Complaints of neuropathic pain, noxious cervical plexus neuropathy and neck tightness are reported by patients who undergo neck dissection: an institutional study and narrative review

There exists a subgroup of patients who undergo neck dissection (ND) who postoperatively complain of either neuropathic pain, dysaesthesia and/or discomfort that is located within the dermatomal distribution of the cervical plexus. The purpose of our study was to determine the prevalence, characteristic, and demographics of these symptoms in our patient cohort. We undertook a retrospective randomised observational cohort study of 105 patients who had undergone ND. The primary predictor variable was the undertaking of a ND. The secondary outcome variable was the complaint of either neuropathic pain or a noxious neuropathy, at a minimum of twelve months after surgery. A recognised symptom questionnaire and a visual analogue score was employed for the purpose of the study. A descriptive and statistical analysis was applied to the assembled data. Twenty patients (19%) complained of either spontaneous (n=9) or evoked (n=11) neuropathic pain that occurred within the surgical site. In addition, 71 patients (68%) described an altered sensation in the dermatomal distribution of the great auricular or tranverse cervical nerves while 70 patients (67%) described the feeling of 'neck tightness'. There were no characteristics of the study cohort that underpinned these results. Neuropathic pain can occur following ND. This can cause distress to a small but defined group of patients. Despite its importance, we found a paucity of studies in the literature that have investigated neuropathic pain following ND. We believe this condition requires more research attention and clinical awareness.

P0835IDENTIFYING THE FREQUENCY OF CHRONIC KIDNEY DISEASE OF UNKNOWN ETIOLOGY (CKDU) IN A RURAL POPULATION OF BANGLADESH

Background and Aims

The common etiologies of CKD are diabetes, hypertension and glomerulonephritis. Prevalence of CKD of unknown (CKDu) etiology is being increasingly considered as an emerging etiology, especially in the developing countries, with environmental predisposition to hot humid climate, dehydration and toxic metal contaminations. The aim was to identify the frequency of CKDu as an etiology in a rural population with environmental exposure.

Method

In this observational study subjects were selected from a geographically defined rural population in Bangladesh. Baseline information was recorded by the translated WHO STEP wise approach surveillance- Instrument v.3.1 (Core and Expanded). Blood Pressure was measured by digital blood pressure monitor. Serum creatinine was measured by enzymatic method using assays traceable to isotope dilution mass spectrometry (IDMS). A fasting blood sample and spot urine was collected. BP ≥140/90mmHg; FBS > 5.6 mmol/l and HbA1c ≥6.5%; and eGFR< 60ml/min (CKD-EPI equation) or urine ACR > 30mg/g was taken as diagnostic cut-offs for hypertension, diabetes and nephropathy respectively. From diagnosed CKD patients CKDu group was further identified by stepwise approach of WHO criteria as suspected and probable stages.

Results

The mean age was 41.3 ± 12.7 years with male/female ratio 37/63 in preliminary 303 study subjects. They were 12.5% diabetic, 21% hypertensive and 75% had some form of dyslipidemia. Among all 51 subjects (16.8%) were diagnosed as CKD based on single measurement of eGFR and ACR. Of these 30 study subjects (58%) met the criteria of suspected CKDu. After repeat measures of eGFR and ACR at 3 months, prevalence of CKD came down to 10.2% persisting in 31 subjects (G1:5.3%, G2:2.3% and G3: 2.6%). Of these 7 study subjects (23%) met the criteria of probable CKDu. The main etiologies of CKD among these subjects were diabetic nephropathy (48%) followed by CKDu. The frequency of CKDu in total study population as a whole was 2.3%.The pattern of environmental exposures like types of farming, use of pesticide-fertilizer, NSAIDs intakes, water sources, amount of drinking water per day, duration of work under direct sun, pattern of fish-meat intakes, etc. were not different between subjects with CKDu versus the others.

Conclusion

The prevalence of chronic kidney disease in a rural area of Bangladesh is one in ten (10.2%). Among these nearly one-fourth (23%) of the subjects belonged to probable CKDu category. This alarmingly high frequency of CKDu needs further extensive evaluation to identify the predisposing factors responsible.

Effect of vitamin D on bone strength in older African Americans: a randomized controlled trial

There is controversy over whether African Americans have higher vitamin D requirements than recommended by the Institute of Medicine. We previously reported that maintaining serum 25(OH)D above 30 ng/mL does not prevent age-related bone loss. Herein, we report that bone strength is also unaffected by maintaining this level in this population.

INTRODUCTION

The role of vitamin D in bone strength has not been investigated in the African American (AA) population.

METHODS

A 3-year randomized controlled trial was designed to examine the effect of vitamin D supplementation on physical performance, bone loss, and bone strength in healthy older AA women. A total of 260 postmenopausal AA women, ages ≥ 60 years were randomized to a vitamin D₃ or placebo arm. Vitamin D₃ dose was adjusted to maintain serum 25OHD > 30 ng/mL. Bone mineral density, femoral axis length, and femoral neck (FN) width were measured by dual-energy X-ray absorptiometry. Composite indices of FN strength [compression strength index (CSI), bending strength index (BSI), and impact strength index (ISI)] were computed.

RESULTS

The mean age of participants was 68.2 ± 4.9 years. Baseline characteristics between groups were similar. The average dose of vitamin D₃ was 3490 ± 1465 IU/day in the active group. The mean serum 25OHD was 46.8 ± 1.2 ng/mL versus 20.7 ± 1.1 ng/mL in the active versus placebo group. Serum 25OHD did not correlate with any composite indices. The longitudinal differences observed in FN width, CSI, BSI, and ISI in both groups were not statistically significant (all p values > 0.05). Further, there was no group × time interaction effect for any of the composite indices (all p values > 0.05).

CONCLUSION

Maintaining serum 25OHD > 30 ng/mL (75 nmol/L) does not affect bone strength in older AA women. There is no evidence to support vitamin D intake greater than the recommended RDA by the Institute of Medicine in this population for bone strength.

A Machine Learning Enabled Wireless Intracranial Brain Deformation Sensing System

A leading cause of traumatic brain injury (TBI) is intracranial brain deformation due to mechanical impact. This deformation is viscoelastic and differs from a traditional rigid transformation. In this paper, we describe a machine learning enabled wireless sensing system that predicts the trajectory of intracranial brain deformation. The sensing system consists of an implantable soft magnet and an external magnetic sensor array with a sensing volume of 12 × 12 × 4 mm³. Machine learning algorithm predicts the brain deformation by interpreting the magnetic sensor outputs created by the change in position of the implanted soft magnet. Three different machine learning models were trained on calibration data: (1) random forests, (2) k-nearest neighbors, and (3) a multi-layer perceptron-based neural network. These models were validated using both in vitro (a needle inserted into PVC gel) and in vivo (blast exposure to live and dead rat brains) experiments. The in vitro gel deformation predicted by these machine learning models showed excellent agreement with the camera measurements and had absolute error = 138 μm, Fréchet distance = 372 μm with normalized Procrustes disparity = 0.034. The in vivo brain deformation predicted by these models had absolute error = 50 μm, Fréchet distance = 95 μm with normalized Procrustes disparity = 0.055 for dead animal and absolute error = 125 μm, Fréchet distance = 289 μm with normalized Procrustes disparity = 0.2 for live animal respectively. These results suggest that the proposed machine learning enabled sensor system can be an effective tool for measuring in situ brain deformation.

Association of Hyperbilirubinemia Requiring Phototherapy or Exchange Transfusion with Hearing Impairment among Admitted Term and Late Preterm Newborn in a NICU

Hearing impairment is one of the deleterious ramifications of neonatal hyperbilirubinemia, but its impact during the newborn period has not been well studied in Bangladesh. This prospective observational study was conducted during January 2016 to December 2017 in the Department of Neonatology and Otolaryngology-Head and Neck Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh to identify the relationship between hyperbilirubinemia requiring phototherapy or exchange transfusion with hearing impairment in term and late preterm neonates. Admitted term and late preterm neonates with hyperbilirubinemia requiring either phototherapy or exchange transfusion were taken as hyperbilirubinemia group. Neonates without hyperbilirubinemia from postnatal ward were taken as control. All newborn were screened with Distortion Product Otoacoustic Emissions (DPOAE) prior to discharge from hospital. A second screen was done in referred newborn after one month of first screen. A diagnostic Auditory Brainstem Response (ABR) was performed in both the ears prior to 3 months of postnatal age if referred in both 1st and 2nd screen. Total 264 neonates included in this study; 132 in the hyperbilirubinemia and 132 in the control group. In the hyperbilirubinemia group 74(56.06%) were male and 58(43.94) were female. Mean gestational ages in the hyperbilirubinemia group and control group were 36.95±1.60 weeks and 37.01±1.67 weeks respectively. Newborn in the hyperbilirubinemia group, 4(3.03%) had hearing impairment and none had hearing impairment in the control group. Peak Total Serum Bilirubin (TSB) 23mg/dl was found as best cut off value with a sensitivity of 100% and specificity of 93% for the development hearing impairment. Hearing impairment was significantly more frequent among newborn with TSB level >23mg/dl when compared to those having TSB level ≤23mg/dl (20% vs. 0.9%, p=0.009; OR=29, 95% CI 2.79, 301). Hearing impairment was associated with newborns with hyperbilirubinemia requiring phototherapy or exchange transfusion. Peak TSB level >23mg/dl can be predictive for the development of hearing impairment.

Proton pump inhibitors and histamine-2 receptor antagonists on the risk of pancreatic cancer: a systematic review and meta-analysis

BACKGROUND

Proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) have been widely used for multiple purposes. Recent studies have suggested an association between these medications and the risk of pancreatic cancer. However, the results have been inconclusive.

AIM

We, therefore, conducted a study to assess the risk of developing pancreatic cancer in patients who used PPI and H2RA.

DESIGN

A systematic review and meta-analysis.

METHODS

A literature search was performed using MEDLINE and EMBASE databases from inception through February 2019. Studies that reported risk ratio comparing the risk of pancreatic cancer in patients who received PPI or H2RA versus those who did not receive treatments were included. Pooled risk ratios (RR) and 95% confidence intervals (CI) were calculated using a random-effect generic inverse variance method. Sensitivity analysis, excluding one study at a time, was performed.

RESULTS

After screening abstracts from the searching methods, seven studies (six case-control studies and one cohort study) were included in the analysis with total 546 199 participants. Compared to patients who did not take medications, the pooled RR of developing pancreatic cancer in patients receiving PPI and H2RA were 1.73 (95% CI: 1.16-2.57) and 1.26 (95% CI: 1.02-1.57), respectively. However, the sensitivity analysis of PPI changed the pooled RR to 1.87 (95% CI: 1.00-3.51) after a study was dropped out. Likewise, H2RA sensitivity analysis also resulted in non-significant pooled RR.

CONCLUSIONS

This meta-analysis did not find the strong evidence for the associations between the use of PPI and H2RA and pancreatic cancer.

Financial support to the poor for the detection of smear-negative pulmonary and extra-pulmonary TB in Bangladesh

BACKGROUND: The study was conducted in BRAC-administered areas of the Bangladesh National Tuberculosis (TB) Programme (42 of 64 districts). According to the 2013-2017 financial support scheme, direct costs due to TB diagnosis were reimbursed among economically disadvantaged people with presumptive smear-negative pulmonary (PTB) and extrapulmonary TB (EPTB).OBJECTIVE: To describe the implementation of the scheme and associated changes in case notification.DESIGN: This was a descriptive study involving programme data.RESULTS: Between 2013 and 2017, persons reimbursed reduced from 125 680 to 88 763, and the case detection ratio increased from 18% to 24%. The number of patients with presumptive EPTB who were reimbursed decreased from 5024 to 3484. More than 95% were reimbursed for chest radiograph, fine-needle aspiration cytology and biopsy. However, large numbers of ancillary investigations were also reimbursed. During 2013-2017, the observed national quarterly new smear-negative PTB case notification rates (CNRs) were significantly higher than the forecasted CNRs (based on CNR trends during 2008-2012). New EPTB and all form TB CNRs increased but not significantly.CONCLUSION: Implementation of the financial support scheme was accompanied by a significant improvement in new, smear-negative PTB notification. The absence of a comparison arm was a key limitation, but comparison was not possible as the scheme was implemented in all districts.

An Ultrasonically Powered Implantable Microprobe for Electrolytic Ablation

Electrolytic ablation (EA) is a promising nonthermal tumor ablation technique that destroys malignant cells through induction of a locoregional pH change. EA is typically performed by inserting needle electrodes inside the tumor followed by application of direct current (DC), thus inducing electrolysis and creating localized pH changes around the electrodes. In this paper, we report an ultrasonically powered implantable EA microprobe that may increase the clinical relevance of EA by allowing wireless control over device operation (capability to remotely turn the device on and off) and providing flexibility in treatment options (easier to administer fractionated doses over a longer period). The wireless EA microprobe consists of a millimeter-sized piezoelectric ultrasonic receiver, a rectifier circuit, and a pair of platinum electrodes (overall size is 9 × 3 × 2 mm³). Once implanted through a minimally invasive procedure, the microprobe can stay within a solid tumor and be repeatedly used as needed. Ultrasonic power allows for efficient power delivery to mm-scale devices implanted deep within soft tissues of the body. The microprobe is capable of producing a direct current of 90 µA at a voltage of 5 V across the electrodes under low-intensity ultrasound (~200 mW/cm²). The DC power creates acidic (pH < 2) and alkaline (pH > 12.9) regions around the anode and the cathode, respectively. The pH change, measured using tissue-mimicking agarose gel, extends to 0.8 cm³ in volume within an hour at an expansion rate of 0.5 mm³/min. The microprobe-mediated EA ablative capability is demonstrated in vitro in cancer cells and ex vivo in mouse liver.

Neuro-Imaging Changes in Cerebral Palsy: A Cross Sectional Study

Cerebral palsy (CP) is a non- progressive disorder of movement and posture due to a lesion of the developing brain. It is the commonest physical disability in childhood that affects function and development. Neuro imaging is currently recommended as a standard evaluation in children with cerebral palsy. This hospital based cross-sectional study was conducted in Paediatric Neurology out-patient department of Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from July 2015 to December 2015 to see the frequency and pattern of neuro-imaging findings in children with cerebral palsy. A total of 130 cases those who were attended and diagnosed as cerebral palsy based on history, clinical examination and neuro developmental assessment included in this study. All patients were sent to radiology & imaging department of same hospital for CT scan of brain. Among total 130 cerebral palsy patients male were more affected than female (88 boys and 42 girls) with male to female ratio 2.09: 1. Their ages ranged between 6-72 months with a mean age 25.6 months. The commonest age group was 6-24 months (46.9%). Common mode of delivery was normal vaginal delivery (62.3%) & Perinatal asphyxia (PNA) occurred in 66.9% cases. The commonest type of cerebral palsy was spastic form. Among them most cases were quadriplegic type, 64 cases (53.3%). Other cases were hemiplegic 27(20.7%) diplegic 13(10.0%). Total 84.7% had documented cerebral neuroimaging abnormalities; among them, diffuse cortical atrophy (46.9%), encephalomalacic change (19.9%), malformation (6.1%), and calcification (5.3%). CT scan was normal in 15.3% cases of cerebral palsy. The commonest co morbidity was speech delay (50%). Most of the patient with CP had abnormal CT scan finding though some patient had normal CT scan. Diffuse cerebral atrophy and encephalomalacic changes constitute frequent CT neuroimaging findings and commonly found in quadriplegic type of cerebral pulsy patients. Though diagnosis of cerebral palsy is essentially clinical, neuro imaging improves the understanding of the neuro-anatomical basis for function in CP. Etiology, type of CP and extent of motor impairments can easily be identified by the neuro imaging.

Association of Estimated GFR (By MDRD) with the Carotid Intima Media Thickness (CIMT) in Different Stages of CKD among Patients with Type 2 Diabetes Mellitus

Most of the mortalities among Diabetic Nephropathy patients are cardiovascular, if we identify the risk factor, measures can be taken to prevent it. Hence an objective was set to evaluate the association between carotid artery intima media thickness (CIMT) with eGFR in patients of CKD stage III, IV and V among patients with type 2 diabetes mellitus; also, correlation with age, BMI, lipid profile. This cross-sectional, observational study was performed in 70 patients in different stages of CKD in Diabetic Patients selected by Inclusion Criteria (Diabetic nephropathy patients with stages III, IV, V and exclusion Criteria (Acute kidney injury, History of carotid surgery, Patients of MI and stroke). This study was performed in Department of Nephrology, Dhaka Medical College in collaboration with the Department of Radiology and Imaging, laboratory of Department of Biochemistry and Department of Microbiology at Dhaka Medical College Hospital (By standard method in laboratory) from 1st January 2016 to 31st December 2016. eGFR was measured by MDRD formula and the CIMT was measured using an ultrasonographic examination. The mean CIMT was 0.9±0.21mm, and 62.9% of the subjects showed IMT thickening (≥1mm). The carotid IMT elevated significantly with the stage progression of CKD (Overall eGFR mean 28.8±14.5mL/min/1.73m² in CIMT<1mm with range from 6 to 54 and 9.1±9.0mL/min/1.73m² in CIMT ≥1mm with range from 3 to 32 (p=0.001). The eGFR was significantly lower in the patients with CIMT thickening than those without CIMT thickening. eGFR was also significantly associated with CKD stages (p=0.001), serum creatinine (p=0.001), BMI (r = -0.330, p=0.005), and negatively associated with age group, duration of hypertension, smoking. However, the CIMT was not significantly different among the patients at different stages of diabetic nephropathy (r = -0.172, p=156) and age group. It has been concluded that the mean CIMT was markedly high in patients with CKD compared to normal expected value. This study showed a relationship between the CIMT and the renal parameters as eGFR and the stages of diabetic nephropathy with a confirm association between the CIMT and diabetic macroangiopathy.

P4755Sex differences in admission rates, use of anticoagulation, and outcomes for emergency department presentations of atrial fibrillation

Background

Studies in non-Emergency Department (ED) settings have shown women with non-valvular atrial fibrillation (NVAF) differ in presentation, treatment, and outcomes compared to men. Despite AF being a common reason for ED visit, little is known regarding sex differences in patients presenting to ED.

Purpose

We sought to determine whether sex differences exist in rates of admission among NVAF patients presenting to the ED and if oral anticoagulant (OAC) use and outcomes differ by ED discharge status.

Methods

Patients≥18 years old, presenting to the ED with incident NVAF in two western Canadian provinces (Alberta and British Columbia) from April 2012 to March 2015 were included. ED records were linked to hospital records to identify patients admitted to hospital versus discharged from the ED. Outcomes of interest were 30-day mortality and 1-year stroke, heart failure (HF) and mortality. Pharmaceutical claims were queried for OAC use within 90 days following NVAF ED event.

Results

Of 16,991 ED NVAF patients, 7,770 (46%) were women and 9,221 (54%) were men (p<0.001). Compared to men, women were older (73.9 vs 65.6 years, p<0.001) and presented with higher CHA2DS2-VASc scores (4.0 vs 2.0, p<0.001). Overall, 41% of women and 37% of men were admitted to hospital (p<0.001). OAC rate was 50% among admitted and 37% among discharged (p<0.001). OAC rates were 53% in women and 48% in men among admitted (p<0.001), and 39% in women and 35% in men among discharged (p<0.001). OAC rates were higher in patients with CHA2DS2-VASc ≥1 who were admitted (53% in women (n=2,781) and 52% in men (n=2,683), p=0.63) than in those who were discharged (39% in women (n=4,435) and 45% in men (n=3,866), p<0.01). Women had higher rates of mortality at 30-days and 1-year, and stroke at 1-year compared to men, irrespective of ED discharge status (all p<0.02). Women admitted had higher HF rates at 1-year compared to men (p=0.002). (Table)

Outcomes by Sex and ED Discharge Status Outcome Discharged Admitted Women (N=4,560) Men (N=5,780) p-value Women (N=3,210) Men (N=3,441) p-value 30 Day Mortality, n (%) 63 (1.4) 50 (0.9) 0.01 261 (8.1) 228 (6.6) 0.019 1 Year Mortality, n (%) 270 (5.9) 248 (4.7) <0.001 717 (22.3) 604 (17.6) <0.001 Stroke*, rate (SE) 1.7 (0.19) 0.9 (0.13) <0.001 4.0 (0.37) 2.6 (0.28) 0.001 Heart Failure*, rate (SE) 3.6 (0.28) 3.1 (0.23) 0.16 12.9 (0.62) 10.4 (0.54) 0.002 *Censored on death.

Conclusions

In this population-based study of patients presenting to ED with NVAF, we found women were more likely to be admitted to hospital than men. Women had a worse prognosis than men, irrespective of ED discharge status. Use of OAC was suboptimal, regardless of patient sex.

Acknowledgement/Funding

Heart and Stroke Foundation of Canada, UBC Cardiology, Servier Alberta Innovation Health Fund

Implementation of screening and management of household contacts of tuberculosis cases in Daru, Papua New Guinea

SETTING

Daru Island, Western Province, Papua New Guinea (PNG).

OBJECTIVE

To describe the implementation of a screening programme for household contacts of tuberculosis (TB) cases residing on Daru Island.

DESIGN

This was a retrospective descriptive study evaluating two periods of implementation: introduction and expansion of a screening programme for household contacts of drug-resistant TB (DR-TB) cases (March 2016 to September 2017), and inclusion of drug-susceptible TB (DS-TB) cases with provision of preventive therapy for eligible contacts between October 2017 and March 2018.

RESULTS

In the first period, the contact screening programme was established and strengthened by increasing coverage over time. There was a large number of contacts (median 8) in each household, and a high uptake of screening. In the second period of evaluation, respectively 412 and 223 contacts of 42 DS-TB and 25 DR-TB index cases were screened. Overall, 156 (24.6%) contacts reported TB-related symptoms and 9 (1.4%) were diagnosed with active TB. All 9 commenced TB treatment: 5 had DS-TB and 4 had DR-TB. Of 82 child contacts of DS-TB cases eligible for preventive therapy, 57 (69.5%) commenced treatment and 45 completed treatment.

CONCLUSION

Community-based household contact screening and management was successfully implemented under programme conditions in this high burden TB and DR-TB setting in PNG.

A pilot model of patient education and counselling for drug-resistant tuberculosis in Daru, Papua New Guinea

Education and counselling for people with drug-resistant tuberculosis (DR-TB) is recommended by the World Health Organization, given the arduous treatment journey. A model of education and counselling involving counsellors and peer counsellors, standard sessions and novel education tools was piloted in the high DR-TB burden context of Daru, Papua New Guinea. The pilot contributed to high retention in care, highlighting the need for investment in scalable models. Future models will need to be adapted as better tolerated regimens are introduced. A focus on patient-centred care requires prioritisation in order to meet the End TB Strategy targets.

Does Time Since Injury and Time Spent in Physical Therapy Treatment Affect Outcomes for Concussion Patients?

Purpose

To evaluate the effects of: 1) time between injury and physical therapy treatment and 2) time spent in physical therapy, on concussion symptom resolution.

Methods

Retrospective data was obtained for 202 patients who sustained a concussion and were referred for physical therapy. Subjects were assigned to groups based on type of injury (sport-related or not), time elapsed between concussion and therapy (0-14 days, 15–30, 31–60, 61–120, 121–365), and months spent in treatment (1 thru 4). Pre- and post- treatment scores were compared for the following measures: Sport Concussion Assessment Tool (SCAT), Convergence Insufficiency Symptom Survey (CISS), Dizziness Handicap Inventory (DHI), and Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) using ANOVAs, with a Bonferroni-corrected p-value of p<.005.

Results

There was no significant difference in outcomes for athletes vs. non-athletes on SCAT Symptom (p=.74) or Severity Score (p=.18), CISS (p=.52), DHI (p=.05), or mCTSIB (p=.10); in outcomes for time elapsed since injury on SCAT Symptom Score (p=.80), SCAT Symptom Severity Score (p=.97), CISS (p=.61), DHI (p=.65), mCTSIB (p=.13); or in outcomes for months in treatment on SCAT Symptom Score (p=.23), SCAT Symptom Severity Score (p=.04), CISS (p=.41), DHI (p=.37), mCTSIB (p=.50).

Conclusion

Post-therapeutic improvements were noted for athletes receiving post-concussive physical therapy. Type of injury, time between injury and treatment, and time spent in treatment did not differentiate treatment outcomes for those receiving physical therapy post-concussion.