Cognitive Performance and Neuro-Metabolites in HIV Using 3T Magnetic Resonance Spectroscopy: A Cross-Sectional Study from India

BACKGROUND

Cognitive impairment in patients with human immunodeficiency virus (HIV) is associated with higher morbidity. The prevalence of the metabolite changes in the brain associated with cognitive impairment in anti-retroviral therapy naïve patients with HIV is unknown.

OBJECTIVE

To estimate the prevalence of the neurometabolites associated with cognitive impairment in antiretroviral therapy (ART) naïve patients with HIV.

METHODS

We conducted a cross-sectional study among ART naïve patients with HIV aged 18-50 years in a tertiary care center in India. Cognition was tested using the Post Graduate Institute battery of brain dysfunction across five domains; memory, attention-information processing, abstraction executive, complex perceptual, and simple motor skills. We assessed the total N-acetyl aspartyl (tNAA), creatine (tCr) and glutamate + glutamine (Glx) using 3T magnetic resonance spectroscopy. Cognitive impairment was defined as an impairment in ≥2 domains.

RESULTS

Among 43 patients eligible for this study, the median age was 32 years (IQR 29, 40) and 30% were women. Median CD4 count and viral load were 317 cells/μL (IQR 157, 456) and 9.3 copies/ μL (IQR 1.4, 38), respectively. Impairment in at least one cognitive domain was present in 32 patients (74.4%). Impairment in simple motor skills and memory was present in 46.5% and 44% of patients, respectively. Cognitive impairment, defined by impairment in ≥2 domains, was found in 22 (51.2%) patients. There was a trend towards higher concentration of tNAA (7.3 vs. 7.0 mmol/kg), tGlx (9.1 vs. 8.2 mmol/kg), and tCr (5.5 vs. 5.2 mmol/kg) in the frontal lobe of patients with cognitive impairment vs. without cognitive impairment but it did not reach statistical significance (p>0.05 for all). There was no difference in the concentration of these metabolites in the two groups in the basal ganglia.

CONCLUSION

There is a high prevalence of cognitive impairment in ART naïve patients with HIV. There is no difference in metabolites in patients with or without cognitive impairment. Further studies, with longitudinal follow-up are required to understand the underlying pathophysiological mechanisms.

The management of women with thoracic endometriosis: a national survey of British gynaecological endoscopists

OBJECTIVES

This study evaluates current national opinions on screening, diagnosis, and management of thoracic endometriosis.

BACKGROUND

Thoracic endometriosis is a rare but serious condition with four main clinical presentations: pneumothorax, haemoptysis, haemothorax, and pulmonary nodules. There are no specialist centres in the United Kingdom despite growing patient desire for recognition, investigation, and treatment.

METHODS

We distributed a multiple-choice email survey to senior members of the British Society for Gynaecological Endoscopy. Descriptive statistics were used to present the results. Results: We received 67 responses from experienced clinicians having provided over 800 combined years of endometriosis patient care. The majority of respondents managed over 100 endometriosis patients annually, for more than five years. Over one third had never managed a patient with symptomatic thoracic endometriosis; just 9% had managed more than 30 cases over the course of their career. Screening varied by modality with only 4% of clinicians always taking a history of respiratory symptoms while 69% would always screen for diaphragmatic endometriosis during laparoscopy. The management of symptomatic thoracic endometriosis varied widely with the commonest treatment being surgery followed by hormonal therapies. Regarding management, 71% of respondents felt the team should comprise of four or more different specialists, and 56% believed care should be centralised either regionally or nationally.

CONCLUSIONS

Thoracic endometriosis is poorly screened for amongst clinicians with varied management lacking a common diagnostic or therapeutic pathway in the United Kingdom. Specialists expressed a preference for women to be managed in a large multidisciplinary team setting at a regional or national level.

106 Exogenous melatonin administration improves behavioural signs, serum melatonin, testosterone, and semen quality in male dromedary (Camelus dromedarius) camels

The present study aimed to evaluate the effects of exogenous administration of melatonin to male camels on reproductive behaviour, seminal parameters, and serum concentrations of melatonin and testosterone during the non-breeding and subsequent breeding seasons. In September 2018, male camels (n=12) were randomly allocated to subcutaneous injections of either melatonin (MLT, 0.643 mg/kg; n=6) dissolved in corn oil, or plain corn oil; (control n=6). The camels were observed for behavioural signs of rut. A second dose of either MLT (1 mg/kg) or corn oil (control) was administered on 7 October 2018 subcutaneously, as camels did not show any change in behaviour until 6 October 2018, and the camels were again observed for behavioural signs of rut. Blood was collected from all camels on 1 September 2018, and then at weekly intervals until 7 January 2019. The serum was separated and stored until further assay of serum melatonin and testosterone using ELISA kits. Semen was collected from camels showing signs of rut period, and the reaction time, copulation time, and seminal parameters were evaluated. Data obtained was analysed by using the computer program SPSS (version 25; IBM Corp.), and means and standard errors were compared. Male reproductive behaviours (protrusion of soft palate, poll gland secretions, frequent urination, increased frothy salivation) were more pronounced in MLT-treated camels (83.33%) than in control camels (50%). Reaction time and copulation times were lower (112.81±30.06s and 229.8±37.91s) in MLT-treated camels than in controls (359.00±41.35s and 301.89±93.90s). Higher semen volume was observed in MLT-treated (5.34±2.06mL) than in control (3.11±1.75mL) camels (P<0.01). Semen collected from MLT-treated camels had more gel formation (81.25%), significantly higher sperm motility (67.50±2.32%), and increased sperm concentration (326.56±38.67 million mL−1) compared with samples obtained from the control males (P<0.01). Serum melatonin concentrations increased in both treated and control camels during the breeding season compared with concentrations before the breeding season. In MLT-treated camels, serum melatonin concentrations increased significantly and continued to be significantly higher than that in control camels for the entire study period (P<0.01). Serum testosterone concentrations were higher in both MLT-treated and control camels during the breeding season compared with those during the non-breeding season (P<0.01). We concluded that exogenous subcutaneous MLT administration improves sexual behaviour, seminal parameters, and serum testosterone concentrations during both the non-breeding and breeding seasons.

THU0415 MELTING OF TOPHI WITH LOCAL STEROIDS IN CHRONIC TOPHACEOUS GOUT: AN OBSERVATIONAL STUDY

Background:

Chronic tophaceous gout is usually difficult to treat with urate lowering therapy (ULT) [1]. Faster resolution of tophi has been seen with use of pegloticase [2], but this drug is costly and not widely available. Local steroid use is recommended in acute gouty arthritis but its role in reduction of tophi has not been studied. This study was aimed to see the effect of local steroids in tophi resolution.

Objectives:

To study the change in size of gouty tophi with local steroid injection compared to conventional treatment.

Methods:

Four crystal proven chronic tophaceous gout patients with multiple tophi were screened and enrolled in the study after taking informed consent. Total 12 tophi in 4 patients were imaged by using Duel Energy Computed Scan (DECT) for their size and volume. All 4 patients were treated with ULT as per recommended dose to achieve target serum uric acid (SUV) level. Six tophi were treated with local steroids injection (methylprednisolone acetate) at two months interval till complete resolution of tophi. Dose of steroid varied from 10 mg to 40 mg depending upon tophi size but subsequent repeat doses were same in each tophi. Six tophi not treated with local steroid served as internal control in the same patients. All 4 patients were followed up regularly in out-patient department to monitor treatment response and local side effects if any.

Results:

All 4 patients achieved target SUV (<356 µmol/L) at three months of follow up. Six tophi which were treated with local steroids injection clinically had marked reduction in size at 7-12 months of follow up [Table-1], while other 6 tophi which served as internal control had no clinically significant change in size and volume of tophi. DECT was repeated in the same settings to confirm the clinical findings. DECT revealed near complete resolution of 5 tophi [Image-1], and 50% reduction in size of one tophi. Six tophi which were not treated with local steroid had no significant reduction in size in DECT as well. Only side effect noted was skin discoloration in 5 out of 6 injected sites, none of the tophi had infection.

Conclusion:

Interestingly this is the first such study to document the use of local steroid in tophi. Thus intralesional steroids can be alternative to pegloticase or surgery where faster dissolution of tophi is required. This observation needs to be explored in large number of patients to calculate the total dose requirement of steroid as per volume and urate burden of tophi. Possible explanation of melting tophi with steroids is breaking down outer fibrous layer of tophi by local steroids which might be acting as barrier in dissolution of urate crystals with ULT.

References:

[1]Dalbeth N, House ME, Horne A et al. Prescription and dosing of urate-lowering therapy, rather than patient behaviours, are the key modifiable factors associated with targeting serum urate in gout.BMC Musculoskelet Disord2012;13:174

[2]Baraf HS, Becker MA, Gutierrez-Urena SR, et al: Tophus burden reduction with pegloticase: results from phase 3 randomized trials and open-label extension in patients with chronic gout refractory to conventional therapy. Arthritis Res Ther 15:R137, 2013

Table 1.Age/sexTotal TophiTreated TophiOutcome of treated tophiInternal control tophiDuration in monthsCase 122/M21Near complete resolutionNo Change 7Case 245/F11Complete resolutionNA 8Case 358/M52Near complete resolutionNo change12Case 424/M42Completely resolved=1,50% size reduction=1No change12Figure 1

a: DECT of Rt foot shows urate crystal deposition at 1stMTP joint and 5thtoe. Figure1b: DECT after 7 months of steroid injection in Rt 1stMTP joint tophi shows almost complete resolution but no change in 5thtoe tophi (served as internal control).

Disclosure of Interests: :

None declared

Determination of Vitamin B12 in Fortified Bovine Milk- Based Infant Formula Powder, Fortified Soya-Based Infant Formula Powder, Vitamin Premix, and Dietary Supplements by Surface Plasmon Resonance: Collaborative Study

A collaborative study was conducted on an inhibition-based protein-binding assay using the Biacore Q™ biosensor instrument and the Biacore Qflex™ Kit Vitamin B12 PI. The samples studied included infant formula, cereals, premixes, vitamin tablets, dietary supplements, and baby food. The collaborative study, which involved 11 laboratories, demonstrated that the assay showed an RSDr of 1.59–27.8 and HorRat values for reproducibility of 0.34–1.89 in samples with levels ranging from ppm to ppb. The assay studied is a label-free protein binding-based assay that uses the principle of surface plasmon resonance (SPR) to measure the interaction between vitamin B12 and a specifc binding protein. A Biacore Q biosensor uses this principle to detect binding directly at the surface of a sensor chip with a hydrophilic gold-dextran surface. The instrument passes a mixture of prepared sample extract and binding protein solution across a covalently immobilized vitamin B12 chip surface, and the response is given as free-binding protein as the mixture binds to the immobilized surface. This technique uses the specifcity and robustness of the protein-ligand interaction to allow minimal sample preparation and a wide range of matrixes to be analyzed rapidly. The reagents and accessories needed to perform this assay are provided as the ready-to-use format “Qflex Kit Vitamin B12 PI.” The method is intended for routine use in the quantitative determination of vitamin B12 (as cyanocobalamin) in a wide range of food products, dietary vitamin supplements, and multivitamin premixes.

Papilloedema: diffusion-weighted imaging of optic nerve head

AIM

To establish the correlation between clinical grading of papilloedema and diffusion abnormalities of optic nerve head (ONH) on diffusion-weighted imaging (DWI).

MATERIALS AND METHODS

Brain magnetic resonance imaging (MRI), including readout segmented echo planar imaging-based DWI, was performed in 32 patients with papilloedema and the same number of age- and sex-matched controls. Clinical grading of papilloedema was done according to the modified Frisén scale. Two neuroradiologists independently evaluated the MRI for ONH hyperintensity and apparent diffusion coefficient (ADC) value of ONH. The comparison between papilloedema clinical grade and qualitative grade of ONH hyperintensity and its presence between cases and control groups were done using the Chi-square test and Fisher's exact test, respectively. The comparison between mean ADC value of ONH among different grades and between cases and controls were done using analysis of variance (ANOVA)-F-test and Student's t-test, respectively. Receiver operating characteristic (ROC) analysis was done to calculate a cut-off ADC value between the case and control groups.

RESULTS

Significant correlation between ONH hyperintensity and mean ADC value of ONH with clinical grades of papilloedema and between cases and control groups were found. ONH hyperintensity was found to be a highly sensitive (87.5% for both) and specific (specificity 97.1% and 98.6% for two observers) sign of papilloedema. A mean cut-off ONH ADC value was found to have high sensitivity (96.83%) and specificity (95.31%) to distinguish between the cases and controls.

CONCLUSIONS

Diffusion parameters of ONH have significant correlation with clinical grading of papilloedema and can serve as a surrogate marker for intracranial pressure.

Wellen's syndrome: Challenges in diagnosis

Wellen's syndrome is a pre-infarction stage of coronary artery disease characterised by predefined clinical and electrocardiographic (ECG) criteria of a subgroup of patients with myocardial ischaemia. Early recognition and appropriate intervention of this syndrome carry significant diagnostic and prognostic value. We report this unusual syndrome in an elderly man who presented with recurrent angina and characteristic ECG changes as T-waves inversion in the precordial leads, especially in V2-V6 during pain-free periods and ECG obtained during episodes of pain demonstrating upright T-waves with possible elevated ST segments from V1-V4. Cardiac enzymes were positive and coronary angiography revealed critical stenosis in the proximal left anterior descending artery. It is important to timely identify this condition and intervene appropriately as these patients may develop extensive myocardial infarction that carries a significant morbidity and mortality.

An overview of the predictors of symptomatic urinary tract infection among nursing students

BACKGROUND

Urinary tract infection (UTI) is the most common infection experienced by humans after respiratory and gastro-intestinal infections, and also the most common cause of nosocomial infections for patients admitted to hospitals indeed UTIs are the most frequent bacterial infection in women.

AIM

The aim was to determine the prevalence of UTI and to identify factors associated with an increased risk of UTI among nursing students.

SUBJECTS AND METHODS

The cross-sectional study involved 177 unmarried nursing students aged 18-30 years studying in the SRMSIMS, Nursing College Bareilly. A structured questionnaire was used, and study subjects were asked regarding the symptoms of UTI in the previous 3 months. Chi-square test and Univariate Logistic Regression was used to analyze the data.

RESULTS

The overall prevalence of UTI was found to be 19.8% (35/177). Rural background, inadequate water intake, and unsatisfactory toilet habits were found to be strong predictors of UTI.

CONCLUSIONS

There is an urgent need to sensitize the nursing students regarding the growing need of the issue so that they themselves become aware in addition to raising the awareness of other high-risk groups.

Study on validity of a rapid diagnostic test kit versus light microscopy for malaria diagnosis in Ahmedabad city, India

Light microscopy of blood smears for diagnosis of malaria in the field has several limitations, notably delays in diagnosis. This study in Ahmedabad in Gujarat State, India, evaluated the diagnostic performance of a rapid diagnostic test for malaria (SD Bioline Malaria Ag P.f/Pan) versus blood smear examination as the gold standard. All fever cases presenting at 13 urban health centres were subjected to rapid diagnostic testing and thick and thin blood smears. A total of 677 cases with fever were examined; 135 (20.0%) tested positive by rapid diagnostic test and 86 (12.7%) by blood smear. The sensitivity of the rapid diagnostic test for malaria was 98.8%, specificity was 91.5%, positive predictive value 63.0% and negative predictive value 99.8%. For detection of Plasmodium falciparum the sensitivity of rapid diagnostic test was 100% and specificity was 97.3%. The results show the acceptability of the rapid test as an alternative to light microscopy in the field setting.

Awareness and knowledge of cervical cancer and its prevention among the nursing staff of a tertiary health institute in Ahmedabad, Gujarat, India

BACKGROUND

Carcinoma of the cervix is the second most common cancer in women worldwide, while it is the commonest cancer among Indian women. Awareness regarding cervical cancer and its prevention is quite low amongst Indian women. The Pap test is a simple and cost effective technique for early diagnosis of cervical cancer. It is necessary to make nursing staff aware of cervical cancer, so that they can impart knowledge regarding cervical cancer and its prevention to the general public.

AIMS AND OBJECTIVES

(1) To assess the knowledge level regarding symptoms, risk factors, prevention and screening of cervical carcinoma among nursing staff. (2) To find out the behaviour of respondents regarding prevention and screening of cervical carcinoma.

MATERIALS AND METHODS

A cross-sectional interview-based survey regarding knowledge levels about cervical carcinoma was conducted among the nursing staff from one of the tertiary health institutes of Ahmedabad, India. A structured questionnaire with multiple choices was used for data collection. Provision for open-ended responses was also made in the questionnaire. Department-wise stratification was carried out, and thereafter 15% of the total nursing staff from all departments were selected randomly so as to include a total of 100 nurses in the current study. Data entry was done in Microsoft Excel. SPSS statistical software was used to generate statistical parameters like proportion, mean, standard deviation, etc. The Z test was used as a test of significance, and a P value of <0.05 was considered as the level of significance.

Lymphocyte ATP immune cell function assay in pediatric renal transplants: is it useful?

The ultimate goal for an allograft is a balanced immunosuppression to provide the longest graft survival with minimal side effects. In this retrospective study, we correlate the immunosuppresion level as determined using the Cylex assay (Immu know, Columbia, MD) with clinical events. Demographic data such as age at the time of transplant, gender, ethnicity, time posttransplantation, tacrolimus level, and induction therapy were correlated with Cylex levels. Cylex from children with an infection or acute rejection were compared to those from stable patients. All children received induction with basiliximab or thymoglobulin followed by a standard regimen with tacrolimus, steroids, and mycophenolate mofetil. Fifty-nine Cylex results were obtained in 44 pediatric renal transplant recipients. Cylex values ranged from 20 ng/mL to 728 ng/mL. We did not find significant correlation between any of the demographic characteristics studied (tacrolimus level, induction therapy, acute rejection, and Cylex levels). Fifteen patients had severe infections requiring hospitalization: 11 of 15 (73%) had Cylex<130 ng/mL; these levels differed significantly from those obtained in patients without infections. We concluded that clinical utility of Cylex is limited in children with kidney transplants because it did noes correlate with the prescribed dosage of medications or with rejection. However, low Cylex levels were highly correlated with serious infections.

Sonographic monitoring of early follicle growth induced by melatonin implants in camels and the subsequent fertility

The present study examined the effect of melatonin implants on follicle growth in dromedary camels two months ahead of their natural breeding season (December to March). Female camels (n = 6) were treated with melatonin implants at the dose rate of 1 implant per 28 kg body weight sc. Control camels (n = 6) were administered an SC placebo implant of 8 ml vitamin A. Ovarian ultrasonography was performed at weekly interval upto 7 weeks. Camels were mated with virile stud when a follicle (≥10 mm) was visible on either of the ovaries. Blood was collected on day 7, 9, 15, 20, 25 and 30 for assay of plasma progesterone and sonography performed at the same time. Small follicles (2-3 mm) appeared around the periphery of ovaries in 83.3% of camels by day 7 and in 100% camels by day 14. By the end of 7th week an ovulatory size follicle (≥1.0 cm) could be observed in 83.3% of treated camels, and these camels were mated with virile studs. In control group, small follicles appeared at the periphery of ovaries only in 66.6% camels but did not progress in growth except in one camel (16.6%) however, ovulating size (≥10 mm) follicle was not observed in any camel by the end of 7th week. All treated camels ovulated and one treated camel became pregnant while early embryonic death occurred in one camel. Non-pregnant camels of both groups were mated during the breeding season. All camels of treatment group and 33.33% camels of control group became pregnant by the end of breeding season (April 2010). It was concluded that melatonin implants can augment the follicle growth in lactating camels ahead of the breeding season and pregnancy can occur on mating. Fertility of treated camels during the breeding season is improved.

Adrenal histoplasmosis: An unusual cause of adrenomegaly

Histoplasmosis is a geographically restricted form of fungal infection. Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease. Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency. We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT, and was diagnosed to have histoplasmosis on fine-needle aspiration cytology.

Pheochromocytoma of urinary bladder

Pheochromocytoma of urinary bladder are rare tumors. They present with nonspecific clinical signs and symptoms, so imaging plays an important role in diagnosing and localizing the tumor. We present two cases of bladder pheochromocytoma, one of them presented with vague abdominal pain and the other with hematuria. Biphasic CT in both the cases showed hypervascular intravesical mass suggestive of bladder pheochromocytoma. The lesions were confirmed biochemically or on postoperative histopathology. A brief review of the imaging in bladder pheochromocytoma is also presented.

Systematic review and meta-analysis of laparoscopic Nissen fundoplication with or without division of the short gastric vessels

BACKGROUND

The aim of this meta-analysis was to provide a pooled analysis of individual trials comparing clinical outcome following laparoscopic Nissen fundoplication with or without division of the short gastric vessels (SGVs).

METHODS

Primary outcome measures were the requirement for reoperation, and the presence of postoperative gastro-oesophageal reflux and postoperative dysphagia. Secondary outcome measures were duration of operation, length of hospital stay, postoperative complications (within 30 days of surgery), postoperative gas bloat syndrome, lower oesophageal sphincter resting pressure and DeMeester score. Pooled odds ratios were calculated for categorical outcomes, and weighted mean differences for secondary continuous outcomes, using random-effects models for meta-analysis.

RESULTS

Five randomized trials were included in the analysis. There was no statistically significant effect on the requirement for reoperation, or presence of postoperative dysphagia or reflux. SGV division was associated with a longer duration of operation and a reduced postoperative lower oesophageal sphincter pressure. There was no statistically significant difference in length of hospital stay, postoperative complications, postoperative gas bloat syndrome or DeMeester score.

CONCLUSION

This meta-analysis has demonstrated that clinical outcome following laparoscopic Nissen fundoplication appears to be similar regardless of whether the short gastric vessels are divided. However, it is not possible to exclude many potentially important clinical differences and further studies are needed.

Delayed transhiatal herniation of the small bowel after Ivor Lewis esophagectomy

Transhiatal intrathoracic herniation of the intestine after an Ivor Lewis esophagectomy is an unusual occurrence. This complication may present after any form of esophagectomy at varying intervals following primary surgery. Diagnosis is established on the basis of presenting symptoms and radiological features on computed tomography (CT scan). The authors herewith report this rare occurrence 42 months after an Ivor Lewis esophagectomy. The patient had herniation of the small bowel into the left pleural cavity , which was treated surgically through an entirely intra-abdominal approach and the defect in the diaphragm was bridged using a prosthetic polypropylene mesh.

Maternal obesity: a review of interventions

BACKGROUND

Obesity has become a serious global public health issue and has consequences for nearly all areas of medicine. Within obstetrics, obesity not only has direct implications for the health of a pregnancy but also impacts on the weight of the child in infancy and beyond. As such, maternal weight may influence the prevalence and severity of obesity in future generations. Pregnancy has been identified as a key time to target a weight control or weight loss strategy to help curb the rapidly growing obesity epidemic. In addition, if delivered sensitively, pregnancy may be a good time to target health behaviour changes by using the extra motivation women tend to have at this time to maximise the health of their child.

AIM

This study reviews the current evidence for interventions to promote weight control or weight loss in women around the time of pregnancy. A comprehensive review of medical research--PubMed, Embase, Ovid Medline and the Cochrane Clinical Trials register--showed that despite numerous reports of the prevalence and complications of maternal obesity, few intervention strategies have been suggested.

CONCLUSION

This study finds that there is a deficiency of appropriately designed interventions for maternal obesity and it concludes by highlighting areas for developing a more effective strategy.