Evaluation of RURS elbow guard in the management of thumb-sucking habit in children with and without intellectual disability

BACKGROUND

Digit sucking is a common oral habit among many children, which involves placing the thumb/finger into the mouth, which can cause malocclusion in mixed and permanent dentition.

AIM

To evaluate the efficacy of the RURS elbow guard in the management of thumb-sucking habits in children with intellectual disabilities and those without in terms of the mean duration of appliance therapy. The secondary objective was to compare the RURS elbow guard with an intraoral crib in healthy children (without intellectual disabilities) to manage the habit of thumb-sucking.

DESIGN

Children with intellectual disabilities and those without between the age of 4 and 16 years were included in the study and categorised into three groups, namely group I (50 normal children; intraoral crib appliance), group II (50 normal children; RURS elbow guard) and group III (50 children with intellectual disabilities; RURS elbow guard).

RESULTS

The mean duration of appliance therapy for groups I, II and III were 200.20 ± 20.43 days, 204.34 ± 20.56 days, and 218.43 ± 15.66 days, respectively (p < 0.001). The differences in the mean duration between group I and group II were statistically non-significant, with statistically significant differences between group I and group III (p < 0.001) and between group II and group III (p < 0.05).

CONCLUSION

The RURS elbow guard was found to be an efficient appliance in treating thumb-sucking among children who had mild to moderate intellectual disabilities. RURS elbow guard was equally efficient as an intraoral crib appliance in managing thumb-sucking habits in children without intellectual disabilities.

Clinical outcome of anterior cruciate ligament reconstruction with modified transtibial and anteromedial portal

Arthroscopic ACL reconstruction is the current standard care of treatment for anterior cruciate ligament (ACL) injuries. Modified transtibial (mTT) and anteromedial portal (AMP) techniques aim at the anatomical placement of femoral tunnel. Controversy existed in the literature with regard to the outcome of these techniques. Hence, we designed a retrospective comparative study to analyse the clinical and functional outcomes of mTT and AMP techniques. We hypothesized that there would be no difference between the clinical and functional outcomes in mTT and AMP techniques. This retrospective observational study was conducted in consecutive patients who underwent arthroscopic ACL reconstruction using semitendinosus-gracilis (STG) quadrupled graft in our tertiary care centre with a minimum follow-up of two years. Out of 69 patients, 37 had undergone ACL reconstruction by mTT technique and remaining by AMP technique. All the patients were assessed clinically by anterior drawer, Lachman's, pivot shift and single-legged hop test. Lysholm Knee Scoring Scale and International Knee Documentation Committee (IKDC) subjective knee evaluation score were used for the functional status. Knee instability was assessed objectively by KT-1000 arthrometer. There was no statistically significant difference in baseline demographic characteristics between mTT and AMP groups. At the end of 2 years, no statistically significant difference was noted in the anterior drawer and Lachman's test. Though not significant, IKDC scores and Lysholm's scores showed a better outcome in the AMP group when compared to the mTT group. AMP group showed significantly better outcome with KT-1000 arthrometer. Based on the results obtained, we presume that overall both mTT and AMP have similar functional outcome. However, as AMP technique offers significantly improved subjective rotational stability on pivot shift test, better hop limb symmetry index and KT 1000 readings compared to mTT, we suggest AMP over mTT.

Comparative in vitro evaluation of remaining dentine thickness following instrumentation with hand and rotary endodontic files during pulpectomy in primary molars: a systematic review

PURPOSE

The aim was to compare the remaining dentine thickness (RDT) following instrumentation with hand and rotary endodontic files during pulpectomy in primary molars. Research question was 'Is there any difference between the remaining dentine thickness following instrumentation with hand and rotary endodontic files during pulpectomy in primary molars?'.

METHODS

Electronic Databases like MEDLINE PubMed, Cochrane Library, EBSCOhost, Google scholar and grey literature were searched between January 1, 2006 and August 31, 2022 for in vitro and ex vivo studies that compared hand and rotary endodontic instrumentation to evaluate the RDT in primary molars. Articles published in English or which could be translated into English were searched. Two reviewers independently selected studies, extracted data, assessed risk of bias using the Revised, validated version of MINORS criteria.

RESULTS

Twelve studies were included in qualitative analysis. All included studies showed low risk of bias. Six studies showed more RDT with rotary instrumentation compared to manual instrumentation. Whereas, five studies showed variable results for RDT with manual and rotary instrumentation at different levels of root canals. One study showed no significant difference between manual and rotary instrumentation. In view of methodological heterogeneity of the findings, a meta-analysis was not conducted.

CONCLUSION

High quality of evidence based on low risk of bias was found in all the included studies. Statistically, rotary instrumentation showed more RDT than manual instrumentation according to majority of studies. Despite the shortcomings of this systematic review, it is possible to infer that the use of rotary instrumentation provides more RDT and thus there is considerable conservation of tooth structure.

Bifocal Stabilisation of Acute Acromioclavicular Joint Dislocation using Suture Anchor and Temporary K-Wires: A Retrospective Analysis

Introduction

The acromioclavicular joint (ACJ) is a major link connecting the upper limb to the torso. The acromioclavicular and coracoclavicular (CC) ligaments help in stabilising the joint. We feel it is prudent to address both these ligament injuries, to achieve optimum result. This study was undertaken to analyse the results of a simple frugal surgical technique we used to deal with this injury considering stabilisation for both these ligaments.

Materials and methods

In this retrospective study, skeletally mature patients with Type III, IV or V ACJ dislocations who underwent open reduction and stabilisation of the joint with temporary K-wires, repair of the capsule and augmentation of CC ligaments with suture anchors were included. Clinico-radiological and functional outcome was evaluated. Functional assessment of the upper limb was analysed using the Disabilities of Arm, Shoulder, and Hand Score (DASH), Constant shoulder score (CSS) and Oxford shoulder score (OSS).

Results

Clinical and radiological evaluation of the 32 patients who had completed two years from the index surgery, was done. Out of the 37 patients included initially, five were lost in follow-up. Majority of the subjects included were males and type V was the most common injury. Mean pre-operative CC distance on the affected side was 13.92±4.94mm. In the immediate post-operative radiograph, it was 7.63±2.08mm and in the final follow- up was 9.36±2.75mm. Measurements were taken by two independent investigators and inter, and intra-observer reliability were analysed by Interclass correlation coefficient. Excellent functional outcome was noted despite the 1.81±1.50mm average loss of correction. At final follow-up, mean DASH score was 4.67±4.18, Oxford shoulder score was 44.06±2.44 and Constant shoulder score was 86.37±5.81. The severity of the injury had no significant effect on the functional outcome post our method of stabilisation and rehabilitation.

Conclusion

Bifocal fixation restores the multidirectional stability of the disrupted ACJ. Adequate radiological reduction, good functional outcome and simplicity of execution make this technique an undemanding one for use in regular practice.

Effects of transplantation-related immunosuppression on co-existent neuroendocrine tumours

BACKGROUND

Here we detail our experience of managing patients found to have a neuroendocrine neoplasm (NEN) whilst on immunosuppression for a transplanted organ.

AIM

We aimed to quantify the behaviour of NENs under solid-organ transplant-related immunosuppression.

DESIGN

This was an observational, retrospective case series.

METHODS

Ten patients were identified from a prospectively kept database. Three were excluded.

RESULTS

Four patients received a liver, two a kidney, and one a heart transplant. All but one received calcineurin-based immunosuppression. NENs were found in five patients post-transplant: one had surgery for transverse colonic neuroendocrine carcinoma NEC (pT4N1M0, Ki67 60%), was cancer-free after four years; one had cold biopsy of duodenal NEN (pT1N0M0, Ki67 2%), cancer-free at four months; one 7 mm pancreatic NEN (pT1N0M0), untreated and stable for seven years; one small-bowel NEN with mesenteric metastasis (pTxNxM1), alive four years after diagnosis; and one untreated small-bowel NEN with mesenteric metastasis, stable at 1 year after liver transplantation. Two NENs were discovered pre-transplant, one pancreatic NEN (pT1N0M0, Ki67 5%), remains untreated and stable at three years. One gastric NEN (type 3, pT1bN0M0, Ki67 2%) remains stable without treatment for two years.

CONCLUSIONS

NENs demonstrate indolent behaviour in the presence of transplant-related immunosuppression.

Short-term and pathologic outcomes of robotic versus open pancreatoduodenectomy for periampullary and pancreatic head malignancy: an early experience

Open pancreatoduodenectomy (OPD) is associated with high perioperative morbidity. Adoption of robot-assisted pancreatoduodenectomy (RAPD) has been slow despite ergonomic advantages, improved visualization and dexterity. We aim to report our experience comparing operative and short-term outcomes following RAPD and OPD. We did retrospective analysis of prospectively maintained database, including all consecutive patients who underwent RAPD or OPD between January 2016 and August 2019. 48 patients were included, 21 in RAPD group and 27 in OPD group. RAPD was associated with longer mean operative time (440 vs. 414.1 min) but had significantly less mean intra-operative blood loss (256.9 vs. 404.5 ml), median length of ICU stay (1 vs. 3 days), overall length of stay (11 vs. 13 days) and lower rates of SSI (23.8% vs. 63%). Both groups showed equal incidence of POPF, comparable R0 resection rates (100% vs. 96.3%) and median number of lymph nodes harvested (14 vs. 18). Rate of open conversion was 28.6% (n = 6), most commonly for bleeding (66.6%) and mesenteric vessel involvement (33.3%). When compared to first ten RAPD cases, mean operative time (483.5 vs. 400.5 min) and rate of conversion (36.36% vs. 20%) was less in last eleven cases. RAPD is significantly better than OPD in terms of intra-operative blood loss, length of ICU stay, length of total stay and SSI. The longer operative time and conversion rate associated with RAPD progressively decreased as experience accumulated and the learning curve was crossed. Further randomized controlled trials are needed to investigate cost-effectiveness and long-term oncologic survival in RAPD patients.

Evaluation of dentinal crack propagation, amount of gutta percha remaining and time required during removal of gutta percha using two different rotary instruments and hand instruments - An In vitro study

Background

One of the most important goal of non surgical endodontic retreatment is the successful removal of gutta percha and sealers from the root canal system. A variety of techniques have been recommended for retreatment procedures for the removal of gutta-percha and sealers with or without the help of adjunctive chemical solvents, by using stainless steel hand files or nickel-titanium rotary files, gate glidden burs, heated instruments, ultrasonic instruments, and lasers 1,3. The current advancements in the design of NiTi instruments have proved efficacious in the removal of filling materials from the root canal wall and various studies have also confirmed their cleaning ability and efficacy 4,5. Nevertheless, the use of rotary instrumentation can lead to the formation of dentinal cracks in the root canal dentin. Many researchers have reported the incidence of crack formation and propagation after the procedure with manual, rotary and reciprocating instruments. The behavior of rotary instruments in the generation of defects have been the point of greatest interest during many years 6. These dentinal cracks can be defined as defects with a complete crack line extending from inner root canal space up to the outer surface of the root when the tensile stress in the root canal wall exceeds the tensile stress of dentin 7.

Aim

This study was conducted to investigate and to compare the amount of dentinal microcracks formation with various new instrumentation methods and conventional hand filing method. It also looks into amount of gutta-percha removed after retreatment from the canal and the time required for all the instrumentation technique.

Methodology

Sixty extracted human maxillary first molars with curved roots were mounted on addition silicone impression material incorporated in an aluminium hollow block, then instrumented using step-back preparation with 35 size K files. Obturation was done using gutta-percha with AH plus sealer. These were stored for 14 days and divided into three groups Mani GPR, Endostar Re Endo and H file and were subjected to retreatment procedures. Retreatment was considered complete when no filling material was observed on the canal wall and the canal was smooth and free of visible debris. The samples were examined under scanning electron microscope and the number of cracks were calculated. The percentage of root canal filling material and time taken was recorded.

Statistical Analysis

The data obtained were analyzed by using descriptive statistics, ANOVA (Analysis of Variance), chi-square test and Scheffe's post hoc test through SPSS for window (version 22.0).

Result

All the techniques showed similar amount of crack propagation, with no statistical difference between the group. Retreatment done using H Files required more time and removed less material. The coronal third showed less amount of gutta-percha remnants than the apical third in all groups.

Conclusion

All the groups showed a similar amount of crack propagation. Less number of cracks were observed in the coronal one third and more amount of cracks were found at the apical third. Endostar RE Endo rotary instrument proved to be most effective and least time-consuming. Hedstrom Files required more time and removed less material.

Adverse neonatal outcome in twin pregnancy complicated by small-for-gestational age: twin vs singleton reference charts

OBJECTIVE

The use of twin-specific vs singleton growth charts in the assessment of twin pregnancy has been controversial. The aim of this study was to assess whether a diagnosis of small-for-gestational age (SGA) made using twin-specific estimated-fetal-weight (EFW) and birth-weight (BW) charts is associated more strongly with adverse neonatal outcomes in twin pregnancies, compared with when the diagnosis is made using singleton charts.

METHODS

This was a cohort study of twin pregnancies delivered at St George's Hospital, London, between January 2007 and May 2020. Twin pregnancies complicated by intrauterine death of one or both twins, fetal aneuploidy or major abnormality, twin-twin transfusion syndrome or twin anemia-polycythemia sequence and those delivered before 32 weeks' gestation, were excluded. SGA was defined as EFW or BW below the 10^th centile, and was assessed using both twin-specific and singleton EFW and BW charts. The main study outcome was composite adverse neonatal outcome. Mixed-effects logistic regression analysis with random pregnancy-level intercepts was used to test the association between SGA classified using the different charts and adverse neonatal outcome.

RESULTS

A total of 1329 twin pregnancies were identified, of which 913 (1826 infants) were included in the analysis. Of these pregnancies, 723 (79.2%) were dichorionic and 190 (20.8%) were monochorionic. Using the singleton charts, 33.3% and 35.7% of pregnancies were classified as SGA based on EFW and BW, respectively. The corresponding values were 5.9% and 5.6% when using the twin-specific charts. Classification as SGA based on EFW using the twin charts was associated significantly with composite adverse neonatal outcome (odds ratio (OR), 4.78 (95% CI, 1.47-14.7); P = 0.007), as compared with classification as appropriate-for-gestational age (AGA). However, classification as SGA based on EFW using the singleton standard was not associated significantly with composite adverse neonatal outcome (OR, 1.36 (95% CI, 0.63-2.88); P = 0.424). Classification as SGA based on EFW using twin-specific standards provided a significantly better model fit than did using the singleton standard (likelihood ratio test, P < 0.001). When twin-specific charts were used, classification as SGA based on BW was associated significantly with a 9.3 times increased odds of composite adverse neonatal outcome (OR, 9.27 (95% CI, 2.86-30.0); P < 0.001). Neonates classified as SGA according to the singleton BW standard but not according to the twin-specific BW standards had a significantly lower rate of composite adverse neonatal outcome than did AGA twins (OR, 0.24 (95% CI, 0.07-0.66); P = 0.009).

CONCLUSIONS

The singleton charts classified one-third of twins as SGA, both prenatally and postnatally. Infants classified as SGA according to the twin-specific charts, but not those classified as SGA according to the singleton charts, had a significantly increased risk of adverse neonatal outcome compared with infants classified as AGA. This study provides further evidence that twin-specific charts perform better than do singleton charts in the prediction of adverse neonatal outcome in twin pregnancies. The use of these charts may reduce misclassification of twins as SGA and improve identification of those that are truly growth restricted. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Robot-assisted versus video-assisted thoraco-laparoscopic McKeown's esophagectomy for esophageal cancer: a propensity score-matched analysis of minimally invasive approaches

Minimally invasive esophagectomy for esophageal cancer decreases overall complication rate and leads to faster postoperative recovery. Robot-assisted minimally invasive esophagectomy is becoming more common. Its three-dimensional view and wristed instruments may provide advantages over traditional thoraco-laparoscopic techniques. There are limited studies comparing robotic and conventional thoraco-laparoscopic esophagectomy. This study aimed to evaluate short-term outcomes of robot-assisted McKeown esophagectomy (RAME) and video-assisted McKeown esophagectomy (VAME). All consecutive patients undergoing minimally invasive McKeown esophagectomy for middle and distal third esophageal cancer between January 2016 and December 2018 at our center were included in this study. Data on baseline characteristics, pathological data and short-term outcomes were collected in a dedicated database. Postoperative complications were defined as per recommendations of Esophagectomy Complications Consensus Group. Histopathologic assessment was performed as per College of American Pathologists guidelines. Propensity score matching was performed for comparison between RAME and VAME groups using age, gender, performance status, American Society of Anesthesiologists grade, body mass index, Charlson Index, tumor location, clinical tumor stage, and neoadjuvant treatment as covariates. A total of 74 patients were included, 25 of whom underwent RAME and 49 underwent VAME. Propensity score matching on 1:1 basis produced 25 pairs of patients, comparable in terms of baseline characteristics. Total operative time and estimated blood loss was similar between the two groups. Length of hospital stay was significantly lower in RAME group. Major postoperative complications (Clavien-Dindo grade ≥ 3A) were more common in VAME group, but not statistically significant. Median number of harvested lymph nodes and R0 resection rate did not differ in between the two groups. In our experience, robot-assisted McKeown esophagectomy was comparable to video-assisted McKeown esophagectomy in terms of safety, feasibility and oncologic adequacy. Use of the robot was associated with reduced hospital stay. Further randomized controlled studies with larger patient samples are needed to compare the two.

Plantar pressure distribution profile of type 2 diabetes mellitus with diabetic foot syndrome: A hospital-based observational study

INTRODUCTION: The prevalence of diabetic foot syndrome is increasing in the Indian population. It is a triad of neurological, vascular, and biomechanical changes due to long term diabetes mellitus (DM). Altered plantar pressure distribution is a risk factor for developing diabetic foot ulcers. The purpose of this study is to evaluate the altered plantar pressure distribution in diabetic peripheral neuropathy individuals with peripheral vascular disease in comparison with diabetic peripheral neuropathy and non-diabetic neuropathy. Therefore, the objective of the study is to evaluate the plantar pressure distribution and parameters in type 2 DM (T2DM) with diabetic foot syndrome.METHODS: In this study, 60 participants with T2DM were recruited in either one of the three groups: 20 Diabetic non-neuropathy (DNN), 20 Diabetic peripheral neuropathy (DPN), and 20 Diabetic peripheral neuropathy with the peripheral arterial disease (DNPAD). Then we compared the plantar pressure parameters like maximum plantar pressure, pressure-time integral, fore foot-hind foot ratio, and total contact area were measured using a WinTrack plantar pressure system.RESULTS: The diabetic peripheral neuropathy with peripheral vascular disease group shown a significant difference in all the  plantar pressure parameters measured in comparison with the diabetic peripheral neuropathy group. There was increased Maximum plantar pressure, pressure-time integral and forefoot hindfoot ratio, and reduced total contact area of the foot (p < 0.05).CONCLUSION: For patients, with combined peripheral neuropathy and peripheral vascular disease have increased plantar pressure distribution, are at higher risks of developing neuro-ischemic foot, which further leads to diabetic foot ulcers.

Over 60 years of age as an independent prognostic factor of in-hospital mortality among COVID-19 patients: a cohort study in an Iranian high-incidence area

Objectives

COVID-19 continues to cause devastation throughout the world. Various factors influence the perioperative course and prognosis of COVID-19. This study aims to collate the independent prognostic factors among hospitalised COVID-19 patients in east Iran.

Study design

In this cohort study, all patients with a confirmed diagnosis of COVID-19 between 19 February 2020 and 1 August 2020 who were admitted to nine public hospitals of South Khorasan province, Iran, were enrolled.

Methods

Univariate analysis (chi-square [χ²], and Mann–Whitney U test) and multiple logistic regression were performed.

Results

This study included 1290 participants; 676 patients (52.4%) were male. A total of 1189 (92.2%) recovered, and 101 (7.8%) died. The results show that in-hospital mortality increases with advanced age (the optimal cut-off point = 62 years). The following three variables were shown to have the most significant role in in-hospital mortality: age >60 years (odds ratio [OR] = 8.01, 95% confidence interval [CI] 4.8–13.35), shortness of breath (OR = 2.65, 95% CI: 1.4–69.17) and atypical radiological manifestations in a chest X-ray on admission (OR = 2.16, 95% CI: 1.3–28.64). In the univariate analysis, associated comorbidities, such as cardiovascular diseases, influenced the in-hospital mortality rate, while the same could not be replicated in the multiple variable analysis.

Conclusions

This study revealed the potential predictors of COVID-19 and highlighted the need to be cautious with advanced age and heightened clinical symptoms at the time of admission.

Well-differentiated gastroenteropancreatic G3 NET: findings from a large single centre cohort

Neuroendocrine neoplasms are known to have heterogeneous biological behavior. G3 neuroendocrine tumours (NET G3) are characterized by well-differentiated morphology and Ki67 > 20%. The prognosis of this disease is understood to be intermediate between NET G2 and neuroendocrine carcinoma (NEC). Clinical management of NET G3 is challenging due to limited data to inform treatment strategies. We describe clinical characteristics, treatment, and outcomes in a large single centre cohort of patients with gastroenteropancreatic NET G3. Data was reviewed from 26 cases managed at Queen Elizabeth Hospital, Birmingham, UK, from 2012 to 2019. Most commonly the site of the primary tumour was unknown and majority of cases with identifiable primaries originated in the GI tract. Majority of cases demonstrated somatostatin receptor avidity. Median Ki67 was 30%, and most cases had stage IV disease at diagnosis. Treatment options included surgery, somatostatin analogs (SSA), and chemotherapy with either platinum-based or temozolomide-based regimens. Estimated progression free survival was 4 months following initiation of SSA and 3 months following initiation of chemotherapy. Disease control was observed following treatment in 5/11 patients treated with chemotherapy. Estimated median survival was 19 months; estimated 1 year survival was 60% and estimated 2 year survival was 13%. NET G3 is a heterogeneous group of tumours and patients which commonly have advanced disease at presentation. Prognosis is typically poor, though select cases may respond to treatment with SSA and/or chemotherapy. Further study is needed to compare efficacy of different treatment strategies for this disease.

Twin chorionicity-specific population birth-weight charts adjusted for estimated fetal weight

OBJECTIVES

To construct chorionicity-specific birth-weight reference charts for dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twin pregnancies, incorporating estimated-fetal-weight (EFW) data in order to adjust for the relationship between suboptimal growth and preterm delivery. An additional aim was to determine if the inclusion of complicated twin pregnancies impacts on the reference charts produced.

METHODS

The inclusion criteria for this retrospective cohort study were twin pregnancy of known DCDA or MCDA chorionicity, known pregnancy outcome, last ultrasound scan within 14 days before birth and delivery between 25 and 38 weeks' gestation (Analysis A). An analysis was also conducted excluding pregnancies with complications recorded (Analysis B). Previously published twin EFW reference ranges were used in the analysis. A joint statistical model for EFW and observed birth weight for each pregnancy was created in order to estimate population birth-weight reference ranges corresponding to the distribution expected if all pregnancies delivered at any given gestational age. It was not assumed that the median EFW was equal to birth weight for any given gestational age. The models were fitted using a Bayesian approach.

RESULTS

We retrieved data on 1664 twin pregnancies, of which 707 DCDA and 241 MCDA pregnancies met the inclusion criteria. In Analysis A, the estimated population median birth weight was similar to the median EFW at around 27 weeks' gestation but fell below the EFW values with increasing gestation, being 156 g lower in both DCDA and MCDA pregnancies at 35 weeks; this finding was confirmed by direct comparison of the last EFW and birth-weight values in each pregnancy. When the analysis was repeated after excluding complicated twin pregnancies (Analysis B), compared with Analysis A, there was very little difference in the median birth-weight results obtained across gestation. The largest absolute difference between Analyses A and B for DCDA twins was at 31, 32 and 33 weeks, with a 9-g lower median birth weight in Analysis A compared with Analysis B. The largest absolute difference for MCDA twins was greater than that for DCDA twins, with a 21-g lower median birth weight at 25 weeks in Analysis A compared with Analysis B.

CONCLUSIONS

We have established population chorionicity-specific birth-weight reference charts for DCDA and MCDA twin pregnancies, corresponding to the range expected were all pregnancies to deliver at any given gestational age. In this population of twins, the median birth weight was consistently lower than that reported for singletons, and there was variation in the median birth weight at different gestational ages according to chorionicity. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. - Legal Statement: This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Association of UGT1A6 gene polymorphism with clinical outcome in pediatric epileptic patients on sodium valproate monotherapy

Pediatric epilepsy comprises chronic neurological disorders characterized by recurrent seizures. Sodium valproate is one of the common antiseizure medications used for treatment. Glucuronide conjugation is the major metabolic pathway of sodium valproate, carried out by the enzyme uridine 5'-diphosphate (UDP) glucuronosyl transferase (UGT) whose gene polymorphisms may alter the clinical outcome. The objective of this study was to assess the association between UGT1A6 genetic polymorphism and clinical outcome in terms of efficacy and tolerability in pediatric epileptic patients on sodium valproate monotherapy. Pediatric epileptic patients (n=65) aged 2-18 years receiving sodium valproate monotherapy for the past one month were included. Genetic polymorphism patterns of UGT1A6 (T19G, A541G, A552C) were evaluated by PCR-RFLP. Clinical outcome was seizure control during the 6 months observation period. Tolerability was measured by estimating the hepatic, renal, and other lab parameters. Out of 65 patients, TT (40%), TG (57%), and GG (3%) patterns were observed in UGT1A6 (T19G) gene, AA (51%), AG (40%), and GG (9%) in (A541G) gene, and AA (43%), AC (43%), and CC (14%) in (A552C) gene. No statistical difference in clinical outcome was found for different UGT1A6 genetic polymorphism patterns. We concluded that different patterns of UGT1A6 genetic polymorphism were not associated with the clinical outcome of sodium valproate in terms of efficacy and tolerability. Sodium valproate was well-tolerated among pediatric patients with epilepsy and can be used as an effective antiseizure medication.

769 Analysing the Change – Outcomes and Benefits of Clinic-Based Removal of Renal Transplant Stents Using A Disposable Cystoscope

Introduction

Literature is chock-full of data regarding the “when” of ureteric stent removal after renal transplantation. We have attempted to address the “who”, “where” and “how” components.

Method

The Isiris disposable scope was used to remove renal allograft stents from 383 patients in the Transplant Clinic from June 2018 to April 2020. An advanced nurse practitioner was trained in the procedure. The learning curve, incidence of complications, benefits and cost implications were studied, and compared with the cohort having stent removal with a traditional flexible cystoscope in theatres.

Results

There were 14 failures necessitating theatre removal. The transplant-to-stent-removal interval was significantly lower in the clinic cohort with a mean of 38.80 days (95%CI 37.26–40.34) to 46.55 days in theatres (95%CI 43.47–49.62). 11 patients had urgent bedside stent removal. The service was delivered independently by the nurse for 5.3% of the patients in June 2018 and progressed to over 80% by April 2019. Estimated net gain was £919/patient.

Conclusions

Moving transplant ureteric stent removals from a resource intensive all-day process in theatres to a one-stop event in the clinic is a safe and economical model that can streamline flow in patient pathway and inculcate new skills in other members of the multidisciplinary team.

Impact of acute kidney injury on in-hospital outcomes among patients hospitalized with acute heart failure: a propensity score matched analysis

Background

Acute kidney injury (AKI) is frequently present in patients admitted for acute heart failure (AHF). Several studies have evaluated the mortality risk and have concluded poor prognosis in any patient with AKI admitted for AHF. For the most part, the additional morbidity and mortality burden in AHF patients with AKI has been attributed to the concomitant comorbidities, and/or interventions.

Purpose

We sought to determine the impact of acute kidney injury (AKI) on in-hospital outcomes in patients presenting with acute heart failure (AHF). We identified isolated AKI patients after excluding other concomitant diagnoses and procedures, which may contribute to an increased risk of mortality and morbidity.

Methods

Data from the National Inpatient Sample (2012- 14) were used to identify patients with the principal diagnosis of AHF and the concomitant secondary diagnosis of AKI. Propensity score matching was performed on 30 baseline variables to identify a matched cohort. The outcome of interest was in-hospital mortality. We further evaluated in-hospital procedures and complications.

Results

Of 1,470,450 patients admitted with AHF, 24.3% had AKI. After propensity matching a matched cohort of 356,940 patients was identified. In this matched group, the AKI group had significantly higher in-hospital mortality (3.8% vs 1.7%, p&lt;0.001). Complications such as sepsis and cardiac arrest were higher in the AKI group. Similarly, in-hospital procedures including CABG, mechanical ventilation and IABP were performed more in the AKI group. AHF patients with AKI had longer in-hospital stay of ∼1.7 days.

Conclusions

In a propensity score-matched cohort of AHF with and without AKI, the risk of in-hospital mortality was &gt;2-fold in the AKI group. Healthcare utilization and burden of complications were higher in the AKI group.

Funding Acknowledgement

Type of funding source: None

Impact of prolotherapy in temporomandibular joint disorder: a quality of life assessment

Chronic pain and functional impairment associated with temporomandibular joint (TMJ) disorders (TMD) considerably reduce oral health-related quality of life (OHRQoL). In the present study we have assessed the influence of prolotherapy in patients with TMD by the subjective measurement of QoL using the Oral Health Impact Profile-14 (OHIP-14). Twenty-five patients diagnosed with TMD (mean (range) age 38 (18 - 70) years) were included. They had all undergone dextrose prolotherapy to the TMJ at regular time intervals (four times at intervals of two weeks) using the method suggested by Hemwall-Hackett. They were asked to answer the OHIP-14 questionnaire before and two years after prolotherapy. Seven domains of OHRQoL were rated on a 5-point Likert scale from 0 (never) to 4 (very often). Domain scores and total OHIP-14 scores were compared using inferential statistics (chi squared and Wilcoxon signed rank tests). Prolotherapy was effective over time, as all the domains' mean scores decreased considerably after treatment. The total mean score before prolotherapy was 21.20, which was extensively reduced to 13.08 after prolotherapy (p=0.001). There was statistically significant improvement in all domains, including functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap (p≤0.005 in all cases). We concluded that prolotherapy has a promising role in the improvement of OHRQoL of patients with TMD, and its beneficial effects persist at least two years after treatment.

Consensus guidelines for interventional cardiology services delivery during covid-19 pandemic in Australia and new Zealand

The global coronavirus disease (COVID-19) pandemic poses an unprecedented stress on healthcare systems internationally. These Health system-wide demands call for efficient utilisation of resources at this time in a fair, consistent, ethical and efficient manner would improve our ability to treat patients. Excellent co-operation between hospital units (especially intensive care unit [ICU], emergency department [ED] and cardiology) is critical in ensuring optimal patient outcomes. The purpose of this document is to provide practical guidelines for the effective use of interventional cardiology services in Australia and New Zealand. The document will be updated regularly as new evidence and knowledge is gained with time. Goals Considerations.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

P4988Beta-blockers in diabetes with stable coronary heart disease - a cause for concern?

Background

Beta-blocker (BB) therapy is a cornerstone for the treatment of coronary heart disease (CHD). The evidence of the benefit from long-term BB therapy in diabetic patients with stable CHD is scarce. This meta-analysis summarises the evidence relating to the BB therapy in diabetic patients with stable CHD.

Methods

A meta-analysis was performed according to PRISMA and MOOSE guidelines for reporting of systematic reviews of observational studies. PubMed, Embase, and Cochrane central were searched and two authors independently screened studies for eligibility. The quality of studies was assessed with the Newcastle Ottawa scale. The primary outcome of interest was all-cause mortality, cardiovascular (CV) mortality and major adverse cardiovascular events (MACE) in diabetic patients with and without BB therapy. A generic inverse variance model was used to pool the odds ratio or hazards ratio from included studies to calculate the overall effect estimate. The significance threshold was set at p-value <0.05. Heterogeneity was assessed by I2.

Results

Four non-randomized studies with 9,515 participants were selected for the analyses. Four studies were post-hoc analyses of randomised controlled trials, and 1 article was an analysis of a nationally representative survey. In a fixed effects model, BB therapy in diabetic patients with stable CHD was found to be associated with increased risk of CV mortality, and MACE (27%, and 32% respectively; p-value <0.05) and was not associated with a reduction in all-cause mortality (HR 1.12; 95% CI 0.94–1.33; p-value =0.22).

Conclusion

BB therapy in diabetic patients with stable CHD appears to be linked to higher mortality. Large randomised trials are needed in this population to confirm these findings.

Acknowledgement/Funding

None

P6535Atrial fibrillation and its impact in hospitalised cancer patients

Background

Atrial fibrillation (AF) is associated with increased morbidity and mortality. However, its impact on outcomes of cancer patients is largely unknown. We sought to determine the prevalence and effect of AF on in-hospital outcomes of patients admitted with AF in the United States.

Methods

We obtained and analyzed data from Nationwide Inpatient Sample (NIS 2002- 2014). The study population included all adults (>18 years old) with the discharge diagnosis of cancer and the associated secondary diagnosis of AF. The associations of AF with in-hospital complications, procedures, discharge outcomes, and mortality, were analyzed after adjusting for potential confounders using logistic regression analyses.

Results

During the study period, 12,410,290 patients were admitted with cancer; of which, 1,013,735 (8.2%) had AF. Patients with AF were likely to be male (51.1% vs 42.7%), white (86.3% vs 73.6%), and had significantly higher rates comorbidities including hypertension (59.6% vs 44.6%), diabetes (20.9% vs 15.8%), heart failure (23.8% vs 4.5%), and stroke (1.3% vs 0.7%). Similarly, in-hospital complications (including infections, venous thromboembolism, gastrointestinal bleeding, myocardial infarction) and hospital procedures (including cardiac catheterization, intubation, blood transfusion, percutaneous coronary intervention) were found at a significantly higher rate in cancer patients with AF compared to without AF (p-value for all <0.0001). After adjusting for all confounding factors, cancer patients in the AF group had higher odds of in-hospital death (odds ratio, 1.26; 95% confidence interval, 1.23–1.28; P<0.0001). The presence of AF conferred on average three days of extra inpatient stay in patients with cancer. Mortality in the cancer patients admitted with a concomitant diagnosis of AF has gradually increased from 7.2% to 9.7% over the 13-year study period.

Table 1. Multivariate model showing Atrial fibrillation as an independent risk factor of inpatient mortality in cancer patients Unadjusted univariate model Multivariate model adjusted for age, sex, race and potential confounders* Odds ratio (95% confidence interval P-value Odds ratio (95% confidence interval P-value Discharged alive Reference Reference In-hospital mortality 2.08 (2.07, 2.10) <0.0001 1.26 (1.23, 1.28) <0.0001 *Confounders adjusted for include all clinical comorbidities and in-hospital complications and procedures.

Conclusions

In patients with cancer, AF confers significant in-hospital burden by increasing the hospital stay by 3 days. AF is also associated with significantly higher rates of in-hospital procedures and complications in cancer patients and is an independent risk factor of in-hospital mortality.

Acknowledgement/Funding

None

P1571Atrial fibrillation is an independent predictor of mortality in hospitalized cancer patients

Background

Atrial fibrillation (AF) is prevalent in patients with cancer. We performed a study to evaluate the outcomes associated with hospitalised cancer patients with AF.

Methods

The Nationwide Inpatient Sample was used to identify patients with a cancer diagnosis, who were found to have atrial fibrillation from the years 2002–2014. Descriptive statistics for mortality were calculated using univariate and multivariate model for each cancer, and we identified the type of cancer associated with the highest inpatient mortality. We also calculated the percentage of hospital mortality attributable to AF.

Results

12,410,290 (nationwide estimate) patients with a cancer diagnosis were identified, and 8.2% of them had AF. In a multivariate adjusted model for various relevant comorbidities, age, gender and race, AF was also found to be an independent risk factor for higher in-hospital mortality in cancer patients, odds ratio (OR) 1.25 (95% CI 1.23, 1.28, p<0.0001). Colon cancer was found to be associated with the worst outcomes and the highest mortality. In cancer patients, the incident percentage of hospital mortality attributed to AF was 46.7%, population attributable mortality risk of was 7.17%, and number needed to harm was 21 (p<0.0001).

Conclusion

AF conferred significant morbidity and was found to be an independent risk factor for increased mortality in hospitalised patients with cancer. Colon cancer was found to have the strongest association of worst outcomes in hospitalized patients with AF.

Acknowledgement/Funding

None

P1574Predictors of mortality in hospitalized atrial fibrillation patients with cancer

Background

Recent reports indicate an important interplay between Atrial fibrillation (AF) and cancer. There is little information regarding the outcomes of these patients. Hence, we performed a study to identify predictors of in-hospital mortality to help guide goals of care discussions.

Methods

The Nationwide Inpatient Sample was used to identify patients with a diagnosis of cancer, who were found to have AF from 2002–2014. Trend rate, patients' and hospital characteristics along with in-hospital complications and predictors of in-hospital mortality were assessed. Backward stepwise elimination technique was used to fit the multivariate regression model.

Results

Over the 13-year study period, 12,410,290 (national estimate) patients with a cancer diagnosis were identified. 1,013,735 had AF, and 10.2% of the AF patients with cancer died while hospitalised. A variety of comorbidities, in-hospital procedures and in-hospital complications increased the odds of in-hospital mortality in these patients. Also, weekend admissions, elective admissions, and rural hospitals in comparison to urban teaching and non-teaching hospitals were associated with higher in-hospital mortality.

Conclusion

Stroke, myocardial infarction, pulmonary embolism, deep venous thrombosis, acute kidney injury, congestive heart failure, sepsis, and cardiogenic shock are most significant predictors of in-hospital mortality in AF patients with cancer.

Acknowledgement/Funding

None

Colonoscopy conversion after flexible sigmoidoscopy screening: results from the UK Bowel Scope Screening Programme

AIM

In the UK Bowel Scope Screening Programme (BSSP), patients progress to colonoscopy based on high-risk features on flexible sigmoidoscopy (FS). We aim to assess the practice of colonoscopy conversion and predictors of detection of additional adenomas on colonoscopy.

METHOD

The Bowel Cancer Screening database was interrogated and collated with endoscopic and histological findings from patients undergoing colonoscopy following FS between August 2013 and August 2016. Multivariate analysis was performed to identify predictors of new adenomas.

RESULTS

FS was performed on 11 711 patients, with an adenoma detection rate (ADR) of 8.5% and conversion to colonoscopy in 421 (3.6%). The additional ADR at colonoscopy was 35.2%, with one additional malignant diagnosis (0.26%). The adenoma miss rate was 3.6%. On multivariate analysis, a polyp ≥ 10 mm was the only high-risk indication associated with additional ADR at colonoscopy (OR 3.68, 95% CI 1.51-3.65, P < 0.001), in addition to male gender (OR 2.36, 95% CI 1.46-3.83, P < 0.001). Predictors of detection of a new adenoma ≥ 10 mm included: villous adenoma (P = 0.002), polyp ≥ 10 mm (P = 0.007) and male gender (P = 0.039). The presence of any conversion criterion was associated with the detection of any proximal adenoma (P < 0.001) and adenoma ≥ 10 mm (P = 0.031).

CONCLUSION

Male gender, polyps ≥ 10 mm and villous-preponderant histology at FS were predictors of adenomas < 10 mm and ≥ 10 mm at colonoscopy. Further data are required to assess the role for gender-based stratification of conversion criteria.

Whistle Abrasion: A Case Report

Abrasion is the physical wearing of a tooth surface which can involve the presence of a foreign object repeatedly being in contact with the tooth. A 40-year-old male patient reported to our dental clinic with a 2–3 mm uneven gap between his upper and lower front teeth on occlusion. A detailed history revealed that he was a physical education teacher, and the habitual placement of the whistle for the last 15 years caused an indentation on the whistle which coincided with the abraded teeth. Conditions such as abrasion may need active restorations. A general dental practitioner should accurately identify the cause and treat the esthetic and functional impairment as required.