle with m.p. 168-171°C; [α]D +62.8° (c 1.0,CHCl3). Spectral analysis confirmed presence of lupenone. Conclusion: In present study lupenone was isolated for the first time from Kakoli. None of adulterants and substitutes of Kakoli are reported to have lupenone hence can be used as marker for identification as well as differentiation of the plant from official substitutes and common adulterants. Bangladesh Journal of Medical Science Vol.19(4) 2020 p.692-696

Was Hawan Designed to Fight Anxiety-Scientific Evidences?

Anxiety is a psychiatric disorder with unknown neurobiology; however, neurotransmitters like gamma-amino butyric acid, norepinephrine and serotonin (5-HT) play crucial roles in mediating anxiety. Present drug modules pose dependence risk to the patient; hence, there is a great need to develop complementary therapies to fight this disorder. Aromatherapy has also been employed in ancient times for a number of mental disorders. Mahamrituanjay Mantra, Om triambkum yajamahe, sughandhim puushtivardhanam, urvarukmev vandhanaat, mrityu mokshay mamritaat!!!!, the part of veda enlightens that aroma gives rise to good health (sughandhim puushtivardhanam). Hawan is a religious practice recommended for mental peace. Hawan is a process in which special herbs are offered in the fire of medicinal woods ignited in a specially designed fire pit. Analysis of literature demonstrates that the components of Hawan are having a number of volatile oils that are specifically useful for prevention and treatment of anxiety through some mechanism of action. Due to high temperature of fire, the vapors of these oils from herbs enter into the central nervous system through nasal route. As per modern science and ancient texts on medicine, nasal drug delivery systems are the best for the diseases related to brain and head. The routine of performing Hawan might keep the threshold value of the therapeutic components in the body and help in preventing anxiety. In the present manuscript, authors highlight and integrate the modern and ancient concepts for treatment and prevention of anxiety through scientific evidences.

Analyzing glycans cleaved from a biotherapeutic protein using ultrahigh-resolution ion mobility spectrometry together with cryogenic ion spectroscopy

A new approach for analysis of cleaved glycans.

Elemental impurities in pharmaceutical products adding fuel to the fire

The pharmaceuticals may generate impurities at various stages of development, transportation and storage which make them risky to be administered. Thus, it is essential that these impurities must be detected and quantified. However, their presence as impurities in finished products is virtually unavoidable, even under GMP conditions. Control of elemental impurities in pharmaceutical materials is currently undergoing a transition from control based on concentrations in components of drug products to control based on permitted daily exposures in drug products. Within the pharmaceutical community, there is uncertainty regarding the impact of these changes on manufactures of drug products. This uncertainty is fueled due to lack of publicly available information on elemental impurity levels in common pharmaceutical excipients. The present compilation gives an account of updated information about elemental impurities and reviews the regulatory aspects for such impurities in active pharmaceutical ingredients/drug formulations. In addition, the aim of this article is to review and discuss the currently used quantitative analytical method, which is used for quality control of elemental impurities in pharmaceutical products.

Recycling waste thermoplastic for energy efficient construction materials: An experimental investigation

A large stream of research has studied the performance of waste plastics impregnated concrete, reporting multiple benefits and advocating its use in construction works. But no study has reported the merits of bricks impregnated with waste plastics. The present paper reports the results of experiments done on bricks made up of varying percentages of waste thermoplastics (0 - 10% by weight) and sand (60 - 70% by weight), holding percentages of fly ash and ordinary Portland cement constant at 15% (by weight) each. Three types of waste thermoplastics were used, forming three separate batches of bricks. The plastics were polycarbonates, polystyrenes, and mixed plastics. The bricks were cured under water for 28 days. Some of the batches were baked at temperatures ranging from 90 °C to 110 °C for 2 hours in order to melt the plastics to form voids. The bricks made with the above-stated compositions were found to possess low thermal conductivity and adequately high compressive strength. The compressive strength of these bricks is observed to be more than 17 MPa, which lies within the upper half of the range of strengths specified for bricks in the IS 1077:1992 standard. The waste plastics impregnated bricks display high thermal resistance, a feature that can add economic value to the brick manufacturers, motivating them to establish the necessary logistics for collection and use of all types of waste thermoplastics. The paper also presents a regression model to predict the compressive strength of bricks at varying plastic contents. The study, thus, introduces a new strand of research on sustainable recycling of waste thermoplastics in the context of the circular economy.

Assessment of compliance level of ICH guidelines for organic volatile impurities in common ayurvedic hepatic formulations

Background Herbal medicines have been used in the treatment of liver diseases for a long time. In recent years, the use of herbal medicines for protection from other strong antibiotics as well as drugs that can damage the liver during their metabolism in liver and for treatment of liver diseases has increased all over the world. It is important to mention that a number of organic solvents are used at different stages of extraction/formulation development for these traditional preparations in industries/pharmacies. In addition, some of these solvents possess established carcinogenic properties and may enter the formulation as residual solvents. Hence as per ICH guidelines it is mandatory to keep the level of these solvents up to permissible limits. There has been a lot of hue and cry that ayurvedic formulations available in the market are not properly standardized for their quality due to lack of stringent regulations and standards from regulatory authorities. Therefore the aim of present work was to assess the compliance of ICH guidelines for level of organic volatile impurities in common marketed ayurvedic hepatic formulations. Methods In this study, 25 ayurvedic herbal formulations available as OTC product have been assessed for presence of residual solvents using gas chromatography with flame ionization detector. Results This study on 25 fast moving hepatic formulations in the market reflects that no residual solvents were detected in any of the formulations however if present were within prescribed permissible limits of ICH guidelines. The data was also subjected to statistical analysis (F-test and t-test at 95% confidence level). Conclusions Results indicate the safety of these hepatic formulations with respect to residual solvents. In addition presents a simple, linear, specific, accurate, precise and rugged gas chromatographic method for estimation of residual solvents.

Health care seeking behavior of parents of under five in District Kanga, Himachal Pradesh

Background: Health seeking behavior denotes the process involved in seeking a particular health state. Whereas, the healthcare seeking behavior of any individual denotes the end point contact of care. The objectives of the study were to understand the health seeking behavior and health care seeking behavior of parents of children, 0-5 yrs of age in Himachal Pradesh.Methods: A community based cross- sectional study on 2400 children of age less then and equal to 59 months was conducted. Morbidity profile and socio demographic indicators along with other variables were defined as indicators of health and health care seeking behaviour. The study was conducted using 30 cluster techniques with 80 participants from each cluster of district Kangra. Results: Water and sanitation was taken as one of the indicators of health seeking behavior and majority of our study population was dependent on ‘bavdi’ as water source. Earthen and steel pots were the most sought after storage vessel. In slums however plastic buckets were used. More than 80% of the households did nothing for purification. Majority responded that (82.6%) their child took bath daily. Institutional delivery was prevalent among 81.2% cases and lowest among rural slum. Nutrition was also taken as an indicator. Exclusive breast feeding was prevalent in 51.1% cases. In case of health care seeking behavior in our study around 47.0% parents visited the health facility, but also 24.0% were dependent on home remedies. Majority (30.5%), took treatment from secondary level of health care followed by 28.4% from private Ayurvedic Doctor. Conclusions: The system needs to understand its weaknesses as to why the population still practices unsatisfactory behavior across various areas. Especially in case of institutional deliveries, breast feeding and seeking treatment from a quack. 

Current Updates on Role of Lipids in Hematopoiesis

Hematopoiesis is the process which generates all the mature blood cells from the rare pool of Hematopoietic stem cells (HSCs). Asymmetric cell division of HSCs provide it dual capacity for self-renewal and multi-potent differentiation. Hematopoiesis is a steady state process in which mature blood cells are produced at the same rate at which they are lost, establishing a homeostasis. HSCs are regulated through their environmental niche, cytokine signalling, and the orchestrated activities of various transcription factors. However, there is very little information available about the signal transduction events that regulate HSC function; in particular, the effects of bioactive lipids and lipid mediators are not well understood. Recent studies have added an important aspect of this process, introducing the role of lipids in cell fate decisions during hematopoiesis. The mechanisms of bioactive lipids and their derivatives have been studied extensively in signal transduction and various other cellular processes. This review focuses on various categories of lipids and their regulatory mechanisms in HSCs and their comment into different blood cells. Moreover, we also discuss the role of lipid signalling specifically in megakaryocyte and platelets.

Development and validation of a stability-indicating RP-HPLC method for simultaneous determination of dapagliflozin and saxagliptin in fixed-dose combination

A simple and precise stability indicating method for the simultaneous estimation of dapagliflozin and saxagliptin in combined tablet dosage form was developed and validated using RP-HPLC.

Hypopituitarism presenting as congestive heart failure

Sheehan's syndrome (SS) develops as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage and is characterized by various degrees of hypopituitarism. Although the occurrence of SS is now rare, it should still be considered in any woman with a history of peripartum hemorrhage who develops manifestations of pituitary hormone deficiency any time following the event. Appropriate hormone replacement therapy results in marked clinical improvement. We present an unusual case of SS in a young lady who continued to have normal menstruation after the index event, had two spontaneous pregnancies, and was diagnosed only 11 years later when she presented to us with acute heart failure.