Low-Dose Paclitaxel-Coated Balloon Angioplasty versus Uncoated Percutaneous Transluminal Balloon Angioplasty for Femoropopliteal Peripheral Artery Disease: 6-Month Results in a Tertiary Care Hospital of Central India

Introduction Superficial femoral and popliteal arteries are the most common locations of peripheral vascular disease (PVD). Endovascular interventional therapy including drug-coated balloon (DEB) angioplasty or percutaneous transluminal angioplasty (PTA) and stenting are important options for treatment of PVD.

Aims and Objectives The main objective is to compare the efficacy of DEB over PTA with optional stenting in management of obstructive femoropopliteal lesions in terms of 6-month patency rate.

Materials and Methods The clinical experimental study was carried out in a tertiary care center over duration of 2 years. All symptomatic patients having lower limb PVD in femoropopliteal segment were included. Total 37 patients were included in this study in which 16 underwent plain balloon angioplasty (with 3 patients undergoing bare metal stenting [BMS]) and 21 additional underwent DEB angioplasty. Patients with previously intervened lesions, primary lesion failure, major ischemic tissue loss, poor aortoiliac or common femoral inflow, or end-stage kidney disorders were excluded.

Result At 1-month follow-up, patency rates in DEB and conventional PTA ± BMS were 85.71% and 87.5%, respectively. On 6-month follow-up, patency rates were found to be 71.4% versus 37.5%, respectively (p = 0.039; significant). In case of occluded lesions, on 6-month follow-up, patency rate in DEB group was higher than that in plain balloon group (66.7% vs. 25%). In both the cohorts, success rate, i.e., patency rates were more in short and intermediate length lesions than long segment lesions. DEB was found to be superior to plain angioplasty with optional stenting in terms of 6-month patency rate.

Ophthalmological manifestation in patients of tuberculous meningitis

BACKGROUND

Vision impairment, blindness in particular is a devastating complication in patients with tuberculous meningitis. However, information regarding ophthalmological manifestation and its impact on vision is sparse in the literature. This study evaluated the spectrum of ophthalmological manifestations in tuberculous meningitis, including retinal nerve fiber layer thickness assessment by optic coherence tomography and its correlation with visual and clinical outcome.

METHODS

This was a prospective observational study done from October 2015 to March 2017. Consecutive patients of tuberculous meningitis, diagnosed as per consensus case definition were included in the study. The patients were divided into two categories: uncomplicated and complicated tuberculous meningitis. Clinical evaluation, cerebrospinal fluid examination and contrast enhanced MRI of brain was done. Detailed ophthalmological evaluation including optic coherence tomography was done in all patients. All the patients were followed for 6 months. The primary outcome was blindness or low vision after 6 months. The secondary outcome was death or severe disability after 6 months. It was defined as modified Barthel index (MBI) ≤ 12 at 6 months (including disability plus death). Appropriate statistical analysis was done.

RESULTS

Out of 101 patients of tuberculous meningitis, 47 patients of TBM belonged to uncomplicated category, while 54 patients were of complicated group. The visual impairment was present in 24 out of 101 (23.76%) patients out of which 20 (19.8%) patients had low vision while 4 (3.96%) had blindness. The visual impairment was more evident in complicated group, low vision 0.03 (1.2-31.5). The most common abnormality on fundus examination was papilledema (22.8%). The complicated group had more incidence <0.0001 (19.6-48). Optic atrophy was found in three patients while choroid tubercles were found in eight patients (all complicated TBM group). RNFL thinning was noted in 10 patients in both the eyes. On univariate analysis, presence of diplopia at baseline, impairment of color vision at baseline, visual impairment at baseline, cranial nerve VIth involvement, optic atrophy and papilledema at baseline, RNFL thinning, abnormal VEP and baseline MBI were associated with poor visual outcome. On multivariate analysis, none of the factors were found to be independently associated with poor visual outcome. On univariate analysis, many factors including baseline MRC staging, altered sensorium, seizure, hemiparesis, basal exudates, infarcts, optochiasmaticarachnoiditis, visual impairment at baseline were found to be associated with poor clinical outcome at 6 months. On multivariate analysis, presence of seizure (P = 0.047, odds ratio = 78.59, 95% confidence interval (1.07-578.72)) was the only factor found to be independently associated with poor outcome.

CONCLUSION

Wide spectrum of ophthalmological manifestation was observed in patients of tuberculous meningitis. The visual impairment was more evident in complicated tuberculous meningitis. Ophthalmological findings like optic atrophy, papilledema and RNFL thinning were associated with poor visual outcome on univariate but not multivariate analysis. Visual impairment at baseline, among other factors was associated with poor clinical outcome on univariate analysis, whereas seizure was the only factor independently associated with poor outcome on multivariate analysis.

Meditation enhances brain oxygenation, upregulates BDNF and improves quality of life in patients with primary open angle glaucoma: A randomized controlled trial

BACKGROUND

Glaucoma (POAG) is a kind of neurodegenerative disease known to be closely associated with stress and adverse quality of life (QOL). Stress has also been shown to be involved in etiopathogenesis of primary open angle glaucoma (POAG). Complementary treatment in form of Meditation has been reported to improve QOL, brain oxygenation and decrease markers of stress. With this premise, a randomized controlled trial was carried out to assess the effect of Meditation on intraocular pressure, subjective QOL and objective markers of stress and brain oxygenation in patients with POAG.

METHODS

Sixty patients were randomized into intervention and control groups. Intervention group underwent 45 minutes of Meditation daily for 6 weeks in addition to standard medical treatment while controls received only standard medical treatment. Inclusion criteria were patients with POAG, age >45 years, best corrected visual acuity >6/60. Patients with other ocular co-morbid conditions contributing to vision loss, systemic diseases, patients already practicing meditation in any form were excluded. An assessment of IOP, brain oxygenation using functional near infrared spectroscopy (fNIRS), QOL (WHO-BREF QOL) and stress markers in serum (cortisol, β-endorphins, interleukin-6, brain derived neurotrophic factor (BDNF), reactive oxygen species) was made at baseline and at 6 weeks.

RESULTS

21 female and 39 male patients were enrolled with a mean age of 57.28±9.37 years. All parameters were comparable between two groups at baseline. At 6 weeks mean level of IOP decreased significantly in intervention group (15.9±1.8 mmHg to 14.4±1.21 mm Hg, p-value 0.0001) as compared to control group (15.7±1.4 mmHg to 15.65±1.41, p-value 0.41). fNIRS showed significant improvement in oxygenated hemoglobin change (ΔHbO) in intervention group in the prefrontal cortex (p-value <  0.0001) as compared to control group (p-value 0.52). WHO-BREF QOL score increased significantly in intervention group (86.6±6.16 to 93.3±5.66, p-value 0.0001) as compared to control (89±7.25 to 89.07±3.24, p-value 0.74).Mean serum cortisol decreased significantly in intervention group (497±46.37 ng/ml to 447±53.78 ng/ml, p-value 0.01) as compared to control group (519.75±24.5 to 522.58±26.63 ng/ml, p-value 0.64). Mean β-endorphin levels increased significantly (33±5.52pg/ml to 43.27pg/ml, p-value <  0.0001) as compared to control group (34.78±4.1pg/ml to 36.33pg±4.07pg/ml p-value 0.27). Interleukin-6 decreased significantly in intervention group (2.2±0.5 ng/ml to 1.35±0.32 ng/ml, p-value <  0.0001) as compared to control group (2.03±0.37 to 2.17±0.34 ng/ml p-value 0.25). BDNF increased significantly in intervention group (52.24±6.71 to 63.25±13.48 ng/ml p-value 0.004) as compared to control group (53.23±5.82 to 54.42±5.66 ng/ml p-value 0.54). ROS decreased significantly in intervention group (1596.19±179.14 to 1261±244.31 RLU/min/104 neutrophils p-value 0.0001) as compared to control group (1577.5±172.02 to 1662.5±84.75 RLU/min/104 neutrophils p-value 0.16).

CONCLUSIONS

A short term course of Meditation was associated with significant improvement in brain oxygenation and QOL along with a reduction in IOP and stress markers. Meditation may be a useful as an adjunct to standard treatment in patients with POAG and potentially decrease the risk of glaucoma progression.

Safety and efficacy of adjunctive transcranial direct current stimulation in treatment-resistant obsessive-compulsive disorder: An open-label trial

INTRODUCTION

The current pharmacological and psychotherapeutic approaches have limited benefit in symptom management of obsessive-compulsive disorder (OCD) urging clinicians and researchers to seek newer avenues of management. Transcranial direct current stimulation (tDCS) has shown promise in this aspect from a neuromodulatory perspective. The current study aims to study the response to tDCS as an adjunctive treatment in patients with treatment-resistant OCD.

MATERIALS AND METHODS

This open-label study was conducted among 20 patients with treatment-resistant OCD. All participants received 20 sessions of tDCS with the cathode at the supplementary motor area (SMA) and the anode at right occipital area. The primary outcome measure was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the secondary outcome was evaluated on the clinical global impression (CGI) and side effect checklist for tDCS.

RESULTS

There was a significant improvement from baseline in the mean scores of Y-BOCS and CGI scales after tDCS intervention. An improvement of >35% Y-BOCS score change was observed in 15% of participants. Short-lasting side effects were reported as mild headache and localized tingling sensation.

CONCLUSION

Cathodal tDCS at SMA may be a useful approach to manage treatment-resistant OCD. The use of tDCS was not associated with any significant harmful consequence to the participants.

Effectiveness of tDCS augmentation for co-morbid obsessive compulsive disorder in chronic schizophrenia: A case report

Management of obsessive compulsive disorder (OCD) remains a challenge, particularly in individuals having co-existing psychotic symptoms. Even in patients with schizophrenia having a fair to good response in psychotic symptoms, these obsessive-compulsive symptoms defy response to antipsychotic and anti-obsessive pharmaco-therapeutic approach to a great extent. Recently developed neuromodulation techniques such as transcranial direct current stimulation (tDCS) can serve a viable and effective approach to manage such cases. The present paper documents the first utilization of tDCS (cathode: supplementary motor area; anode: right occipital cortex) as an add-on approach to pharmacotherapy to manage co-morbid OCD in a case of chronic schizophrenia.

Psychological health of caregivers of individuals with type 2 diabetes mellitus: A cross-sectional comparative study

Introduction: The quality-of-life in individuals with diabetes is also dependent upon the quality of family relationships and general well-being of caregivers because the patient depends on them to uphold in the community. Only limited studies have assessed the psychological health of caregivers to individuals with diabetes. Aims and Objective: The current study aims at comparison of depression and anxiety levels among patients with diabetes and their caregivers. Materials and Methods: Fifty consecutive patients-care giver dyads of subjects having type 2 diabetes were recruited at an out-patient clinic of medicine at a tertiary care center. The dyads were assessed using a semi-structured proforma for the socio-demographic details and for anxiety and depression levels using the Hospital Anxiety and Depression Scale (HADS). The data were analyzed using SPSS version 17.0. Correlation analysis was performed for multiple variables including blood glucose profile. Results: The mean duration of illness (4.93 ΁ 3.53 years) and blood glucose parameters were not found to be associated to depressive or anxiety symptoms. Depressive and anxiety disorder was observed in 24% and 44% of patients and 10% and 18% of caregivers, respectively. Patients had significantly more HADS anxiety (HADS-A) scale scores than caregivers but not for HADS depression (HADS-D) scale. Female patients were found to be having more HADS-D scores than male patients (P = 0.02), but were not significantly different from caregivers. HADS-A scores were comparable among male and female gender in intragroup as well as intergroup comparison for patient and caregiver groups. Conclusion: Diabetes mellitus affects the psychological health of not only the patients but as well as the family caregivers and patients tend to be more anxious than the caregivers. Furthermore, it was seen that women with diabetes had higher rates of depression than their male counterparts.

Gardener-associated fibroma: an unusual cause of upper airway obstruction

We present the first case of upper airway obstruction secondary to a retropharyngeal Gardner-associated fibroma (GAF). A 16-month-old infant presented with a 3-month history of worsening dyspnoea and apnoeic episodes. Examination revealed stridor and left-sided retropharyngeal asymmetry. MRI demonstrated a mass in the retropharynx. Tracheostomy and pharyngeal biopsy under anaesthesia were performed, and histology confirmed a diagnosis of GAF. The mass was excised using a transcervical approach, and postoperative recovery was unremarkable. GAF is associated with Gardner's syndrome (GS) and familial adenomatous polyposis (FAP), both of which are associated with multiple colonic polyps and increased risk of colorectal malignancy. Subsequent testing for an APC mutation seen in GS and FAP was negative in our patient. The details of this unusual presentation of a rare disease are given in addition to a review of the literature.

Is India ready for mental health apps (MHApps)? A quantitative-qualitative exploration of caregivers' perspective on smartphone-based solutions for managing severe mental illnesses in low resource settings

Background

Mobile application based delivery of psycho-social interventions may help reduce the treatment gap for severe mental illnesses (SMIs) and decrease the burden on caregivers. Apps developed in high income settings show effectiveness, but they suffer from lack of applicability in low resource scenarios due to the difference in technology penetration, affordability, and acceptance.

Objective

This study aimed to understand health technology usage, perceived needs, and acceptability of app based interventions in patients with SMIs to improve illness management and reduce caregiver burden.

Methods

The study was conducted in inpatient and outpatient settings of a tertiary care center in North India. A cross-sectional survey assessed smartphone and health app usage. Further, three focus group discussions evaluated the needs and apprehensions in using apps in management of SMIs.

Results

A total of 176 participants including 88 patients and 88 caregivers completed the survey. Smartphone ownership was similar to the national average (30%) in both caregivers (38.6%) and in patients (31.8%). Although subjects regularly used a third party app, health app usage was very low. Cost, unfamiliarity, and language were significant barriers to adoption. The focus group discussions provided insight into the various apprehensions of caregivers in using and in allowing patients to use smartphones and such apps. Caregivers wanted mobile apps for accessing information regarding services and resources available for people with SMI, and they felt such apps can be helpful if they could automate some of their routine caregiving activities. However, the significant difficulty was perceived in regards to the cost of the device, language of the medium, and unfamiliarity in using technology. Apprehensions that SMI patients might misuse technology, or damage the device were also prevalent.

Conclusions

The study systematically looks into the scope, design considerations and limitations of implementing a mobile technology based intervention for low resource settings. With only one-third of the patients and caregivers having access to smartphones and internet, parallel outreach strategies like IVRS should be actively considered while designing interventions. The difficulty of understanding and searching in a non-native language needs to be addressed. Hand holding of caregivers and frequent encouragement from treating doctors might significantly help in technology adoption and in surmounting the apprehensions related to using technology. To make the solution acceptable and useful to the already over-burdened caregivers, developers need to work closely with patients’ family members and follow a ground-up collaborative approach to app development. The scope of delivering mental health services through technology is immense in resource constrained settings like India, provided we, researchers, appreciate and accept the fact that in the varied landscape of a divergent economic, educational, and cultural milieu, a single solution will never suffice for all, and intervention modality matching with end user capacity will be of paramount importance in determining the success of the endeavor.

Low-frequency Repetitive Transcranial Magnetic Stimulation for Treatment of Tourette Syndrome: A Naturalistic Study with 3 Months of Follow-up

The objective of this study is to report the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) in three patients with medication-refractory Tourette syndrome (TS) and over 3-month follow-up. A review of literature on the use of rTMS for the treatment of TS is also presented. Three patients with severe, medication-refractory TS and comorbid obsessive-compulsive disorder (OCD) in two of them, received an open-label trial of rTMS at 1 Hz frequency for 4-week duration. The first two cases of TS-OCD showed, on average, around 57% improvement in Yale Global Tic Severity Scale (YGTSS) scores (65% and 50%) and 45% improvement in Yale-Brown Obsessive-compulsive Scale (Y-BOCS) scores; however, the third case of pure-TS showed marginal improvement of 10% only. The improvement in TS-OCD patients with rTMS treatment was maintained at the end of 3-month follow-up, with an average reduction of about 49% (58% and 40%) and 36% observed in YGTSS and Y-BOCS scores, respectively. The present study supports the use of low-frequency rTMS to improve tics and OCD symptoms in patients with severe, medication-refractory TS-OCD. Further, the beneficial effects of rTMS treatment were maintained substantially over 3-month follow-up period.

Effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) in patients with comorbid panic disorder and major depression

OBJECTIVE

To explore the role of dorsolateral prefrontal cortex (DLPFC) stimulation in the treatment of panic disorder with comorbid depression.

METHODS

The present study reports findings from retrospective analysis of 13 treatment-resistant patients diagnosed with comorbid panic disorder and depression, given 20 sessions of high-frequency transcranial magnetic stimulation (rTMS) over left-DLPFC over a period of 1 month.

RESULTS

There was a significant reduction in both the panic and depressive symptom severity, assessed by applying Panic Disorder Severity Scale (PDSS) and Hamilton Depression Rating Scale (HDRS) at baseline and after 20 sessions of rTMS. There was a 38% and 40% reduction of PDSS and HDRS scores, respectively, in the sample. The changes in PDSS and HDRS scores were not significantly correlated (ρ = -0.103, p = 0.737).

CONCLUSIONS

High-frequency rTMS delivered at left-DLPFC may have a potential role in treatment of comorbid panic disorder and depression. Future studies done on a larger sample in a controlled environment are required to establish its role.

Effectiveness of adjunctive repetitive transcranial magnetic stimulation in management of treatment-resistant depression: A retrospective analysis

BACKGROUND

There is limited number of studies from India investigating role of repetitive transcranial magnetic stimulation (rTMS) in treatment-resistant depression (TRD). This clinic-based study reports on the efficacy of rTMS as an add-on treatment in patients suffering from TRD.

MATERIALS AND METHODS

Twenty-two right-handed patients suffering from major depressive disorder who failed to respond to adequate trials of at least two antidepressants drugs in the current episode received rTMS as an augmenting treatment. High-frequency (Hf) rTMS at 110% of the estimated resting motor threshold (MT) was given over the left dorsolateral prefrontal cortex (DLPFC). A total of 15 sessions were given over 3 weeks with 3000 pulses per session. The outcome was assessed based on the changes in scores of Hamilton Rating Scale for Depression or Montgomery-Asberg Depression Rating Scale.

RESULTS

There was a significant reduction in final assessment scores after rTMS intervention as compared to baseline with almost 50% of the participants showing response in either scale.

CONCLUSION

Hf rTMS applied over left DLPFC is an effective add-on treatment strategy in patients with TRD.

Straight-to-test faecal tagging CT colonography for exclusion of colon cancer in symptomatic patients under the English 2-week-wait cancer investigation pathway: a service review

AIM

To present the initial 12 months of data of a straight-to-test (STT) computed tomography colonography (CTC) protocol as the first-line investigation for change in bowel habit (CIBH) and iron deficiency anaemia (IDA) in patients over 60 referred directly from primary care.

MATERIALS AND METHODS

In 12 months, 1,792 STT CTC for IDA and CIBH were performed. No colonoscopies were performed as the primary investigation in this cohort. Data from this cohort were gathered prospectively.

RESULTS

The colorectal cancer (CRC) detection rate was 4.9% and polyp detection rate was 13.5%. The CRC rate increased related to age (p=0.001), the CRC detection rate was 2.6% in patients aged 60-69 years, compared to 4.9%, 7.4%, and 11.4% in the 70-79, 80-89, and >90 years age groups. The CRC rate was higher in patients with IDA compared to CIBH (6.8% versus 3.9%, p=0.017). There were significantly more left-sided cancers (p=0.0165). Non-colonic cancers were found in 4.3% of patients and 6.8% had incidental findings that required further investigation and 11.9% had a new, potentially significant, incidental finding.

CONCLUSION

These results are comparable to colonoscopy in terms of diagnostic accuracy and similar to those of CTC in published multicentre trials. This exciting model of care within radiology enables earlier testing, reduces waiting times, with fewer outpatient appointments, and results in good clinician and patient satisfaction.

Utility of Oxford Classification in Post-Transplant Immunoglobulin A Nephropathy

BACKGROUND

With increasing graft survival, post-transplant immunoglobulin A nephropathy (IgAN) has emerged as an important cause of chronic graft dysfunction in renal allograft recipients. We studied the clinico-pathological features of post-transplant IgAN regardless of the primary disease. The aim was to study the usefulness of the Oxford classification in predicting survival.

METHODS

Indication graft biopsy specimens (n = 915) were received during a 10-year period; 27 biopsy specimens from 22 patients were diagnosed as IgAN.

RESULTS

Post-transplant IgAN was seen in 2.6% of biopsy specimens. Mean time to occurrence was 71.6 ± 47.6 months (range, 6.8 months to 16 years), occurring most commonly 4 to 8 years after transplant. Associated rejection was present in 4 biopsies; 72.7% (16/22), 91% (20/22), and 31.8% (7/22) presented with rise in serum creatinine, proteinuria, and hematuria, respectively. Four (21%) patients had nephrotic range proteinuria. Mesangial hypercelullarity (M1), endocapillary hypercelullarity (E1), segmental glomerulosclerosis (S1), and tubulo-interstitial fibrosis (T1-2) was present in 36.6%, 22.7%, 54.5%, and 31.8% biopsies, respectively. The most frequent Haas class was III (n = 7; 29.1%), followed by classes IV and I (n = 5; 20.8% each). The 2- and 5-year graft survival rates were 75% and 56%, respectively. High serum creatinine, low estimated glomerular filtration rate, E1 and T lesions, and degree of interstitial inflammation predicted graft survival. Interestingly, percentage (>25%) of segmentally sclerosed glomeruli and not S1 correlated with graft outcome.

CONCLUSIONS

The Oxford MEST scheme is useful in predicting graft survival in post-transplant IgAN. The degree of interstitial inflammation is also an important feature for determining graft outcomes in post-transplant IgAN.

The Effects of Repetitive Transcranial Magnetic Stimulation at Dorsolateral Prefrontal Cortex in the Treatment of Migraine Comorbid with Depression: A Retrospective Open Study

Objective

The literature on managing migraine non-responsive to pharmacological approaches and that co-occurring with depression is scanty. The comorbid condition predicts a poorer prognosis for migraine as well as depression. The present report assesses efficacy and tolerability of high frequency repetitive transcranial magnetic stimulation (rTMS) over left dorsolateral prefrontal cortex as a treatment modality for migraine with comorbid depression.

Methods

The current retrospective chart review assesses effectiveness of high frequency rTMS over left dorsolateral prefrontal cortex as a treatment modality to manage migraine occurring comorbid with depression in 14 subjects.

Results

The mean scores on Migraine Disability Assessment Test (MIDAS) and depression rating scale reduced significantly from 21.14±3.01 and 20.71±3.95 at baseline to 13.93±6.09 and 14.21±5.52 respectively, after rTMS. There was significant improvement in migraine frequency, severity and functional disability assessed using MIDAS scores (p＜0.05) following high frequency rTMS compared to baseline.

Conclusion

There is a role of applying rTMS as a potential therapeutic modality in the integrated management of a distinct subgroup of migraine patients with comorbid depression.

Cathodal neuromodulation of dominant temporoparietal cortex with transcranial direct current stimulation for tinnitus: A case series

There is scant literature on the effectiveness of using transcranial direct current stimulation (tDCS) as an intervention modality for managing tinnitus. The current case series reflects the use of tDCS as an effective intervention for tinnitus while inhibiting the dominant temporoparietal cortex and simultaneous stimulating the non-dominant dorsolateral prefrontal cortex.