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Redoy Ranjan,1 Gie Ken-Dror,1 Pankaj Sharma1,2 On behalf of the BEAST Collaborators1Department of Biological Sciences, Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham, Greater London, UK; 2Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London, UKCorrespondence: Pankaj Sharma, Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham, Greater London, TW20 0EX, UK, Email pankaj.sharma@rhul.ac.ukIntroduction: Risk prediction models are commonly performed with logistic regression analysis but are limited by skewed datasets. We utilised neural networks (NNs) model to identify independent predictors of poor outcomes in cerebral venous thrombosis (CVT) due to the limitations of logistic regression (LR) analysis with complex datasets.Methods: We evaluated 1309 adult CVT patients from the prospective BEAST (Biorepository to Establish the Aetiology of Sinovenous Thrombosis) study. The area under the receiver operating characteristic (AUROC) curve confirmed the goodness-of-fit of prediction models. The normalised importance (NI) of the NNs determines the significance of independent predictors.Results: The stepwise logistic regression model found thrombolysis (OR 32.1; 95% CI 3.6– 287.0; P=0.002), craniotomy (OR 6.9; 95% CI 1.3– 36.8; P=0.02), and cerebral haemorrhage (OR 4.5; 95% CI 1.3– 15.4; P=0.01) as predictors of poor clinical outcome with the AUROC of 0.71. Conversely, the NNs model identified major independent predictors of long-term poor clinical outcomes as cerebral haemorrhage (NI 100%) and thrombolysis (NI 98%), as well as trivial predictors of age (NI 2.8%) and altered mental status (NI 3.5%). The accuracy of the NNs model was 95.1% and 94.1% for self-learned randomly selected training and testing samples with an AUROC of 0.82. Positive and negative predictive values for poor outcomes were 13.2% and 97.1% for the LR model, compared with the NNs model of 18.8% and 98.7%, respectively.Conclusion: Cerebral haemorrhage and thrombolysis was a strong independent predictor, whereas age merely impacts the long-term poor clinical outcome in adult CVT. Integrating unorthodox neural networks risk prediction model can improve decision-making as it outperforms conventional logistic regression with complex datasets.Keywords: cerebral venous thrombosis, neural network, stroke, predictors, outcome

Redoy Ranjan,1 Md Kamrul Hasan,2 Asit Baran Adhikary1,3 1Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh; 2Department of Cardiac Surgery, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh; 3Department of Cardiac Surgery, Impulse Hospital & Research Centre, Dhaka, BangladeshCorrespondence: Redoy Ranjan, International Journal of General Medicine, Department of Cardiac Surgery, Bangabandhu Sheikh Mujib medical University, Dhaka, 1000, Bangladesh, Email redoy_ranjan@bsmmu.edu.bdBackground: Genetic factors contribute significantly to the risk of ischaemic heart disease (IHD), which is the leading cause of mortality in Bangladesh. The BANGABANDHU (Bangladeshi Atherosclerosis Biobank AND Hub) study will allow a hypothesis-free genome-wide association study (GWAS) to identify genetic risk factors associated with ischaemic heart disease patients undergoing coronary artery bypass graft (CABG) surgery in Bangladesh.Methods: This is a multi-centre population-based case–control study aimed to evaluate 1500 (Fifteen Hundred) adult (≥ 18 years of age) people divided into 2 study groups: Case/Proband (750 IHD patients undergoing CABG surgery) and Control (750 healthy people). Spouses or family members are preferred as healthy control subjects due to their shared geographic location and similar environmental exposure.Results: This will be the first largest DNA repository of CABG patients in Bangladesh, and identifying novel gene loci among CABG patients might help to discover novel therapeutic targets for Bangladeshi IHD patients. Further, identifying and comparing novel gene loci among CABG patients with other ancestry might help devise national guidelines for treating coronary artery disease.Conclusion: Promising current study results will encourage Bangladeshi researchers and pharmaceutical companies to conduct further studies into the genetic basis of Bangladeshi complex coronary artery disease, which might identify novel genes for therapeutic targets for Bangladeshi patients and strengthen the healthcare standards in Bangladesh.Keywords: Bangabandhu, Bangladesh, biobank, IHD, CABG

Aziz Momin,1 Redoy Ranjan,1,2 Oswaldo Valencia,1 Adam Jacques,3 Pitt Lim,4 David Fluck,3 Tuan P Chua,5 Venkatachalam Chandrasekaran1 1Department of Cardiac Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK; 2Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh; 3Department of Cardiology, Ashford and St Peter’s Hospitals NHS Foundation Trust, London, UK; 4Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK; 5Department of Cardiology, Royal Surrey NHS Foundation Trust, London, UKCorrespondence: Aziz Momin, Consultant Cardiac Surgeon, St George’s University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom, Tel +447956336739, Email aziz.momin@stgeorges.nhs.ukObjective: This study determined hazard factors and long-term survival rate of total arterial coronary artery bypass graft surgery over 20 years in an extensively large, population-based cohort.Methods: A total of 2979 patients who underwent isolated CABG from April 1999 to March 2020 were studied in 4 groups- Group-A (bilateral internal mammary artery ± radial artery), Group-B (single internal mammary artery + radial artery ± saphenous vein), Group-C (single internal mammary artery ± saphenous vein; no radial artery), and Group-D (radial artery ± saphenous vein; no internal mammary artery). The study endpoints analysed the correlation between the number and types of grafts with the survival time following isolated CABG surgery.Results: The total arterial revascularization (Group A) group had an admirable mean long-term survival of ~19 years, compared to 18.6 years (Group B), 15.86 years (Group C), and 10.99 years (Group D). A Kaplan-Meier curve demonstrated confidence interval (CI) for study groups- (95% CI 18.33– 19.94), (95% CI 18.14– 19.06), (95% CI 15.40– 16.32), and (95% CI 9.61– 12.38) in Group A, B, C, D respectively. In the Holm-Sidak method analysis, significant associations existed between the number of arterial grafts and the long-term outcome. A statistically significant (P≤ 0.05) long-term survival advantage for arterial grafting was demonstrated, especially total arterial revascularisation over all other combinations except single internal mammary artery + radial artery grafting.Conclusion: In this series, over 20 years, total arterial CABG use has excellent long-term survival, achieving complete myocardial revascularisation. There is no significant difference between the BIMA group and SIMA with radial artery. However, there is a reduced survival with decreased use of arterial conduits.Keywords: coronary artery bypass graft, CABG, bilateral internal mammary artery, total arterial CABG, long term outcome, multiple arterial graft, mortality, survival benefits

Byline: Richa. Kumar, Manas. Chatterjee, R. Ranjan Sir, A 42-year-old male, resident of Ajmer district, Rajasthan, and armed forces personnel by occupation presented with complaints of swelling and pain over [...]

Redoy Ranjan,1,2 Dipannita Adhikary,2 Debasish Das,3 Asit Baran Adhikary1 1Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh; 2Department of Medicine & Veterinary Medicine, The University of Edinburgh, Edinburgh, UK; 3Department of Thoracic Surgery, Dhaka Medical College & Hospital, Dhaka, BangladeshCorrespondence: Redoy Ranjan, Department of cardiac Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, 1000, Bangladesh, Tel +8801717556046, Email redoy_ranjan@bsmmu.edu.bdPurpose: This study aimed to evaluate the prevalence of carotid stenosis among ischaemic heart disease (IHD) patients undergoing coronary artery bypass graft (CABG) surgery and identify risk factors associated with carotid stenosis at a tertiary-level hospital in Bangladesh.Patients and Methods: This cross-sectional study examined 200 IHD patients scheduled for isolated and elective CABG surgery, and multivariate regression analysis was used to determine the impact of independent variables on carotid stenosis with coronary artery disease. A vascular surgeon and sonographer assessed carotid stenosis, and the severity of stenosis was classified according to the current Grayscale and Doppler US diagnosis models.Results: We observed that the prevalence of carotid artery stenosis was 13.5%, and the male was significantly higher (85.2%) in the carotid stenosis group. A multivariate regression analysis observed that age (OR 1.79), dyslipidaemia (OR 2.19), uncontrolled hypertension (OR 2.38), uncontrolled DM (OR 2.51), multivessel coronary artery disease (OR 3.79), and multiple comorbidities (OR 4.46) are potential predictors of having significant carotid stenosis in a patient undergoing CABG surgery.Conclusion: In Bangladesh, multivessel coronary artery disease, especially in elderly patients with multiple comorbidities, are 4 (four) times higher risk to have significant carotid artery stenosis. Preoperative carotid duplex screening should be performed to curtail the risk of postoperative adverse cerebrovascular events, particularly those who have carotid stenosis associated potential risk factors.Keywords: prevalence, carotid stenosis, coronary artery disease, ischaemic heart disease

Niroj Kumar Sahoo,1 Richa Ranjan,2 Mudit Tyagi,3 Hitesh Agrawal,3 Subhakar Reddy3 1Department of Retina and Vitreous, L V Prasad Eye Institute, Vijayawada, India; 2Bharti Eye Foundation and Hospital, New Delhi, India; 3Smt. Kanuri Santhamma Centre for Vitreo-Retinal Diseases, L V Prasad Eye Institute, Hyderabad, IndiaCorrespondence: Mudit TyagiSmt. Kanuri Santhamma Centre for Vitreo-Retinal Diseases, L V Prasad Eye Institute, Banjara Hills, Hyderabad, 34, IndiaTel +91-9553339042Email drmudittyagi@gmail.comAbstract: A gradual shift in trend from primary enucleation to globe salvaging radiation therapy for the management of ocular tumors has resulted in the rise of several post-treatment ocular complications including radiation retinopathy. Radiation retinopathy is a chronic, progressive, and occlusive vasculopathy that can manifest anytime between 1 month to 15 years after starting radiation therapy. The aim of treatment in most of these cases is to prevent further vision loss. Treatment options such as laser photocoagulation, anti-vascular endothelial growth factor and intraviral steroids have been described. However, despite several advances in diagnostic and therapeutic modalities, a significant proportion of eyes with radiation retinopathy eventually go blind. This review summarises some of the clinical features, investigative modalities, and recent therapeutic strategies used in the management of radiation retinopathy.Keywords: radiation retinopathy, radiation maculopathy, anti-VEGFs, laser photocoagulation, ocular tumors

Amit Patil, Ranvir Ranjan, Prabhat Kumar, Himanshi Narang Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Patna, Bihar, 801507, IndiaCorrespondence: Amit PatilDepartment of Forensic Medicine and Toxicology, Second Floor, Academic Building, All India Institute of Medical Sciences, Phulwarisharif, Patna, Bihar, 801507, IndiaTel + (+91) 9920193750Email dramp1976@gmail.comAbstract: Hands-on or practice-based learning is the foundational objective of postgraduate teaching and training. A skilled and competent postgraduate resident is critical to the country’s health needs and is more relevant in the ongoing COVID-19 pandemic. The postgraduate medical training in India is speciality-specific and based on a structured curriculum and syllabus to achieve precise educational goals and objectives. The impact of this pandemic on postgraduate medical education and training is controversial, challenging, unknown, and far-reaching. The exceptional contagious nature of the virus and country-wide lockdowns have tremendously decreased hospital visiting patients. Abolition of outpatient and inpatient services, disruptions in clinical postings, curtailment of elective operations and procedures have adversely affected the training of residents and fellowship students in India and abroad. Apart from this, research work, mentoring, academic conferences, and workshops that offer learning experiences to these residents have been cancelled or suspended, thus denying them a chance to achieve domain knowledge and enhance their skills. Although this pandemic has offered new learning modes like teleconsultation, videoconferencing, virtual simulations, digital podcasts, etc., how much actual knowledge transfer and skill gain will be achieved is unanswered. Despite this disruption, this pandemic has offered a golden opportunity to relook at the current PG resident education and training programme. The lessons learned from this adversity offer medical universities, medical educators, and regulatory authorities many opportunities to develop a novel and innovative curriculum that enables the current and future residents to achieve the necessary proficiency and competency.Keywords: COVID-19 pandemic, postgraduate, residents, medical education, training

This paper provides a practical, empirical and theoretical framework that allows investment managers to evaluate stock exchanges’ market quality when choosing among different plausible international trading venues. To compare trading exchanges, it extends the hypothesis of market microstructure invariance to trading across exchanges. A measure ω, the ratio of the market-wide volatility to microstructure invariance, is introduced. The paper computes ω for the exchanges around the world. Its value for the NSE (India) is 24.5%, the Korea Exchange (Korea) is 7.9%, the Shanghai Exchange (China) is 3.5%, and the Shenzhen Exchange (China) is 4.4%, which is significantly different from that of major exchanges in the USA (NYSE – 0.8%, NASDAQ – 1.3%) and Europe (LSE (UK) – 0.4). This country risk dimension clearly identifies which equity exchanges cannot hold their own direct correlational hedges and therefore mandatorily require derivative positions, and has significant implications for the decision making of global long-short equity asset allocators in the Asian listed equity markets.

Bhupesh Singh,1 Sourabh Sharma,2 Neha Bharti,3 Richa Ranjan,3 Sudhank Bharti1 1Cornea Department, Bharti Eye Foundation and Hospital, New Delhi, India; 2Glaucoma Department, Bharti Eye Foundation and Hospital, New Delhi, India; 3Vitreoretina Department, Bharti Eye Foundation and Hospital, New Delhi, IndiaCorrespondence: Sourabh SharmaBharti Eye Foundation and Hospital, New Delhi, IndiaTel +91-9910790540Email dr_sourabh@rediffmail.comAbstract: We report a rare case of bilateral keratoglobus with hypermature intumescent cataract in a 55-year-old woman. Clinical examination and corneal topography confirmed generalized corneal bulging and global corneal thinning. A Pentacam® (Oculus Optikgerate, Wetzlar, Germany) demonstrated bilateral diffuse corneal thinning (368 μm in the right eye and 371 μm in the left eye). Phacoemulsification was performed in the right eye after thorough workup and modification of the surgical technique. This case report helps in better understanding of the challenges of cataract surgery and intraocular lens selection in a keratoglobus patient, and stresses the need for both thorough preoperative planning and intraoperative surgical modifications.Keywords: keratoglobus, intumescent cataract, corneal ectasia

INTRODUCTION: To analyse the results of Cauda Equina Syndrome (CES) operated by Percutaneous Transforaminal Endoscopic Lumbar Discectomy (PTELD). MATERIALS AND METHODS: The study is a retrospective series of 15 patients operated by PTELD. Bladder dysfunction was classified as incomplete CES (CESI) and complete CES retention (CESR). Bladder / motor recovery rate and its timing, Oswestry Disability Index (ODI), Visual Analogue Score (VAS), patient satisfaction index, and sexual dysfunction were used to measure the outcome objectively. Additionally, in CESR patients, post-void residual (PVR) urine was measured by sonography. Complications and technical problems were noted. RESULTS: There were ten patients of CESI and five patients of CESR. The average follow-up was 20.33(12.05) months. Bladder symptoms recovery was 100%, and motor recovery was 80%. VAS for back pain recovered to 0.53(0.52) from 8(2.39). VAS for leg pain recovered to 0.13(0.35) from 9.20(1.32). ODI improved to 6.07(2.85) from 77.52(13.20). The time to the recovery of bladder function was 1.47(1.55) days. All CESR patient’s abnormal PVR urine was normalised at five weeks post-operative. No complications were reported. However, five technical executional problems occurred. CONCLUSION: PTELD can be considered for CES treatment due to its substantial and quick recovery advantages. However, more evidence support is needed to make it a practice recommendation.

The anatomical and physiological differences in children make the administration of anesthesia difficult compared to the adults which is made more challenging when the child presents with a congenital anomaly. In this case, we report the anesthetic challenges presented by an 8-month-old baby born of full gestation with a lumbar swelling and hydrocephalus posted for ventriculoperitoneal shunt insertion. Magnetic resonance imaging scan revealed the presence of a large meningomyelocele with tethered sac and Arnold–Chiari malformation (Type 2). Anesthetic management included a thorough preoperative assessment of associated comorbidity, proper positioning, management of a difficult airway, prevention of any rise in intracranial pressure, and prevention of hypothermia. The perioperative period was uneventful, and the child recovered well.

Rajesh Ranjan,1,2 Nidhi Bharal Agarwal,1 Prem Kapur,3 Amit Marwah,1 Rizwana Parveen1 1Centre for Translational and Clinical Research, School of Chemical and Life Sciences, New Delhi 110062, India; 2Department of Pharmaceutical Medicine, School of Pharmaceutical Education And Research, New Delhi 110062, India; 3Department of Medicine, Hamdard Institute of Medical Sciences and Research, New Delhi 110062, IndiaCorrespondence: Nidhi Bharal AgarwalCentre for Translational and Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi 110062, IndiaTel +98 1833 4770Fax +91-11- 2605 9663Email nidhi.bharal@gmail.comPurpose: To identify the specific motivations that drive healthy volunteers to consent for their participation in clinical studies. Additionally, the study aimed to document the socio-demographic determinants of participation in the trial related solely to the intention of securing financial gains.Patients and methods: This cross-sectional study was conducted among subjects who participated as healthy volunteers in clinical trials conducted by Contract Research Organizations (CROs) of Delhi. Pre-tested, validated semi-structured questionnaires were used to collect baseline socio-demographic data, information about factors motivating participation in clinical trials, and pattern of utilisation of money received against participation in the trial. Logistic regression analysis was done to determine the factors that influenced participation in the trial related purely to the motive of securing financial gains.Results: A total of 400 participants were selected. The majority of the volunteers (77.5%) reported that their sole reason for participating in clinical trials was for monetary gain. Around a tenth of the volunteers participated with the intent to advance scientific knowledge and another 4.5% participated due to benefits of free medical check-ups. Participants in the age group of 29–38 years, those that were married, those residing in an urban slum, male participants, those with a high number of dependent family members (ie, 5 to 8), and those earning less than 5000 INR (71 USD) a month had higher odds of participating in a clinical trial purely for the financial benefits. Those educated till intermediate and above had lower odds of participation in the trial due to monetary benefits.Conclusion: Our study shows that healthy volunteers in Delhi consider participation in clinical trials mainly because of the prospect of financial reward. More research is needed to inform judgments around the ethics of providing financial rewards and enrollment of healthy research volunteers.Keywords: clinical trial, healthy volunteers, financial incentive, India

Background: The assessment of hidradenitis suppurativa (HS) severity requires detailed, and error‐prone lesion counts. This proof‐of‐concept study aimed to automatically classify HS disease severity using machine learning of clinical smartphone images. Methods: 777 ambient‐light and size‐controlled images were used to build a class‐balanced synthetic dataset (n = 7675). Convolutional neural networks (CNN) were used for automated severity classification (scale 0–3), and to assess disease‐dynamics. International Hidradenitis Suppurativa Severity Score System (IHS4) served as reference. A U‐NET algorithm was implemented for automated localization of diseased skin. Results: CNNs were able to distinguish no/mild from moderate/severe disease with an overall prediction accuracy of 78% [receiver operating curve (AUC) 0.85]. Correct IHS4 classification was achieved with an overall accuracy of 72% (AUC 0.84–0.89). In addition, disease dynamics using IHS4 numerical values aligned with CNN outputs (NRMSE 0.262). The UNET algorithm localized lesions with a pixel accuracy of 88.1% and test loss of 0.42. Limitations: Limitations in assessing tattooed and hairy skin. Limited number of patients with dark skin colour and Hurley I. Conclusion: CNNs were able to distinguish no/mild from moderate/severe disease, classify disease severity over time, and automatically identify diseased skin areas and the skin phototype. This study breaks new grounds for fast, reliable, reproducible and easy‐to‐use HS severity assessments using clinical images. [ABSTRACT FROM AUTHOR]

Introduction: Patients with suspected cervical spine fracture or cervical pathology, utmost care has to be taken while intubating these patients to prevent further cervical cord injury. Protective measures include application of rigid collar, a forehead tape and manual inline stabilisation. Application of these manoeuvres reduces the cervical spine movement, making it more difficult to intubate. Aim: To compare the performance of McCoy blade with C-MAC D blade for endotracheal intubation in patients with simulated cervical spine injury. Materials and Methods: One hundred and twenty adult patients were randomly allocated into two groups to achieve tracheal intubation with McCoy (group M=sixty patients), or C-MAC D video laryngoscopes (group C=sixty patients). The ASA patients of grade I-II undergoing elective surgery for having immobilised cervical spine using manual inline axial cervical spine stabilisation technique were enrolled in the study. Patient’s Comparative data on the total time to intubate (Z-test), CormackLehane (CL) laryngoscopic view (Chi-Square test), number of optimising manoeuvres (Yate’s corrected Chi-Square test) and haemodynamic variables (Z-test) were recorded in both groups. Results: The time taken for tracheal tube insertion was significantly longer with C-MAC D blade group of thirty eight seconds compared with McCoy blade group which was thirty one seconds. There was an increase in heart rate at first and second minute in both the groups which returned back to normal after five minutes. Good grade glottic visualisation was obtained with both the laryngoscopic blades. Conclusion: C-MAC D blade as well as McCoy blade forms an effective tool for the airway management of suspected cervical spine injured patients with cervical immobilisation.