The aetiology of maxillofacial trauma in Australia: A scoping review

BACKGROUND

The oral and maxillofacial complex is subject to a range of traumas. Injuries to the region are devastating and have a great impact on social health outcomes. This review intends to investigate the aetiologies of maxillofacial trauma across Australia.

METHODS

This review was written in accordance with the PRISMA-ScR. Comprehensive searches of CINAHL, MEDLINE, Ovid, Scopus, and Web of Science databases were conducted to identify potentially relevant literature. Quantitative observational epidemiological studies were sought and were required to include at least one aetiology to the maxillofacial region in their data set. A total of 31 eligible studies were included.

RESULTS

The greatest recorded causes of maxillofacial injuries included inter-personal violence (34.98%) falls (20.87%), sports (15.62%), and motor-vehicle accidents (14.31%). These four aetiologies cumulatively accounted for more than 85% of maxillofacial injuries. From all sustained injuries (n = 7661), the orbit was the most prevalent site of fracture (31.85%), followed by the zygoma (22.01%), mandible (21%), nasal bone (12.45%), maxilla (10.04%), dentoalveolus (1.84%), antrum (<1%), and frontal bone (<1%).

CONCLUSION

Violence was an unprecedented cause of trauma-additional research is recommended to further characterize the correlation between the two variables. Research is also recommended specifically in regional/rural communities, where data was particularly limited. © 2024 Australian Dental Association.

Fractional flow reserve and instantaneous wave-free ratio in coronary artery bypass grafting: a meta-analysis and practice review

Objective

Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive methods to assess the functional significance of intermediate severity coronary lesions. Both indexes have been extensively validated in clinical trials in guiding revascularisation in patients with stable ischaemic heart disease undergoing percutaneous coronary intervention (PCI) with improved clinical outcomes. However, the role of these tools in coronary artery bypass grafting (CABG) is less clear.

Methods

A meta-analysis of randomised trials and observational studies was carried out to help in determining the optimal strategy for assessing lesion severity and selecting graft targets in patients undergoing CABG. Electronic searches were carried out on Embase, MEDLINE, and Web of Science. A group of four authors independently screened and then assessed the retrieved records. Cochrane's Risk of Bias and Robins-I tools were used for bias assessment. A survey was conducted among surgeons and cardiologists to describe current attitudes towards the preoperative use of functional coronary investigations in practice.

Results

Clinical outcomes including mortality at 30 days, perioperative myocardial infarction, number of grafts, incidence of stroke, rate of further need for revascularisation, and patient-reported quality of life did not differ in CABG guided by functional testing from those guided by traditional angiography.The survey revealed that in half of the surgical and cardiology units functional assessment is performed in CABG patients; there is a general perception that functional testing has improved patient care and its use would clarify the role of moderate coronary lesions that often need multidisciplinary rediscussions; moderate stenosis are felt to be clinically relevant; and anatomical considerations need to be taken into account together with functional assessment.

Conclusions

At present, the evidence to support the routine use of functional testing in intermediate lesions for planning CABG is currently insufficient. The pooled data currently available do not show an increased risk in mortality, myocardial injury, and stroke in the FFR/iFR-guided group. Further trials with highly selected populations are needed to clarify the best strategy.

Systematic Review Registration

ClinicalTrials.gov, identifier (CRD42023414604).

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

A luminous fast radio burst that probes the Universe at redshift 1

Fast radio bursts (FRBs) are millisecond-duration pulses of radio emission originating from extragalactic distances. Radio dispersion is imparted on each burst by intervening plasma, mostly located in the intergalactic medium. In this work, we observe the burst FRB 20220610A and localize it to a morphologically complex host galaxy system at redshift 1.016 ± 0.002. The burst redshift and dispersion measure are consistent with passage through a substantial column of plasma in the intergalactic medium and extend the relationship between those quantities measured at lower redshift. The burst shows evidence for passage through additional turbulent magnetized plasma, potentially associated with the host galaxy. We use the burst energy of 2 × 1042 erg to revise the empirical maximum energy of an FRB.

The effect of a novel, digital physical activity and emotional well-being intervention on health-related quality of life in people with chronic kidney disease: trial design and baseline data from a multicentre prospective, wait-list randomised controlled trial (kidney BEAM)

BACKGROUND

Physical activity and emotional self-management has the potential to enhance health-related quality of life (HRQoL), but few people with chronic kidney disease (CKD) have access to resources and support. The Kidney BEAM trial aims to evaluate whether an evidence-based physical activity and emotional wellbeing self-management programme (Kidney BEAM) leads to improvements in HRQoL in people with CKD.

METHODS

This was a prospective, multicentre, randomised waitlist-controlled trial, with health economic analysis and nested qualitative studies. In total, three hundred and four adults with established CKD were recruited from 11 UK kidney units. Participants were randomly assigned to the intervention (Kidney BEAM) or a wait list control group (1:1). The primary outcome was the between-group difference in Kidney Disease Quality of Life (KDQoL) mental component summary score (MCS) at 12 weeks. Secondary outcomes included the KDQoL physical component summary score, kidney-specific scores, fatigue, life participation, depression and anxiety, physical function, clinical chemistry, healthcare utilisation and harms. All outcomes were measured at baseline and 12 weeks, with long-term HRQoL and adherence also collected at six months follow-up. A nested qualitative study explored experience and impact of using Kidney BEAM.

RESULTS

340 participants were randomised to Kidney BEAM (n = 173) and waiting list (n = 167) groups. There were 96 (55%) and 89 (53%) males in the intervention and waiting list groups respectively, and the mean (SD) age was 53 (14) years in both groups. Ethnicity, body mass, CKD stage, and history of diabetes and hypertension were comparable across groups. The mean (SD) of the MCS was similar in both groups, 44.7 (10.8) and 45.9 (10.6) in the intervention and waiting list groups respectively.

CONCLUSION

Results from this trial will establish whether the Kidney BEAM self management programme is a cost-effective method of enhancing mental and physical wellbeing of people with CKD.

TRIAL REGISTRATION

NCT04872933. Registered 5th May 2021.

Bedside Index of Severity in Acute Pancreatitis (BISAP) Score on Outcome of Patients Presenting with Acute Pancreatitis in a Tertiary Care Hospital

Background Acute pancreatitis is a life-threatening condition characterized by inflammation of the pancreas causing intense abdominal pain and potential harm to multiple organs. The mortality rate is 1-5% and thus requires specialized and interdisciplinary care to inhibit it. Objective To describe the bedside index of severity in acute pancreatitis score on the outcome of acute pancreatitis patients in a tertiary care hospital. Method This is a hospital based observational cross-sectional study conducted in the internal medicine inpatient department of Dhulikhel Hospital from April 2018 and March 2019. This study reviewed the medical records of the department. Result The study included 70 participants with 44 (±14) years of average age and stating common cause as gallstone (45.7%). The study showed that those with bedside index of severity in acute pancreatitis score ≥ 3 during hospital admission had significantly higher rate of organ failure (p-value < 0.05), as well as had a prolonged hospital stay (mean: 20 [±7.9] days). The mean hospital stay was 12.9 days. Conclusion Patients with bedside index of severity in acute pancreatitis score greater than three at admission were found to have an increased risk of organ failure, significantly higher chances of requiring mechanical ventilation, and a longer duration of hospital stay.

Intermediate syndrome following organophosphate poisoning: A case report in a low resource and poor socio-economic setting

Intermediate syndrome with respiratory failure is a serious complication that can be fatal as in our case of a 24‐year‐old‐man who developed intermediate syndrome requiring intubation and respiratory support. Furthermore, the patient's socio‐economic situation significantly impacts the illness's progress and prognosis.

With this case report, we want to stress how a patient's socio‐economic background affects the course and outcome of a particular disease condition.

Steroid induced psychosis in a child with nephrotic syndrome: A case report

Background

and Importance: Steroids induced psychosis is one of major adverse effects of corticosteroids therapy especially in patients with disease causing low serum albumin level like nephrotic syndrome. The literature review about this adverse effects is lesser in children than adults population. The management is done by tapering dose of steroids in aid of immunosuppressive drug with an antipsychotics drug.

Case presentation

Here we present a case of 14 years old female child known case of nephrotic syndrome secondary to Focal segmental glomerulosclerosis with steroids induced psychosis who is managed by tapering dose of prednisolone with Tacrolimus as immunosuppressive and Quetiapine as antipsychotic.

Conclusion

The prevalence of steroids induced psychosis is higher in our locality which is still unreported due to lack of detailed history and proper diagnosis and it is manageable if early diagnosis and treatment is initiated. Thus, proper counselling to parents about the adverse effect of steroids therapy and timely follow up will prevent Nepalese children from this illness.

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Disturbance in mental state is one of the adverse effect of steroids.

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Patient treated with corticosteroids presents various forms of psychiatric symptoms, most of them suffering from mild symptoms not fulfilling any diagnostic criteria.

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Patient with disease causing low levels of serum proteins like nephrotic syndrome is likely to suffer from adverse effects of steroids treatment.

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The literature review about the steroids induced psychosis in children and adolescents is insufficient and rare though it is well known complication in adults. To our knowledge, this is the first reported case of steroids induced psychosis to be reported from Nepal.

Homozygous Lepore Syndrome: A case report

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Lepore Hemoglobin is a structurally abnormal type of haemoglobin consisting of an abnormal globin chain which is a hybrid or fused globin chain comprising an N-terminal amino acid sequence of a delta chain and the C-terminal amino acid sequence of a beta chain.

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The synthesis of these hybrid chains is substantially less than that of the β-chains, resulting in an overall reduction in the non-α globin chains and patients present with a clinical picture of haemolytic anemia.

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But Hb Lepore can be differentiated from β-Thalassemia by the presence of a distinct Hb Lepore band on cellulose acetate electrophoresis or quantification in High Performance Liquid Chromatography (HPLC).

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Presumptive diagnosis can be made in lab by a multi-faceted approach consisting of a series of blood count/red cell indices, Hb electrophoresis and haemoglobin analysis by HPLC. Quantitative analysis for any Hb variant disorder is made by HPLC better than Hb Electrophoresis, the same was done in our case report.

Full coverage crowns for rehabilitation of MIH affected molars: 24 month randomized clinical trial

BACKGROUND

Teeth affected with severe molar incisor hypomineralization (MIH) require extensive restorations, which do not last for a long time and often require treatment in the form of onlays or full coverage restorations.

AIM

To evaluate and compare the clinical performance of zirconia, lithium disilicate, and cast metal crowns as full-coverage restorations on MIH-affected first permanent molars (FPMs).

METHODS

60 MIH affected FPMs requiring full-coverage crowns were identified in children aged 8-15 years and were randomly allocated to the three treatment groups according to the type of full coverage restoration received using block randomization technique. After an adequate removal of the MIH defect and restoration with composite resin, the tooth preparation was done followed by fabrication of crown and its cementation using resin cement. The intergroup comparison was done on the basis of USPHS criteria, gingival, plaque scores, patient and parents acceptance through a visual analog scale to decipher their clinical performance at 6, 12, 24 months.

RESULTS

After 24 months, the crowns showed similar clinical success in terms of the criterias used to compare their clinical performance. The retention, marginal adaptation, relief from hypersensitivity, proximal contact, gingival health with no statistically significant difference among the three groups.

CONCLUSION

Based on the observations, Lithium disilicate, Zirconia and full cast metal crowns showed similar clinical success in rehabilitation of First permanent molars with severe MIH over 24 months of evaluation. The clinical success is not influenced by the material of the restoration. However, prospective studies with a longer follow-up are required to reach a more definitive conclusion.

Cardiac magnetic resonance strain and mechanical dispersion assessment in patients with chronic total coronary artery occlusion

Background

Chronic total occlusions (CTO) are a frequent angiographic finding. Viability of CTO-subtended myocardium is dependent on the presence of an adequate collateral circulation. At rest, collateral supply may be sufficient to avert ischaemia and maintain normal systolic function. However, it remains unclear whether CTO-subtended myocardium may be considered truly normal, or whether subtle functional abnormalities may be present at rest.

Purpose

To determine whether, in the absence of infarction and hibernation, CTO-subtended myocardium remains functionally normal or whether abnormalities of strain and/or mechanical dispersion may be present at rest.

Methods

In a retrospective, single centre, observational study, we studied patients with ≥1 angiographically-diagnosed CTO referred for clinical stress perfusion cardiovascular magnetic resonance (CMR), and compared healthy volunteers (HVs) with a normal stress CMR scan. CMR imaging comprised functional and scar assessment with qualitative [visual] evaluation of infarction and segmental wall motion. Patients with infarction and/or wall motion score index (WMSI) ≥1 were excluded from further analysis. In remaining CTO subjects and HVs, segmental peak systolic longitudinal strain and circumferential strain were analysed (in 3 long-axis planes and 3 short-axis planes, respectively) and mechanical dispersion for both orientations was computed. Image analysis was performed using Medis (QStrain) software blinded to all clinical information.

Results

From a total of 389 patients with ≥1 angiographically-diagnosed CTO, 68 had normal WMSI and no infarction (63.0±11.7 years, 79.4% male, LVEF 62.6±4.5%). Fifty HVs (61.1±7.0 years, 74.0% males, LVEF 61.1±5.3%) were also studied. The majority of CTO patients had concomitant coronary artery disease in at least one non-CTO vessel (n=37, 54.4%). GLS was lower in CTO patients than HVs (−21.8%±1.5% versus −24.0±1.1%; p&lt;0.0001; Figure 1). By contrast, GCS was greater in CTO patients (−32.7±2.5% versus −28.8±2.1%; p&lt;0.0001). Mechanical dispersion was increased in CTO patients (Figure 2), both longitudinally (90.3±14.6 ms in CTO patients versus 68.6±11.1 ms in HVs; p&lt;0.0001) and circumferentially (66.7±9.1 ms versus 55.3±6.6 ms, respectively; p=0.02).

Conclusion

Subclinical changes in left ventricular dynamics are present at rest in CTO patients with fully viable myocardium and no evidence of resting regional wall abnormality. Further study is warranted to evaluate the potential association between mechanical dispersion and arrhythmic events in CTO.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): NIHR Clinician Scientist Award (CS-2018-18-ST2-007 to J.R.A.) and Research Professorship award (RP-2017-08-ST2-007 to G.P.M.). Figure 1. Strain analysis. CTO vs HVFigure 2. Mechanical dispersion. CTO vs HV

Seroprevalence of Scrub Typhus in Patients Attending Dhulikhel Hospital, Kavre

Background Scrub typhus is a largely ignored tropical disease and a leading cause of undifferentiated febrile illness. It is caused by Orientia tsutsugamushi. Scrub Typhus is frequently observed in South Asian countries. However, clear epidemiological information of this disease is lacking in case of Nepal. Nepal has shown steady increase in cases of Scrub Typhus since 2015. The epidemiological data related to this disease would support the decision making and surveillance design for early outbreak detection and immediate responses including prevention and treatment of scrub typhus in Nepal. Objective To understand prevalence of Scrub Typhus in subjects who had visited outpatient department at Dhulikhel Hospital. Method In this study, we have studied antibody test data (n=784) for Scrub Typhus from 2019 to 2021. The tests were performed on serum samples of patients who had visited OPD at Dhulikhel Hospital with fever lasting more than 5 days. The kit used in analysis was Scrub Typhus Detect™ IgM ELISA Kit from InBios International. Result Out of the total subjects (n=784), 133 were positive (16.9%) for IgM antibody of Scrub Typhus. The positivity in female (18.6%) was higher than the male subjects (15.3%). The positivity rate was variable among the different age groups, with highest positivity for age group 0-14 years (25%). The seasonal variation was also observed among the seropositive cases. Conclusion Scrub Typhus being a neglected tropical disease has high prevalence. It can be postulated that female subjects and subjects of age group 0-14 years are vulnerable to the infection with Scrub Typhus. There is need to increase the surveillance of Scrub Typhus to add the knowledge for diagnosis and treatment.

A multicentre prospective double blinded randomised controlled trial of intravenous iron (ferric Derisomaltose (FDI)) in Iron deficient but not anaemic patients with chronic kidney disease on functional status

BACKGROUND

Iron deficiency (ID) is common in patients with chronic kidney disease (CKD). Intravenous (IV) iron in heart failure leads to improvement in exercise capacity and improvement in quality-of-life measurements; however, data in patients with CKD are lacking.

METHODS

The Iron and the Heart Study was a prospective double blinded randomised study in non-anaemic CKD stages 3b-5 patients with ID which investigated whether 1000 mg of IV iron (ferric derisomaltose (FDI)) could improve exercise capacity in comparison to placebo measured at 1 and 3 months post infusion. Secondary objectives included effects on haematinic profiles and haemoglobin, safety analysis and quality of life questionnaires (QoL).

RESULTS

We randomly assigned 54 patients mean (SD) age for FDI (n = 26) 61.6 (10.1) years vs placebo (n = 28; 57.8 (12.9) years) and mean eGFR (33.2 (9.3) vs. 29.1 (9.6) ml/min/1.73m2) at baseline, respectively. Adjusting for baseline measurements, six-minute walk test (6MWT) showed no statistically significant difference between arms at 1 month (p = 0.736), or 3 months (p = 0.741). There were non-significant increases in 6MWT from baseline to 1 and 3 months in the FDI arm. Haemoglobin (Hb) at 1 and 3 months remained stable. There were statistically significant increases in ferritin (SF) and transferrin saturation (TSAT) at 1 and 3 months (p < 0.001). There was a modest numerical improvement in QoL parameters. There were no adverse events attributable to IV iron.

CONCLUSION

This study demonstrated a short-term beneficial effect of FDI on exercise capacity, but it was not significant despite improvements in parameters of iron status, maintenance of Hb concentration, and numerical increases in functional capacity and quality of life scores. A larger study will be required to confirm if intravenous iron is beneficial in iron deficient non-anaemic non-dialysis CKD patients without heart failure to improve the 6MWT.

TRIAL REGISTRATION

European Clinical Trials Database (EudraCT) No: 2014-004133-16 REC no: 14/YH/1209 Date First Registered: 2015-02-17 and date of end of trail 2015-05-23 Sponsor ref R1766 and Protocol No: IHI 141.

Vitamin D in Infant Formula and Enteral Products by Liquid Chromatography: Collaborative Study

Results from a collaborative study of a new liquid chromatographic (LC) method for determination ofvitamin D in infant formulas and enteral products are presented. Each of 15 laboratories was provided with 11 blind duplicate samples covering a range ofapproximately 200-500 International Units/quart (normal dilution), a system suitability sample, and the U.S. Pharmacopeia ergo- and cholecalciferol standards. Product types included liquid and powder forms of milk (whey and casein), soy, and hydrolyzed protein-based infant formulas and enteral products. The method includes a single liquid-liquid extraction following saponification, solid-phase extraction,and then concentration by evaporation. An isocratic, nonaqueous, chromatographic system with reversed-phase, zero end- capped C18 column, and UV detector set at 265 nm are used. Statistical evaluation ofdata from participating laboratories showthe average reproducibility and repeatability of the method across all samples to be excellent, with RSDR and RSDr values of 13.48 and 9.44, respectively, after elimination of out liers. The LC method for determination of vitamin D in infant formulas and enteral products has been adopted by AOAC INTERNATIONAL.

Determination of Ethoxyquin in Feeds by Liquid Chromatography: Collaborative Study

Ethoxyquin is a chemical antioxidant used in feeds, ingredients, fats, and oils. A liquid chromatographic (LC) method for determination of ethoxyquin was developed. The method involves acetonitrile extraction of the sample and isocratic Cis reversed-phase chromatography with ammonium acetate buffer-acetonitrile as mobile phase and fluorescence detection. A collaborative study of the determination of ethoxyquin in various meals and extruded pet foods was conducted by The lams Company Research Laboratory. Eleven laboratories analyzed 16 samples (including 2 blind duplicates) consisting of 7 meat meals and 9 extruded pet foods. Sample means ranged from 0.25 to 289 ppm. Repeatability standard deviations ranged from 0.08 to 3.2 ppm, and repeatability relative standard deviations ranged from 4.5 to 32%. Reproducibility standard deviations ranged from 0.12 to 13 ppm, and reproducibility relative standard deviations ranged from 4.5 to 55%. The LC method for determination of ethoxyquin in feeds has been adopted first action by AOAC INTERNATIONAL.

Determination of Total Dietary Fiber (CODEX Definition) by Enzymatic-Gravimetric Method and Liquid Chromatography: Collaborative Study

A method for the determination of total dietary fiber (TDF), as defined by the CODEX Alimentarius, was validated in foods. Based upon the principles of AOAC Official MethodsSM 985.29, 991.43, 2001.03, and 2002.02, the method quantitates high- and low-molecular-weight dietary fiber (HMWDF and LMWDF, respectively). In 2007, McCleary described a method of extended enzymatic digestion at 37C to simulate human intestinal digestion followed by gravimetric isolation and quantitation of HMWDF and the use of LC to quantitate low-molecular-weight soluble dietary fiber (LMWSDF). The method thus quantitates the complete range of dietary fiber components from resistant starch (by utilizing the digestion conditions of AOAC Method 2002.02) to digestion resistant oligosaccharides (by incorporating the deionization and LC procedures of AOAC Method 2001.03). The method was evaluated through an AOAC collaborative study. Eighteen laboratories participated with 16 laboratories returning valid assay data for 16 test portions (eight blind duplicates) consisting of samples with a range of traditional dietary fiber, resistant starch, and nondigestible oligosaccharides. The dietary fiber content of the eight test pairs ranged from 11.57 to 47.83. Digestion of samples under the conditions of AOAC Method 2002.02 followed by the isolation and gravimetric procedures of AOAC Methods 985.29 and 991.43 results in quantitation of HMWDF. The filtrate from the quantitation of HMWDF is concentrated, deionized, concentrated again, and analyzed by LC to determine the LMWSDF, i.e., all nondigestible oligosaccharides of degree of polymerization 3. TDF is calculated as the sum of HMWDF and LMWSDF. Repeatability standard deviations (sr) ranged from 0.41 to 1.43, and reproducibility standard deviations (sR) ranged from 1.18 to 5.44. These results are comparable to other official dietary fiber methods, and the method is recommended for adoption as Official First Action.

Determination of β-Carotene in Supplements and Raw Materials by Reversed-Phase High Pressure Liquid Chromatography: Collaborative Study

Twelve laboratories representing 4 countries participated in an interlaboratory study conducted to determine all-trans-β-carotene and total β-carotene in dietary supplements and raw materials. Thirteen samples were sent as blind duplicates to the collaborators. Results obtained from 11 laboratories are reported. For products composed as softgels and tablets that were analyzed for total β-carotene, the reproducibility relative standard deviation (RSDR) ranged from 3.35 to 23.09% and the HorRat values ranged from 1.06 to 3.72. For these products analyzed for trans β-carotene, the reproducibility relative standard deviation (RSDR) ranged from 4.28 to 22.76% and the HorRat values ranged from 0.92 to 3.37. The RSDr and HorRat values in the analysis of a beadlet raw material were substantial and it is believed that the variability within the material itself introduced significant variation in subsampling. The method uses high pressure liquid chromatography (LC) in the reversed-phase mode with visible light absorbance for detection and quantitation. If high levels of α-carotenes are present, a second LC system is used for additional separation and quantitation of the carotene species. It is recommended that the method be adopted as an AOAC Official Method.

Determination of Retinyl Palmitate (Vitamin A) in Fortified Fluid Milk by Liquid Chromatography: Collaborative Study

A liquid chromatographic (LC) method was developed for fast and simple measurement of retinyl palmitate (vitamin A) in fortified milk. Retinyl acetate internal standard was added to a test portion of milk followed by extraction into hexane. The hexane extract was analyzed by LC using a normal-phase silica gel column equilibrated with mobile phase (conditioned hexane–isopropanol, 99.85 + 0.15, v/v) about 1 h before injections. The retinyl palmitate concentration was calculated by using a relative response factor determined with calibration standards. In the collaborative study, 11 laboratories analyzed 13 pairs of fluid milk materials in blind duplicate. Twelve of the materials were composed of skim milk (&lt;0.5% fat), 1% fat milk, 2% fat milk, and 1% fat chocolate milk. Each material was fortified at 3 concentrations of retinyl palmitate of approximately 581 μg/L (1000 IU/qt), 1163 μg/L (2000 IU/qt), and 2236 μg/L (4000 IU/qt). The 13th material, unfortified skim milk, served as a matrix blank. Repeatability standard deviations (RSDr) without outliers ranged from 1.5 to 5.7% and reproducibility standard deviations (RSDR) without outliers ranged from 5.0 to 22.7%. cis-Isomers co-eluted with the predominant trans-retinyl palmitate isomer and were included in the results reported by all the collaborative laboratories. Endogenous long-chain esters from milk fat were also measured with the retinyl palmitate additive. The Study Director recommends that this method for determination of retinyl palmitate in fluid milk by LC be adopted First Action.

Oral Cysticercosis Presenting as an Innocuous Lesion

Cysticercosis is a parasitic infection with potential of causing significant morbidity especially in developing countries. The larval form of the parasite Taenia Solium, 'Cysticercus Cellulosae' primarily colonizes in the small intestine and has the potential to disseminate to different sites of the body. Oral presentation is rare and difficult to detect owing to its innocuous presentation. This report describes the presentation of cysticercosis involving the tongue and presenting as a submucosal mass. An incisional biopsy was performed and evaluation of the histopathological features lead to the diagnosis of oral cysticercosis. This article highlights the importance of inter-departmental collaboration for the accurate diagnosis and effective management of oral cysticercosis in order to avoid potential systemic complications.

A single fast radio burst localized to a massive galaxy at cosmological distance

Fast radio bursts (FRBs) are brief radio emissions from distant astronomical sources. Some are known to repeat, but most are single bursts. Nonrepeating FRB observations have had insufficient positional accuracy to localize them to an individual host galaxy. We report the interferometric localization of the single-pulse FRB 180924 to a position 4 kiloparsecs from the center of a luminous galaxy at redshift 0.3214. The burst has not been observed to repeat. The properties of the burst and its host are markedly different from those of the only other accurately localized FRB source. The integrated electron column density along the line of sight closely matches models of the intergalactic medium, indicating that some FRBs are clean probes of the baryonic component of the cosmic web.

Chronic hyponatremia and association with osteoporosis among a large racially/ethnically diverse population

Chronic hyponatremia may contribute to decreased bone density. We studied 341,003 men and women who underwent DXA testing and observed that individuals with chronic hyponatremia (sodium < 135 mEq/L) had an 11% greater likelihood of having osteoporosis. There was a dose-dependent effect with lower sodium and stronger association with osteoporosis.

INTRODUCTION

Chronic hyponatremia has been associated with both neurologic deficits and increased risk of gait abnormalities leading to falls and resultant bone fractures. Whether chronic hyponatremia contributes to decreased bone density is uncertain. We evaluated whether chronic, mild hyponatremia based on serial sodium measurements was associated with increased risk of osteoporosis within a large, ethnically diverse population.

METHODS

This is a retrospective cohort study between January 1, 1998 and December 31, 2014 within Kaiser Permanente Southern California, an integrated healthcare delivery system. Men and women were aged ≥ 55 years with ≥ 2 serum sodium measurements prior to dual-energy X-ray absorptiometry (DXA) testing. Time-weighted (TW) mean sodium values were calculated by using the proportion of time (weight) elapsed between sodium measurements and defined as < 135 mEq/L. Osteoporosis defined as any T-score value ≤ - 2.5 of lumbar spine, femoral neck, or hip.

RESULTS

Among 341,003 individuals with 3,330,903 sodium measurements, 11,539 (3.4%) had chronic hyponatremia and 151,505 (44.4%) had osteoporosis. Chronic hyponatremic individuals had an osteoporosis RR (95% CI) of 1.11 (1.09, 1.13) compared to those with normonatremia. A TW mean sodium increase of 3 mEq/L was associated with a lower risk of osteoporosis [adjusted RR (95% CI) 0.95 (0.93, 0.96)]. A similar association was observed when the arithmetic mean sodium value was used for comparison.

CONCLUSIONS

We observed a modest increase in risk for osteoporosis in people with chronic hyponatremia. There was also a graded association between higher TW mean sodium values and lower risk of osteoporosis. Our findings underscore the premise that chronic hyponatremia may lead to adverse physiological effects and responses which deserves better understanding.

Abstract P1-12-12: Bubble packaging of adjuvant endocrine therapy:updated analysis of compliance and survival

Introduction: Adherence to endocrine therapy is a long recognized problem despite efficacy of these drugs with reported compliance rates of 89% in first year and 50% in fourth year. Most of our knowledge of noncompliance is observational and retrospective. This final analysis of the Bubble Study reports the compliance rate of adjuvant endocrine therapy among women with early stage breast cancer using “bubble” packaging. We previously reported adherence rates of 97% with bubble packaging. This updated analysis includes disease free survival (DFS) and overall survival (OS) at 5 years.

Methods: The Bubble study is a non-blinded, prospective observational cohort study, which enrolled 86 patients between August 2012 and April 2014. Demographic and clinical data were collected prospectively including age, race, insurance, duration of therapy, stage, treatment, comorbidities, recurrence and survival. Duration of therapy was divided into 3 cohorts: &lt;12 months, 12-36 months, and 37-60 months. All patients received routine prescriptions in a “bubble” pack or daily blister pack. Patients returned all used bubble packs at follow up appointments for review and kept a diary of missed doses for analysis. DFS and OS data were obtained at 78 months. Compliance was defined as &gt;90% adherence. We calculated institutional DFS and OS for breast cancer patients treated within a similar time frame from the tumor registry.

Results: 53 patients were included in the analysis. The remaining patients withdrew from the study prior to data collection or were deemed ineligible. The overall compliance rate was 97%; however, only 72% of enrolled patients were continued in the analysis. None of the variables examined (race, age, insurance status and stage) had an impact on compliance. Only duration of endocrine therapy had a marginal effect on compliance (p value = 0.06). The latest cohort (duration of therapy 37-60 months) was least likely to be compliant at 89.53%. Our 5-year DFS is 92% and 5-year OS is 96%. There is no statistically significant difference in DFS and OS between patients with compliance&gt;90% and &lt;90%. For ER+ breast cancer patients treated during similar timeframe at our institution outside the trial, 5-year DFS is 94% and 5-year OS is 90%.

Conclusion: There was no difference in OS or DFS based on compliance to oral anti-estrogens. Given the high overall compliance rate in this small patient population, the lack of OS and DFS difference is not surprising. However, the compliance rate of bubble packaging (&gt;90%) is higher than expected based on current literature. Although this may suggest improved compliance with bubble packaging, more studies are necessary to confirm this given small sample size and high trial dropout rate. Trial withdrawal likely altered analysis of adherence rates as it selects for a largely compliant group of patients.This bias may also explain the lack of difference in compliance rate among race, insurance status and/ or age, which contradicts our current knowledge of high-risk groups.There was a trend towards lower DFS in the bubble cohort, but overall better survival when comparing to institutional rate. Studies are ongoing to confirm bubble packaging adherence rates and compare this to established strategies to improve adherence.

Citation Format: Bhandari S, Ngo PT, Mandadi M, Wu X, Brown C, Rai S, Riley EC. Bubble packaging of adjuvant endocrine therapy:updated analysis of compliance and survival [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-12-12.

Induction of labor in Mid-Western Hospital in Nepal: Practice and Solution

 IntroductionInduction of labour has been common intervention in modern obstetrics. This study is aimed to determine the distribution of practice and outcomes related to induction of labour in Mid-Western Regional Hospital in Nepal. MethodsThis is a retrospective cross-sectional study conducted at Mid-Western Regional Hospital in Surkhet, Nepal. Secondary data were collected from patients’ records of the hospital dating from 16 July 2016 to 15 July 2017. All women who underwent induction of labour with oral misoprostol were included in this study. For induction of labour, maximum five doses of 50 microgram oral misoprostol was administered in every four hours. Descriptive summary statistics such as frequency and percentages were calculated.ResultsOut of total 3,694 pregnant women who delivered in MWRH, 10.5% (n = 387) were induced by oral misoprostol. Majority of labour induced women were in the age group of 20 – 24 years (52.9%), 37 – 42 weeks of gestation (69.5%), and multi-gravida (49.9%). Majority (77.0%) who underwent induction of labour had vaginal delivery. Among total induction of labour, 88.9% had healthy babies. Majority of new borns had APGAR score of six or more in both one minute (87.9%) and five minutes (93.6%). More than half of the new borns (54.5%) had birth weight of 3000 – 3500 grams. Most of the induced cases (97.4%) were free of complications. Only 1.3% of cases had post-partum haemorrhage. ConclusionsInduction of labour using oral misoprostol is a common practice in Mid-Western Regional hospital in Nepal and majority (77.0%) who underwent induction of labour had vaginal delivery. 

Imaging quantum dot formation in MoS2 nanostructures

Among two-dimensional materials, semiconducting ultrathin sheets of MoS₂ are promising for nanoelectronics. We show how a scanning probe microscope (SPM) can be used to image the flow of electrons in a MoS₂ Hall bar sample at 4.2 K allowing us to understand device physics at the nanoscale. The SPM tip acts as a movable gate and capacitively couples the SPM tip to the device below. By measuring the change in device conductance as the tip is raster scanned across the sample, spatial maps of the device conductance can be obtained. We present images showing the characteristic 'bullseye' pattern of Coulomb blockade conductance rings around a quantum dot formed in a narrow contact as the carrier density is depleted with a backgate. These images show that multiple dots are created by the disorder potential in MoS₂. From these SPM images, we estimate the size and position of these quantum dots using a capacitive model.

Treatment of Immunoglobulin A Nephropathy Recurrence Post-Renal Transplant

Immunoglobulin A nephropathy (IgAN) is the most commonly occurring glomerulonephritis. Recurrence of disease in the transplanted kidney can significantly reduce allograft survival rates. Currently, there is no definitive management plan for IgAN recurrence in a transplant that reduces the rate of decline of allograft function and prolongs time to dialysis or re-transplantation. Herein we present a 48-year-old man who had received a renal transplantation in 2006 following his diagnosis of IgAN. In 2015, the patient was noted to have an elevated blood pressure and proteinuria (urinary protein:creatinine ratio [uPCR] 170 mg/mmol). A transplant biopsy confirmed recurrent IgAN. A year later, he presented with dipstick hematuria, nephrotic-range proteinuria (uPCR 820 mg/mmol), and a serum creatinine of 90 to 140 μmol/L. A second biopsy revealed mesangioproliferative glomerulopathy consistent with crescentic IgAN. An optimal management plan is currently unknown for recurrent crescentic IgAN in the transplanted kidney. We decided to treat this patient with oral cyclophosphamide daily and high-dose prednisolone. The treatment has so far yielded a positive response and managed to preserve allograft function without significant adverse effects for our patient. Our case illustrates the importance of timely biopsies to identify recurrence of disease and highlights an effective therapeutic option for recurrent IgAN with crescent formation in a transplant.

Identification of factors associated with treatment refractoriness of oral lesions in pemphigus vulgaris

BACKGROUND

The oral mucosal lesions of patients with pemphigus vulgaris are known to show more treatment refractoriness than skin lesions.

OBJECTIVES

To identify which clinical and laboratory parameters may indicate treatment refractoriness of oral lesions in pemphigus vulgaris.

METHODS

This was a prospective study of 50 adults with pemphigus vulgaris and oral lesions; patients were given treatment appropriate for overall disease severity. Treatment refractoriness was defined arbitrarily as less than 75% reduction in oral objective Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) after treatment for 6 months.

RESULTS

Of 46 patients who completed the study, 17 (37%) were treatment refractory whereas 29 (63%) were treatment responsive. At baseline, the treatment refractory group had a significantly longer mean duration of disease (P = 0·02) and mean duration of oral lesions (P = 0·01), a higher percentage of lesions in the retromolar trigone (P = 0·05) and on the occlusion line along the buccal mucosa (P = 0·04), a higher percentage of deep/crateriform ulcers (P < 0·001) and erosions with a lichenoid hue (P < 0·001). Herpes simplex virus (HSV) DNA positivity, assessed by polymerase chain reaction in oral tissue scrapings (P = 0·02), was also significantly higher in the treatment refractory group. No other factors we tested for were statistically significant.

CONCLUSIONS

Treatment refractoriness of oral lesions was significantly associated with duration of disease/oral lesions; specific morphology and location of oral lesions; and the presence of HSV DNA in the oral cavity. These factors may forewarn the treating physician about a refractory course of oral lesions that may help with counselling patients.

Clinico-Pathological Correlation of Colorectal Diseases by Colonoscopy and Biopsy

Background Colonoscopy is a simple, safe and well tolerated procedure, the visualization of the mucosa of the entire colon and terminal ileum to detect intestinal abnormalities and obtain biopsy leads to the early detection of the pathologic process and institution of appropriate therapy. Objective To find out the correlation between clinical and histopathological diagnosis of colorectal diseases. Method A cross-sectional study was conducted at Department of Pathology, Dhulikhel Hospital, Kathmandu University Hospital from Jan. 2015 - Jan. 2016. Altogether, 95 colonoscopic biopsies were examined and recorded clinical data using pre-designed pro forma. The specimens were grossed, processed and embedded using standard procedures, stained with Hematoxylin and Eosin stain and were analyzed using light microscope. Special stains Ziehl Neelsen, and Periodic Acid-Schiff were used whenever necessary. Result Analyses of 95 cases of colonoscopic biopsies were done. The most common clinical diagnosis was polyp in 49 cases (51.57%) and the common histopathological diagnosis was non-neoplastic polyps 31(32.63%). There was no correlation in cases for suspected infectious colitis, microscopic colitis and hemorrhoids. Conclusion Colonoscopy is incomplete without biopsy and histopathology is the gold standard for the diagnosis of colorectal lesions. The clinico-pathological correlation for neoplastic lesions was excellent. However, correlation was poor in non-neoplastic lesion.

The magnetic field and turbulence of the cosmic web measured using a brilliant fast radio burst

Fast radio bursts (FRBs) are millisecond-duration events thought to originate beyond the Milky Way galaxy. Uncertainty surrounding the burst sources, and their propagation through intervening plasma, has limited their use as cosmological probes. We report on a mildly dispersed (dispersion measure 266.5 ± 0.1 parsecs per cubic centimeter), exceptionally intense (120 ± 30 janskys), linearly polarized, scintillating burst (FRB 150807) that we directly localize to 9 square arc minutes. On the basis of a low Faraday rotation (12.0 ± 0.7 radians per square meter), we infer negligible magnetization in the circum-burst plasma and constrain the net magnetization of the cosmic web along this sightline to <21 nanogauss, parallel to the line-of-sight. The burst scintillation suggests weak turbulence in the ionized intergalactic medium.

Biomarkers of Tolerance in Kidney Transplantation: Are We Predicting Tolerance or Response to Immunosuppressive Treatment?

We and others have previously described signatures of tolerance in kidney transplantation showing the differential expression of B cell-related genes and the relative expansions of B cell subsets. However, in all of these studies, the index group-namely, the tolerant recipients-were not receiving immunosuppression (IS) treatment, unlike the rest of the comparator groups. We aimed to assess the confounding effect of these regimens and develop a novel IS-independent signature of tolerance. Analyzing gene expression in three independent kidney transplant patient cohorts (232 recipients and 14 tolerant patients), we have established that the expression of the previously reported signature was biased by IS regimens, which also influenced transitional B cells. We have defined and validated a new gene expression signature that is independent of drug effects and also differentiates tolerant patients from healthy controls (cross-validated area under the receiver operating characteristic curve [AUC] = 0.81). In a prospective cohort, we have demonstrated that the new signature remained stable before and after steroid withdrawal. In addition, we report on a validated and highly accurate gene expression signature that can be reliably used to identify patients suitable for IS reduction (approximately 12% of stable patients), irrespective of the IS drugs they are receiving. Only a similar approach will make the conduct of pilot clinical trials for IS minimization safe and hence allow critical improvements in kidney posttransplant management.

Renal Squamous Cell Carcinoma of a Native Kidney After Renal Transplant: A Case Report

BACKGROUND

Renal squamous cell carcinoma is a rare primary tumor of the kidney that rapidly invades local structures and has a poor prognosis. Presentation is usually nonspecific and is associated with renal stone disease and chronic infection. Immunosuppressed renal transplant recipients are more likely to develop a malignancy than the general population. Squamous cell carcinoma of the kidney in the context of a renal transplant and long-term immunosuppression has not previously been described in the literature.

CASE REPORT

A 46-year-old white man with previous renal stones and recurrent urinary infections underwent a right nephrectomy and subsequent renal transplantation owing to failure of the remaining kidney. Five years posttransplant, an abdominal ultrasound scan was performed owing to recurrent urinary infections and ongoing pyuria. This was reported as normal, but he later developed a discharging sinus in his left flank. A computed tomography (CT) scan revealed a tracking perinephric abscess with an associated cystic lesion of the left kidney. A left nephrectomy was performed and histologic examination suggested an invasive squamous cell carcinoma of the renal pelvis. The patient later required major surgery for chronic infection, and further imaging revealed metastatic disease, resulting in the decision to manage palliatively.

CONCLUSION

Given the nonspecific nature of the symptoms and the poor prognosis, health care professionals should have a lower threshold for diagnostic imaging in these patients. Abdominal ultrasonography was unhelpful and only a later CT scan revealed the underlying malignancy. This should be expedited if there is a persistent abnormality on urinalysis. Once diagnosed, a change in immunosuppressant regime to include sirolimus should be considered.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Correlation of Cervical Pap Smear with Biopsy in the Lesion of Cervix

Background Cervical cancer can be controlled to a greater extent by screening to improve morbidity and mortality. Pap smear is important screening method, which has proven to be highly effective in reducing the number of cases and the mortality from cervical carcinoma. Any abnormality detected in pap smear has to be confirmed with cervical biopsy, which remains the reference investigation. Objective To find the changes of cervical cytology by pap smear, to classify cervical lesions into malignant and benign groups on cytological and histopathological basis and to correlate the changes observed in cervical cytology with cervical biopsy. Method This is a prospective cross sectional study done in between July 2014 and July 2015 in Dhulikhel Hospital, Kathmandu University Hospital. During the period, all the samples requested for pap smear were studied. The cases who had undergone both pap smear and cervical biopsy were compared. Clinical data were obtained from requisition submitted along with the cytology and tissue specimens received in the department. Result During the study period, total 1922 pap smears were performed and out of them 75 patients were advised to do cervical biopsy. On cytology, out of total 1922 number of cases, 67.90% were normal, 27.90% were inflammatory smears, 3.80% were unsatisfactory (inadequate) and 0.40% were high grade intraepithelial lesions. Highest numbers of patients screened for pap smear ranged from 31 to 40 years. On histopathology, 78.70% had chronic cervicitis, 8% had normal findings, 1.30% had moderate and 6.70% had severe squamous intraepithelial lesions. The frank malignancy was found in 5.30%. The mean age ± SD for carcinoma was 52.75±6.29. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value of pap smear were 77.80%, 100%, 100% and 97% respectively considering cervical biopsy as the gold standard Conclusion This study revealed a good correlation of cervical cytology with cervical biopsy. Pap is a cost effective screening method for early detection of premalignant and malignant cervical lesions. However, biopsy is considered as the gold standard for the confirmation of abnormalities detected in cervical smear.

Outcome of Extended Thymectomy in Myasthenia Crisis Patient

Myasthenic crisis is a life-threatening condition. We studied the demographic, frequency, causes and clinical presentation of isolated Myasthenic crisis, steps of treatment and to review our experience of extended thymectomy on patients with at least one episode myasthenic crisis. A prospective and retrospective study was conducted on patients with at least one episode of myasthenic crisis, from March 2010 to September 2014, at the Department of Cardiac Surgery, BSMMU, Dhaka, Bangladesh who were referred for thymectomy. Eighteen patients (13.6% of the total 132 patients with myasthenia gravis were admitted with single to multiple episodes of myasthenic crisis, median crisis was 2.5 episodes. Mean age of the patient was 35.5 (18-72) years with male predominance. All eighteen patients had undergone extended thymectomy after completion of 5 cycle plasmapheresis, of which 2 had experienced postoperative respiratory crisis, required invasive ventilator support for median 14 days. One patient required invasive ventilator support after third post operative day. Six patients had thymoma and 12 had thymic hyperplasia. Three patients needed Intravenous immunoglobin. Nine patients needed post operative anti acetylcholinesterase inhibitor after median 2.5 post days. Post thymectomy remission and decreases the frequency of myasthenic crisis was seen in follow up and post operative medication requirement reduced significantly as compared to the preoperative requirement. This report highlights that the patients who had extended thymectomy after episodes of myasthenia crisis are benefitted even in the histhopathology report does not confirmed thymoma. After thymectomy, there was remission of myasthenic crisis. Patients with myasthenic crisis should have judicious drug adjustments under supervision and should be treated aggressively during impending myasthenic crisis. With modern management of myasthenia gravis, early surgery with myasthenic crisis is safe with good long-term outcomes.