Optimization of eco-friendly concrete with recycled coarse aggregates and rubber particles as sustainable industrial byproducts for construction practices

In this technology era, sustainable construction practices have become quite imperative. The exploration of alternative materials to reduce the environmental footprint is of paramount importance. This research paper delves into an exhaustive investigation concerning the utilization of recycled coarse aggregates (RCA) and rubber particles (RP) in concrete. It contributes to the growing body of knowledge aimed at fostering sustainable development in the construction industry by reducing waste, promoting recycling, and mitigating the environmental footprint of building materials. The objective of the study is to evaluate the potential benefits and limitations associated with incorporating these materials, thereby providing a sustainable alternative to conventional concrete. In this research, construction and demolition waste were recycled and used as RCA as a fractional switch of natural coarse aggregate (NCA) from 0% to 100%, with an increment of 20% replacement of NCA in concrete. The RP received from discarded tires generated as automobile industry waste were used as a volumetric fractional substitution of sand in concrete from 0% to 20%, with a 5% increment. No pre-treatment for RCA and RP was carried out before their utilization in concrete. A total of 26 mixes, including control concrete without NCA and RP, with a design strength of 40 MPa, were prepared and tested. Concrete mixes were examined for workability, density, mechanical, and durability properties. It was found that the concrete with 60% RCA and 10% RP showed satisfactory results in evaluation with the strength parameters of control concrete, as the compressive strength obtained for this concrete mix is 40.18 MPa, similar to the control mix. The optimization for RCA and RP was conducted using Response Surface Methodology (RSM). The major concern observed was a rise in water absorption with an increase in the percentage replacement of NCA and natural sand by RCA and RP. Findings from the investigation illustrate a promising prospect for the use of RCA and RP in concrete applications, displaying competent mechanical properties and enhanced durability under certain conditions, offering a viable option for environmentally friendly construction practices. However, the research also sheds light on some constraints and challenges, such as the variability in the quality of RCA and the necessity for meticulous quality control to ensure the reliability and consistency of the end product. It is discerned that further refinement in processing techniques and quality assurance measures is pivotal for mainstream adoption of RCA and RP in concrete construction.

Upfront tofacitinib in patients with biological-naïve ulcerative colitis - An Indian multicentric experience

OBJECTIVES

Tofacitinib is a Janus Kinase inhibitor used for treating moderate to severe ulcerative colitis (UC), mainly after the failure of biological therapy. There is a paucity of data on the outcome of tofacitinib in biological-naïve UC patients. The present study was aimed at analyzing the safety and efficacy of tofacitinib in biological-naïve Indian patients with UC.

METHODS

The present study retrospectively evaluated consecutive patients with biological-naïve moderate-to-severe active UC from six tertiary care centers in India receiving tofacitinib from September 2020 to September 2022. Clinical remission or response assessment was based on partial Mayo score (PMS) calculated at baseline and weeks eight, 16 and 24.

RESULTS

Total 47 cases (57.4% male, median age: 32 years) were included. After eight weeks of therapy, 33 (70.2%) achieved clinical remission and eight (17.0%) had a primary failure. The baseline serum albumin at treatment initiation was the only independent predictor of remission at eight weeks (Odds ratio: 11.560, 95% CI: 1.478 - 90.404), but not at 16 weeks. By 24 weeks, 59.6% (28/47) of the patients were in remission and 29.8% (14/47) had stopped tofacitinib either due to failure (27.6%) or adverse events (AEs) (2.1%). Among the 47 patients, 10 (21.2%) cases developed AEs during follow-up, including two tuberculosis (4.2%), one cytomegalovirus (CMV) colitis (2.1%) and one herpes zoster (2.1%). Four patients with infection required temporary drug discontinuations. One required permanent discontinuation (mania).

CONCLUSION

Upfront tofacitinib is effective in biologic-naïve Indian patients with moderate-severe UC. Further randomized studies are required to validate the study findings.

Role of contrast-enhanced ultrasound for differentiation of benign vs. malignant portal vein thrombosis in hepatocellular carcinoma - A systematic review a meta-analysis

Introduction/Purpose

Patients with cirrhosis and hepatocellular carcinoma (HCC) can develop both benign and malignant portal vein thrombosis (PVT). Characterising the nature of PVT is important for planning an optimal therapeutic strategy. In the absence of typical findings or contraindications to computed tomography (CT) or magnetic resonance imaging (MRI), contrast-enhanced ultrasound (CEUS) could help in this differentiation. The present meta-analysis aimed to evaluate the performance of CEUS for characterising PVT in patients with HCC.

Methods

Electronic databases of PubMed, Embase and Scopus were searched from inception to 31 December 2022 for studies analysing the role of CEUS in the differentiation of benign and malignant PVT in HCC. Using the bivariate random effect model, pooled sensitivity and specificity were calculated, and the summary receiver operating characteristic (sROC) curve was plotted.

Results

A total of 12 studies with data from 712 patients were included in the meta-analysis. The pooled sensitivity and specificity of CEUS for the diagnosis of tumour in vein were 97.0% (95% CI: 93.0-98.7) and 96.8% (95% CI: 92.1-98.7), respectively, without significant heterogeneity. A sROC curve was plotted, and the area under the receiver operating characteristic was 0.99 (95% CI: 0.98-1.00). Despite the presence of publication bias, sensitivity analysis did not show any change in sensitivity and specificity.

Discussion

Our meta-analysis summarises the accuracy data from 12 studies, including >700 subjects. Contrast-enhanced ultrasound had excellent diagnostic accuracy with pooled sensitivity and specificity of 97.5% (95% CI: 93.5-99.1) and 98.2% (95% CI: 91.5-99.6), respectively, without any significant heterogeneity. Additionally, the pooled positive LR, negative LR and DOR were 54.6 (95% CI: 11.1-25.6), 0.02 (0.01-0.07) and 2186.8 (318.3-15022.2), respectively. A positive result increases the pretest probability of malignant PVT from 50% to 98%, whereas a negative result decreases it from 50% to 2%. Most of the studies included in our meta-analysis used identical techniques and 6-12-month follow-up scans to check for thrombus progression or regression. Our analysis showed no significant heterogeneity in the studies, and area under receiver operating characteristic curve (AUROC) with 95% CI was 1.00 (95% CI: 0.99-1.00). This critical meta-analysis thus propels CEUS to the forefront for differentiating benign from tumoural PVT and suggests routinely using CEUS in patients presenting with HCC and evidence of thrombus on greyscale ultrasound.

Conclusion

Contrast-enhanced ultrasound is an effective diagnostic modality differentiation of benign and malignant PVT in patients with HCC and can be an alternative modality to CT or MRI. Further studies are required to study the role of CEUS as initial diagnostic modality for the characterisation of PVT in HCC.

Early allograft dysfunction after living donor liver transplantation-current concepts and future directions

Early allograft dysfunction (EAD) after liver transplantation is a significant clinical problem that negatively impacts graft and patient outcomes. The rising incidence of EAD and what it means concerning living donor liver transplantation (LDLT) is an area of great interest. However, EAD after LDLT is a complex research topic yet to be reviewed comprehensively. Most of the literature on EAD is based on experience in deceased donor liver transplantation, and limited information is available in the context of LDLT. Thus, in this review, we present an overview of EAD after LDLT and have attempted to present balanced points of view on all its aspects, such as definitions, pathogenesis, risk factors, predictive markers, and management. The review aims to broadly overview the nature and extent of ongoing research evidence on this complex topic and inform practice in the field by identifying key concepts and knowledge gaps and highlighting areas that require further inquiry.

Tenofovir versus entecavir for tertiary prevention of hepatocellular carcinoma in chronic hepatitis B infection after curative therapy: A systematic review and meta-analysis

Entecavir (ETV) and Tenofovir disoproxil fumarate (TDF) are the first-line drugs for the treatment of chronic hepatitis B virus (HBV). However, the impact of these two antiviral agents on the outcome of HBV-related hepatocellular carcinoma (HCC) after curative therapy remains to be explored. The purpose of the present study was to compare the effect of ETV and TDF on recurrence and mortality after curative treatment for HBV-related HCC. A comprehensive literature search of multiple electronic databases was conducted from 2000 to January 2022 for studies comparing ETV and TDF for HBV-related HCC patients after curative therapy. The adjusted hazard ratios (aHR) were pooled using a random-effects model. A total of nine studies with 5298 patients were included in the final meta-analysis. TDF was associated with a lower risk of HCC recurrence [aHR 0.73, 95% confidence interval (CI) 0.65-0.81] compared to HCC. TDF reduced the risk of late recurrence compared to ETV (aHR 0.58, 95% CI 0.45-0.76) but not early recurrence (aHR 0.88, 95% CI 0.76-1.02). The mortality risk was also lower with TDF compared to ETV (aHR 0.62, 95% CI 0.50-0.77). TDF was associated with a lower risk of recurrence and mortality than ETV after resection or ablation of HBV-related HCC. Further prospective randomized controlled studies are warranted to validate these results.

Diagnostic outcome and safety of plugged liver biopsy in high-risk patients: a systematic review and meta-analysis

BACKGROUND

Percutaneous liver biopsy is the gold standard test for the assessment of liver disease. In patients with coagulopathy, ascites, post-transplantation, and hypervascular tumors, biopsy is associated with increased risk of adverse events (AEs). Transjugular liver biopsy (TJLB) is recommended in these conditions but is expensive and unavailable at many centers. Plugged liver biopsy (PLB) provides an alternate diagnostic modality in these high-risk cases.

PURPOSE

To analyze the pooled diagnostic outcome and safety of PLB in high-risk cases.

MATERIAL AND METHODS

A literature search of various databases from January 1990 to July 2022 was conducted for studies evaluating the outcome of PLB in high-risk cases. The primary outcomes were pooled sample adequacy and AEs. Pooled event rates across studies were expressed with summative statistics.

RESULTS

A total of 17 studies (2329 patients) were included in the meta-analysis. The pooled proportion of sample adequacy was 98.9% (95% confidence interval [CI]=98.2-99.6). Severe AEs, major bleeding, and minor AEs were seen in 0.7% (95% CI=0.1-1.3), 0.4% (95% CI=0.1-0.8), and 11.5% (95% CI=2.4-20.6) of the patients. There was only one reported mortality, giving a pooled incidence of 0.0002% (95% CI=0.0-0.0038). Compared to TJLB (5 studies, n = 336), there was no difference in either sample adequacy (odds ratio [OR]=2.34, 95% CI=0.83-6.58) or risk of serious AEs (OR=0.47, 95% CI=0.173-1.31).

CONCLUSION

PLB can be safely performed on patients with coagulopathy and/or ascites with high sample adequacy rates and low incidence of AEs and mortality.

Long-term lead and mortality following pacemaker and defibrillator implantation in adult congenital heart disease

Background

Adult congenital heart disease (ACHD) survival has dramatically improved in recent decades. As such, clinicians now face the complex long-term interactions of congenital and chronic heart diseases. One area of continuing mortality in this group is arrhythmias, especially in those with cardiovascular implantable electronic devices (CIEDs). With these developments in survival, the long-term outcomes of the CIED systems and their effects on mortality are beginning to be elucidated.

Aims

This study aims to compare the effects of system location, surgical history, patient demographics and congenital disease complexity on lead survival, complication distributions and patient mortality in ACHD CIED patients.

Methods

A retrospective cohort of 250 ACHD CIED patients with follow up at a heart centre was collated from clinical correspondence letters and CEID records. Data was collected on demographics, mortality and lead survival and complications. Survival data was analysed with Kaplan-Meier (KM) curves and hazard ratio tests.

Results

Complex ADHD patient survival was less than the non-complex cohort (HR 0.38, 95% CI 0.22–0.67, p<0.01). Lead survival was longer in non-surgical patients (HR 1.42, 95% CI 1.13–1.78, p<0.01) and longer in female patients (HR 1.35, 95% CI 1.07–1.69, p<0.01) (Figure 1). No significant differences in mortality or lead survival were seen between epicardial and transvenous systems.

Conclusions

Complex ACHD is associated with worse patient mortality in CEID patients. Surgical history and male gender are associated with worsened lead survival.

Funding Acknowledgement

Type of funding sources: None.

Intra- and inter-observer agreement in the classification of dyssynergic defecation on high-resolution anorectal manometry using water-perfusion system

BACKGROUND AND AIMS

Dyssynergic defecation (DD) classified on anorectal manometry is based on variations in anal sphincter pressures and rectal pressure generated during bearing down. There is a paucity of data on intra- and inter-observer agreement in the classification of DD on high-resolution anorectal manometry (HRAM) using a water-perfusion system.

METHODS

This cross-sectional observational study was conducted between June 2014 and May 2016 on 70 adult patients with DD. Observer 1 did the baseline analysis and reanalyzed the readings at least 6 months later, blinded to the initial analysis results (intra-observer variability). Four other blinded observers (5-25 years in anorectal manometry and minimum 5 years of experience in HRAM) then individually analyzed the manometry data (inter-observer variability).

RESULTS

Intra-observer agreement was excellent (kappa 0.862) for classifying DD. Agreement between the six observations (i.e. two from observer 1 and four from independent observers) was also good (kappa 0.632). The highest agreement was for type 4 DD (kappa 0.738), followed by type 1 (0.680), type 2 (0.664), and type 3 (0.537). Cronbach's alpha value was 0.93, suggesting excellent internal consistency.

CONCLUSION

The diagnosis of the types of DD on anorectal manometry using a water-perfusion system has excellent intra-observer and good inter-observer agreement .

Utilization of SARS-COV-2 positive donors and recipients for liver transplantation in the pandemic era - An evidence-based review

The current SARS-COV-2 pandemic led to a drastic drop in liver donation and transplantation in DDLT and LDLT settings. Living donations have decreased more than deceased organ donation due to the need to protect the interest of donors. In the SARS-COV-2 pandemic, major professional societies worldwide recommended against the use of organs from donors with acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The basis for these recommendations are; SARS-CoV-2 could be transmitted to the recipient through organ transplantation and can result in severe manifestations; only limited effective targeted therapies are available, risk of transmission to the healthcare professionals, logistical limitations, and ethical concerns. In addition, end-stage liver disease patients on the waiting list represent vulnerable populations and are at higher risk for severe COVID-19 infection. Therefore, deferring life-saving transplants from COVID-positive donors during a pandemic may lead to more collateral damage by causing disease progression, increased death, and dropout from the waitlist. As this SARS-COV-2 pandemic is likely to stay with us for some time, we have to learn to co-exist with it. We believe that utilizing organs from mild/ asymptomatic COVID19 positive donors may expand the organ donor pool and mitigate disruptions in transplantation services during this pandemic.

Presence of Ascites at Presentation is Associated With Absence of Long-Term Response Amongst Patients With Budd-Chiari Syndrome When Treated With Medical Therapy Alone: A Single Centre Real-Life Experience

BACKGROUND

There is lack of data on long-term outcomes of patients with Budd-Chairi Syndrome (BCS) treated with medical therapy including anticoagulation alone.

METHODS

Consecutive patients (N = 138, mean [standard deviation, SD] age 29.3 [12.9] years; 66 men) with BCS, treated with medical therapy alone including anticoagulation, with minimum follow-up of 12 months were included. Initial response was classified as complete (CR), partial (PR) or nonresponse (NR) and on follow-up as loss of response (LoR) or maintenance of response (MoR). The association of baseline, clinical and biochemical parameters with different responses was evaluated.

RESULTS

Seventy-six patients (55.1%) had CR, 26 (18.8%) had PR and 36 (26.1%) had NR. None with PR or NR had CR later. At a median follow-up of 40 (range 12-174) months, LoR was more common in PR group than in CR group (12 [46.2%] vs 18 [23.7%], P = 0.03). LoR was associated with presence of ascites (odds ratio [OR] 1.5; 95% confidence interval [CI] 0.06-0.71), gastrointestinal bleed (OR 1.33; 95% CI 0.09-0.82) or jaundice (OR 1.01; 95% CI 0.11-0.97) at baseline and duration of follow-up (OR 0.018; 95% CI 1.006-1.030). Mortality was higher in NR (28 [77.8%]) compared with CR (15 [19.7%], P = 0.001) and PR (8 [30.8%], P = 0.001). On binary logistic regression analysis, presence of ascites at baseline was associated with LoR (OR 0.303 [0.098-0.931]).

CONCLUSION

Patients with initial CR have better survival than nonresponders. One-third had LoR on follow-up. The presence of ascites at baseline is associated with LoR.

Reference Charts of Fetal Biometric Parameters at Different Gestational Age Groups in Indian Population

To develop, a reference charts of fetal abdominal circumference and femur length in normal pregnant women by using ultrasonography for Indian population. Further comparison of our findings with data derived from different population. This retrospective cross-sectional study included 300 normal singleton pregnancies and was carried out in the department of Anatomy, All India Institute of Medical Sciences, Jodhpur (Rajasthan), India from September 2017 to April 2019. Ultrasonography measurements included Abdominal circumference (AC) and Femur length (FL). Reference charts with mean AC and FL for corresponding Gestational age (GA) in weeks were developed. Also reference centiles (10th, 50th, 90th and 95th) were derived from this model and compared with similar studies done on different population. There was no statistically significant difference in age distribution of pregnant women (p=0.87). Both AC and FL were found to have statistically significant linear relationship with advancing gestational age (p=0.0005 & p=0.0003 respectively). There is significant difference observed between the values obtained in present study with studies concluded on Chinese and European population. Measurement of AC and FL are used to predict gestational age of fetus by using various regression formulae, also AC is known to be good predictor of nutritional status of fetus in utero. A separate chart is required for every different population because ethnicity, nutrition and environmental factor can have impact on normal values. Therefore, a reference chart for these parameters according to Indian population standards is essential to avoid misinterpretation of data. This would help to avoid misdiagnosis of intrauterine growth retardation or macrosomia during prenatal and perinatal period.

Combined endovascular and surgical approaches to treat intralobar pulmonary sequestration: a case report

Pulmonary sequestration is a congenital abnormality of a non-functional pulmonary mass with anomalous systemic arterial supply. Surgical resection is the gold standard treatment, but it carries a risk of life-threatening haemorrhage from accidental injury of the anomalous artery. Endovascular embolisation has been introduced as a safe alternative, but does not eliminate the possibility of symptom recurrence. We report a case of a 61-year old woman with intralobar pulmonary sequestration treated with a combination of endovascular coil embolisation and surgical resection.

Estimation of Fetal Weight: An Ultrasonography Study in Indian Population

To create a reference chart for estimated fetal weight (EFW) in normal pregnancy for use in Indian population and compare it with reference chart from other population. This retrospective cross-sectional study included 300 normal singleton pregnancies coming for routine antenatal ultrasonography examination and was carried out at All India Institute of Medical Sciences, Jodhpur from September 2017 to April 2019. Ultrasonographic measurements included fetal biparietal diameter (cm), head circumference (cm), abdominal circumference (cm) and femur length (cm). Estimated fetal weight was calculated by using Hadlock algorithm which is already fed into ultrasonography machine. Reference chart with mean EFW for corresponding Gestational age (GA) in weeks was developed. Also Reference centiles (10th, 50th, 90th and 95th) were derived from this model. There was no statistically significant difference in age distribution of pregnant women (p=0.87). Statistically significant linear relationship found between EFW and advancing gestational age (p=0.0004). Maximum gain in EFW (34.05%) was observed after second trimester (28 week). Maximum and minimum fetal weight at 38 weeks of GA in our study found to be 3389 grams and 2567 grams respectively, which has significant difference. This could be due to huge difference in socio-economic and nutritional status among Indian population which might have impacted on maternal and fetal health. Estimated fetal weight was found to be at lower range in Indian population compared to reference chart developed into western population. Fetal weight to their corresponding GA is an important factor in determining growth and development in fetus. In normally developing fetus the EFW has linear correlation with advancing GA. A separate reference chart is required for every different population because ethnicity, nutrition and environmental factor can have impact on normal EFW values. This would help to avoid misdiagnosis of intrauterine growth retardation or macrosomia in fetuses and hence unnecessary medical interventions can be prevented during prenatal and perinatal period.

Monitoring steady production of 1,3-propanediol during bioprospecting of glycerol-assimilating soil microbiome using dye-based pH-stat method

AIM

In this investigation, a dye-based pH-stat method was devised for monitoring steady production of 1,3-propanediol (1,3-PDO) during bioprospecting of glycerol-assimilating soil microbiome.

METHODS AND RESULTS

Soil samples were collected from two potential sites of CSIR-IIP, India. Selective enrichment of microbial consortia was done using the glycerol-based medium at initial stage, followed by purification to isolated colonies, after positive high-performance liquid chromatography detection of 1,3-PDO in the fermentation broth. When the purified isolated were re-tested for 1,3-PDO production, only two isolates namely Isolate 1 and Isolate 3 were capable of producing the targeted product preferably under anaerobic conditions. Based on better 1,3-PDO fermentation efficiency (Isolate 3, 22% vs Isolate 1, 4·48%) and acetic acid as the only major by-product, Isolate 3 was shortlisted for further studies. A dye-based technique was devised in which bromothymol blue was incorporated into the medium to monitor the pH drop due to acetic acid formation and hence change in colour. Visual change in colour helped in intermittent pH restoration. During fermentation, with pH stat being 8-8·5, Isolate 3 at 32°C yielded 0·67 mol mol^-1 1,3-PDO within a short span of 12 h only with an initial concentration of glycerol being 20 g l^-1 . Phylogenetic analysis revealed that Isolate 3 shared 95·8% homology with Citrobacter freundii CFNIH1 and hence designated as C. freundii IIP DR3.

CONCLUSION

This study demonstrated that during bioprospecting glycerol-assimilating microbiome, dye-based technique can be successfully employed. This technique can further be exploited to monitor consistent production of all microbial secondary metabolites that accompanies acid production.

SIGNIFICANCE AND IMPACT OF THE STUDY

Incorporation of 'Bromothymol blue' can visually help in the identification of pH drop in the medium, so that pH stat can be easily maintained during 1,3-PDO production from glycerol especially under shake flask conditions.

Evaluating novel fungal secretomes for efficient saccharification and fermentation of composite sugars derived from hydrolysate and molasses into ethanol

This paper evaluates the ability of secretome from two thermotolerant fungal strains (Aspergillus terreus 9DR and Achaetomium strumarium 10DR) for boosting the hydrolytic efficiency of benchmark cellulolytic preparation (Cellic CTec2). Further we report enhanced saccharification of different agro-residues under semi-aerobic when compared to aerobic conditions. The mass spectroscopic analysis of the hydrolysates indicates the role of auxiliary oxidative enzymes present in A. terreus and A. strumarium secretomes for enhancing the capability of the cellulolytic cocktails. The paper further demonstrate positive effect of using the cocktails for enhanced saccharification and subsequent fermentation to ethanol of acid pre-treated rice straw, corn residues and sugarcane bagasse at higher substrate loading rates (20% w/v). The paper also reports co-utilization of composite sugars derived from molasses and enzymatic hydrolysate obtained from agnostic lignocellulosics for efficient bioconversion to ethanol applicable for developing BOLT-ON technology.

Budd-Chiari Syndrome With Spontaneous Intrahepatic Portosystemic Shunts: A Case Series

Intra-hepatic portal-venous collaterals are characteristic of Budd-Chiari syndrome (BCS) and are usually of small caliber and seen on Doppler. Creation of large portal-systemic shunt, either radiologically (Transjugular intrahepatic porto-systemic shunt) or surgically results in excellent long term outcomes in BCS. Here, we report a series of three rare cases of asymptomatic BCS, who had spontaneous large intra-hepatic portal-systemic shunts.

SOFA Score and Critically Ill Elderly Patients

OBJECTIVE

To study correlation between SOFA Score and Outcome in Elderly Patients admitted In Intensive Care Unit.

METHODS

A single centre prospective observational study in Medical Intensive Care Unit (MICU) of large teaching Institute. A total of 84 elderly patients were studied and the outcome was correlated with SOFA Score at admission and 48 hours after admission.

RESULTS

Elderly patients constituted 10.94% (84 out of 764) of total MICU admissions. Critically ill elderly patients had a very high mortality of 73.8% (62 out of 84), as compared to their younger counterparts with mortality rates of 43.53% (296 out of 680) with a highly significant P value of <0.0001. The mean SOFA scores are statistically significantly higher at both time points in the expired group (7.84±3.74 and 8.64±3.72 respectively on admission and at 48 hours).

CONCLUSIONS

There is positive correlation between mortality and SOFA score at admission and at 48 hours. SOFA score thus can be effectively used as predictive scoring system for critically ill elderly patients.

Higher infliximab trough levels are associated with perianal fistula healing in patients with Crohn's disease

BACKGROUND

Infliximab has been found to be efficacious in the treatment of fistulas in the setting of Crohn's disease, even though some patients do not benefit from therapy.

AIM

To assess the correlation between perianal fistula healing and trough levels of infliximab.

METHODS

In this cross-sectional study, we identified patients with Crohn's disease who had perianal fistulas and were treated with infliximab for at least 24 weeks. We excluded patients who underwent a faecal diversion procedure or proctectomy. Predictive variables included demographics, disease phenotype, disease activity, infliximab levels, anti-infliximab antibodies. The primary outcome was fistula healing defined as the absence of drainage. The secondary outcome was complete fistula closure and mucosal healing.

RESULTS

117 patients were included. Patients with fistula healing had significantly higher median serum infliximab levels when compared to those with active fistulas [15.8 vs. 4.4 μg/mL, respectively (P < 0.0001)]. There was an incremental gain in fistula healing with higher infliximab levels. The AUC for the association between fistula healing and infliximab levels was 0.82 (P < 0.0001), while the AUC for the association of infliximab levels and fistula closure was 0.69 (P = 0.014). Patients with anti-infliximab antibodies had a lower chance of achieving fistula healing (OR: 0.04 [95%CI: 0.005-0.3], P < 0.001).

CONCLUSIONS

There is a significant association between serum infliximab levels and rates of fistula healing. Achieving infliximab levels ≥10.1 mcg/mL in patients with Crohn's disease and perianal fistulas may improve outcomes as part of a treat-to-target strategy.

The toxic effects of sodium fluoride on the reproductive system of male rats

The present study was undertaken to evaluate the effect of fluoride toxicity on the reproductive system of male rats. Sexually mature male Wistar rats were exposed to 2, 4, and 6 ppm sodium fluoride in their drinking water for 6 months ad libitum. Sperm motility and density in cauda epididymis were assessed. Biochemical and histological analysis were performed in reproductive organs. Fluoride treatment brought about a significant decrease in the weight of testis, epididymis, and ventral prostate. The sperm motility and density were significantly reduced. There was a marked reduction in the number of primary spermatocyte, secondary spermatocyte, and spermatids. The Sertoli cell counts and their cross sectional surface areas were significantly decreased. The Leydig cell nuclear area and the number of mature Leydig cells were also significantly decreased. The protein content of the testis and epididymis were significantly reduced. Fructose in the seminal vesicles and cholesterol in testes were increased significantly. In conclusion, sodium fluoride administrated in drinking water of 2, 4, and 6 ppm concentration for 6 months to male rats adversely affected their fertility and reproductive system.

A comparative study of central versus posterior approach for internal jugular hemodialysis catheter insertion

Internal jugular (IJ) catheter insertion for hemodialysis (HD) is an indispensable procedure in the management of patients with renal failure. The central approach is favored over posterior approach to insert IJ catheters. There are no studies comparing the outcomes between the two approaches. The aim of this study was to compare central approach with posterior approach for IJ HD catheter insertion and to analyze various outcomes like procedure-related complication rates, catheter insertion failure rates, interruptions during dialysis due to blood flow obstruction and catheter infection rates between the two methods among patients receiving HD. All patients requiring IJ HD catheter insertion during a 1-month period were randomly assigned to undergo catheter insertion via either conventional central approach or posterior approach. Patients were followed-up till the removal of the catheter. Among 104 patients included in the study, 54 were assigned to the central approach group and 50 to the posterior approach group. The central approach group had higher rate of procedure-related complications (14.81% vs. 6%, P = 0.04). Catheter insertion failure rates were marginally higher in posterior approach group (20% vs. 12.96%, P = 0.07). One or more instance of interruption during HD due to obstruction in blood flow was more common in posterior approach (46% vs. 9.25%, P < 0.01). Catheter infection rates were similar between the two groups; 16.66% (n = 9) in central group vs. 14% (n = 7) in posterior group. Posterior approach is a reasonable alternative to conventional central approach in IJ cannulation for HD catheter. It is, however, associated with a significantly high rate of interruption in HD blood flow and catheter insertion failure rates. The posterior approach can be used in patients with local exit site infection or in failed attempts to cannulate IJ vein via the conventional central approach.

Periodic Peritoneal Dialysis in End Stage Renal Disease: Is it Still Relevant? A Single Center Study from India

BACKGROUND

High cost of maintenance hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD) in India has made renal replacement therapy out of reach of many patients with end stage renal disease (ESRD). Repeated puncture PD although inferior to HD biochemically, is easily and freely available across Rajasthan, India, and is simple to perform, and does not require sophisticated machines, thus making it an attractive option for dialysis for ESRD.

AIM

To analyze the outcomes of periodic PD in patients with ESRD requiring dialysis support.

SUBJECTS AND METHODS

A prospective study analyzing the data of patients who underwent PD between August 2010 and January 2013 in Sawai Man Singh Hospital, Jaipur, India was conducted. Patients were divided into three groups based on the time period between first and second session of PD. Detailed demographic and clinical data during the study period were collected along with PD related complications. The main outcome studied was technique survival 1 year post initiation of PD.

RESULTS

234 patients received an initial session of PD, of which 174 had a good response and were included in the study. 19 patients received the second PD within 7 days of first (Group 1), 45 patients within 8-14 days (Group 2) and 110 patients within 15-21 days (Group 3). The overall 1 year technique survival was 68.4% (91/133), with a rate of 50% (5/10), 56.8% (21/37), and 75.6% (65/86) for Group 1, Group 2, and Group 3, respectively. The time duration between first and second PD proved to be reliable indicator of the subsequent response, with a technique survival rate significantly lower in Group 1 patients compared to Groups 2 and 3 (P = 0.04). Median dialysis free days were 11, 16 and 21 days in Group 1, Group 2, and Group 3, respectively. Peritonitis rate observed was 2.1% (49/2261) during the study period.

CONCLUSION

Periodic PD is a simple, safe and cheap procedure, which can be considered as used as a palliative measure in terminal uremia in underprivileged areas.

Use of Iron Chelating Agents in Transfusion Dependent Thalassaemia Major Patients

This cross-sectional study was done to find and investigate the utilization pattern of iron chelating agents among 73 transfusion-dependent thalassaemia major patients with continuous enrolment for at least 1 year in a day care treatment centre run by The Thalassaemia Society of India, Kolkata from November 2014 to January 2015. Transfusion dependent thalassaemia major patients above the age of 2 years managed by various haematologists and Thalassaemia specialists were studied. The administration of iron chelators namely Desferrioxamine (DFO), Deferiprone (DFP) and Deferasirox (DFX) were evaluated. Forty seven (64%) of the thalassaemics had serum ferritin level below 2500 ng/dl, of whom 20(27%) patients have ferritin level below 1000ng/dl. A number of 55(75%) of 73 patients who were treated with a single chelating agent consisted 50 patients only on DFX. Exact 8(67%) patients were on DFO+DFP and 4(33%) are treated with DFX+DFP. The mean age was 19 and mean serum ferritin level was 2280 ng/dl among the thalassaemia major patients. DFX was used 68% of patients as monotherapy and 5% patients in combination therapy with DFP. DFX in the dose of 30-40 mg/kg/day was prescribed in 52% of patients. Mean dose of 15 mg/kg/day of DFX was been administered in combination with DFP (75 mg/kg/day) in 5% patients. DFO+DFP were preferred by 8 patients, out of which 6 were aged above 25. Cost of monotherapy is twice that of combination therapy. These data demonstrates the ferritin status and present scenario of utilization of chelating agents among thalassaemia major patients on repeated transfusions. The dosing of new drug, Deferasirox and the cost analysis of various chelating regimen has also been dealt. Individualization rather than rationalization of chelation therapy should be focussed upon in managing iron overload in thalassaemia.

Morphometry and variations of the human suprascapular notch

AIM

The present study proposes a simple method to study variations in shape and dimensions of suprascapular notch, to classify different types and subtypes of notch and to measure the thickness of superior transverse scapular bar (ossified superior transverse ligament of scapula).

MATERIAL AND METHODS

Seven hundred and twenty-eight dried scapulae were observed, examined and studied in detail. Scapulae with suprascapular notch, with suprascapular foramen having varying degree of ossification in the form of transverse scapular bar were included in the present study. Measurements of suprascapular notch and superior transverse scapular bar were taken with the help of digital vernier calliper and recorded in millimetres. The superior transverse diameter, inferior transverse diameter, depth, maximum thickness of suprascapular notch and thickness at lateral and medial end of transverse scapular bar, mean thickness of superior transverse scapular bar were recorded. The data was analyzed statistically.

OBSERVATIONS AND RESULTS

We observed five types of notch in scapulae, type I: without a discrete notch (ill defined), 25 (3.43%); type II: a "V" shaped notch, 192 (26.37%); type III: "U" shaped notch, 383 (52.60%); type IV: inverted "V" shaped notch, 28 (3.84%); type V with absent suprascapular notch: 6 (0.82%). Type II and type III were again subclassified into subtypes (a, b, c and d) on the basis of depth of notch. Scapulae with superior transverse scapular bar (n=94, 12.91%) were classified according to variation in mean thickness of transverse scapular bar (MTSB).

CONCLUSION

This study will help clinicians to correlate suprascapular nerve entrapment with a specific type of suprascapular notch and notch with ossified transverse scapular ligament.

Cytological Diagnosis of Primary Thyroid Tuberculosis

Primary thyroid tuberculosis is an extremely rare disease, even in countries where other forms of tuberculosis are abundant. TT has no age bar but usually affects women in fourth and fifth decade. Hereby, we report a case of 16-years-old girl presented with complaint of progressively increasing, painful thyroid swelling. Diagnosis of TT was made on cytology and there was no evidence of involvement of any other organ by tuberculosis. Despite of its rarity, TT is usually misdiagnosed. So, a clinician should always consider this entity in the differential diagnosis of thyroid swelling. Fine needle aspiration cytology is the best diagnostic method and can result in the avoidance of unnecessary thyroid surgeries.