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A previously healthy 12-year-old boy presented to the emergency department on the seventh day of illness with classical symptoms of postinflammatory multisystemic syndrome in children temporally associated with SARS-CoV-2 (fever, vomiting, loose stools and rashes all over the body) with COVID-19 seropositivity, high inflammatory markers and elevated cardiac enzymes with cardiogenic shock with multiple organ dysfunction syndrome. After having improved over the first 48 hours following intravenous immunoglobulin and pulsed steroids, this young boy developed sudden cardiac arrest and died. No reversible cause could be identified at the time of resuscitation. Despite an apparent clinical recovery in the myocardial function, it is likely that the myocardium remains arrhythmogenic due to cytokine-induced myocardial inflammation. There are several reports in the literature of fatality in multisystemic inflammatory syndrome in children (MISC) due to cardiovascular complication during the acute phase of the illness. To the best of our knowledge, this is the first report of sudden cardiac death in a child with MISC days after recovery from critical illness, suggesting that fatal outcome remains a potential risk during follow-up, even when there is no evidence of coronary aneurysm. Further studies are needed to identify clinical characteristics of such high-risk children presenting with MISC. We will need to follow these children closely to understand what implications they may have in the long term, and this helps in raising awareness among families of such children.

The case demonstrates the use of bariatric surgery to improve a patient’s candidacy for surgical treatment for endometrial cancer (EC). A 50-year-old morbidly obese woman with early-stage EC was initially treated with levonorgestrel-releasing intrauterine system (52 mg) . She had to reduce her body mass index (BMI) to become eligible for definite EC treatment. Using conservative methods, she was unable to lose weight effectively. She then underwent bariatric surgery that reduced her BMI from 71.3 to 54.3 kg/m2. She maintained her weight and was eligible for total hysterectomy and bilateral salpingo-oopherectomy. Her procedure was successful and had no complications. She has 6-monthly follow-ups, and the most recent review showed no evidence of recurrence.

The most common cause of spontaneous intracranial hypotension headache is a cerebrospinal fluid (CSF) leakage, but the underlying mechanisms remain unknown. Intracranial hypotension is characterised by diffuse pachymeningeal enhancement on cranial MRI features, low CSF pressure and orthostatic headaches mostly caused by the dural puncture. We report a 31-year-old woman who presented to our services with reports of continuous severe bifrontal headache, which increased on sitting up and resolved on lying down. MRI of the cervical and lumbosacral spine showed signs of CSF leak; hence, patient was diagnosed with spontaneous intracranial hypotension headache. A CT-guided epidural blood patch was done at L4–5 with fibrin glue injected at the site of leak. The patient’s signs and symptoms improved after the procedure.

Background Congenital external cervical os stenosis is a form of Mullerian duct abnormality which is rare in virginal adolescents. Case Pre-operatively, two non-sexually active adolescents of 12 and 14 years of age, with history of light menses and severe lower abdominal pain for 2 and 4 months respectively, were diagnosed with an obstructed, oblique vaginal septum syndrome. However, at operative vaginoscopy, a single cervix with a duplicated cervical os and unilateral cervical stenosis was discovered, confirming the diagnosis of a complete uterine septum involving the cervix and unilateral cervical stenosis. They were treated by expanding the affected external cervical os while leaving the hymen intact. A year following the treatment, follow up results found no recurrence of symptoms. Summary and conclusion Operative vaginoscopy using a hysteroscope is crucial and recommended for the diagnosis and treatment of congenital external cervical os stenosis in virginal adolescents.

Objective: Oral cancer is widespread in South Asia, particularly India. In Australia, Indians are one of the fastest‐growing communities. This study aimed to explore the oral cancer‐related knowledge, attitudes and practices of Indian immigrants in Australia. Methods: Fourteen semi‐structured interviews were conducted with Indian immigrants residing across New South Wales and Victoria. Purposive and snowball sampling were used for recruitment. Data were analysed through a directed content analysis approach. Results: All participants were knowledgeable of oral cancer risks associated with tobacco and alcohol, but few were familiar with the harmful effects of areca nut preparations. Varied attitudes were evident with most participants acknowledging the importance of oral cancer check‐ups, yet very few followed this practice. All participants admitted engaging in oral cancer risk practices including areca nut use at least once or more in their lifetime. Conclusion: Oral cancer risk practices are common among Indian immigrants in Australia who possess limited knowledge with varying attitudes in this area. Implications for public health: Preventative strategies are needed to limit the use of oral cancer risk products among Indian immigrants. General practitioners and community organisations can play a key role in raising awareness in this area.

Background A prospective study to evaluate the rotational stability of toric intraocular lenses (IOLs). Methods A prospective study of 30 eyes in 29 patients. All patients with regular astigmatism of range 0.75–4 D were included in the study. Exclusion criteria included irregular corneal astigmatism, post-refractive surgery and corneal dystrophies. All patients underwent uncomplicated phacoemulsification cataract surgery by the same surgeon. Three eyes with corneal astigmatism of 0.75–1.5 D were implanted with the AcrySof SA60T3 IOL, eight eyes with astigmatism between 1.5 and 2.0 D received the SA60T4 IOL and eight eyes with astigmatism between 2.0 and 2.50 D received the SA60T5 and rest with astigmatism of 2.5 D and higher received SA60T6 and above models. Main outcome measure was the post-operative position of the lens, assessed at day 1, 1 week, 1 month and 6 months, using toric marker and the slit lamp. Results There was no significant rotation of IOL observed during a follow-up period of 6 months. Overall, the post-operative rotation was within 5° in 95% of cases. There was no trend for either clockwise or anti-clockwise rotation. However, IOL rotation happens mostly within the first month of surgery, and if it is significant, it requires early repositioning. Conclusion Toric IOLs are very effective and consistent in correcting astigmatism during the cataract surgery. Once placed to its position, toric IOLs demonstrate rotational stability in the capsular bag.

Epidemiological and clinical studies have demonstrated a consistent relationship between increased systemic inflammation and increased risk of cardiovascular events. In chronic inflammatory states, traditional risk factors only partially account for the development of coronary artery disease (CAD) but underestimate total cardiovascular risk likely due to the residual risk of inflammation. Computed coronary tomography angiography (CCTA) may aid in risk stratification by noninvasively capturing early CAD, identifying high risk plaque morphology and quantifying plaque at baseline and in response to treatment. In this review, we focus on reviewing studies on subclinical atherosclerosis by CCTA in individuals with chronic inflammatory conditions including rheumatoid arthritis (RA), systemic lupus erythematous (SLE), human immunodeficiency virus (HIV) infection and psoriasis. We start with a brief review on the role of inflammation in atherosclerosis, highlight the utility of using CCTA to delineate vessel wall and plaque characteristics and discuss combining CCTA with laboratory studies and emerging technologies to complement traditional risk stratification in chronic inflammatory states.

Objective To examine demographic, clinical, and biochemical differences in patients with adrenocorticotropin (ACTH)-dependent Cushing syndrome (CS) based on etiology, sex, and tumor size. Methods This was a single-center study of 211 patients with ACTH-dependent CS followed for 35 years. Patients were stratified into 3 groups based on etiology: Cushing disease (CD)/transsphenoidal surgery, Cushing disease/total bilateral adrenalectomy (CD/TBA), and ectopic ACTH secretion (EAS). Patients were also stratified based on sex and tumor size (nonvisualized, microadenoma, and macroadenoma). Results CD was the commonest cause of ACTH-dependent CS (190; 90%). Most patients presented in the third decade (median age, 29 years). Clinical features, cortisol, and ACTH were significantly greater in the EAS group. The CD/TBA group had more nonvisualized tumors (22% vs 8%; P = .000) and smaller tumor size (4 vs 6 mm; P = .001) compared with the CD/transsphenoidal surgery group. There was female predominance in CD (2.06:1) and male predominance in EAS (2:1). Men had shorter duration of symptoms (2 years; P = .014), were younger (23 years; P = .001), had lower body mass index (25.1 kg/m2; P = .000), and had more severe disease (low bone mineral density, hypokalemia). Macroadenomas were frequent (46; 24.2%), and ACTH correlated with tumor size in CD (r = 0.226; P = .005). Conclusion Our cohort presented at an earlier age than the Western population with a distinct, but slightly lower, female predilection. Patients with CD undergoing TBA had frequent negative imaging. Men had a clinical profile suggesting aggressive disease. Microadenoma and macroadenoma were difficult to distinguish on a clinicobiochemical basis.

PURPOSE The COVID-19 pandemic has placed unprecedented demands on the health system. This led to delays in the initiation and completion of cancer treatment. We assessed the long-term health consequences because of the delay in diagnosis and treatment for cervical cancer due to COVID-19 in India. METHODS We used a Markov-model–based analysis assessing the lifetime health outcomes of the cohort of women population at risk from cervical cancer in India. The decrease in survival for those with the treatment interruption was calculated based on the number of days the treatment was extended beyond the standard duration. Furthermore, to model the impact of late diagnosis and delayed treatment initiation, the patients were assumed to have upstaged during the delay period, as per natural progression of disease. RESULTS We estimate 2.52% (n = 795) to 3.80% (n = 2,160) lifetime increase in the deaths caused by cervical cancer with treatment restrictions ranging from 9 weeks to 6 months, respectively, as compared to no delay. On the contrary, 88-238 deaths because of COVID-19 disease are estimated to be saved during this restriction period among the patients with cervical cancer. Overall, the excess mortality because of cervical cancer led to 18,159-53,626 life-years being lost and an increase of 16,808-50,035 disability-adjusted life-years. CONCLUSION Delays in diagnosis and treatment are likely to lead to more cervical cancer deaths as compared to COVID-19 mortality averted among the patients with cervical cancer. Health systems must reorganize in terms of priority setting for provision of care, starting with prioritizing the treatment of patients with early-stage cervical cancer, increasing use of teleconsultation, and strengthening the role of primary care physicians in provision of cancer care.

Introduction The aim of this study was to compare the effect of different application techniques of ozone on the prevalence of postendodontic pain in patients undergoing single-visit root canal treatment. Methods hundred eight patients with necrotic pulp in single-rooted teeth and apical periodontitis participated in the trial. A standard single-visit endodontics protocol was followed with 5.25% sodium hypochlorite and rotary nickel-titanium files. After shaping and cleaning, patients were randomly allocated into the following groups: group 1 (n = 21), ozone treatment with no activation (NA); group 2 (n = 22), ozone treatment with manual dynamic activation (MDA); group 3, (n = 21), ozone treatment with passive ultrasonic activation (PUA); group 4 (n = 23), ozone treatment with sonic activation (SA); and group 5 (n = 21), no ozone treatment (the control group). Patient levels of discomfort were recorded at 6 different time intervals using the visual analog scale (VAS). Comparison of the mean difference between the groups and time intervals was performed using 2-way analysis of variance followed by a post hoc Bonferroni test. The level of significance was set at 5%. Results VAS scores were highest for the control > NA > MDA > SA > PUA groups. A statistically significant reduction in VAS scores was observed in the PUA and SA groups in comparison with the NA, control, and MDA groups. Timewise comparison showed a highly significant decline in VAS scores at all time intervals (P Conclusions Ultrasonic and sonic activation of ozone resulted in less pain in patients undergoing single-visit endodontics compared with no ozone treatment.

Background and aims Psoriasis is an immune-mediated inflammatory disease with increased risk of myocardial infarction. Preclinical studies in psoriasis models show an association between chronic inflammation and immune cell proliferation in the spleen and bone marrow (BM). We sought to test the hypothesis that splenic and BM 18F-fluorodeoxyglucose (18F-FDG) uptake is heightened in psoriasis and that higher uptake associates with systemic inflammation and subclinical atherosclerotic disease measures in this cohort. Methods Multimodality imaging and biomarker assays were performed in 240 participants (210 with psoriasis and 30 healthy). Splenic and BM uptake was obtained using 18F-FDG positron emission tomography/computed tomography (PET/CT). Coronary artery plaque characteristics including non-calcified burden (NCB) and lipid rich necrotic core (LRNC) were quantified using a dedicated software for CT angiography. All analyses were performed with StataIC 16 (Stata Corp., College Station, TX, USA). Results Splenic and BM 18F-FDG uptake was increased in psoriasis (vs. healthy volunteers) and significantly associated with proatherogenic lipids, immune cells and systemic inflammation. Higher splenic 18F-FDG uptake associated with higher total coronary burden (β = 0.37; p Conclusions Heightened splenic and BM uptake of 18F-FDG is associated with proatherogenic lipids, immune cells, inflammatory markers and coronary artery disease. These findings provide insights into atherogenic mechanisms in psoriasis and suggest that immune cell proliferation in the spleen and BM is associated with subclinical atherosclerosis.

Pneumonia continues to be a major cause of morbidity and mortality in children. Pneumonia is the leading killer of children worldwide. For the diagnosis of pneumonia, the World Health Organization has introduced guidelines for the management of cases to reduce the mortality of these diseases on the basis of simple clinical signs followed by the empirical treatment with antibiotics. More than 99% of deaths related to pneumonia among children occur in countries having a low and middle income. To study the Radiological finding of Community-Acquired Pneumonia (CAP) in children. Across sectional study was conducted in which the sample size for the study was calculated from the expected prevalence of CAP based on other studies (74%). The sample size calculated by the required criterion for this study is 96. I was able to cover 118 patients as per the inclusion criteria in this study. The Patients of pediatric age groups and either sex attending tertiary care hospital with complaints suggestive of CAP. In this study total number of patients are 118 included who presented with the signs and symptoms suggestive of pneumonia. The findings of chest X-Ray of Right Lung with respect to different bacterial agents. Consolidation of the Right upper lobe is found to be statistically significant with respect to Streptococcus pneumonia and consolidation of the right lower lobe is found to be statistically significant with respect to bacteria Staphylococcus aureus whereas there is no statistically significant association with respect to other bacteria. The radiological finding of CAP in children attending pediatric OPD was observed that there was no association with any other bacteria.

The current article aims to highlight the varied presentation and management of vallecular cysts. We report three children, aged four years, 11 months and three days, diagnosed with vallecular cyst presenting to the Chacha Nehru Bal Chikitsalaya hospital, New Delhi, India in 2018 and 2019. They were reviewed retrospectively for clinical presentation, diagnostic tools and treatment options. All three cases had respiratory and feeding difficulties. The diagnosis in all of the three cases was made with laryngoscopy (flexible/direct) and imaging. All three patients were treated with the transoral approach aimed at the excision of the cyst using cold instruments. The postoperative period was uneventful. No recurrences were observed during the long-term follow-up. Vallecular cysts should be considered as one of the differentials in children with respiratory distress and dysphagia despite being a rare anomaly. A direct transoral approach is recommended for the excision of the vallecular cyst as it is a safe and reliable method with no recurrences to date. Keywords: Benign Cyst; Dyspnea; Dysphagia; Laryngoscopy; Case Report; India.

Micro perforate hymen is an uncommon congenital defect in which the hymen has a microscopic pinpoint aperture. It is a different entity from imperforate hymen, but it might present with more or less similar complaints. Here we are discussing about a unique case of pinpoint hymenal opening or microperforate hymen where the patient presented to us with primary infertility. Most cases of micro perforate hymen present in the paediatric age group with recurrent urinary tract infections and recurrent vulvovaginitis. Rare cases in a review of literature noted that a patient was seen to present with urethral dilatation during coital activity. In this case report, we present a patient who came with primary infertility who has never been examined in the past. She had regular menstrual cycles but scanty flow with the main complaint of dyspareunia. After examination, she was found to have microperforate hymen and suspected transverse vaginal septum defect. Hence, routine investigations were done, and we proceeded with hymenectomy. This example demonstrates the importance of a thorough genital examination and the inclusion of hymenal abnormalities in the differential diagnosis of women with recurrent dysuria, vaginitis, primary infertility, and oligomenorrhoea, so that early intervention can be done to improve the woman's quality of life and reduce pregnancy difficulties.

Menstruation is a physiological process which starts around 11-16 yrs of age in most girls andcontinues throughout the reproductive life until menopause. During these years females spend one-sixth of their time menstruating and in discomfort. It is of utmost importance that hygienic practices are followed for a healthy and safe life. Various social and cultural taboos and habits have clouded the situation along with restricted facilities creating a disease burden such as genital infections and menstrual problems, including missed days at schools and work. It is the responsibility of the policy makers and also the health care workers to help in bridging the gap of lack of knowledge and availability of resources in creating a female hygiene friendly infrastructure in all the places. The study was conducted to assess the knowledge and awareness about menarche and menstrual cycle in school going girls. Also it was carried to study the prevailing practices of menstrual hygiene among the adolescent girls. The various sociocultural restrictions and taboos under practice in relation to menstruation and were analysed the reasons alongwith their solutions to improve the present situation of female hygiene practices were tabulated. A semi structured, question answer style written survey was conducted among adolescentgirls aged 11-18 yrs from nearby schools of Index Medical College, with help of PG resident doctors and medical interns. The survey was followed by educational and awareness talk on female hygiene practices that need to be followed.The result of the study were as follows-56.4%% were aware about menstruation before attaining menarche, and 88.20% had attained menarche at the time of study. 68.5% had mother as first informant, 40.3% knew about menstruation only after getting their 1 period. 28.5% felt insecure, 18.4% had anxiety, 30.5% were worried about menstruation. 95.5% perceived menstruation as a natural process, 98.6% used sanitary pads for bleeding, 1.4% used old cloth. 98.6% cleaned private parts during menses of which 75.3% used only water. Only 78.1% had the facility to change pads in school, of which only 58.9% changed pads in school. 90.4% had a daily bath during menses. 38.6% were not allowed to pray. 5% were not allowed to attend school, 8.3% were not allowed to sleep on their regular bed, and 11% were asked not to touch family members. 5% were restricted from playing outside and were not even allowed to go out of their home. 81.3% shared their menstrual health problems with mother. This study provided an understanding of perception of menstruation amongschool going girls. It also deals with the understanding of the society that still menstruation is not taken as a natural process, but rather as a curse and menstruating girls and women are being put under a lot of restrictions due to such practices. Lack of proper infrastructural facilities are a reason why so many girls drop out and restrict their attendance at school after menarche and much still needs to be done in this field to ensure smooth and healthy transition of adolescent girls into adulthood.

COVID-19 pandemic is an ongoing global pandemic which has resulted in significant morbidity and mortality. India has been one of the worst affected nations. The second wave has gripped the country in an unforeseen way. In an effort to contain the pandemic, the measures taken have led to all other health conditions taking a back seat. Patients of chronic diseases like cancer, marked by a continuity of care, have been bearing a major brunt. Access to cancer treatment has been disrupted as a result of COVID-19. This adversely affects the outcomes of the disease. This pandemic is here to stay, so cancer services should continue to be provided with due safeguarding of the health personnel and patients against the COVID-19 infections. Due modifications of the treatment schedules for systemic therapy, surgery and radiation treatment should be incorporated as per the guidelines. Vaccination of the immunocompromised, high risk, cancer patients on priority, besides that of the health care providers should be aimed at. In the long term, capacity of primary care physicians needs to be strengthened to provide basic cancer care services using a hub-and-spoke model with tertiary care centres. Keywords: COVID-19 infection

Purpose To report the phenomenon of spontaneous regression in presumed ocular surface squamous neoplasia (OSSN) Methods Retrospective chart review of clinically diagnosed cases of OSSN during 2016 to 2019 Results Of the 449 OSSN lesions, spontaneous regression was seen in 8 lesions (2%). The mean age at diagnosis of OSSN was 37 years (median, 36 years; range, 21 to 59 years). All were males with unilateral, treatment-naïve tumors. Mean duration of symptoms was 3 months (median, 2 months; range, 1 to 12 months). All tumors arose within the interpalpebral region, located in the nasal quadrant in 88% (n = 7) and in temporal quadrant in 12% (n = 1). The mean tumor diameter was 4 mm (median, 4 mm; range, 3 to 5 mm). Lesions showed nodular (n = 4; 50%) or placoid (n = 4; 50%) morphology. The other features included keratin production and intrinsic vascularity (n = 8; 100%), feeder vessels (n = 4; 50%), and intratumoral pigmentation (n = 4; 50%). The diagnosis of OSSN was confirmed by classic anterior segment optical coherence tomography (AS-OCT) features. Tumors regressed after a mean period of 5 months (median, 4 months; range, Conclusion OSSN can spontaneously regress in 2% of cases. Immune-mediated reversal of dysplastic changes may explain this phenomenon. Précis In this study, spontaneous regression of presumed ocular surface squamous neoplasia was noted in 2% patients. Tumor regression resulted in restoration of normal epithelial architecture and no recurrences were observed during the follow-up period.

Introduction: Nearly 60-80% of the term and preterm neonates are affected due to rise in bilirubin levels during early postnatal days, and causes readmission of the neonate sometimes with severe jaundice, which can be reduced if neonatal hyperbilirubinemia can be predicted early. The study was conducted to evaluate the predictive values of cord blood albumin and bilirubin for neonatal hyperbilirubinemia and to evaluate the better predictor between them. Method: In this hospital based observational study, 152 healthy term newborns with birth weight more than 2.5 kg were included. Assessment of cord blood haemoglobin, blood group, albumin and bilirubin levels was done. Follow-up for first consecutive five days after birth was done and assessed daily to look for evidence of jaundice, sepsis or any other illness. Serum bilirubin was evaluated at 72-96 hours of life in all neonates and was done early, if clinically indicated. Receiver’s Operating Characteristics curves were used for calculating the cut-off values of cord blood albumin and bilirubin in relation to hyperbilirubinemia. Result: The cut-off values obtained for albumin and bilirubin of cord blood was < 2.56 mg/dL and >2.33 mg/dL respectively at optimum sensitivity and specificity. Cord blood bilirubin was found to be highly sensitive for early recognition of significant neonatal hyperbilirubinemia as compared to cord blood albumin and can be used for screening purpose. Conclusion: Cord blood albumin and bilirubin can be used for negating the development of NNHB, but for screening purpose, cord blood bilirubin is more predictive of neonatal hyperbilirubinemia.

Cold agglutinin disease (CAD) is a rare type of autoimmune hemolytic anemia which usually results due to production of immunoglobulin M-type autoantibody against the I/i and H antigens on red blood cell membrane. They can be idiopathic or may be due to underlying lymphoproliferative disorders or atypical infections. It can have a varied presentation ranging from being incidentally detected to being totally transfusion dependent for a longer or shorter duration. Several factors play a role in determining the ability of cold agglutinins in inducing hemolysis such as antibody concentration and temperature. Here, we present a 54-year-old patient, a known case of chronic obstructive pulmonary disease who was admitted to our hospital in the winter months as a case of alcohol withdrawal syndrome. During the course of the stay, the patient developed respiratory insufficiency and went into Type II respiratory failure and hematological investigations revealed features of CAD.

Dimple Butani,1 Nidhi Gupta,2 Gaurav Jyani,1 Pankaj Bahuguna,1 Rakesh Kapoor,3 Shankar Prinja1 1Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 2Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India; 3Department of Radiation Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, IndiaCorrespondence: Shankar PrinjaDepartment of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, IndiaTel +91 9872871978Email shankarprinja@gmail.comBackground: Breast cancer is the leading cause of cancer among women in India. Treatment with hormone therapy reduces recurrence. We undertook this cost-effectiveness study to ascertain the treatment option offering the best value for money.Methods: The lifetime costs and health outcomes of using tamoxifen, AI and switch therapy were measured in a cohort of 50-year-old women with HR-positive early stage breast cancer. A Markov model of disease was developed using a societal perspective with a lifetime study horizon. Local, contralateral, and distant recurrence were modelled along with treatment related adverse effects. Primary data collected to obtain estimates of out-of-pocket expenditure (OOPE) and utility weights. Both health system cost and OOPE were included. The future costs and consequences were discounted at 3%. A probabilistic sensitivity analysis was used.Results: The lifetime cost of hormone therapy with tamoxifen, AI and switch therapy was to be ₹1,472,037 (I$ 68,947), ₹1,306,794 (I$ 61,208) and ₹1,281,811 (I$ 60,038). The QALYs lived per patient receiving tamoxifen, AI and switch were 13.12, 13.42 and 13.32. tamoxifen was found to be more expensive and less effective. As compared to switch therapy, AI for five years incurred an incremental cost of ₹259,792 (I$12,168) per QALY gained. At the willingness to pay equals to per capita GDP of India, there is 55% probability of AI therapy to be cost-effective compared to switch therapy.Conclusion: In postmenopausal women with HR-positive early-stage breast cancer, switch therapy is recommended for use on the basis of cost-effectiveness.Keywords: cost-effectiveness, aromatase inhibitor, tamoxifen, endocrine therapy, breast cancer

Cardiovascular diseases including cardiac arrhythmias lead to fatal events in patients with coronary artery disease; however, clinical associations from echocardiography, electrocardiography (ECG), and biomarkers remain unknown. We sought to identify the factors that may be related to elevated QRS intervals in patients with risk for coronary artery disease. In this study, we performed analysis of clinical data from 503 patients divided into two groups, i.e., patients with either 50% coronary artery stenosis. We further examined patients with elevated ECG parameters such as QRS > 100 ms and QTc > 440 ms. Patients with >50% coronary artery stenosis exhibited significant increases in age, triglycerides, and troponin levels. Further, ECG parameters demonstrated increased QRS and QTc durations, while echocardiographic parameters highlighted a decrease in ejection fraction (EF) and fractional shortening (FS). Patients with QTc > 440 ms exhibited increased brain natriuretic peptide and creatinine levels with a decrease in estimated glomerular filtration rate clearance rates. Patients with QRS > 100 ms had greater left ventricular (LV) mass and LV internal diameter in systole and diastole. Multimodal logistic regression showed significant relation between QTc, age, and creatinine. These findings suggest that patients with significant coronary stenosis may have lower EF and FS with prolonged QRS intervals, demonstrating greater risk for arrhythmic events.

Introduction: Sociodemographic factor, awareness of the health effects and legislative law can lead to an increase in cessation of tobacco. Tobacco related knowledge and awareness are found to be better in people working in the health care sector as compared to the general population. The objective of the study was to find the prevalence of quitting rate amongst the health workers and perceived harmful effects on health, tobacco types and awareness of the anti -smoking legislation law in India among the health care workers working in a tertiary care hospital. Methods: A cross-sectional study was conducted among 306 hospital staff (196 housekeeping staff and 110 nursing orderlies) at a tertiary care hospital of Faridabad in 2018. Convenience sampling was conducted, and data were collected through pre tested semi structured questionnaires on sociodemographic details, awareness of ill effects of tobacco and intention to quit. Results: Among 133 current tobacco users, intention to quit smoking was present in only 96 respondents (72.18%). There was association between age, marital status and type of family with the intention to quit. 63 respondents (21%) were unaware that smoking causes lung cancer and 115 (38%) of the total respondents did not consider smokeless tobacco as a causal risk factor for cancer. A total of 180 respondents (58.8%) were not aware of anti-tobacco control laws in India. Moreover, it was found that health concern was commonest reason of intention to quit. Conclusions: Intention to quit tobacco among study participants was low, so there is need to look for knowledge gaps about harms of different types of products and anti-tobacco legislation. More comprehensive tobacco cessation services should also be prioritized in the heath sector.Keywords: awareness of ill effects, COTPA, India, intention to quit, tobacco

Background Mixed cortico-medullary adrenal carcinoma (MCMAC) is an extremely rare entity with scarce literature on its cytomorphology. Case presentation A 2-year-old girl presented with abdominal pain for 3 days and a past history of fever with significant weight loss. On examination, a non-tender left hypochondrial firm mass and an enlarged left supraclavicular node were found. Twenty-four-hour urinary levels of VMA were marginally high. Contrast-enhanced computed tomography of the abdomen showed a suprarenal heterogeneous mass encasing major vessels. Aspiration cytology of both mass and node showed similar features comprising a predominant population of singly scattered large cells with moderate cytoplasm, eccentric nucleus and prominent nucleolus in a necrotic background. Tumour cells expressed Synaptophysin and Melan-A. In view of increasing respiratory distress, debulking surgery was performed, and histopathology of the specimen revealed the presence of both malignant medullary and cortical components supported by immunohistochemistry making a final diagnosis of MCMAC. The patient succumbed to death in the postoperative period. The cytology slides were reviewed and were seen to show a dual cell population. Conclusion Coexistent malignant cortical and medullary tumour of the adrenal gland is the first case reported in the paediatric age group in the literature with only three previous case reports in adults.

Background: With the rapid evolution in advanced computer systems and various statistical algorithms, it is now a days possible to analyze complex biological data. Bioinformatics is an interface between computational and biological assemblies. It is applied in various fields of biological as well as medical sciences. Aim: The manuscript aims to summarize the developments in the field of breast cancer research through the applications of bioinformatics. Methods: Various search engines like google, science direct, Scopus, PubMed, etc., were used for the literature survey. Results: It describes the bioinformatics analysis tools and models, which include mainly artificial neural network models. Conclusion: Bioinformatics is the evolutionary approach that is used for the capturing of data from the various case studies related to breast cancer.

Objectives To determine if there are age-related differences in sickle cell disease (SCD)-related healthcare utilization and to describe temporal healthcare utilization following an emergency department (ED) visit or hospitalization in treated SCD patient population. Methods Texas Medicaid prescription and medical claims from 1 September 2011 to 31 August 2016 were used. Patients aged 2–63 years with at least one inpatient or outpatient SCD medical claim and receiving one or more SCD-related medications (hydroxyurea, opioid or non-opioid analgesics) were included. The primary outcomes were utilization of SCD-related ED, inpatient and outpatient visits, all-cause prescription medications and type of SCD-related service at index and subsequent healthcare services. Age group was the primary independent variable. Key findings Overall (N = 2339), healthcare service utilization was relatively higher among age groups 2–12, 18–25 and 26–40. Proportions of patients having ≥1 ED and ≥1 inpatient visits, respectively, were significantly higher among age groups 2–12 (33.2%; 23.0%), 18–25 (29.3%; 25.1%) and 26–40 (32.3%; 22.4%) as compared with age group 13–17 (21.3%; 12.9%). The number of outpatient visits was highest among children aged 2–12 (4.5 ± 7.6, P < 0.0001), while mean number of all-cause medications was the highest for older adults aged 41–63 (22.4 ± 16.3; P < 0.0001). After an index ED visit (N = 598), outpatient visits were the most prevalent healthcare services. After an index hospitalization (N = 203), a subsequent hospitalization was the most prevalent healthcare service. Conclusions Texas Medicaid SCD patients receiving treatment have a high use of healthcare services, especially among children and young adults who are transitioning from childhood to adulthood. Age-specific interventions should be developed to promote optimal care transitions among young adults.

Background: Type 2 diabetes mellitus (T2DM) is linked to a significant rate of depression and cognitive impairment, according to previous studies. However, limited research has been done on the effects of diabetes treatment on depression, cognitive function, or overall quality of life (QoL). This planned study investigated into depression, cognitive function, and quality of life in T2DM patients, as well as its relationship to treatment received. To study the association of insulin therapy with depression, cognition and quality of life in T2DM patients. Methods: This was a crosssectional study that included 300 participants, comprising of 150 T2DM patients and 150 healthy individuals. The Patient health questionnaire and the Mini-mental state examination were used to measure depression and cognitive function, respectively. QoL was assessed using the Short-Form 36 (SF-36) questionnaire. Based on the type of treatment, all of the patients were divided into two subgroups: oral hypoglycemic medications (OHAs) and insulin. Results: The study included 300 participants, including T2DM patients (n=150) and healthy controls (n=150). In individuals with T2DM, the chances of mild (aOR 2.21, 95 % Ci 1.16-4.20; p=0.016) and severe (aOR 4.32, 95 % Ci 1.27-14.67; p=0.019) depression was higher. T2DM patients were also more likely to have cognitive impairment (aOR 2.86, 95 % Ci 1.16-6.99; p=0.021). Patients taking insulin had a substantially increased risk of depression (OR 2.127, 95 % Ci 1.070-4.228, p=0.036). Insulin-treated patients exhibited considerably poorer QoL ratings. Conclusion: The research illustrates that insulin therapy has a negative impact on depression and QoL in T2DM patients. As a result, it is recommended that insulin-treated T2DM patients require psychological assistance. In such cases, it is advised that measures to enhance QoL be implemented.

Purpose We lack knowledge on whether the advice of “being physically active” should be the same for prevention and rehabilitation of low back pain (LBP). Sickness absence is a key outcome for LBP prevention and rehabilitation. We investigated the associations between physical activity and long-term sickness absence (LTSA) among employees with and without LBP. Methods Between 2011 and 2013, 925 Danish employees wore a Actigraph GTX3 accelerometer for 1–5 workdays to measure physical activity and reported LBP in past 7 days. Employees were followed for 4 years to determine their first register-based LTSA event (≥ 6 consecutive weeks). Results Among employees with LBP, increasing moderate-to-vigorous-intensity physical activity at work by 20 min and decreasing the remaining behaviors at work (ie., sitting, standing and light-intensity activity) by 20 min was associated with 38% (95% CI 17%; 63%) higher LTSA risk. Increasing light-intensity activity at work by 20 min and decreasing 20 min from the remaining behaviors was associated with 18% (95% CI 4%; 30%) lower risk. During leisure, increasing moderate-to-vigorous-intensity activity by 20 min or standing by 40 min was associated with 26% (95% CI 3%; 43%) lower and 37% (95% CI 0%; 87%) higher risk, respectively. Among employees without LBP, we found no such associations. Conclusions The physical activity advice ought to be different for LBP prevention and rehabilitation to reduce LTSA risk, and specified by domain and activity intensity. At work, employees with LBP should be advised to spend time on light-intensity physical activity and limit their time on moderate-to-vigorous-intensity physical activity. During leisure, employees should spend time on moderate-to-vigorous-intensity physical activity.

A severe pandemic of Coronavirus Disease (COVID‐19) has been sweeping the globe since 2019, and this time, it did not stop, with frequent mutations transforming into virulent strains, for instance, B.1.1.7, B.1.351, and B.1.427. In recent months, a fungal infection, mucormycosis has emerged with more fatal responses and significantly increased mortality rate. To measure the severity and potential alternative approaches against black fungus coinfection in COVID‐19 patients, PubMed, Google Scholar, World Health Organization (WHO) newsletters, and other online resources, based on the cases reported and retrospective observational analysis were searched from the years 2015–2021. The studies reporting mucormycosis with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) coinfection and/or demonstrating potential risk factors, such as a history of diabetes mellitus or suppressed immune system were included, and reports published in non‐English language were excluded. More than 20 case reports and observational studies on black fungus coinfection in COVID‐19 patients were eligible for inclusion. The results indicated that diabetes mellitus, hyperglycemic, and immunocompromised COVID‐19 patients with mucormycosis were at a higher risk. We found that it was prudent to assess the potential risk factors and severity of invasive mycosis via standardized diagnostic and clinical settings. Large‐scale studies need to be conducted to identify early biomarkers and optimization of diagnostic methods has to be established per population and geographical variation. This will not only help clinicians around the world to detect the coinfection in time but also will prepare them for future outbreaks of other potential pandemics., Highlights Observational studies and case reports of Post‐COVID black fungus co‐infection highlighted in review.Along with risk factors, radiological interventions of black fungus co‐infection in COVID‐19 patients and challenges for accurate diagnosis were elaborated.The review discusses interconnection between fungus and SARS‐CoV‐2 co‐infection of mechanism to identify potential biomarkers.Our conclusion will contribute to motivate researchers to design follow‐up plans for black fungus infection in COVID‐19.

Background Moderate sedation is performed frequently in the hospital setting for same-day, invasive procedures. The primary administrators of moderate sedation are nurses who have been trained to administer medication based on patient responsiveness, airway, ventilation and cardiovascular function. This study evaluated the safety and efficacy of nurse-administered conscious sedation by assessing medication use, clinical outcomes and patient satisfaction. Methods Data from same-day, elective procedures in the cardiac catheterisation laboratory and interventional radiology departments were collected, including comorbidities, procedural characteristics and post-sedation questionnaires. Results Procedure duration was found to be longer in the cardiac catheterisation laboratory (55 minutes; interquartile range: 37–81 minutes) than in interventional radiology (24 minutes; interquartile range 16–45 minutes; P value of Conclusions: Patients receiving conscious sedation while undergoing procedures in the cardiac catheterisation laboratory and interventional radiology were found to have no adverse clinical outcomes, as evidenced by the absence of reversal agents and advanced airway requirements. The procedural duration of the catheterisation procedures were significantly longer than interventional radiology and patients received overall less sedation medication.

Background and Aims: Surgical interventions involving urinary catheterisation often lead to catheter-related bladder discomfort (CRBD). With a very high incidence rate of 47%–90%, CRBD often leads to a distressing and painful recovery after surgery. Although many opioids have been used for the treatment of CRBD, the search for the best is still going on. This study investigated the efficacy and tolerability of oral tapentadol and tramadol on postoperative CRBD. Methods: This was a prospective, randomised double-blind study. 100 patients, undergoing transurethral resection of the prostate were randomly assigned into two groups to receive tramadol 100 mg (Group A) or tapentadol 50 mg (Group B) orally 1 h before surgery. CRBD was evaluated on a 4-point severity scale in the post-operative area at 0, 0.5, 1, 2, 3, 4, 5 and 6 h. Pain and adverse effects were assessed postoperatively. Serum cortisol levels before and after the procedure were noted. Statistical analysis was done with the analysis of variance, t test. Results: Postoperative CRBD, 2 h after surgery was significantly reduced in group B than group A (P = 0.012). Cortisol levels, postoperatively were significantly lower in Group B (113 ± 65.45) (P = 0.001) than group A (162.64 ± 118.84 ng/dL). Dry mouth was seen in four, nausea in eight and sedation in six patients in group A while none in group B. 14 patients in Group A and one patient in Group B needed intravenous paracetamol (P = 0.000). Conclusions: Premedication with tapentadol was more effective in reducing CRBD and pain postoperatively. The surgical stress response and side effects were significantly reduced with tapentadol.

Objective: Prolactin-secreting tumors respond well to medical management, with a few patients requiring surgery. We conducted a systematic review and meta-analysis to study the determinants of surgical remission in these tumors. Methods: We searched PubMed to identify eligible studies reporting postoperative remission in patients treated with transsphenoidal surgery for prolactinoma. Primary outcomes included postoperative remission, follow-up remission, and recurrence. Postoperative and follow-up remission were defined as normoprolactinemia at 1 year after operation, respectively. Recurrence was defined as hyperprolactinemia after initial normalization of prolactin levels. Odds ratios (ORs) were calculated, stratified by radiologic size, tumor extension, and tumor invasion, and analyzed using a random-effects model meta-analysis. Results: Thirty-five studies were included. Macroadenomas were associated with lower rates of postoperative remission (OR, 0.20; 95% confidence interval [CI], 0.16–0.24) and lower rates of remission at follow-up (OR, 0.11; 95% CI, 0.053–0.22). Postoperative remission was less likely in tumors with extrasellar or suprasellar extension (OR, 0.16; 95% CI, 0.06–0.43) and tumors with cavernous sinus invasion (OR, 0.03; 95% CI, 0.01–0.13). Female gender and absence of preoperative dopamine agonist treatment were also associated with higher remission rates. Across the included studies, there was considerable heterogeneity in each primary outcome (postoperative remission, I2 = 94%; follow-up remission, I2 = 86%; recurrence, I2 = 68%). Conclusions: Transsphenoidal surgery for prolactinomas may be particularly effective in small, noninvasive, treatment-naive tumors and may provide a viable first-line alternative to dopamine agonist therapy in such patients.

Both incidence and mortality of uterine cancer are on the rise and mortality is higher for African American women. The aim of our study was to evaluate how Next Generation Sequencing (NGS) may facilitate identification of and intervention for treatment disparities when integrated into clinical workflows.Our cohort included 159 uterine cancer patients with recurrent/progressive and newly diagnosed advanced stage and/or high-risk histology. The most common tumor histological subtypes included EEC (n = 67), SEC (n = 34), UCS (n = 20), and mixed (n = 14). Black patients were most likely to present with aggressive histology: (SEC, 34.0%) and carcinosarcoma (UCS, 14.0%). The four most common mutations across all subtypes were TP53, PIK3CA, PTEN, and ARID1A. There was racial disparity between Black versus non-Black patients who were initiated on targeted therapy (28.2% vs. 38.2%, respectively) and clinical trial (15% vs. 22.6%, respectively). Compared to non-Black patients, Black patients had a significantly higher percentage TP53 mutations (p0.05) and a significantly lower percentage ARID1A mutations (p0.05).NGS for uterine malignancies provides actionable information for targetable mutations and/or clinical trial enrollment in most patients; further investigation is necessary to identify potentially modifiable factors contributing to current disparities that may improve targeted therapy uptake and clinical trial participation.

Objective To identify, screen, highlight, review, and summarize some of the most rigorously conducted and impactful original research and review articles in global emergency medicine (EM) published in 2020 in the peer-reviewed and gray literature. Methods A broad systematic search of peer-reviewed publications related to global EM indexed on PubMed and in the gray literature was conducted. The titles and abstracts of the articles on this list were screened by members of the Global Emergency Medicine Literature Review team to identify those that met our criteria of original research or review articles in the domains of Disaster and Humanitarian Response, Emergency Care in Resource-Limited Settings, and Emergency Medicine Development. Those articles that met these screening criteria were then scored using one of three scoring templates appropriate to the article type. Those articles that scored in the top 5% then underwent in-depth narrative summarization. Results The 2020 GEMLR search initially identified 35,970 articles, more than 50% more than last year's search. From these, 364 were scored based on their full text. Nearly three-fourths of the scored articles constituted original research, of which nearly three-fourths employed quantitative research methods. Nearly 10% of the articles identified this year were directly related to COVID-19. Research involving Emergency Care in Resource-Limited Settings again constituted most of the articles in this year's review, accounting for more than 60% of the literature scored. A total of 20 articles underwent in-depth narrative critiques. Conclusions The number of studies relevant to global EM identified by our search was very similar to last year. Revisions to our methodology to identify a broader range of research were successful in identifying more qualitative research and studies related to Disaster and Humanitarian Response. The number of COVID-19-related articles is likely to continue to increase in subsequent years.

Purpose To report patients who demonstrated an alteration in the clinical and optical coherence tomography features of neovascular age-related macular degeneration after resolution of endophthalmitis. Methods Retrospective case series of the subsequent changes in the macula and need for anti-vascular endothelial growth factor therapy in patients with neovascular age-related macular degeneration who developed endophthalmitis after intravitreal injection. Results The study included seven eyes of seven patients with follow-up ranging between 3 months and 11 years. The vitreous cultures (n = 7) before intravitreal antibiotic injection were the following: culture-negative (4) and coagulase-negative Staphylococcus (3). Initial treatment included vitreous tap and injection (4) and pars plana vitrectomy (3). In 5/7 eyes, the optical coherence tomography showed resolution of subretinal fluid and serous pigment epithelial detachment, and there was no additional anti-vascular endothelial growth factor treatment administered. Conclusion After successful treatment of endophthalmitis in patients with neovascular age-related macular degeneration, there was relative involution of the maculopathy and reduced anti-vascular endothelial growth factor treatment burden in this series.

Summary A wide variety of stem cell-derived therapies are under development for the treatment of retinal degeneration. In order to better understand patient perspectives about these therapies, we assessed risk tolerance using an in-person survey of 178 patients at an academic eye center. Risk of malignancy served as a hypothetical, readily understood, and serious adverse event to be considered in trade for potential visual improvement from a stem cell-derived treatment. The results indicate that patients were willing to trade visual improvement against a risk of malignancy that far exceeds actual risk. Two novel findings were that older patients and those with an intermediate level of visual loss were particularly risk tolerant. The quantitative survey results provide a step toward understanding patient perspectives that will, over the long term, guide the development of ocular stem cell-derived therapies., Highlights • Patients surveyed were willing to trade visual acuity and risk of cancer • Age and visual function score modify utility of risk of cancer and visual acuity • Greatest changes in utility of visual acuity occurred between 20/40 and 20/100, In this article, Zhao and colleagues explore the patient perspective on ocular stem cell-derived treatments. Using a patient survey containing a discrete-choice experiment, they demonstrated that patients are willing to accept a higher risk of cancer in the eye in exchange for improved visual acuity, and identify age and visual function as factors that influence decision making.

Intellectual disability (ID) is still unexplained in 60% of cases and prenatal diagnosis is very challenging for this condition. A second gravida presented to us at 6 weeks of gestation for counseling. Her previous child had been diagnosed with ID and autism. Detailed family history showed that her brother also had ID. Screening investigations were normal for the affected child. Exome sequencing report revealed variation of unknown significance (VOUS) on SIN3A gene and UPF3B gene. The variation in X-linked UPF3B gene was reclassified as novel pathogenic variation after segregation studies with parents and affected maternal uncle for both the genes variations. An amniocentesis was done at 18 weeks gestation for the novel mutation in the UPF3B gene and the fetus was found unaffected. The patient delivered a healthy male child who is doing well at two years of age. To conclude, we should not disregard VOUS on exome sequencing. Identification of VOUS requires careful genotype-phenotype correlation and segregation studies to counsel parents regarding the risk of having another affected child.

Background: Coronavirus disease 2019 (COVID19) has evolved as a global pandemic. The patients with COVID-19 infection can present as mild, moderate, and severe disease forms. The reported mortality of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection is around 6.6%, which is lower than that of SARS-CoV and (middle east respiratory syndrome CoV). However, the fatality rate of COVID-19 infection is higher in the geriatric age group and in patients with multiple co-morbidities. The study aimed to evaluate the utility of early warning scores (EWS) to predict mortality in patients with moderate to severe COVID-19 infection. Methods: This retrospective study was carried out in a tertiary care institute of Uttarakhand. Demographic and clinical data of the admitted patients with moderate-to-severe COVID-19 infection were collected from the hospital record section and utilized to calculate the EWS-National early warning score (NEWS), modified early warning score (MEWS), Rapid Acute Physiology Score (RAPS), rapid emergency medicine score (REMS), and worthing physiological scoring system (WPS). Results: The area under the curve for NEWS, MEWS, RAPS, REMS, and WPS was 0.813 (95% confidence interval [CI]; 0.769–0.858), 0.770 (95% CI; 0.717–0.822), 0.755 (95% CI; 0.705–0.805), 0.892 (95% CI; 0.859–0.924), and 0.892 (95% CI; 0.86–0.924), respectively. Conclusion: The EWS at triage can be used for early assessment of severity as well as predict mortality in patients with COVID-19 patients.

Objective Unlike schizophrenia, comparisons of different methods of estimating inadequate adherence in bipolar disorder (BD) are scarce. This study compared four methods of identifying inadequate adherence among outpatients with BD. Materials and Methods Two self-reports, the Morisky Medication Adherence Questionnaire (MAQ) and the Drug Attitude Inventory (DAI-10), clinician ratings employing the Compliance Rating Scale (CRS), mood-stabilizer levels, and clinic-based pill counts were compared at intake in 106 outpatients with BD and after 6 months of follow-up (n = 75). Statistical Analysis Rates of nonadherence were determined for each method. The ability to detect inadequate adherence was based on sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (LR positive and LR negative). Correlation coefficients and Cohen's kappa values were used to determine the agreement between measures. Correlation coefficients were also used to evaluate the determinants of inadequate adherence Results The MAQ and the DAI-10 (cut-off score of two) yielded higher rates of nonadherence (35–47%) than the other methods. They were better at detecting adherence (specificity, 34–42%; PPV, 40–44%; and LR negative, 0.70–0.96) than other measures and had moderate ability to identify nonadherence compared with them (sensitivity, 63–73%; NPV, 54–70%; and LR positive, 1.02–1.16). They were associated with several established predictors of nonadherence. The MAQ and DAI-10 scores and the MAQ and CRS scores were modestly correlated. Multivariate analysis showed that 20% of the variance in the DAI-10 scores was explained by the MAQ scores. Despite their low yield, serum levels had a high sensitivity (88%) and higher accuracy (55%) in identifying inadequate adherence. CRS ratings and pill counts had high sensitivity but low specificity to detect inadequate adherence. Conclusion Self-reports appeared to be the most efficient method of ascertaining inadequate adherence among outpatients with BD. However, since none of the measures were adequate by themselves, a combination of different measures is more likely to maximize the chances of identifying inadequate adherence among these patients.

Background: Indefinite maintenance therapy after autologous stem cell transplant (ASCT) is the current standard of care in multiple myeloma (MM). However, in the real world, patients often discontinue treatment due to various reasons. In this study, we sought to analyze the effect of and reasons for early discontinuation of maintenance therapy on survival outcomes, studying patients who received less than 3 years of maintenance therapy (short-term maintenance group) or more than 3 years (continuous maintenance group). Methods: We retrospectively reviewed 340 patients who underwent ASCT from 2005-2016 and received maintenance therapy for at least six months without progression. The patients started maintenance therapy after 100 days of ASCT. Lenalidomide (89%) and bortezomib (10%) were the most commonly used agents for maintenance therapy. The primary endpoints included were progression-free survival (PFS) and overall survival (OS). All the endpoints were measured from the time of ASCT. The discontinuation was defined as permanently stopping the maintenance therapy. Patient, disease, and transplant-related characteristics were compared between the two groups using the Mann-Whitney U test for continuous variables, and chi-squared or Fisher's exact test for categorical variables. The probabilities of PFS and OS were calculated using the Kaplan-Meier (KM) method and compared using log-rank test. Results: One hundred and two (n= 102; 30%) patients discontinued maintenance therapy in the first 3 years (short-term maintenance group), while 238 patients remained on maintenance therapy for ≥ 3 years (continuous maintenance group). The groups had similar baseline characteristics in terms of age, gender, ISS staging, cytogenetics, response before ASCT, and melphalan dosing. About 20% of patients in both groups were older than 65 years. Among those alive at the last contact, the median follow up were 5.4 years and 6.1 years for the short-term and continuous maintenance therapy group, respectively. At the time of the last follow-up, 131/238 (55%) patients in the continuous maintenance group were still on maintenance therapy. The median PFS in the short-term maintenance group was 5.1 years (95% CI: 4.4-7.4) and median OS was 9.8 years (95% CI: 8.2- to NR), whereas in the continuous maintenance group both median PFS (95% CI: 8.5- NR) and OS were not reached. This latter group had significantly longer PFS and OS than the short-term maintenance group with a 5-year estimated PFS of 80% (95%CI: 74-85%) vs. 50% (95% CI: 39-60%) (p The most common reasons for early discontinuation of maintenance therapy (< 3 years) were adverse events related to maintenance therapy (58%). Four patient (4%) patients developed second primary malignancy (SPM) in this group. The most frequent hematological adverse events (AEs) were pancytopenia and isolated neutropenia. Fatigue and diarrhea were the most common non-hematological AEs. The reasons for stopping maintenance in the continued maintenance group were disease progression (24%) and adverse events (14%), while five patients (2%) developed SPM. Conclusion: In our institutional experience, 30 percent of MM patients discontinued maintenance therapy within 3 years of ASCT due to AEs or patient preference. These patients had inferior PFS and OS after ASCT compared to patients on continuous maintenance. Therefore, continuation of maintenance therapy should be strongly encouraged as safely possible and strategies like dose reduction or switching therapy are recommended. Figure 1 Figure 1. Disclosures Bumma: Janssen: Membership on an entity's Board of Directors or advisory committees; Amgen: Speakers Bureau; Sanofi: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Background: The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has affected the world at large. To control the spread of the virus, the Government of India promoted simple measures such as social distancing and hand hygiene. Yet, the most prominent one was a strict nationwide lockdown on all non-essential services and complete curtailment of the public transport. Objective: Our study aims to quantify the impact of COVID-19 pandemic and lockdown measures on the pediatric services of a tertiary care center in North India. Materials and Methods: A retrospective observational study was done to analyze the change in our outpatient visits, admissions, and number of institutional deliveries, immunization services, pediatric surgeries, and mortality rates during the lockdown period when compared to the pre-lockdown period. Data of all children aged 0–12 years who presented to the pediatric medicine and pediatric surgery departments were collected. Data were divided into two groups; January 1, 2020–March 31, 2020 and April 1, 2020–June 30, 2020. Results: There was a reduction of 79.1% OPD attendance and 70.8% in immunization visits. Inpatient admission in pediatrics medicine and surgery decreased by 59.8% and 67.6%, respectively. The mortality rate increased from 11.8% to 13% and 7.6% to 19.6%, respectively. Emergency area visits decreased by 55.3% with an increase in mortality rate from 2.4% to 6.2%. Intramural births decreased by 55.4%. Conclusion: The COVID-19 pandemic has led to an unmet need of pediatric services. This requires urgent management or else it may halt the progress made in different aspects of health care.

Objectives Follicular hyperplasias (FHs) with light chain–restricted (LCR) plasmacytoid/plasma cells (PCs) within germinal centers (GCs) based on immunohistochemistry (IHC)/in situ hybridization (ISH) can potentially lead to diagnostic error. This study aims to better characterize such cases, including their clinical implications. Methods LC expression by IHC/ISH was quantitatively assessed in GCs of 17 FHs with LCRGCs. BCL2, CD10, BCL6, BCL2, immunoglobulin (Ig) heavy chains, IgG4, and Epstein-Barr encoding region stains were performed. In total, 8 cases had polymerase chain reaction (PCR)–based clonality studies. Results All cases showed FH, including 4 with progressively transformed GCs (PTGCs); 0.8% to 52% (median, 21%) of the GCs were LCR; 13 of 17 had both κ- and λ-LCRGCs, and 4 of 17 had only κ-LCRGCs; 7 of 16 had prominent intrafollicular IgG4-positive cells. One case demonstrated BCL2-positive cells in focal LCRGCs but lacked BCL2 rearrangement. B-cell monoclonality was demonstrated in 3 of 8 cases (only after microdissection). Seven patients had autoimmune disorders, and 1 had had a transplant. Three patients had a history of lymphoma, 1 developed lymphoma, and 1 developed lymphomatoid granulomatosis subsequently. Conclusions FHs with LCRGC by IHC/ISH are typically not associated with the development of lymphoma, even though they can express BCL2 and show monoclonality by PCR. They may be associated with increased intrafollicular IgG4-positive cells, PTGC, and autoimmunity.

Introduction: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is a major pandemic and continuously emerging due to unclear prognosis and unavailability of reliable detection tools. Older adults are more susceptible to COVID-19 than children showing mature Angiotensin-Converting Enzyme 2 (ACE2), low concentration of immune targets, and comorbid conditions. Several detection platforms have been commercialized to date and more are in pipeline, however, the rate of false-positive results and rapid mutation of SARS-CoV-2 is increasing. Additionally, physiological, and geographical variations of affected individuals are also calling for diagnostic methods optimization. Areas Covered: Extensive information related to the optimization and usefulness of SARS-CoV-2 diagnostic methods based on sensitivity and specificity as definitive and feasible investigative tools is discussed. Moreover, an option of combining laboratory diagnostic methods to improve diagnostic strategies is also proposed and discussed in the comparative section of optimization studies. Expert Opinion: The review article explains the importance of optimization strategies for SARS-CoV-2 detection in children and older adults. There are advancements in COVID-19 detection including CRISPR-based, electrochemical, and optical-based sensing systems. However, the lack of sufficient studies on a comparative evaluation of standardized SARS-CoV-2 diagnostic methods among children and older adults, limit the authentication of commercialized kits.

Objective: The purpose of this study was to look for the earliest, cost -effective method that can be added to the routine antenatal screening for identifying patients who might develop gestational diabetes mellitus (GDM) in a proactive manner, as opposed to the current reactive approach of screening and treating GDM, during the second trimester of pregnancy. Materials and Methods: 190 singleton pregnant women in the age group 18-35 years were selected for the study. On these women two step assessment was done. The current project was carried out to utilize sonography as an early, cost-effective method which could be added to routine antenatal screening for identifying patients, at risk for developing GDM. Results: Body mass index was found to have a significant association in those patients with GDM with a P < .001. There was a significant association between subcutaneous adipose tissue (SAT) depth and occurrence of GDM, with a P-value of Conclusion: The sonographic measurement of SAT, VAT, and TAT, could be potential marker to identify probable events for the development of GDM, among Asian Indian women who tend to have T2DM, due to differential distribution of fat.

Introduction: Anxiety is the state of feeling nervous or worried that something bad is going to happen. Dental anxiety is defined as a patient’s response to stress that is associated with a dental procedure. The aim of our study is to investigate the anxiety status of dental patients visiting Orthodontic department at Nobel Medical College Teaching Hospital, Biratnagar. Materials and Method: Total 80 ongoing orthodontic patients (M =21 F=59) who completed modified Dental Anxiety Scale questionnaire were included in the study. Result: Majority of patients (65%) had moderate anxiety where as 25% had mild anxiety and around 9% had severe to extreme anxiety. Patients’ age and education level had significant association with the level of dental anxiety. Conclusion: Dental anxiety in orthodontic patients is unavoidable but needs appropriate counseling. Orthodontist’s role is crucial in bridging the gap between patients’ perception towards orthodontic treatment and the actual treatment.

Background: The alveolar–arterial oxygen (A–a) gradient measures the difference between the oxygen concentration in alveoli and the arterial system, which has considerable clinical utility. Materials and methods: It was a retrospective, observational cohort study involving the analysis of patients diagnosed with acute COVID pneumonia and required noninvasive mechanical ventilation (NIV) over a period of 3 months. The primary objective was to investigate the utility of the A–a gradient (pre-NIV) as a predictor of 28-day mortality in COVID pneumonia. The secondary objective included the utility of other arterial blood gas (ABG) parameters (pre-NIV) as a predictor of 28-day mortality. The outcome was also compared between survivors and nonsurvivors. The outcome variables were analyzed by receiver-operating characteristic (ROC) curve, Youden index, and regression analysis. Results: The optimal criterion for A–a gradient to predict 28-day mortality was calculated as ≤430.43 at a Youden index of 0.5029, with the highest area under the curve (AUC) of 0.755 (p

Background: Since last decades, breast cancer has emerged as one of the most aggressive forms of cancer which causes the highest mortality rates. The synthetic drugs that are available for the treatment of breast cancer either have high toxicity or becoming resistant. Given this, researchers are constantly in search of natural drugs that can control aggressive breast cancer and at the same time possess less toxicity. Aim: The manuscript aims to summarize potential herbal molecules having significant activity against breast cancer. Methods: Extensive literature survey was carried out to compile data obtained from primary and secondary information sources. Google Scholar, Science Direct, Bentham Science, Springer, PubMed, etc. were used as the source of data. Results: In the present review, an attempt has been made to summarize herbal molecules that have shown promising results against breast cancer either in preliminary studies or in clinical studies. Herbal molecules gain good attention among the scientific community for their therapeutic properties against breast cancer. Conclusion: After the literature survey, it was also concluded that herbal molecules have significant potential to control the growth of breast cancer.

The objective of the present study is to find the prevalence of Mycobacterium tuberculosis from respiratory samples like sputum, BAL and pleural fluid, compare conventional LJ culture with rapid culture method i.e Mycobacterium growth indicator tube (MGIT) and to determine the pattern of drug resistance by automated methods i.e Gene Xpert. Respiratory samples were collected in sterile, wide-mouth, disposable, leak proof containers without any preservatives. Specimens were inoculated into MGIT for primary isolation of Mycobacteria. The specimen was processed according to the SOP manual provided by Becton Dickinson Company. The tubes were read for increasing fluorescence by MGIT reader. Reported results only when a MGIT tube was positive by the MGIT reader and smear made from the positive broth is also positive for AFB. For further identification, TBcID card test was put from MGIT positive tube and the result was given accordingly as mentioned in the procedure for TBcID kit insert. Polymerase chain reaction (PCR) was done in all 17 positive cases. The drug sensitivity test (CB-NAAT) was done at State Intermediate Reference Laboratory, Chandan Nagar, Dehradun, Uttrakhand as per RNTCP laboratory operational guidelines. In our study total number of samples received from the clinically suspected cases of pulmonary tuberculosis were 156, out of which 11% were positive and 89% were negative. The predominant age group involved was 51-60 years 24%, followed by 61-70 years 22%. In young children and adolescent age group very less number of samples were received i.e. 0-5%. Out of 17 positive samples, 94.11% (16/17) were detected as sensitive for Rifampicin and 5.89% (1/17) were resistant. On the statistical analysis of our data for MGIT, Positive Predictive Value (PPV) was 29% against Negative Predictive Value (NPV) of 100%. The specificity of MGIT was 92% against a sensitivity of 100%. Culture is still needed for species identification, confirmation and drug susceptibility testing. The diagnostic superiority of MGIT, both in terms of sensitivity and specificity has been proven better as compared to LJ in previous other studies and supported by our study as well. In our study, the diagnostic efficacy of MGIT culture was found to be superior as compared to the conventional LJ culture. The positivity rate was 10.89% (17/156) in MGIT & 3.2% (5/156) in LJ culture.