Component separation repair of incisional hernia: evolution of practice and review of long-term outcomes in a single center

PURPOSE

To review the long-term outcomes of complex abdominal wall reconstruction using anterior and posterior component separation (CS) techniques in our center.

METHODS

This was a descriptive analytical study. Analysis of data from a prospectively collected database of patients who had undergone Component Separation (CS) repair of incisional hernias was performed. Two techniques were used. Anterior component separation (ACS) and posterior component separation with transversus abdominis release (PCS/TAR). Follow-up was clinical review at 6 weeks, 6 months, and 12 months with direct access telephone review thereafter. Long-term outcome data was obtained from electronic records and based on either clinical or CT assessment. Minimum physical follow-up was 6 months for all patients.

RESULTS

89 patients with large incisional hernias underwent CS repair. 29 patients had ACS while 60 underwent PCS/TAR. Mean follow-up was 60 months (range 6-140 months) in the ACS group and 20 months (range 6-72 months) in the PCS group. Twenty-five patients (28%) had simultaneous major procedures including 21 intestinal anastomoses. Twenty-six (29%) of patients had associated stomas. Twenty-seven (30.3%) of the patients had undergone previous hernia repairs. Seromas occurred in 24 (26.97%) patients. Wound infections were more common after ACS. There have been 10 (11.2%) recurrences to date.

CONCLUSION

Component separation repair techniques result in good long-term outcomes with acceptable complication rates. They can be performed simultaneously with gastrointestinal procedures with low morbidity. Appropriate patient selection and use of appropriate mesh are important.

ABO-Incompatible Renal Transplant: A Single-Center Experience from India

Introduction

In view of ever-increasing end-stage renal disease (ESRD) population but inadequate availability of suitable donors, ABO-incompatible (ABOi) transplantation can be an important void filler. However, at present, ABOi transplantation is limited to a few centers in India and there is a lack of adequate experience and expertise to guide this program to other centers in the country.

Methods

Data of all the ABOi transplants performed from 2012 to 2021 in a tertiary care hospital was retrospectively analyzed. The anti-ABO antibody (IgG) titers (≤1:4) were considered safe before transplantation. Desensitization included rituximab, plasma exchange, or selective immunoadsorption column. Tacrolimus and mycophenolate mofetil were initiated at day -7. Induction agents included ATG, ATLG, basiliximab, or no induction. Postoperatively, anti-ABO titers were done daily for 2 weeks.

Results

A total of 202 patients underwent transplantation; of these, 195 patients whose data were for available for 12 months were included in the study. Mean duration of follow-up was 28.9 ± 21.7 months. UTI was the most common source of infection, occurring in almost half (46.1%) of the patients. Antibody-mediated rejection (ABMR; 15%) was common in the first year. Patient survival was 86.6% (169/195) at 1 year. Sepsis was the most common of death in more than two-thirds of the population, including coronavirus disease 2019 (COVID-19)-associated mortality in nine patients (4.6%). Death-censored graft survival was 89.3% (174/195). AMR was the leading cause of graft loss in almost half of the patients.

Conclusion

ABOi should be considered in ESRD patients for whom suitable ABO-compatible donor is not available. Higher rate of rejection and infection are still a major concern.

Comparison of Clinico-pathologic features and outcomes of ANCA negative and ANCA positive pauci immune crescentic glomerulonephritis: A single centre study

Introduction

Pauci-immune crescentic glomerulonephritis (PICN) is an important cause of rapidly progressive renal failure. 10-40% of PICN cases have ANCA (antineutrophil cytoplasmic antibody) negative serology. The present study compared clinico-pathologic features, Brix's renal risk score, Berden's histopathological classes and differences in outcome between ANCAnegative vs ANCA positive PICN patients.

Materials and Methods

Sixty-one patients of biopsy-proven PICN were studied. Biochemical findings and ANCA serology were recorded. Renal biopsy slides were reviewed along with direct immunofluorescence. Clinical and histological features were compared between ANCA negative and positive PICN using the Man Whitney U test and Chi-square test. Patients were compared for distribution in Berden's histological classes and Brix's renal risk categories. Patient and renal survival were compared using Kaplan-Meier survival analysis.

Results

ANCA negative PICN patients were younger (44.9 ± 16.5 years vs 53.6 ± 15.1 years, P = 0.049). Nasal (0 vs 18%, P = 0.035) and pulmonary involvement (9% vs 38%, P = 0.014) were lower in ANCA negative group. Both ANCA groups had similar renal biochemical profiles, percentage normal glomeruli, 16.3 ± 18.2 vs 21.7 ± 20.4 and percentage glomeruli with crescents, 64.5 ± 28.1 vs 64.3 ± 27.1. Twenty-seven per cent of ANCA negative cases fell in the sclerotic class in Berden's classification vs just 2.5% in ANCA positive group (p = 0.037) without significant difference in Brix's renal risk categories (p = 0.329). Thirteen per cent of ANCA negative patients achieved complete remission on treatment compared to 33% in ANCA positive patients. Patient survival and overall probability of progressing to ESRD were similar in the two groups.

Conclusion

ANCA negative PICN cases present at younger ages. Nasal and pulmonary involvement is uncommon in these patients. Patient survival and progression to ESRD are similar in both ANCA groups.

Prevalence, risk, and outcomes of venous thromboembolic events in kidney transplant recipients: a nested case-control study

INTRODUCTION

Thromboembolism is more common in kidney transplant recipients (KTRs) than in the general population. Studies evaluating arterial and venous thromboembolism (VTE) in KTRs are scarce and the magnitude and risk factors are mostly undefined.

METHODS

A nested control study was conducted from January 1, 2007, to December 31, 2019. Adult KTRs who were detected to have VTE events during this period were included. The primary outcome was to assess the prevalence of VTE in this population. Secondary outcomes were the assessment of the time to occurrence of the thromboembolic events after transplantation and assessing the risk factors and patient survival. For each subject studied, 4 controls were matched from the data set.

RESULTS

Amongst 2158 patients, 97 (4.5%) were found to have VTE. The median follow-up time was 3.9 years (6-156 months). A total of 101 VTE events were recorded. The most common site of VTE was the lower limb deep vein thrombosis in 79 patients (0.03%)).In multivariate Cox regression analysis, serum creatinine of more than 3 mg/dl [HR 1.30, 95% CI (1.03-1.38)] was independently associated with increased VTE risk. Patients who developed a VTE had higher mortality as compared to patients who did not develop VTE. No increased risk of graft failure was found in VTE patients.

CONCLUSION

This study suggests that kidney transplantation surgery is a moderate risk factor for VTE, and VTE is associated with higher morbidity and mortality. However, prospective studies are needed to establish a definite role of VTE in outcomes in KTRs.

Nocardiosis in Renal Transplantation: Case Series from India

Nocardiosis is a rare opportunistic infection seen in kidney transplant patients and is caused by aerobic actinomycete. Disease manifestations can vary from a localized infection to multisystem organ failure. In this retrospective case series, we present 16 cases of Nocardiosis. The median age of the patients was 44 years. The median time from transplant to nocardiosis was 21 months. Acute rejection episodes and CMV infection within 6 months of nocardiosis were found in 12.5% and 25%, respectively. The most common organ involvement was the lungs (75%), followed by the brain (12.5%). Only one patient showed cutaneous involvement (6.25%). Mean creatinine at presentation was 0.7 mg/dL (mean eGFR: 92 ± 27 mL/min/1.73 m2). Trimethoprim/sulfamethoxazole resistance was found in 25% of patients. Five patients (31.25%) succumbed to the infection. Nocardiosis has a very low incidence but a high rate of mortality.

In vitro comparative evaluation of physical and chemical properties of surface enamel after using APF and SDF with or without laser activation

PURPOSE

To evaluate and compare the changes in physical and chemical properties of the enamel surface after application of Silver Diamine Fluoride (SDF), Acidulated Phosphate Fluoride (APF), LASER activated SDF and LASER activated APF.

METHODS

Sample consisted of 72 freshly extracted healthy human premolar teeth, extracted for orthodontic purpose, free from caries, fracture or any anomalies. The selected samples were randomly divided into four groups (n = 18): Group 1 (SDF); Group 2 (APF); Group 3 (LASER activated SDF) and Group 4 (LASER activated APF). All samples were evaluated for values of DIAGNOdent at baseline, after demineralisation and after remineralisation. They were further divided and assessed for colour changes, surface alterations and fluoride content of surface enamel using Spectrophotometer, Scanning Electron Microscopy and Energy Dispersive X-ray Spectrometry respectively. The statistical analysis was done using One-Way ANOVA, Tukey's HSD test, Mann-Whitney U test and Kruskal-Wallis Test.

RESULTS

Highest remineralising potential and maximum colour changes of surface enamel was exhibited by Group 3. Scanning Electron Micrographs of Group 3 and Group 4 exhibited regular globular structures of enamel whereas Group 1 and Group 2 showed irregular globular surface of the enamel at 2000× and 5000× magnification. Maximum fluoride uptake on the surface enamel was seen in Group 4 followed by Group 3.

CONCLUSION

Use of LASER activated topical fluorides helps to achieve superior caries prevention. LASER activated APF can be used as an aesthetic alternative to SDF, as LASER activated APF showed higher uptake of fluoride on the enamel surface without discoloration effect.

Efficacy of spinal manipulations and Schroth exercises on psychological parameters in patients with functional scoliosis: a randomised controlled trial

Functional scoliosis is defined as the reversible and temporary lateral spinal curvature that mainly occurs due to abnormal postural habits that leads to non-structural and compensatory changes in spine. Functional scoliosis can lead to the development of mental health issues, such as stress, anxiety and depression. The purpose of the present study was to evaluate the effects of spinal manipulation techniques and Schroth exercises on psychological parameters in patients with functional scoliosis. The subjects were randomly allocated into experimental (n=31) and control group (n=31). Spinal manipulation techniques and Schroth exercises were given to the patients of experimental group, while only Schroth exercises were given to the patients of control group. Outcome measures were Depression, Anxiety & Stress Score that was examined by using ‘DASS-21 questionnaire’. Treatment was given for four weeks, thrice weekly. After the completion of four weeks, DASS scores were obtained from the participants. Patients were followed up after 2 months and data was collected again. Repeated measures ANOVA were used to compare the mean changes within-group. Independent t-test was used to analyse the mean improvement between-group. Results suggested that there was a statistically significant difference between pre-/post and pre-/follow-up scores of the DASS, but there was statistical non-significant difference between post-/follow-up scores of the DASS. Results also suggested that experimental group showed better improvement compared to the control group. This study concluded that the combine use of spinal manipulation techniques and Schroth exercise protocol can significantly reduce the psychosomatic symptoms in functional scoliosis.

Clinical Trial Registry of India: CTRI/2020/02/023221

Spectrum of fetal limb anomalies

PURPOSE

Antenatal detection of limb anomalies is not uncommon, and pregnancies are usually terminated in view of the expected physical handicap. The aim of this retrospective observational study is to delineate the spectrum of fetal limb anomalies and provide evidence in support of complete postnatal evaluation in establishing recurrence risk.

METHODS

We present 54 cases of limb malformations detected antenatally and discuss the spectrum of abnormalities, the utility of fetal autopsy, and genetic testing to establish recurrence risk in subsequent pregnancies.

RESULTS

16/54 cases were isolated radial ray anomalies. There were five cases of amniotic band syndrome, five limb body wall complex cases, three VACTERL (vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities) associations, one case of sirenomelia, two cases of limb pelvis hypoplasia, and one case of OEIS (Omphalocele Exstrophy Imperforate anus and spinal defects). Four fetuses with non-isolated radial ray anomaly had trisomy 18. One case with bilateral radial ray defect had a mutation in the FANC-E gene confirming fanconi anemia. Twelve cases were unclassified.

CONCLUSION

Autopsy is the most important investigation in fetuses with limb anomalies. We suggest chromosomal microarray (CMA) as a first-tier test after autopsy. However, in cases of bilaterally symmetrical limb anomalies, in case of previous similarly affected child, or history of consanguinity, whole exome sequencing (WES) can be offered as the primary investigation, followed by CMA if WES is normal.

T-wave alternans poorly prognostic in primary prophylactic ICD patients: a prospective EU-CERT-ICD study

Background

New methods to identify patients who truly benefit from primary prophylactic implantable cardioverter defibrillation (ICD) are urgently needed. T-wave alternans (TWA) represents a beat-to-beat fluctuation in the morphology of the ST-segment and T-wave. It has been shown to associate with arrhythmogenesis of heart and sudden cardiac death [1]. We hypothised that TWA might associate with benefit from ICD implantation in primary prevention.

Methods

In EU-CERT-ICD study, we prospectively enrolled 2327 primary prophylactic ICD candidates from 15 European countries. A 24-hours Holter-monitoring was taken from all recruited patients at enrolment. TWA was assessed from Holter-monitoring using MMA method with Getemed Cardioday software. To assess the benefit from ICD treatment, we used outcomes all-cause mortality, appropriate shock and survival benefit. We conducted Cox regression model, competing risk regression model and propensity score adjusted Cox regression model. TWA was assessed both as contiguous variable and with cut-off points <47 μV and <60 μV.

Results

Final cohort included 1,734 valid T-wave alternans samples, 1,211 patients with ICD and 523 control patients with conservative treatment, with mean follow-up time 2.3 years. TWA <60 μV predicted lower all-cause mortality in ICD patients in univariate cox regression model (HR 1.484, 95% CI 1.024–2.151, p=0.0374). In multivariate models, TWA did not predict death or appropriate shocks in ICD patients. In addition, TWA did not predict death in control patients. In propensity score adjusted Cox regression model, TWA did not predict ICD benefit.

Conclusion

T-wave alternans is poorly prognostic in primary prophylactic ICD patients. Altough it may predict life-threatening arrhythmias and sudden cardiac death in several patient populations, it cannot be used in assessing benefit from implantable cardioverter defibrillator in primary prevention among patients with ejection fraction ≤35%.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Community's 7th Framework Program FP7/2007-2013

Adherence and discontinuation of sglt2-inhibitors and glp1-r agonists in patients with type 2 diabetes with and without cardiovascular disease

Background

Sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucacon-like-peptide-1 receptor (GLP-1R) agonists are two novel therapies in type 2 diabetes (T2D) that are recommended in patients with manifestations of cardiovascular disease or high risk of cardiovascular disease due to their cardioprotective benefits. Despite the increasing use of these drugs, there is still limited knowledge on the adherence patterns and the risk of discontinuation, according to the presence or absence of different cardiovascular conditions.

Purpose

To investigate the adherence and estimate the risk of discontinuation of SGLT2 inhibitors and GLP1-R agonists in patients with T2D with and without cardiovascular disease.

Methods

From Danish nationwide registers, we included all individuals >40 years with T2D who redeemed the first prescription of a SGLT2 inhibitor or GLP1-R agonist, between December, 2012 and December, 2018. Patients were divided into subgroups according to the presence or absence of different cardiovascular conditions (heart failure, ischemic heart disease, peripheral artery disease, atrial fibrillation), at the time of inclusion. Adherence over the course of one year after initiation of treatment was estimated by the proportion of days covered (PDC) for each subgroup, and adherence was defined as PDC 80%. The risk of discontinuation was estimated using multivariable cause-specific Cox regression models, and was defined as a break in treatment of 90 days. The Aalen-Johansen estimator was used to account for censoring and competing risks. Patients were followed until date of emigration, death or study end (December 31, 2019).

Results

We included 24,061 patients with T2D who initiated treatment with a SGLT2 inhibitor, and 13,899 patients with T2D who initiated treatment with a GLP1-R agonist, for the first time between December 10, 2012 and December 31, 2018. Median age at inclusion was 62 years (IQR 54–70) and 40% were female. In the analyses, 67% of the patients treated with SGLT2 inhibitors were adherent to therapy throughout the first year, whereas the same proportion of patients, 67%, were adherent to therapy with GLP-1R agonists. Mean PDC was 77% (SD 33) and 79% (31) for patients in therapy with SGLT2 inhibitors and GLP1-R agonists, respectively. No significant difference was observed related to the presence or absence of cardiovascular disease (SGLT2 inhibitor: mean PDC 77 (33) vs. 77 (33), GLP1-R agonist: 78 (32) vs. 79 (31)).

Conclusions

In this nationwide cohort study, we found that patients with T2D who initiated therapy with a SGLT2 inhibitor and those who initiated therapy with a GLP1-R agonist were almost equally adherent to therapy throughout the first year. Adherence in both treatment groups did not differ according to the presence or absence of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

AB1510 INFLAMMATORY MYOSITIS – FINAL ANSWER?

Background

Motor neurone disease may mimic inflammatory myositis. There is an overlap in clinical symptoms (such as muscle weakness, dysphagia and respiratory involvement) which may pose a diagnostic challenge. Careful history, thorough clinical examination and appropriate investigations can help to distinguish between the two. Monitoring the response to treatment is also crucial. We present a case that presented to rheumatology with progressive muscle weakness, she was investigated and treated for inflammatory myositis but was later diagnosed with motor neurone disease.

Objectives

To illustrate the need for thorough clinical assessment and investigations in patients with suspected inflammatory myositis and consider alternative diagnoses as clinical picture evolves.

Methods

A 68 year old lady, presented with 6 months history of progressive proximal muscle weakness. She also reported weakness of grip, affecting activities of daily life. She was finding it difficult to get up from chair. There was no swallowing difficulty, respiratory symptoms and skin rash. She had no weight loss or constitutional symptoms. She did not have any joint pain or features of connective tissue disease. She had history of hypertension. On clinical examination, she did not have any features of connective tissue disease. There was no evidence of joint synovitis or skin rash. Proximal power in upper and lower limbs noted to be 4/5 with intact reflexes. Initial investigations revealed mildly raised CPK at 287 with normal thyroid function and inflammatory markers. Immunological tests including ANA and myositis panel were requested alongside EMG, MRI thighs and CT chest/abdomen/pelvis. Myositis panel was positive for anti-MDA-5 antibodies (in the absence of any skin or respiratory symptoms). There was no evidence of malignancy on CT imaging. MRI thighs revealed fluid in the trochanteric bursae. She was trialled on oral prednisolone in view of her clinical features and positive anti-MDA5 antibody. However, there was no improvement in her symptoms or functional status. EMG revealed widespread neurogenic process affecting upper and lower limbs on both sides, without significant evidence of acute myopathy. The progressive nature of symptoms with the upper motor neurone signs raised the possibility of an evolving anterior horn cell disorder. She was referred to neurology and was subsequently diagnosed to have Motor Neurone Disease. The steroids were rapidly tapered off and stopped.

Results

Motor neurone disease is an important differential when considering inflammatory myopathy, particularly inclusion body myositis which causes more progressive muscle weakness. It is a neurological disorder characterised by degeneration of neurons. There is no clear cause identified. MND causes both upper and lower motor neurone signs. Symptoms include limb weakness, bulbar weakness that can affect speech and swallowing, muscle twitching and fasciculation. Respiratory weakness may occur. Thorough clinical examination and EMG findings help identify the diagnosis. Imaging may be needed. There is no cure. Management requires an MDT approach, primarily guided by neurology, including physiotherapy, occupational therapy, speech and language therapy and respiratory support.

Conclusion

This lady was initially treated for inflammatory myositis based on her symptoms, mildly raised CK and positive anti-MDA5 antibodies. On review of her clinical progress, we noted poor response to steroids and EMG results pointing at an alternative diagnosis of MND. This case highlights the importance of EMG in the assessment and management of patients with suspected inflammatory myositis as well as the need to closely monitor progress and re-evaluation where needed. Although she had anti-MDA-5 antibodies and mildly raised CK, she did not have any skin disease or other systemic features, inflammatory markers and muscle imaging was normal. Response to steroids was inadequate.

References

[1]Turner MR, Talbot K. Mimics and chameleons in motor neurone disease. Pract Neurol. 2013

[2]Ryan A, Nor AM, Costigan D, et al. Polymyositis Masquerading as Motor Neuron Disease. Arch Neurol. 2003

Disclosure of Interests

None declared

Anti-T-Lymphocyte Immunoglobulin (Grafalon) as an Induction Agent for Renal Transplantation: A Real-World, Retrospective, Single-Center Experience

OBJECTIVES

Polyclonal antithymocyte globulins are widely used in the induction regimens of solid-organ transplant recipients; however, their doses and outcomes remain to be standardized in Indian patients. We report our clinical experience from the real-world use of Grafalon (an anti-T-lymphocyte globulin; ATG-Fresenius) as an induction agentin renal transplant recipients from India.

MATERIALS AND METHODS

In this retrospective, single- center, observational study, we analyzed the medical records of 177 consecutive, kidney-only transplant recipients who received induction therapy with Grafalon from September 2016 to March 2018 at our center. Incidences of biopsy-proven acute rejection and graft dysfunction, immunosuppression protocol, Grafalon dosage, 18-month post-transplant graft and patient survival, treatment-related adverse events, and infective complications were reported.

RESULTS

Mean age of patients was 41.46 years (range, 14-68 years), (85% were males). The average dose of Grafalon was 5.81 ± 1.95 mg/kg (range, 2.41 to 10.07 mg/kg). Graft dysfunction (ie, at least 20% increase in serum creatinine from baseline) was observed in 26 patients (14%): 11 patients (6.2%) had biopsy-proven acute rejections, 11 patients (6.2%) had acute tubular necrosis, and 4 patients (2.2%) had calcineurin inhibitor toxicity. Seven deaths were recorded: 2 each from fungal pneumonia, bacterial pneumonia, and acute coronary syndrome and 1 with urinary tract infection with septicemia. Death-censored graft survival was 100% at 12 months and 98% at 18-month follow-up; overall patient survival was 96%. Infective complications occurred in 40 patients (22.5%), with the most common being urinary tract infection in 32 patients (18%). No malignancies were reported.

CONCLUSIONS

Use of a potent induction therapy like anti-T-lymphocyte globulin (Grafalon) is often restricted by the risk of side effects and lack of local clinical evidence supporting its role in long-term graft survival. Real-world evidence support the safe and effective use of anti-T-lymphocyte globulin as an induction agent in renal transplant recipients with an individualized dosing approach.

QRS duration as an independent risk factor for appropriate shocks and mortality in patients with prophylactic implantable cardioverter-defibrillator

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Community’s 7th Framework Programme FP7/2007-2013

Background

The implantable cardioverter defibrillator (ICD) is an established therapy for the prevention of sudden cardiac death (SCD) in high-risk heart failure patients. However, improvements in risk stratification are necessary to increase the efficiency of ICD use. We performed an analysis of the retrospective EU-CERT-ICD registry with respect to QRS duration and effects of cardiac resynchronisation therapy (CRT) on outcomes.

Methods/Results

A total of 5033 patients (81% males) from 14 European centres had an ICD implanted for primary prophylaxis. Mean age at the time of ICD implantation was 64±11 years and ischemic cardiomyopathy was the underlying pathology in 65% of patients. CRT was used in 43% of the patients. The median follow-up was 2.7 years (IQR 1.4-4.6 years). Predefined primary endpoints were all-cause mortality, first appropriate and first inappropriate shocks. The effect of covariates on the cumulative primary endpoints were assessed through hazard ratios in the Fine and Gray subdistributional hazard models (accounting for the competing risks) stratified by centres.

Because of resynchronization by the device, the analysis considered a different influence of QRS on outcomes in the CRT-D and the ICD groups. We observed an increase in the cumulative incidence of the first appropriate shock with increasing QRS values for patients implanted with only an ICD (HR 1.12 per 10ms increase, p<0.001). In patients with CRT-D, increasing QRS values related to a (statistically non-significant) decrease in the cumulative incidence of the first appropriate shocks (HR 0.96 per 10ms, p=0.299).

Since a wide QRS is an indication for CRT-D therapy, high QRS values cluster among those patients with implanted CRT-D, while among patients with QRS under 130ms standard ICD implantations are more frequent. This can explain the observed increase in the cumulative incidence of the first appropriate shocks for increasing QRS values up to 130ms in the ICD-group and its decrease for increasing QRS values over 130ms in the CRT-D group.

Regarding all-cause mortality, hazard ratios for age, LVEF, NYHA, ICM, AF, diabetes and sex category agreed with the results obtained in previously published meta-analyses.

Increased QRS values are associated with higher mortality in the ICD group (HR 1.09 per 10ms increase, p<0.001), but not in the CRT-D group (HR 0.99 per 10ms increase, p=0.695).

Conclusion

In our study, we confirmed QRS duration as an independent risk factor for appropriate ICD shocks and all-cause mortality in patients with ICD for primary prophylaxis. However, this was only observed in patients with single- or dual-chamber ICD, while there was no correlation in CRT-D patients. The findings suggest that CRT-D exerts a protective effect regarding the occurrence of first appropriate shock and all-cause mortality for patients with QRS values higher than 130 ms and indication for resynchronization.

3D Finite Element Simulation of Processing of Generalized Newtonian Fluids in Counter-rotating and Tangential TSE and Die Combination

A full three-dimensional finite element analysis of the nonisothermal flow of generalized non-Newtonian fluids in counter-rotating tangential twin screw extruder is presented. Previous studies of the simulation of processing in tangential twin screw extruders have focused solely on the twin screw extruder, whereas here the coupled flow and heat transfer occurring in the integrated geometry of the extruder, connected to a die are considered. The FEM based numerical simulation of the coupled momentum-mass-energy conservation equations allowed the determination of the effects of some of the important system parameters, including the power law index and the staggering angle of the screws, on the pumping and pressurization capability of the extruder and the associated degree of fill in the extruder.

Vraag & Antwoord

- Intestinaal microbioom/dysbiose-index bij chronische darmproblemen bij kleine huisdieren - Effect of anemia on performance and immune response in piglets - Behandeling van FIP bij katten

Assessment of land use cover changes, carbon sequestration and carbon stock in dry temperate forests of Chilas watershed, Gilgit-Baltistan

Abstract Land use and land cover change are affecting the global environment and ecosystems of the different biospheres. Monitoring, reporting and verification (MRV) of these changes is of utmost importance as they often results in several global environmental consequences such as land degradation, mass erosion, habitat deterioration as well as micro and macro climate of the regions. The advance technologies like remote sensing (RS) and geographical information system (GIS) are helpful in determining/ identifying these changes. In the current study area, changes in carbon stocks, notably in forest areas, are resulting in considerable dynamics of carbon stocks as a result of climate change and carbon sequestration. This study was carried out in the Diamer district of the Gilgit Baltistan (GB) Pakistan to investigate the change in cover change/land use change (particularly Forest Land use) as well as carbon sequestration potential of the forests in the district during almost last 25years. The land cover, temporal Landsat data (level 1, LIT) were downloaded from the USGS EROS (2016), for 1979-1989, 1990-2000 and 2001-2012. Change in land uses, particularly forest cover was investigated using GIS techniques. Forest inventory was carried out using random sampling techniques. A standard plot of size 0.1 ha (n=80) was laid out to determine the tree density, volume, biomass and C stocks. Simulation of C stocks was accomplished by application of the CO2FIX model with the data input from inventory. Results showed a decrease in both forest and snow cover in the region from 1979-2012. Similarly decrease was seen in tree volume, tree Biomass, dynamics of C Stocks and decrease was in occur tree density respectively. It is recommended we need further more like project such as BTAP (Billion Tree Afforestation Project) and green Pakistan project to increase the forest cover, to control on land use change, protect forest ecosystem and to protect snow cover.

Atypical HUS triggered by COVID-19: A case report

We hereby present a case of an atypical hemolytic uremic syndrome (aHUS) precipitated by coronavirus disease 2019 (COVID-19). A 26-year-old male was diagnosed with COVID-19 and acute kidney injury. His kidney biopsy was suggestive of thrombotic microangiopathy. Five sessions of plasmapheresis were done but were discontinued in view of nonrecovery of kidney function. He was then referred for a kidney transplant. On genetic analysis, he was found to have mutations in the complement system (CFHR1 and CFHR3), which suggested this was a case of aHUS precipitated by COVID-19. In view of the high risk of recurrence of the primary disease in live-related kidney donor transplantation, he was advised for simultaneous liver and kidney transplants.

Lung ultrasound could reduce X-ray after major lung resection

OBJECTIVES

This study evaluated the role of ultrasound in postoperative care after major lung resection.

BACKGROUND

High accuracy of lung ultrasound imaging was proved in various medical fields. The experience with ultrasound after thoracic surgery is limited.

METHODS

Patients scheduled for major lung resection were consecutively included in a prospective study comparing two modalities of imaging examinations, namely those employing ultrasound and X-ray in the diagnoses of pneumothorax and pleural effusion. Two examinations were performed. One after recovery from anaesthesia, the second before chest tube removal.

RESULTS

Forty-eight patients underwent 87 examinations. X-ray and ultrasound examinations showed substantial and fair agreements for pneumothorax (Cohen's kappa coefficients 0.775 and 0.397) and slight and substantial agreements for pleural effusion (Cohen's kappa coefficients 0.036 and 0.611). The sensitivity bounds for pneumothorax were 45.5-58.5 % at the first and 29.7-59.4 % at the second examination. Sensitivity bounds for pleural effusion were 0-86.2 % at the first and 32.6-36.9 % at the second examination. Except for two cases of pneumothorax being missed by X-ray imaging, the rest of mismatches were clinically irrelevant conditions with no impact on clinical decision and patient's outcome.

CONCLUSION

The use of ultrasound can reduce the number of X-ray examinations and thus lower the radiation exposure after major lung resections (Tab. 4, Ref. 30).

Chylous Ascites after Laparoscopic Donor Nephrectomy: Case Report

Chylous ascites refers to the accumulation of chyle in the abdominal cavity. Postoperative chylous ascites is most commonly associated with abdominal aortic surgeries. However, it is a rare complication following laparoscopic nephrectomy. It causes loss of fat, protein, and antibodies causing malnutrition and immunodeficiency. Thus, it is important to treat it as early as possible. We hereby report a case of chylous ascites following laparoscopic donor nephrectomy. A 55-year-old female was admitted at our center 2 weeks after undergoing left laparoscopic donor nephrectomy with abdominal distension and constipation. USG abdomen revealed free fluid in the abdomen. Paracentesis revealed chylous ascites. The patient was started on conservative treatment, including a diet rich in proteins and low in fats; conservative treatment, however, was unsuccessful. Lymphangiography and subsequent embolization of the defect were done, and she made a full recovery.

IgA Nephropathy with Wilson's Disease: A Case Report and Literature Review

The most common glomerulonephritis seen in the world is immunoglobulin A nephropathy (IgAN). It can be primary or secondary associated with various conditions like Chronic Liver disease, Crohn's disease, neoplasms, etc. However, IgAN secondary to Wilson's disease is very rare. A 9 year old boy presented with gross hematuria and proteinuria. He had a history of recurrent jaundice in the past. Ultrasonography (USG) whole abdomen showed altered echotexture of the liver with normal-sized kidneys. An extended workup for liver disease was done, and the diagnosis of Wilson's disease was confirmed with decreased serum ceruloplasmin levels, increased urinary copper, and the Kayser-Fleischer ring. Urine routine microscopy showed numerous red blood cells, few red blood cell casts, and mild proteinuria. Renal biopsy showed IgAN. The patient was started on D-penicillamine. On follow-up at 3 months, he showed complete resolution of proteinuria and hematuria. Thus, we suggest that Wilson's disease should be considered as one of the causes of secondary IgAN in pediatric patients with hematuria, proteinuria with liver dysfunction.

The Haleem-Marks-Botchu classification: a novel CT-based classification for intracanal rib head penetration

PURPOSE

Intracanal rib head penetration is a well-known entity in dystrophic scoliotic curves in neurofibromatosis type 1. There is potential for spinal cord injury if this is not recognised and managed appropriately. No current CT-based classification system is currently in use to quantify rib head penetration. This article aims to propose and evaluate a novel CT-based classification for rib head penetration primarily for neurofibromatosis but which can also be utilised in other conditions of rib head penetration.

MATERIALS AND METHODS

The grading was developed as four grades: normal rib head (RH) position-Grade 0, subluxed extracanal RH position-Grade 1, RH at pedicle-Grade 2, intracanal RH-Grade 3. Grade 3 was further classified depending on the head position in the canal divided into thirds. Rib head penetration into proximal third (from ipsilateral side)-Grade 3A, into the middle third-Grade 3B and into the distal third-Grade 3C. Seventy-five axial CT images of Neurofibromatosis Type 1 patients in the paediatric age group were reviewed by a radiologist and a spinal surgeon independently to assess interobserver and intraobserver agreement of the novel CT classification. Agreement analysis was performed using the weighted Kappa statistic.

RESULTS

There was substantial interobserver correlation with mean Kappa score (k = 0.8, 95% CI 0.7-0.9) and near perfect intraobserver Kappa of 1.0 (95% CI 0.9-1.0) and 0.9 (95% CI 0.9-1.0) for the two readers.

CONCLUSION

The novel CT-based classification quantifies rib head penetration which aids in management planning.

1576 Safeguarding Tools in Paediatric Burns

Introduction

When assessing paediatric patients presenting with burns, non-accidental injury always has to be considered. In our department, local policy dictates that all patients aged 18 or below should have a child safeguarding tool completed on initial clerking.

Method

A retrospective audit of all paediatric burns seen over one month was performed. Primary outcome measures included completion of a safeguarding tool and documentation of referral outcome. These results were presented locally and implementing changes were carried out. This was then re-audited over a further monthly period.

Results

Initial data collection showed a safeguarding tool completion rate of 69% and referral outcome documentation rate of 50% (n = 16). Implement changes included dissemination of initial audit results to the department, changing the layout of our clerking proformas and introducing posters in the unit which provided more information on risk assessing paediatric patients. The re-audit results showed a safeguarding tool completion rate of 100% and a referral outcome documentation rate of 100% (n = 14).

Conclusions

There was a significant improvement in both the safeguarding tool completion and referral outcome documentation rates following our interventions. Simple measures just such education and strategic adjustments of clerking proformas have been shown to be effective measures for increasing documental compliance of child safeguarding tools.

1013 Dupuytren’s Contracture Treatment with XIAPEX Injection: Reviewing A Single Surgeon's Experience

Aim

To review a single surgeon's experience for the treatment of Dupuytren's disease with XIAPEX injection and the clinical outcomes as measured by a URAM score.

Method

Retrospective review of patient notes, clinical photography and URAM scores for patients who underwent the procedure between August 2013 and October 2016.

Results

33 patients underwent the procedure. 25 patients completed pre and post URAM scores. Average pre procedure score was 19.4 and avergae post procedure score was 3.28 a difference of 16.12 (clinically important change for URAM score is 2.9). Average pre procedure MCPJ contracture was 46.67 degrees and average post procedure contracture was 3.3 degrees. Average pre procedure PIPJ contracture was 66.8 degrees and average post procedure contracture was 8.2 degrees. Where both MCPJ and PIPJ affected of the same digit average pre procedure MCPJ and PIPJ contracture was 60 degrees. The post procedure contracture was 0 degrees in the MCPJ and 29.7 degrees in the PIPJ. 1 patient underwent surgery for progressive disease.

Conclusions

XIAPEX injection has shown a clinically significant result in the treatment of Dupuytren's disease. There were minimal complications and only 1 patient needed further surgery. However, a small sample size thus conclusions have to be cautious.

1632 Improving Excision Margins in Skin Oncology

Aim

There are 152,000 new non-melanoma skin cancer (NMSC) cases in the UK every year, and excision and reconstruction of basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) form a significant part of the clinical workload in plastic surgery. In this quality improvement project, we aimed to identify and improve our unit’s compliance of guidelines for excision margins for NMSCs.

Method

A retrospective audit was undertaken in June 2020 to determine compliance with British Association of Dermatology and local guidelines on excision margins for NMSCs. A repeat audit was undertaken in October 2020 following quality improvement interventions.

Results

The first audit cycle examined 66 lesions in total. Guidelines were met in 53% (BCCs) and 50% (SCCs) of lesions. 12% of lesions had unclear documentation of margins. 16 lesions had margins that were too small as according to the risk factors present. These findings were presented to the department, and a new operative note template specifically designed for skin oncology was launched. Key audit findings were displayed along with the guidelines on posters. A repeat cycle was undertaken in October 2020, which examined 52 lesions. Significant improvement was seen with 100% documentation, and excision margin guideline compliance rate of 71% (BCCs) and 79% (SCCs).

Conclusions

Adequate excision margins in skin oncology is vital to ensure complete excision and to minimise the risk of recurrence. Our project demonstrates significant improvement in excision margin compliance through the launch of a specific operative note template and information posters.

Conventional oxygen therapy versus CPAP as a ceiling of care in ward-based patients with COVID-19: a multi-centre cohort evaluation

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is commonly used for respiratory failure due to severe COVID-19 pneumonitis, including in patients deemed not likely to benefit from invasive mechanical ventilation (nIMV). Little evidence exists demonstrating superiority over conventional oxygen therapy, whilst ward-level delivery of CPAP presents practical challenges. We sought to compare clinical outcomes of oxygen therapy versus CPAP therapy in patients with COVID-19 who were nIMV.

METHODS

This retrospective multi-centre cohort evaluation included patients diagnosed with COVID-19 who were nIMV, had a treatment escalation plan of ward-level care and clinical frailty scale ≤ 6. Recruitment occurred during the first two waves of the UK COVID-19 pandemic in 2020; from 1^st March to May 31^st, and from 1^st September to 31^st December. Patients given CPAP were compared to patients receiving oxygen therapy that required FiO₂ ≥0_.4 for more than 12 hours at hospitals not providing ward-level CPAP. Logistic regression modelling was performed to compare 30-day mortality between treatment groups, accounting for important confounders and within-hospital clustering.

FINDINGS

Seven hospitals provided data for 479 patients during the UK COVID-19 pandemic in 2020. Overall 30-day mortality was 75.6% in the oxygen group (186/246 patients) and 77.7% in the CPAP group (181/233 patients). A lack of evidence for a treatment effect persisted in the adjusted model (adjusted odds ratio 0.84 95% CI 0.57-1.23, p=0.37). 49.8% of patients receiving CPAP-therapy (118/237) chose to discontinue it.

INTERPRETATION

No survival difference was found between using oxygen alone or CPAP to treat patients with severe COVID-19 who were nIMV. A high patient-initiated discontinuation rate for CPAP suggests a significant treatment burden. Further reflection is warranted on the current treatment guidance and widespread application of CPAP in this setting.

FUNDING

L Pearmain is supported by the MRC (MR/R00191X/1). TW Felton is supported by the NIHR Manchester Biomedical Research Centre.

Granulomatosis with Polyangiitis Masquerading as Renal Mass: Case Report and Literature Review

Wegener's granulomatosis or granulomatosis with polyangiitis (GPA) is multisystemic vasculitis. Kidney involvement in GPA often presents with rapidly progressive renal failure and requires urgent treatment. A 60-year-old female presented with prolonged history of fever, generalized weakness, decreased appetite, and weight loss over 4 months. Her renal function was normal; urine culture was sterile. On further evaluation, she was found to have large, hypodense solid lesion in mid pole of the right kidney on CECT. CT guided renal biopsy was done, which showed granulomatous interstitial nephritis with focal crescents. On further evaluation, she was found to have high titers of anti-MPO antibody. She was started on steroid and methotrexate with subsidence of fever. Follow-up after 12 months showed resolution of the lesion. GPA solely presenting as solid mass like lesion in the kidney is extremely rare presentation. Early diagnosis and prompt initiation of the treatment can prevent the progression of the disease.

Outcomes of Kidney Transplantation in the Elderly Recipients

Introduction:

In a developing country with a predominantly young population, the valid assumption is directed toward medical care toward the young. However, as medical technology has advanced, quality care has ensured better survival for the elderly population also. The aim of this study was to determine the clinical outcomes in elderly patients undergoing kidney transplantation.

Materials and Methods:

A retrospective analysis of 1150 patients who had undergone live related renal transplantation was done from January 2006 to December 2014. These patients were divided into two groups; Group 1: age >60 years (N = 150), Group 2: age 18–60 years (N = 1000). The clinical outcomes were compared.

Results:

The mean age in Group 1 was 69 ± 7.5 years (SD ± 7.5), and group 2 was 41 ± 8 years. In groups 1 and 2, males were 80% and 82%; death censored graft survival at 5 years was 82% and 87%; patient survival at 5 years was 86% and 94%, respectively. The incidence of biopsy-proven acute rejection was similar in both groups (11.3 vs. 10.2%, P = 0.12). Urinary tract infection was the most common infectious complication. Sepsis was the primary cause of death in both groups.

Conclusion:

In the elderly patients who underwent kidney transplantation, satisfactory graft function, and patient survival were maintained over a period of 60 months. Urinary tract infections were common, and sepsis was the most common cause of death with a surviving allograft. The acute rejection and mortality rates were comparable to the literature published from India so far.

Double whammy: anticoagulant-related nephropathy with leukocytoclastic vasculitis due to warfarin

Anticoagulation-related nephropathy (ARN) is a rare form of acute kidney injury where the use of anticoagulation causes hemorrhage in various compartments of nephron including glomerulus, renal tubules, and interstitial compartment. Also, warfarin-induced vasculitis is an extremely rare condition characterized by the appearance of purpuric lesions on the skin which on biopsy are suggestive of leukocytoclastic vasculitis (LV). We hereby report a case presenting with coexistent warfarin-induced nephropathy and cutaneous vasculitis. A 64-year-old male, on warfarin for 10 years, presented with complaints of palpable purpuric rashes over lower limbs, hematuria, and decrease urine output. INR was in the supratherapeutic range (INR-6.3). Skin biopsy of the lesion was suggestive of LV and kidney biopsy showed RBCs in Bowman's capsule, RBCs and RBC casts in tubules suggestive of ARN. All vasculitic markers were negative. Thus, a diagnosis of warfarin-induced nephropathy and cutaneous vasculitis was made. Warfarin was discontinued and oral steroids were started. Gradually, his skin lesions improved, and he became dialysis independent. He was then discharged on apixaban. On follow-up after 3 months, his skin lesions had disappeared with partial recovery of kidney function (cr-5.49).

Comparison of short-term outcomes with and without induction therapy in low-risk renal transplant recipients

With low rates of rejection with current immunosuppression consisting of steroids, mycophenolic acid and tacrolimus, the question arises whether induction offers any additional benefit in low-risk renal transplant recipients. This study evaluated outcomes with and without induction in low-risk renal transplant recipients. A prospective observational study in which 100 low-risk renal transplant recipients were included and divided into two groups - one that received induction (IND) and another that did not (NO IND). They were followed for 1.5 years. Three endpoints were compared - efficacy of induction, patient and graft survival, and adverse effects. Incidence of rejection in early posttransplant period did not differ (4% NO IND vs. 6% IND; P = 0.171). Rejection as cause of late graft dysfunction was seen in 16% in IND vs. 20% NO IND; (P = 0.603). No difference in serum creatinine at end of 1.5 years was seen. Graft survival was also similar. Relapsing and recurrent urinary tract infections (46% IND vs. 16% NO IND; P = 0.09), hospitalization requiring infections (76%IND vs. 64% NO IND; P = 0.119 NS) were more common in IND. Cytomegalovirus infection affected only IND (6% vs. none; P = 0.07). Patient survival at 1.5 years was comparable (94% IND vs. 96% NO IND; P = 0.646). The study showed comparable results between IND and NO IND with however an increased incidence of infections and hospitalizations in the IND group. The use of induction may be avoided in low-risk renal transplant recipients.

Stretching the boundaries: suitability of an arteriovenous fistula in elderly patients on hemodialysis-a northern India experience

PURPOSE

Considering various factors, such as multiple co-morbidities, unsuitable vessels for access creation, non-maturation, vascular calcifications, the outcome of arteriovenous fistula (AVF) in the elderly population, may not be similar to the younger people. Our study aims to analyze the outcomes of AVF in elderly patients (> 65 year).

METHODS

It was a prospective observational study. Patients of more than 65 years of age in whom AVF was created from January 2012 to December 2015 were included in the study. These patients were followed up for 4 years. The primary endpoint of our study was to assess primary and secondary patency rates.

RESULTS

A total of 450 AVFs were included in the study. The mean age was 68.5 years. The most common site of AVF was radiocephalic (RCAVF) in 70% (n = 315), brachiocephalic (BCAVF) in 24% (n = 108) and basilic vein transposition (BVT) in 6% (n = 27). At 48 months, the primary patency rate of RCAVF, BCAVF, and BVT was 55%, 61.6%, and 60.4%, respectively. The commonest cause of access failure was thrombosis followed by non-maturation.

CONCLUSION

AVF remains the preferred vascular access for hemodialysis even in the elderly population. Failure to mature and thrombosis continue to be a concern with AVF. Location of the AV access does not seem to impact the long-term patency.

Development, Characterization, and Evaluation of SLN-Loaded Thermoresponsive Hydrogel System of Topotecan as Biological Macromolecule for Colorectal Delivery

BACKGROUND

Chemotherapeutic drugs cause severe toxicities if administered unprotected, without proper targeting, and controlled release. In this study, we developed topotecan- (TPT-) loaded solid lipid nanoparticles (SLNs) for their chemotherapeutic effect against colorectal cancer. The TPT-SLNs were further incorporated into a thermoresponsive hydrogel system (TRHS) (TPT-SLNs-TRHS) to ensure control release and reduce toxicity of the drug. Microemulsion technique and cold method were, respectively, used to develop TPT-SLNs and TPT-SLNs-TRHS. Particle size, polydispersive index (PDI), and incorporation efficiency (IE) of the TPT-SLNs were determined. Similarly, gelation time, gel strength, and bioadhesive force studies of the TPT-SLNs-TRHS were performed. Additionally, in vitro release and pharmacokinetic and antitumour evaluations of the formulation were done.

RESULTS

TPT-SLNs have uniformly distributed particles with mean size in nanorange (174 nm) and IE of ~90%. TPT-SLNs-TRHS demonstrated suitable gelation properties upon administration into the rat's rectum. Moreover, drug release was exhibited in a control manner over an extended period of time for the incorporated TPT. Pharmacokinetic studies showed enhanced bioavailability of the TPT with improved plasma concentration and AUC. Further, it showed significantly enhanced antitumour effect in tumour-bearing mice as compared to the test formulations.

CONCLUSION

It can be concluded that SLNs incorporated in TRHS could be a potential source of the antitumour drug delivery with better control of the drug release and no toxicity.

MO190NORMATIVE DATA FOR GLOMERULAR FILTRATION RATE IN HEALTHY KIDNEY DONOR POPULATION

Background and Aims

Glomerular filtration rate (GFR) is estimated traditionally from 24-hour urinary creatinine clearance. Creatinine is mainly filtered by glomerulus. The collection of 24-hour urinary sample is a difficult task with many patients fail to collect all the urine samples. As measuring GFR is cumbersome, expensive, and not easily available in all centers, various equations are developed for estimating GFR from creatinine like MDRD, CKD EPI creatinine. GFR obtained from serum creatinine shows wide variation as muscle mass and dietary protein intake are important determinants of serum creatinine concentration. Literature shows very few studies with GFR estimation with reference to age in Indian population. Hence, this study is planned to develop age specific nomogram for GFR in healthy kidney donor population as well as to study agreement between GFR obtained by 99m Tc DTPA three sample method and GFR estimated by 24-hour urinary creatinine. The aim of this stidy was to develop age-specific nomogram GFR in healthy kidney donor population and to study the agreement between the GFR measured by Technetium-99m diethylene triamine pentaacetic acid (99m Tc DTPA) and 24-hour urinary creatinine method.

Method

This study was conducted at Sir Ganga Ram hospital, New Delhi. All healthy individuals aged more than 20 years and less than 65 years, undergoing evaluation as prospective kidney donor at our hospital were the part of this study. GFR was measured by 99m Tc DTPA clearance using 3 sample method. GFR measured by DTPA method was used to develop nomogram. Creatinine Clearance was calculated from 24-hour urinary creatinine by formula U x V/P where, U is urinary creatinine level, P is plasma creatinine level and V is total volume of urine. Nomogram was developed with respect to these 3 Age groups; namely, 20 to 40 years, 40 to 50 years and 50 to 65 years

Results

Total 100 kidney donors were included in this study. Enrolled subjects were divided into 3 age groups; 20 to 40 years (n=28), 40 to 50 years (n=46) and 50 to 65 years (n=26). Majority of the donors were females (n=80). The agreement between GFR obtained by 99m Tc DTPA and 24-hour urinary creatinine clearance methods was 92.6 vs. 94 ml/min, 80.4 vs. 76 ml/min and 76.3 vs. 70 ml/min in respective age groups.

Conclusion

In the younger age group (20 to 40 years), there is better agreement in GFR measured by 99m Tc DTPA method and 24-hour urinary creatinine clearance methods.

Quality of life and well-being of population at the end of third phase of lockdown in india against the COVID-19 pandemic

Background. On March 24, 2020, a nationwide Lockdown for 21 days was ordered by the Government of India which was then extended till May 31, 2020. Researchers have predicted lockdown is a necessary step to prevent COVID-19 spread. However, others have also stated that it could cause serious damage to the economic, mental, social, and physical well-being of the people. Objective. The aim of the study is to evaluate the impact of lockdown on the quality of life and well-being of the Indians. Methods. It is a cross sectional prospective web-based questionnaire study. A link (https://forms.gle/pX25VuahP5NxT88QA) was created. Total 426 responses were received via that link and the data was included in the statistical analysis. Results. Our study revealed that during the lockdown 61.5% of the respondents were performing physical activities lesser than before. More than half responded they had a reduced financial satisfaction. Most answers on emotional well-being and social-family wellbeing were also positive, but some responses showed disturbing too, like 22% felt anxious and nervous over half of the days. It was found in the study that physical, financial, emotional, mental, social and family wellbeing were disturbed during the lockdown and quality of life was also hampered. Conclusion. Though, may be Nationwide Lockdown was the most required action at that point of time to prevent virus spread, but our study revealed that uncertainty regarding its cure and management guidelines like lockdown and social distancing has badly affected quality of life and wellbeing of the population.

Renal Biopsy and Clinical Outcomes in Patients With ABO-Incompatible Renal Transplant: Experience From a Tertiary Care Hospital

OBJECTIVES

Renal transplant with ABO-incompatible donors expands the donor pool. Earlier studies have focused the use of protocol biopsies in ABO-incompatible transplant patients. Our study described outcomes of indication (for cause) renal biopsies and clinical outcomes in patients with ABO-incompatible renal transplant.

MATERIALS AND METHODS

This retrospective study included 164 patients from January 2012 to June 2019. Biochemical parameters, serial immunoglobulin G anti-ABO titers, and class I and II donor-specific antibody findings were obtained from hospital records, and renal graft biopsies were reviewed according to the Banff 2017 update.

RESULTS

We analyzed the results of 65 biopsies from 54 patients. Biopsy-proven acute antibody-mediated rejection (12.8%) was found to be more prevalent than acute cellular rejection (1.8%). Patients with antibodymediated rejection all had microvascular inflammation (g+ptc score of 2 or more, where g+ptc is the sum of the glomerulitis and peritubular capillaritis scores) and were positive for C4d. Acute tubular injury per se was seen in 10.3% of patients; 65% of these patients had C4d positivity in peritubular capillaries, and only 1 patient developed chronic active antibody-mediated rejection on follow-up. Patient and death-censored graft survival rates were 92% and 98% at 1 year after transplant and 88% and 91% at 3 years, respectively. Patients with an episode of antibody-mediated rejection had lower rates of patient (76.5%) and deathcensored graft survival (84.6%) at 1 year.

CONCLUSIONS

The microvascular inflammation score (g+ptc score of 2 or higher) is more reliable than diffuse C4d positivity to determine antibody-mediated rejection in ABO-incompatible transplants because diffuse C4d positivity may also be seen in etiologies unrelated to antibody-mediated rejection. Acute tubular injury with C4d positivity without microvascular injury does not confirm antibody-mediated rejection. We suggest that Banff classification be updated in ABO-incompatible transplants to include diagnostic criteria for the diagnosis of antibody-mediated rejection.

COVID-19 Infection in Renal Transplant Patients: Early Report From India

INTRODUCTION

COVID -19 has gripped the whole world and patients with comorbidities especially kidney ailments are at higher risk of developing severe disease. Among kidney disease, transplant patients are the most vulnerable group. Information on coronavirus disease 2019 (COVID-19) in kidney transplant patients is very limited.

METHODS

An observational study was conducted on 20 kidney transplant patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction from April to June 2020.

RESULTS

The majority of cases were males (85%). The median age of the patients was 50 years (interquartile range [IQR] 40.75-60.75). Diabetes and hypertension were present in 55% and 95% of patients, respectively. Coronary artery disease was present in three patients (15%). The median time from transplant to COVID-19 testing was 54 months (IQR 36-105). Chronic allograft nephropathy was found in 35% of patients. The mean baseline creatinine was 1.71 mg/dL. The most common symptom was fever (80%). Acute Kidney Injury was seen in 60% of patients with a mean creatinine of 2.60 mg/dL. Based on severity, 50% of patients had mild disease, 25% moderate disease, and the remaining 25% had severe disease. All 20 patients were on oral steroids, calcineurin inhibitors (18 on tacrolimus and two on cyclosporine), and antimetabolite (19 on mycophenolate mofetil and one on azathioprine). Antimetabolite agents were stopped in all patients and tacrolimus was stopped in severe cases (25%). Hydroxychloroquine was given in 15 patients (75%). Fifteen patients (75%) recovered while five (25%) died.

CONCLUSION

Kidney transplant recipients infected with COVID-19 have high mortality.

Prescription understanding among out-patients in government and private hospitals: A cross-sectional study in Lahore, Pakistan

INTRODUCTION

Like many other countries, Pakistan's healthcare system is divided into the public and the private sector. According to some studies and the mindset of many Pakistani people, private hospitals provide better services than government hospitals.

PURPOSE

The paucity of research studies compelled us to compare the understanding of prescription among outpatients of the government and private hospitals since the understanding of prescription by the patient is an important patient care indicator according to WHO.

METHOD

A cross sectional study was conducted by virtue of convenience sampling. The study included 365 patients; 182 from the government sector and 183 from the private sector. The study was conducted over a period of 3 months. A structured questionnaire was prepared to gather data that was analyzed using SPSS Version 22.0.

RESULTS

Patients from both government and private hospitals got no counseling while only 45.9% of the government hospital patients and 65.9% of private hospital patients were satisfied with the counseling they received. Our study concluded that the role of a pharmacist must be extended besides dispensing only, in counseling and educating patients to reduce the burden on the physicians and hospitals as well.

CONCLUSION

It was concluded that although the patients of private hospitals scored somewhat better at answering the questions than the government hospital patients but they failed to hit the benchmark. Their slightly better results were attributed to higher education levels and better socioeconomic status rather than better services of the hospital.