Retrospective Comparative Analysis of Clinical and Functional Outcome After Arthroscopic Bankart Repair using All-Suture Anchor and Metal Anchor

Introduction

Both knotted all suture anchors and metal anchors are used for arthroscopic Bankart repair. We retrospectively evaluated and compared clinical and functional outcomes after arthroscopic Bankart repair using the knotted all-suture anchors and knotted metal anchors.

Materials and methods

In a retrospective cohort analysis, patients who underwent arthroscopic Bankart repair without any concomitant additional lesion repair using either all-suture anchors or metal anchors, between January 2015 and May 2018 were identified. Their pre- and post-operative functional and clinical outcomes were compared using Rowe and WOSI scores. The recurrence rate in the two groups was also compared.

Results

A total of 41 patients in all suture anchors group and 47 in the metal anchors group were identified as per inclusion and exclusion criteria. The demographic profile of both groups was comparable. There was no significant difference in clinical and functional outcome between the two suture anchor groups as per Rowe (pre-operative 40.13+6.51 vs 38.09+6.24 and post-operative 2 years 93.28+7.09 vs 92.55+9.2) and WOSI (pre-operative 943.05+216.64 vs 977.55+165.46 and post-operative 2 years 278.21+227.56 vs 270.94+186.25) scores. There was a significant improvement in both the groups between preoperative and post-operative ROWE and WOSI scores at 6 months and 2 years follow-up as compared to pre-operative scores (p<0.001). Re-dislocation rates were also comparable (4.8% vs 6.3%).

Conclusion

All-suture anchors showed comparable clinical and functional results as the metal anchors for arthroscopic Bankart repair at two-year follow-up.

Biosimilars in Oncology: Latest Trends and Regulatory Status

Biologic-based medicines are used to treat a variety of diseases and account for around one-quarter of the worldwide pharmaceutical market. The use of biologic medications among cancer patients has resulted in substantial advancements in cancer treatment and supportive care. Biosimilar medications (or biosimilars) are very similar to the reference biologic drugs, although they are not identical. As patent protection for some of the most extensively used biologics begins to expire, biosimilars have the potential to enhance access and provide lower-cost options for cancer treatment. Initially, regulatory guidelines were set up in Europe in 2003, and the first biosimilar was approved in 2006 in Europe. Many countries, including the United States of America (USA), Canada, and Japan, have adopted Europe's worldwide regulatory framework. The use of numerous biosimilars in the treatment and supportive care of cancer has been approved and, indeed, the count is set to climb in the future around the world. However, there are many challenges associated with biosimilars, such as cost, immunogenicity, lack of awareness, extrapolation of indications, and interchangeability. The purpose of this review is to provide an insight into biosimilars, which include various options available for oncology, and the associated adverse events. We compare the regulatory guidelines for biosimilars across the world, and also present the latest trends and challenges in medical oncology both now and in the future, which will assist healthcare professionals, payers, and patients in making informed decisions, increasing the acceptance of biosimilars in clinical practice, increasing accessibility, and speeding up the health and economic benefits associated with biosimilars.

Short term outcome of patients attending a renal-immunology clinic in central India

Background:

Glomerular diseases (GDs) and other renal immunologic diseases are an important cause of morbidity and mortality. Providing a single point of service in collaboration with various specialists at a renal immunology clinic for such patients is not novel, but outcomes have not been reported. Here, we report the short-term outcome of Indian patients attending our clinic.

Methods:

This single-center prospective cohort study enrolled biopsy-proven immunologically-mediated adults with renal diseases between April 2018 and December 2019, and followed them for six months. The primary end point for the analysis was an incidence of end-stage renal disease (ESRD) or loss of >50% estimated glomerular filtration rate (eGFR) and patient survival at six months. Secondary endpoints were the rate of complete or partial remission, and impact of demographic factors.

Results:

Ninety two patients underwent renal biopsy for suspected immunological renal diseases. Fourteen (15.2%) cases were excluded for nonimmune etiologies, whereas 78 (84.7%) confirmed cases of immune etiology were included. Most common primary GD (n = 51) (93.5%) was membranous nephropathy (n = 20) (25.6%), whereas lupus nephritis was the most common (n = 8) (29.6%) secondary GD. Overall, 10 (12.8%) patients reached renal endpoint of ESRD or >50% fall in eGFR. Focal segmental glomerulosclerosis (FSGS) (27%) patients had worst renal outcome. Patient survival was 94.8%. Thirty patients (38.4%) achieved complete, whereas 24 each (30.7%) achieved partial remission and remained resistant to disease specific therapies, respectively. Univariate analysis identified hypertension, severity of hypertension, and resistance to achieve proteinuria remission as significantly associated (P < 0.001) factors with poor renal outcome.

Conclusions:

The present study shows that short term renal outcome of Indian patients with renal immune diseases remains poor. FSGS remains the GD with the worst renal outcome. Hypertension, its severity, failure to achieve proteinuria remission were significantly associated with poor renal outcomes.

A global comparison of implementation and effectiveness of materiovigilance program: overview of regulations

Medical devices, being life-saving tools, are considered to be a boon for healthcare system. However, in addition to their therapeutic effects, there are several ill consequences that are caused by these devices. An effective cohort vigilant system was needed to manage such adverse effects. This had led to the introduction of materiovigilance. Materiovigilance is the study and follow-up of occurrences that arise as a result from the usage of the medical equipment. It not only manages adverse events (AE) but also creates harmonization among countries. Keeping these objectives in focus, the principles, perspectives, and practices with regard to materiovigilance that are followed in the USA, Europe, China, Japan, Australia, Canada, and India are being compared. Such a comparison is essential, which will help us to understand the gaps in the current regulatory systems in the above-mentioned countries and furthermore will provide a comprehensive picture to the regulatory authorities to amend any existing laws if required. These amendments may ensure optimal patient safety by providing them a benign experience from the use of medical devices.

A highly contiguous reference genome assembly for Colletotrichum falcatum pathotype Cf08 causing red rot disease in sugarcane

Among the biotic factors, which affect the productivity and quality of sugarcane, red rot disease caused by the fungal pathogen, Colletotrichum falcatum is the most devastating that cause enormous loss to millers as well as cane growers. We present a highly contiguous genome assembly of C. falcatum pathotype Cf08 which is virulent to popular sugarcane varieties grown in more than 3 million hectares in sub-tropical India. By performing long read sequencing on PacBio RSII system, 56.06 Mb assemblies with 238 contigs having N50 of 0.51 Mb and L50 of 34 was produced. A BUSCO completeness score of 97.24% (including 4.1% fragmented) of the entire C. falcatum Cf08 nuclear genome, greatly improved contiguity compared to an existing highly fragmented draft of C. falcatum Cf671 genome (48.13 Mb) was obtained. This Cf08 assembly had 54.14% GC content and possessed < 1% repetitive elements. A total of 18,635 protein-coding genes were predicted compared with 12,270 for Cf671. Among 617 CAZymes predicted, glycoside hydrolases were the predominant (298), and among 7264 genes associated with pathogenicity/virulence, 77 genes having effector functions were identified. The assembled genome showed its similarity with the genome of C. graminicola and C. higginsianum, the causal organisms of anthracnose in maize and in members of Brassicaceae, respectively. A total of 94 large sequences (> 100 kb) of Cf08 were mapped over C. higginsianum 10 of 12 chromosomes with 106 synteny blocks. Results discussed here would provide an important tool for future studies of evolutionary and functional genomics in C. falcatum.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13205-021-02695-x.

Cystic fibrosis precision therapeutics: Emerging considerations

Small molecules that address fundamental defects underlying cystic fibrosis (CF), including modulators such as the approved drugs ivacaftor, lumacaftor, tezacaftor, and elexacaftor, have advanced dramatically over the past few years and are transforming care and prognosis among individuals with this disease. The new treatment strategies are predicated on established scientific insight concerning pathogenesis, and applying "personalized" or "precision" interventions for specific abnormalities of the cystic fibrosis transmembrane conductance regulator (CFTR). Even with the advent of highly effective triple drug combinations-which hold great promise for the majority of patients with CF worldwide-barriers to precision therapy remain. These include refractory CFTR variants (premature truncation codons, splice defects, large indels, severe missense mutations, and others) not addressed by available modulators, and access to leading-edge therapeutic compounds for patients with ultrarare forms of CF. In addition to describing the remarkable progress that has occurred regarding CF precision medicine, this review outlines some of the remaining challenges. The CF experience is emblematic of many conditions for which personalized interventions are actively being sought.

Atypical Location of an Atrial Myxoma: A Case Report

Here, we report a case of a right atrial myxoma attached to the lateral wall, which is seen in only 10% cases, impinging upon the tricuspid valve. A 57 year old male normotensive, non-diabetic, nonsmoker patient was presented to us on 5th of August 2018 with the complaints of cough, dyspnea and orthopnea for the last two years. This type of presentation is very rare. After excision of myxoma, there was a significant improvement in the signs and symptoms of the patient. In this report, we emphasize the rarity of myxoma in the Right Atrium, and its difficulty in diagnosis because of its uncommon location and atypical presentation, surgical management has shown to quickly alleviate the majority of symptom and expectant sequeale.

Depression and anxiety in patients with multidrug-resistant tuberculosis in Nepal: an observational study

Setting

Multidrug-resistant tuberculosis (MDR-TB) patients in the national TB treatment programme of Nepal.

Objective

To estimate the prevalence of depression and anxiety in people receiving treatment for MDR-TB, identify potential risk factors for depression and anxiety and determine temporal changes in their severity during treatment.

Design

An observational study using a screening tool, the Hopkins Symptom Checklist (HSCL-25) for depression and anxiety, administered monthly to a group of 135 patients in Nepal. Logistic and multilevel linear regression models were used to identify any patient characteristics associated with depression and anxiety.

Results

Most of the 135 patients were male (76%) and living with their families (68%). The period prevalences of depression and anxiety were respectively 22.2% and 15.6%. Patients reporting physical side effects of MDR-TB treatment had a higher depression score on HSCL by 2.63 points (95%CI 0.77-4.48) and a 1.59 point higher anxiety score (95%CI 0.45-2.73) than those who did not report any side effects. Being single was associated with having anxiety (aOR 0.2, 95%CI 0.03-1.0).

Conclusion

Given the high rates of depression observed among MDR-TB patients, national TB treatment programmes should ensure their patients are routinely screened for depression and anxiety, and effective treatment offered.

Efficacy of red contact lens in improving color vision test performance based on Ishihara, Farnsworth D15, and Martin Lantern Test

Background

The aim of this study was to evaluate the efficacy of red contact lens in improving color vision test performance based on Ishihara, Farnsworth D15, and Martin Lantern Test (MLT).

Methods

Thirty subjects with a known color vision defect were enrolled after consent. The color vision was assessed using Ishihara test, D15 test, and MLT. The error scores were recorded. The test was repeated after using a red contact lens.

Results

The mean error scores were 7.87 (±1.00), 3.33 (±3.15), and 5.67 (±2.52) on Ishihara, MLT, and D15 test, respectively. The error scores reduced to 3.93 (±3.78), 1.33 (±1.34), and 2.77 (±2.12) Ishihara, MLT, and D15 test, respectively (P value < 0.05, Wilcoxon rank test). None of the subjects were in color perception (CP) II at presentation but 47.5% became CP II with the lens on Ishihara test. Ninety percent could pass the MLT CP III standard.

Conclusion

This study shows that red lens reduced error scores and subjects could pass the color vision tests. Notwithstanding the improvement in performance on color vision tests, lens is not recommended for personnel on active combat duty. The recruiting medical officer needs to be aware of the fact that a subject with defective color vision can pass various tests with a red contact lens.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Management of chronic hepatitis B before and after liver transplantation

Chronic hepatitis B infection is a global public health problem associated with significant morbidity and mortality. Persistent infection may evolve to liver cirrhosis and hepatocellular carcinoma, and hepatitis B-related liver disease is a common indication for liver transplantation. Patients with advanced liver disease should be treated with antiviral therapy which may result in clinical improvement. The management of patients after liver transplant then focuses on preventing hepatitis B recurrence in the graft. With the introduction of prophylactic treatment, patient and graft survival has improved significantly. In this review, we will discuss the management of patients with hepatitis B-related cirrhosis, both compensated and decompensated. We also review the management of hepatitis B after liver transplantation.

Optically transparent dense colloidal gels

Traditionally it has been difficult to study the porous structure of dense colloidal gels and (macro) molecular transport through them simply because of the difference in refractive index between the colloid material and the continuous fluid phase surrounding it, rendering the samples opaque even at low colloidal volume fractions. Here, we demonstrate a novel colloidal gel that can be refractive index-matched in aqueous solutions owing to the low refractive index of fluorinated latex (FL)-particles (n = 1.37). Synthesizing them from heptafluorobutyl methacrylate using emulsion polymerization, we demonstrate that they can be functionalized with short DNA sequences via a dense brush-layer of polystyrene-b-poly(ethylene oxide) block-copolymers (PS-PEO). The block-copolymer, holding an azide group at the free PEO end, was grafted to the latex particle utilizing a swelling-deswelling method. Subsequently, DNA was covalently attached to the azide-end of the block copolymer via a strain-promoted alkyne-azide click reaction. For comparison, we present a structural study of single gels made of FL-particles only and composite gels made of a percolating FL-colloid gel coated with polystyrene (PS) colloids. Further we demonstrate that the diffusivity of tracer colloids dispersed deep inside a refractive index matched FL-colloidal gel can be measured as function of the local confinement using Dynamic Differential Microscopy (DDM).

Serum vitamin D levels in Indian patients with retinal venous occlusions

Purpose

To estimate serum vitamin D (25 OH D) level in patients of retinal vein occlusion (RVO) and compare it with age-matched controls.

Methods and material

Forty patients above 18 years of age with retinal vein occlusion and forty age-matched controls underwent serum vitamin D (Vit D) level estimation using a standard protocol. Student’s t test was used to analyse differences between the mean of two groups.

Results

The mean age in RVO and control group was 60.25 and 60.73 years respectively. The mean (±SD) level of vitamin D in RVO patients was 13.68 (±4.58) ng/mL (range 5.5–24.8), and the 95% CI of mean was 12.21–15.14 with SD 4.58 while in control group it was 23.03 (±2.89) ng/ml (range 18.4–30.1) with 95% CI of mean being 22.11–23.96 with SD 2.89 (p value of <0.005). While comparing the level of Vitamin D based on type of occlusion the mean level of Vit D in CRVO patients was 15.36 (SD 5.30) and in BRVO it was 12.77 (SD 3.96) which was statistically not significant (p = 0.08). The odds ratio calculated for RVO cases versus controls was 133.33 which was statistically significant (P < 0.05).

Conclusions

There is a paucity of published literature on level of Vit D in RVO. This study shows significantly lower levels of serum vitamin D in Indian patients with retinal vein occlusion as compared to age matched controls. Establishment of this correlation has possible implications for prophylaxis or treatment of RVOs.

Universal institutional delivery among mothers in a remote mountain district of Nepal: what are the challenges?

Setting: Eight village development committees of Mugu District, a remote mountainous district of Nepal that has poor maternal health indicators. Objectives: 1) To assess the proportion of mothers who delivered in health facilities (institutional delivery); 2) among mothers who delivered at home, to understand their reasons for doing so; and 3) among mothers who delivered in health facilities, to understand their challenges. Design: Cross-sectional study involving semi-structured interviews with mothers conducted in 2015. Results: Of 275 mothers, 97 (35%) had an institutional delivery. Multivariate logistic regression analysis showed that women who resided within 1 h distance from the birthing centre, had adequate mass media exposure or had only one child were more likely to deliver in hospital. Reasons for non-institutional delivery (n = 178) were related to geographical access (49%), personal preferences (18%) and perceived poor quality care (4%). Mothers who accessed institutional delivery (n = 97) also reported difficulties related to travel (60%), costs (28%), dysfunctional health system (18%) and unfriendly attitudes of the health-care providers (7%). Conclusion: To improve access to institutional delivery, the government should establish a 24/7 emergency ambulance network, including air ambulance. Health system issues, including unfriendly staff attitudes, urgently need to be addressed to gain the trust of the mothers.

Development and Characterization of Novel Medicated Nanofibers Against Periodontitis

Periodontitis is an inflammatory disease of gums involving degeneration of periodontal ligaments, creation of periodontal pocket and resorption of alveolar bone, thus disrupting the support structure of teeth causing their loosening and finally removal. Since this disease is mainly confined to the periodontal pocket, so site specific drug delivery of an antibiotic is the best suitable option. This also eradicates the demerits of oral dosing like low drug concentration reaching the target site and the various systemic side effects. In the present work, an efficient and easy technique of electrospinning has been used to develop non-woven drug loaded and biodegradable nanofiber patch with inbuilt property of high surface area to volume ratio. Hyaluronic acid (HA) has been used specifically as the polymer since it possesses remarkable properties like providing an extracellular matrix supporting tissue regeneration, anti-inflammation and mucoadhesion. A blend of this natural polymer with another polymer (Polyvinyl alcohol) has been tried since HA alone cannot be electrospun efficiently as it shows very high viscosity at very low polymer concentration. The developed formulation presented controlled release behavior with good mucoadhesive strength. The in vivo studies confirmed the maintenance of minimum inhibitory concentration (MIC) over an extended period of time in addition to a significant antiinflammatory effect. All these observations suggested that the above formulation forms a stable intra periodontal pocket drug delivery system.

Seasonal immunohistochemical reactivity of S-100 and α-smooth muscle actin proteins in the epididymis of dromedary camel, Camelus dromedarius

The S-100 and alpha smooth muscle actin (α-SMA) proteins have been localised in epididymal tissue of several mammalian species, but there have been no data for a seasonal work in camel. The aim of this study was to investigate the immunoreactivities of S-100 and α-SMA proteins in the epididymis of dromedary camel during breeding and nonbreeding seasons. The immunopositive signals for both proteins were observed in different regions of camel epididymis. S-100-immunopositive signals were noted in both the epididymal epithelium and the intertubular connective tissue, while α-SMA signals were confined to the intertubular connective tissue, especially in the peritubular smooth muscle coat and the blood vessels. This study showed an increase in the intensity of S-100 and α-SMA immunoreactions during the breeding season in different regions of camel epididymis than that seen in the nonbreeding season. In conclusion, epididymis might be considered as a source of S-100 and α-SMA proteins in the camel and the secretion of these proteins showed distinct seasonal variations. Further, S-100 and α-SMA may affect the structural and physiological states of the epididymal duct.

Spectrum of ocular diseases in patients attending eye camps in Andaman and Nicobar

BACKGROUND

Andaman and Nicobar Island is a group of 572 islands with a population of 3,80,500. The only service hospital as well as govt hospital is situated at its capital, Portblair. The islands are interconnected only by sea passage and to reach the capital by this route it sometimes takes two days.

METHODS

The objective of this study is to assess the spectrum of different ocular diseases in remote islands of Andaman and Nicobar. Author had conducted various camps on these remote islands as a community outreach programme over two years.

RESULTS

Top eye diseases found were refractive error (35%), cataract (22%), conjunctival infammatory disease (15%), glaucoma cases (07%), pterygium (07%), NLDO (02%) and uveitis (02%). Out of total 132 cataract patients screened, 32 patients (approximately 24%) were operated in INHS Dhanvantari at free of cost with help of NPCB (National Programme for Control of Blindness).

CONCLUSION

This was the first kind of study conducted on these remote islands to know the prevalence of different ocular diseases. The important point to be seen in this study was unawareness of glaucoma and cataract load. No optometrist was posted in the PHCs to provide primary eye care like prescribing glasses, which is also a big concern.

Designing disordered materials using DNA-coated colloids of bacteriophage fd and gold

DNA has emerged as an exciting binding agent for programmable colloidal self-assembly. Its popularity derives from its unique properties: it provides highly specific short-ranged interactions and at the same time it acts as a steric stabilizer against non-specific van der Waals and Coulomb interactions. Because complementary DNA strands are linked only via hydrogen bonds, DNA-mediated binding is thermally reversible: it provides an effective attraction that can be switched off by raising the temperature only by a few degrees. In this article we introduce a new binary system made of DNA-functionalized filamentous fd viruses of ∼880 nm length with an aspect ratio of ∼100, and 50 nm gold nanoparticles (gold NPs) coated with the complementary DNA strands. When quenching mixtures below the melt temperature Tm, at which the attraction is switched on, we observe aggregation. Conversely, above Tm the system melts into a homogenous particulate 'gas'. We present the aggregation behavior of three different gold NP to virus ratios and compare them to a gel made solely of gold NPs. In particular, we have investigated the aggregate structures as a function of cooling rate and determine how they evolve as function of time for given quench depths, employing fluorescence microscopy. Structural information was extracted in the form of an effective structure factor and chord length distributions. Rapid cooling rates lead to open aggregates, while slower controlled cooling rates closer to equilibrium DNA hybridization lead to more fine-stranded gels. Despite the different structures we find that for both cooling rates the quench into the two-phase region leads to initial spinodal decomposition, which becomes arrested. Surprisingly, although the fine-stranded gel is disordered, the overall structure and the corresponding length scale distributions in the system are remarkably reproducible. Such highly porous systems can be developed into new functional materials.

An 'omics' approach towards the characterisation of laboratory scale anaerobic digesters treating municipal sewage sludge

In this study, laboratory scale digesters were operated to simulate potential shocks to the Anaerobic Digestion (AD) process at a 350 ML/day wastewater treatment plant. The shocks included high (42 °C) and low (32 °C) temperature (either side of mesophilic 37 °C) and a 20% loading of fats, oil and grease (FOG; 20% w:v). These variables were explored at two sludge retention times (12 and 20 days) and two organic loading rates (2.0 and 2.5 kgTS/m(3)day OLR). Metagenomic and metabolomic approaches were then used to characterise the impact of operational shocks in regard to temperature and FOG addition, as determined through monitoring of biogas production, the microbial profile and their metabolism. Results showed that AD performance was not greatly affected by temperature shocks, with the biggest impact being a reduction in biogas production at 42 °C that persisted for 32 ± 1 days. The average biogas production across all digesters at the completion of the experiment was 264.1 ± 76.5 mL/day, with FOG addition observed to significantly promote biogas production (+87.8 mL/day). Metagenomic and metabolomic analyses of the digesters indicated that methanogens and methane oxidising bacteria (MOB) were low in relative abundance, and that the ratio of oxidising bacteria (methane, sulphide and sulphate) with respect to sulphate reducing bacteria (SRB) had a noticeable influence on biogas production. Furthermore, increased biogas production correlated with an increase in short chain fatty acids, a product of the addition of 20% FOG. This work demonstrates the application of metagenomics and metabolomics to characterise the microbiota and their metabolism in AD digesters, providing insight to the resilience of crucial microbial populations when exposed to operational shocks.

The Man Behind the Royal Massacre

Delusional disorder is a relatively uncommon psychiatric condition in which patients present with non-bizarre delusions, but with no accompanying prominent perceptual disturbances, thought disorder or significant and sustained mood symptoms. Apart from their delusions, people with delusional disorder may continue to socialize and function in a normal manner and their behavior does not generally seem odd or bizarre to others for many years of the onset of their symptoms. Because of this, they are brought to the clinician many years after the onset of their symptoms, only when their delusional behavior becomes overt. Thus, identifying and treating delusional disorders in time is a challenging task.

Feto-maternal Outcome Using New Screening Criteria of Serum TSH for Diagnosing Hypothyroidism in Pregnancy

INTRODUCTION

Evidence suggests that by using the classical non pregnant reference range for serum TSH (STSH), one might miss hypothyroidism in pregnancy. Therefore, upper normal cut off value of S TSH should be taken as <2.5 mIU/L in the first trimester and <3mIU/L in the second and third trimester. However, two Indian studies have reported higher trimester specific reference ranges in the Indian pregnant women.

OBJECTIVES

To assess the maternal and fetal outcomes using new screening criteria with upper S TSH cut off as >3mIU/L, for diagnosing hypothyroidism in pregnancy.

MATERIALS AND METHODS

This study was a cross sectional study, carried out in the Department of Obstetrics and Gynaecology of a tertiary care hospital, in collaboration with the Department of Endocrinology. Pregnant women with ≤ 20 weeks gestation, attending antenatal OPD from December 2010 to January 2012 were included in the study. On the basis of S TSH level, women were divided into Study Group with S TSH level between 3.1 to 6.2 mIU/L, (new range to be studied) and an equal number of age and parity matched Control Group with S TSH levels between 0.4 to 3 mIU/L. The maternal and fetal outcomes were compared between study and control groups.

RESULTS

During the study period, a total of 66 women had S TSH between 3.1-6.2 mIU/L. Maternal and fetal outcomes in both the groups were comparable. There was no difference in the mode of delivery between study and control groups.

CONCLUSION

The lower S TSH cut off recommended for diagnosing hypothyroidism in pregnancy may not be applicable to pregnant Indian women.

Can ganglion cell complex assessment on cirrus HD OCT aid in detection of early glaucoma?

Context

Ganglion cell complex is damaged early in glaucoma. Does this loss of GCC help in early diagnosis of glaucoma.

Aims

To compare the RNFL thickness and ganglion cell complex (GCC) in diagnosed patients of glaucoma, pre-perimetric glaucoma and normal controls.

Settings and design

Case controlled, observational study.

Methods and material

33 glaucoma patients, 45 pre-perimetric glaucoma, and 30 controls were enrolled in the study. ONH parameters on cirrus HD OCT like CD ratio, para papillary RNFL thickness and GCC were calculated for each case.

Statistical analysis used

ANOVA test to analyse differences between groups. ROC for ganglion cell layer.

Results

RNFL thickness was 71.6 μ and GCC was 69.19 μ in glaucoma patients. RNFL thickness was 77.31 μ and GCC was 71 μ in pre-perimetric glaucoma and 99.6 μ and 85.16 μ in controls respectively. The difference of mean for RNFL and GCC by ANOVA was statistically significant for controls, glaucoma patients and pre-perimetric glaucoma patients. RNFL (p < 0.001) and GCC (p < 0.001). Receiver operating characteristic curve for GCC was 0.83 (p < 0.000).

Conclusions

The RNFL analysis is increasingly being used as newer tool in diagnosis of glaucoma. In addition, GCC can be used as a supplementary tool in picking up cases of pre-perimetric glaucoma as loss is significant in pre-perimetric glaucoma also.

Experience of propofol sedation in a UK ERCP practice: lessons for service provision

OBJECTIVE

Endoscopic retrograde cholangiopancreatography (ERCP) in the UK has been historically performed under conscious sedation. However, given the increasing complexity of cases, the role of propofol-assisted ERCP (propERCP) is increasing. We describe our experience of propERCP and highlight the importance of this service.

DESIGN

Our prospective ERCP database was interrogated between January 2013 and January 2014. Data collection included procedural information, patient demographics, American Association of Anaesthesiologists (ASA) status, Cotton grade of endoscopic difficulty and endoscopic and anaesthetic complications. Comparison was made with patients undergoing conscious sedation ERCP (sedERCP).

RESULTS

744 ERCPs were performed in 629 patients (53% male). 161 ERCPs were performed under propofol. PropERCP patients were younger compared with the sedERCP group (54 vs 66 years, p<0.0001) but ASA grade 1-2 status was similar (84% vs 78%, p=0.6). An increased number of Cotton grade 3-4 ERCPs were performed in the propERCP group (64% vs 34%, p<0.0001). Indications for propERCP included sphincter of Oddi manometry (27%), previously poorly tolerated sedERCP (26%), cholangioscopy (21%) and patient request (8%). 77% of cases were elective, 12% were urgent day-case transfers and 11% were urgent inpatients. 59% of cases were tertiary referrals. ERCP was completed successfully in 95% of cases. Anaesthetic and endoscopic complications were comparable between the two groups (5% and 7% vs 3% and 5%). Where sedERCP had been unsuccessful due to patient intolerance, the procedure was completed successfully using propofol.

CONCLUSIONS

PropERCP is safe and is associated with high endoscopic success. The need for propERCP is likely to increase given patient preference and the high proportion of complex procedures being undertaken. All endoscopy units should look to incorporate propofol-assisted endoscopy into aspects of their services.

Biliary and hepatic involvement in IgG4-related disease

BACKGROUND

IgG4-related disease (IgG4-RD) is a multi-systemic disorder. IgG4-related sclerosing cholangitis (IgG4-SC) is the biliary manifestation of the disease, often in association with autoimmune pancreatitis (AIP). Hepatic manifestations of IgG4-RD are less well described within the literature.

AIM

To examine and present an overview of IgG4-RD with a focus on the biliary and hepatic manifestations.

METHODS

An electronic search using Medline was performed. Search items included 'IgG4 multi-system disease, IgG4 associated cholangitis, IgG4 associated liver disease and autoimmune pancreatitis (AIP)'.

RESULTS

IgG4-RD is characterised by an IgG4-positive lymphoplasmacytic tissue infiltrate, storiform fibrosis and an obliterative phlebitis. The HISORt criteria may be used to establish the diagnosis and incorporate a multi-disciplinary approach involving histology, radiology, serum IgG4 levels and response to steroid therapy. IgG4-SC is the commonest extrapancreatic manifestation of type-1 AIP, while the hepatic manifestations remain poorly defined. Important differential diagnoses include primary sclerosing cholangitis, secondary sclerosing cholangitis, cholangiocarcinoma and pancreatic carcinoma. Current treatment regimens remain ill defined although steroid therapy is used first line unless contraindicated. Patients with relapsing disease or multifocal disease should be considered for azathioprine. Available data would also suggest a role for rituximab.

CONCLUSIONS

IgG4-related sclerosing cholangitis is a common manifestation of IgG4-related disease which requires a multi-disciplinary approach to establish the diagnosis. Differentiating IgG4-related sclerosing cholangitis from other conditions, both benign and malignant, is challenging, but vital. Steroids remain the mainstay of treatment. Our understanding of the pathogenesis of the hepatic manifestations of IgG4-related disease continues to evolve.

Evaluation of two delirium screening tools for detecting post-operative delirium in the elderly

BACKGROUND

Postoperative delirium in the elderly is common and associated with poor outcomes, but often goes unrecognized. Delirium screening tools, validated in postoperative settings are lacking. This study compares two screening tools [Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Nursing Delirium Symptom Checklist (NuDESC)] with a DSM-IV-based diagnosis of delirium, conducted by neuropsychiatric examination in postoperative settings.

METHODS

Consecutive English-speaking patients, ≥70 yr, undergoing surgery with general anaesthesia and capable of providing informed consent, were recruited. Diagnostic test characteristics were compared for each screening tool vs neuropsychiatric examination, both in the Post-Anaesthesia Care Unit (PACU), and daily during inpatient hospitalization, adjusting for repeated measures.

RESULTS

Neuropsychiatric examination identified delirium in 45% of 91 patients evaluated in the PACU and in 32% of 166 subsequent delirium assessments on the ward in the 58 admitted patients. The sensitivity [95% confidence interval (CI)] of delirium detection of the CAM-ICU in the PACU, and in all repeated assessments was 28% (16-45%) and 28% (17-42%), respectively; for the NuDESC (scoring threshold ≥2), 32% (19-48%) and 29% (19-42%), respectively, and the NuDESC (threshold ≥1), 80% (65-91%) and 72% (60-82%), respectively. Specificity was >90% for both the CAM-ICU and the NuDESC (threshold ≥2); specificity for the NuDESC (threshold ≥1), in the PACU was 69% (54-80%) and 80% (73-85%) for all assessments.

CONCLUSIONS

While highly specific, neither CAM-ICU nor NuDESC (threshold ≥2) are adequately sensitive to identify delirium post-operatively; NuDESC (threshold ≥1) increases sensitivity, but reduces specificity.