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Large adrenal pheochromocytomas encasing the renal artery are a rare entity. The management of such challenging cases is surgical resection. The involvement of renal tissue and renal artery may necessitate meticulous dissection and concomitant nephrectomy. Here, we present a case of 41-year-old man diagnosed with left adrenal pheochromocytoma with complete encasement of left renal artery and partial encasement of aorta. Open left adrenalectomy and nephrectomy was performed after adequate preoperative optimisation. The patient is doing well at 6-month follow-up. Large adrenal pheochromocytoma with renal involvement is a rare presentation and requires optimal preoperative imaging, adequate preoperative alpha and beta blockade and meticulous surgical technique.

BACKGROUND: There remains controversy regarding the outcomes resulting from treatment versus conservative management of patent ductus arteriosus (PDA) among preterm infants. The effects of extreme prematurity, hemodynamic status of the PDA, and age at treatment remain poorly defined. STUDY DESIGN: This retrospective case-control study including infants

BACKGROUND: Recidivism in patients who underwent liver transplantation for alcohol-related liver disease (ALD) is shown to be associated with poor survival in some studies. METHODS: Living donor liver transplantation (LDLT) recipients for ALD with at least 2 years of follow-up and history of significant alcohol relapse were included. The recipients underwent LDLT from June 2010 to December 2016, and data were analyzed until June 2019. The cohort had a median follow-up of 54 (33–78 IQR) months. Recidivism (significant alcohol intake) was defined as >21 units per week. RESULTS: A total of 27 of 463 (5.8%) LDLT recipients (all men), aged 43.5 ± 9.6 years, had significant alcohol intake. A liver biopsy was performed on demand in 14 patients (in the presence of raised levels of liver enzymes or jaundice). The histological diagnoses in these patients were as follows: alcoholic hepatitis in 7 (50%), alcoholic hepatitis and acute cellular rejection or chronic rejection in 4 (28.5%), cirrhosis in 2 (14.2%), and acute cellular rejection and cirrhosis in 1 (7.1%) patient. Four of 5 patients with a biopsy diagnosis of acute or chronic rejection were noncompliant with immunosuppression. Six of these patients died. The mortality after 1 year of transplant was significantly more in patients with recidivism. CONCLUSION: Recidivism was associated with significant morbidity and mortality after liver transplantation.

Adolescents and young adults (AYA) with sickle cell disease (SCD) experience high rates of acute care utilization and increased morbidity. At this high-risk time, they also face the need to transition from pediatric to adult services, which, if poorly coordinated, adds to heightened morbidity and acute care utilization. The study objective was to characterize the feasibility, acceptability, and short-term efficacy of a protocolized transition navigator (TN) intervention in AYA with SCD.We developed a protocolized TN intervention that used ecological assessment and motivational interviewing to assess transition readiness, identify goals, and remove barriers to transition, and to provide disease and pain management education and skills to AYAs with SCD.Ninety-three percent (56/60) of enrolled individuals completed the intervention. Participation in the TN program was associated with significant improvement in mean transition readiness scores (3.58-4.15, P.0001), disease knowledge scale (8.91-10.13, P.0001), Adolescent Medication Barriers Scale (40.05-35.39, P = .003) and confidence in both disease (22.5-23.96, P = .048) and pain management (25.07-26.61, P = .003) for youth with SCD.The TN intervention was acceptable to youth with SCD, feasible to implement at an urban academic medical center, and addressed barriers to transition identified by the youth. Longer-term assessment is needed to determine if the TN intervention improved successful transfer to and retention in adult care.

PURPOSE: Results from adjuvant trials evaluating 6 cycles of epirubicin-based chemotherapy regimens suggested these programs may be more effective than 4 cycles of doxorubicin-based chemotherapy. METHODS: NSABP B-36 was a phase III clinical trial originally designed as a 2x2 factorial study comparing 6 cycles of FEC-100 (5-FU, epirubicin, cyclophosphamide) to 4 cycles of conventional AC (Adriamycin/cyclophosphamide) with celecoxib or placebo. Shortly after activation, concerns regarding increased cardiovascular risks among selective COX-2 inhibitors resulted in a decision to remove the celecoxib/placebo from the trial. Women with histologically node-negative invasive breast cancer who had undergone primary surgery with a lumpectomy or total mastectomy were eligible. Primary endpoint was disease-free survival (DFS).RESULTS: Between May 2004-July 2008, 2,722 patients were enrolled. Administration of FEC-100 did not result in improvement in DFS compared to AC (HR=1.09; 95% CI 0.92-1.29, p-value=0.31). The effect of FEC-100 compared to AC on DFS was significantly different for receptor-positive (HR=1.32, 95% CI=1.05-1.66) compared to receptor-negative patients (HR=0.86, 95% CI=0.66-1.11) (treatment-by-receptor status interaction p-value=0.02). There was no statistically significant difference in the effect of treatment on overall survival (OS) with FEC-100 compared to AC (HR=1.06; 95% CI 0.84-1.35, p-value=0.61). Overall, Grade 3 and 4 adverse events were more frequent in the FEC-100 group.CONCLUSIONS: The results of B-36 do not support use of six-cycle anthracycline-based regimens in node-negative breast cancer. Prolongation of anthracycline-based therapy with FEC-100 does not improve DFS or OS, relative to AC for 4 cycles, and was associated with expected increases in toxicity. A statistically significant interaction between treatment and hormone receptor status favoring AC in hormone-receptor-positive breast cancers is consistent with the hypothesis that optimal duration of chemotherapy may be four cycles in these patients. Late cardiac events and deaths prior to recurrence or second cancer were infrequent on both arms, but slightly higher with FEC-100.ClinicalTrials.gov: NCT00087178

Purpose The systematic review study aimed to investigate the following details in the clubfoot children treated with the Ponseti technique: (1) to review the various designs and prescriptions of unilateral limb orthosis described in literature (2) to find the outcome following use of this orthosis, especially patient adherence and recurrence (3) comparison with standard bilateral limb foot abduction orthosis. Material and methods A literature search was performed for articles published in 'Pubmed (includes Medline indexed journals)' electronic databases for broad key words: 'Clubfoot or CTEV or congenital talipes equinovarus', 'orthosis or brace or splint'. Included were studies that addressed the treatment of idiopathic clubfoot in children up to 2 years of age using the Ponseti technique and use of unilateral limb orthosis for the subsequent maintenance phase. We excluded studies reporting Ponseti technique for nonidiopathic clubfoot, child age older than 2 years at the time of primary treatment, studies where unilateral limb orthosis was used as a tool for primary correction of all or some components of clubfoot and design descriptions of orthosis without practical usage data. Results Of the 1537 articles from the database, 10 articles were included in the final review. Most studies were retrospective, underpowered and had a short term follow-up. In some series, the use of this orthosis was driven by personal experiences and regional preferences rather than a just scientific explanation. The tested designs were variable and nonstandardized. Being less restrictive, unilateral limb orthosis may have an edge over bilateral limb orthosis in terms of patient adherence. The available comparative studies however showed inferiority of unilateral orthoses when compared to the bilateral limb orthosis in preventing recurrences in clubfoot treatment. Conclusions There is insufficient evidence to support use of unilateral limb orthosis for maintenance of deformity correction following treatment of clubfoot with the Ponseti technique. Their use was found associated with high recurrence rates.

Objective The present study aimed to evaluate gestational diabetes mellitus (GDM) incidence in pregnant women following the Mediterranean diet with additional extra virgin olive oil (EVOO) and pistachios. Methods 560 pregnant patients were enrolled in the present study. The Mediterranean diet (MedDiet) was introduced in both the interventional group (IG) and control group (CG). The females received 40 ml of extra virgin olive oil (EVOO) every day along with 25 - 30 gm of roasted pistachios in the interventional group. The incidence of Gestational Diabetes Mellitus (GDM) was recorded along with specific maternal and neonatal outcomes. Materials and Methods The nutritional and MEDAS scores were not statistically different among the groups at baseline, but the difference was statistically significant and higher in IG at 24–28 weeks (p = 0.001) and 36–38 weeks (p = 0.001). GDM was diagnosed in 51(20.4%) females in the Control group and 34 (13.6%) females in the Interventional group. The MedDiet significantly reduced the GDM incidence (p=0.02) after adjusting the confounding factors. Conclusion The present study depicts that dietary intervention in pregnant women, including MedDiet and increased consumption of EVOO and pistachios, decreased the incidence of GDM.

The prevalence of sleep-disordered breathing (SDB) is higher in older adults compared with younger individuals. The increased propensity for ventilatory control instability in older adults may contribute to the increased prevalence of central apneas. Reductions in the cerebral vascular response to CO(2) may exacerbate ventilatory overshoots and undershoots during sleep. Thus, we hypothesized that hypercapnia-induced cerebral vasodilation (HCVD) will be reduced in older compared with younger adults. In 11 older and 10 younger adults with SDB, blood flow velocity in the middle cerebral artery (MCAV) was measured using Doppler transcranial ultrasonography during multiple steady-state hyperoxic hypercapnic breathing trials while awake, interspersed with room air breathing. Changes in ventilation, MCAV, and mean arterial pressure (MAP) via finger plethysmography during the trials were compared with baseline eupneic values. For each hyperoxic hypercapnic trial, the change (Δ) in MCAV for a corresponding change in end-tidal CO(2) and the HCVD or the change in cerebral vascular conductance (MCAV divided by MAP) for a corresponding change in end-tidal CO(2) was determined. The hypercapnic ventilatory response was similar between the age groups, as was ΔMCAV/Δ [Formula: see text]. However, compared with young, older adults had a significantly smaller HCVD (1.3 ± 0.7 vs. 2.1 ± 0.6 units/mmHg, P = 0.004). Multivariable analyses demonstrated that age and nadir oxygen saturation during nocturnal polysomnography were significant predictors of HCVD. Thus, our data indicate that older age and SDB-related hypoxia are associated with diminished HCVD. We hypothesize that this impairment in vascular function may contribute to breathing instability during sleep in these individuals. NEW & NOTEWORTHY This study demonstrates, for the first time, in individuals with sleep-disordered breathing (SDB) that aging is associated with decreased hypercapnia-induced cerebral vasodilation (HCVD). In addition to advanced age, the magnitude of nocturnal oxygen desaturation due to SDB is an equal independent predictor of HCVD.

Background/Purpose This research aimed to compare the effects of systemically prescribed Lycopene as a monotherapy and as an alternative to scaling and root planing in patients with chronic gingivitis. Materials and methods The participants were randomly assigned to one of two treatment groups: the experimental group (n = 50), which received 10 mg of Lycopene a day for two weeks, or the control group (n = 50) received a placebo for two weeks. For each category, quadrant distribution was randomized, with two quadrants receiving oral prophylaxis (OP) and two quadrants receiving no care (non-OP). At baseline, 1st, and 2nd weeks, the sulcus bleeding index, plaque index, gingival index, and salivary uric acid level were measured. Results All clinical criteria, including SBI, PI, GI, and salivary uric acid levels, showed a statistically significant decline in all patient types. Both clinical parameters were significantly reduced (p

BACKGROUND: The recurrence score based on the 21-gene breast-cancer assay has been clinically useful in predicting a chemotherapy benefit in hormone-receptor–positive, human epidermal growth factor receptor 2 (HER2)–negative, axillary lymph-node–negative breast cancer. In women with positive lymph-node disease, the role of the recurrence score with respect to predicting a benefit of adjuvant chemotherapy is unclear. METHODS: In a prospective trial, we randomly assigned women with hormone-receptor–positive, HER2-negative breast cancer, one to three positive axillary lymph nodes, and a recurrence score of 25 or lower (scores range from 0 to 100, with higher scores indicating a worse prognosis) to endocrine therapy only or to chemotherapy plus endocrine (chemoendocrine) therapy. The primary objective was to determine the effect of chemotherapy on invasive disease–free survival and whether the effect was influenced by the recurrence score. Secondary end points included distant relapse–free survival. RESULTS: A total of 5083 women (33.2% premenopausal and 66.8% postmenopausal) underwent randomization, and 5018 participated in the trial. At the prespecified third interim analysis, the chemotherapy benefit with respect to increasing invasive disease–free survival differed according to menopausal status (P = 0.008 for the comparison of chemotherapy benefit in premenopausal and postmenopausal participants), and separate prespecified analyses were conducted. Among postmenopausal women, invasive disease–free survival at 5 years was 91.9% in the endocrine-only group and 91.3% in the chemoendocrine group, with no chemotherapy benefit (hazard ratio for invasive disease recurrence, new primary cancer [breast cancer or another type], or death, 1.02; 95% confidence interval [CI], 0.82 to 1.26; P = 0.89). Among premenopausal women, invasive disease–free survival at 5 years was 89.0% with endocrine-only therapy and 93.9% with chemoendocrine therapy (hazard ratio, 0.60; 95% CI, 0.43 to 0.83; P = 0.002), with a similar increase in distant relapse–free survival (hazard ratio, 0.58; 95% CI, 0.39 to 0.87; P = 0.009). The relative chemotherapy benefit did not increase as the recurrence score increased. CONCLUSIONS: Among premenopausal women with one to three positive lymph nodes and a recurrence score of 25 or lower, those who received chemoendocrine therapy had longer invasive disease–free survival and distant relapse–free survival than those who received endocrine-only therapy, whereas postmenopausal women with similar characteristics did not benefit from adjuvant chemotherapy. (Funded by the National Cancer Institute and others; RxPONDER ClinicalTrials.gov number, NCT01272037.)

Objective: Examine whether caregiver depressive symptoms at baseline predict longitudinal child asthma outcomes in the two populations with the largest asthma disparities: Mexicans and Puerto Ricans. Methods: 267 Hispanic caregiver-child dyads (Mexican =188, Puerto Rican =79; children 5-12 years) were recruited from clinics and hospitals in Phoenix, AZ and the Bronx, NY. The Center for Epidemiological Studies Depression Scale assessed caregiver depressive symptoms; higher scores indicate greater depressive symptomology. Medical records verified child asthma diagnosis. Assessments for outcome variables occurred at baseline, 3, 6, 9, and 12-month follow-ups. Pulmonary function was measured by spirometry, asthma control was measured by the Asthma Control Test, steroid bursts and acute healthcare utilization were assessed by caregiver report and medical records, and adherence was measured by doser devices on controller medications. Structural equation modeling analyzed baseline caregiver depressive symptoms as a predictor of longitudinal child asthma outcomes, and differences between subgroups. Results: Higher caregiver depressive symptoms predicted better pulmonary function (β = 0.02, p=.001) in Mexican children, and fewer steroid bursts (β= -0.41, p=.01) and better medication adherence (β = 0.02, p=.07) in Puerto Rican children. Caregiver depressive symptoms did not predict pediatric asthma control or acute healthcare utilization in either subgroup. Conclusions: Caregiver depressive symptomology had unexpected effects on child asthma outcomes. Results may be explained by the Hispanic paradox, caregiver resilience, acculturation, and the study's longitudinal nature. Further research is needed on social determinants of health that may influence differences in child asthma outcomes in heterogeneous Hispanic communities.

Introduction: Vibration is a known aeromedical stressor in rotary-winged aircraft and is known to affect visual acuity (VA). In aerospace operational conditions, contrast sensitivity (CS) takes the upper hand over VA for optimal visual performance. Examination of the effects of low frequencies whole body vibration of short duration on CS was the desired objective of the study. Material and Methods: Thirty healthy volunteers were exposed to low frequency whole body vibration using Multi-axial Vibration Simulator. Vibration frequency along the Z-axis varied from 4 to 20 Hz over a period of 30 min. CS was recorded in no vibration, under vibration and 30 min following exposure to vibration using CSV-1000 equipment at spatial frequencies of 3, 6, 12, and 18 cycles per degree (cpd). Results: CS, after an initial degradation, gradually improved with the increase in frequencies of vibration for the lower spatial frequencies (3, 6 cpd). The increasing trend was also noticed for higher spatial frequencies (12, 18 cpd) till 16 Hz; thereafter, a significant dip (P = 0.048) was observed at 20 Hz of vibration. No significant difference was observed following 30 min of post exposure. Conclusion: In contrast to the popular belief, an improvement in CS with increasing frequencies of vibration could be concluded from the results of the study. However, the sudden decrement in CS at higher CPD at higher frequencies of vibration could adversely affect visual performance of an aircrew.

Background (1) To determine the prevalence of hepatopancreatic injury in coronavirus disease 2019 (COVID-19) patients. (2) To correlate hepatopancreatic injury in COVID-19 with mortality, disease severity, and length of stay in this cohort. Results Forty-five thousand three hundred sixty patients were included in the analysis, 62.82% of which had either hepatic or pancreatic injury. There was a significant upward trend in transaminases, alkaline phosphatase, prothrombin time, bilirubin, lactate dehydrogenase, and lipase and a downward trend in albumin with an increase in disease severity. COVID-19-positive patients with hepato-pancreatic injury have a significantly higher mortality (OR 3.39, 95%CI 3.15–3.65) after controlling for the differences in age, sex, race/ethnicity, liver cirrhosis, and medication exposures. They also have increased disease severity (OR 2.7, 95%CI 2.5–2.9 critical vs mild/moderate; OR 1.4, 95% CI 1.3–1.5 severe vs mild/moderate) and longer hospital length of stay (2 days). Conclusion COVID-19 can cause liver injury. Mortality, disease severity, and hospital length of stay are increased in COVID-19 patients with hepatopancreatic injury. Graphical Abstract

Introduction: Smoking is associated with the occurrence and progression of cardiovascular diseases, inflammatory disorders and malignancies. Objective: To study the platelet indices, neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) in smokers and their correlation with smoking pack-years. Method: A total of 110 smokers and 110 non-smokers were included. The smokers were grouped into three groups: mild (10 pack-years). The platelet count, plateletcrit (PCT), mean platelet volume (MPV) and platelet distribution width (PDW) were noted. The NLR and PLR were calculated and the statistical analysis was made using the Student’s T-test, Analysis of Variance (ANOVA) and Spearman’s correlation coefficient. Results: The platelet count, PCT and PDW were significantly higher with mean values: 218.56 ± 121.31 vs 203.23 ± 80.35 (p-value = 0.038), 0.27 ± 0.10 vs 0.26 ± 0.10 (p-value = 0.041) and 12.54 ± 1.45 vs 11.99 ± 1.70 (p-value = 0.001) in smokers and non-smokers, respectively. The PLR differed significantly with mean values: 119.40 ± 84.81 in smokers and 181.99 ± 313.09 in non-smokers, with a p-value of 0.045. A significant positive correlation was found between pack-years of smoking and platelet count and PLR with the Pearson correlation coefficient of 0.250 and 0.198 and p-values, 0.008 and 0.037, respectively. The Platelet Count, PCT, MPV and PDW varied significantly between mild, moderate and heavy smoker groups, with p-values of 0.045, 0.010, 0.015 and 0.017, respectively. Conclusion: The platelet indices and inflammatory markers NLR and PLR are derived from routine blood investigations, which are easily available and inexpensive. The monitoring of platelet indices, along with the PLR, can be used as early predictors of morbidity in smokers.

Diverse ethnic genetic populations display variability in the risk regarding anti-seizure medicine (ASM)-induced severe cutaneous adverse reactions (SCARs). However, clinical and epidemiological data on ASM-induced SCARs in Asians is limited.We conducted a retrospective, post-market study until April 30, 2020 using VigiBase® for demographic characteristics, causative ASMs, complications and mortality. The study included adverse events as classified by Standardized Medical Dictionary for Regulatory Activities (MedDRA) queries of SCARs, mainly Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug rash with eosinophilia and systemic symptoms (DRESS), and SJS/TEN overlap reported for ASMs.A total of 694,811 adverse events were reported across the world while using ASMs. Of this, skin and subcutaneous tissue adverse events were 122,885 (17.6%). Among ASM-induced skin and subcutaneous tissue adverse events, SJS, TEN, DRESS and SJS/TEN overlap represented 11,181 (9.1%), 3,645 (3.0%), 5,106 (4.1%) and 6 (0.004%) cases, respectively. Female SJS/TEN/DRESS patients were 54.1%, and 75% of them were adults (18Y). Nearly 64% of the ASM-induced SCARs were serious and culminated in death (3.5%), life-threatening conditions (11.5%), and hospitalization/prolonged hospitalization (43.5%) of patients on ASM therapy. Carbamazepine (31.6%), phenytoin (29.6%), lamotrigine (24.3%), valproic acid (6.4%) and phenobarbital (5.7%) are the most commonly used ASMs linked with SCARs. ASMs associated with significantly higher risk of SCARs in Asians were carbamazepine [n = 3265, ROR 3.55 (95% CI 3.38-3.72, P 0.0001)], lamotrigine [n = 1253, ROR 3.90 (95% CI 3.63-4.18, P 0.0001)], gabapentin [n = 85, ROR 3.58 (95% CI 2.79-4.60, P 0.0001)], pregabalin [n = 68, ROR 3.16 (95% CI 2.40-4.16, P 0.0001)], clonazepam [n = 53, ROR 3.19 (95% CI 2.31-4.41, P 0.0001)], lorazepam [n = 31, ROR 3.07 (95% CI 2.06-4.59, P 0.0001)] and acetazolamide [n = 28, ROR 3.90 (95% CI 2.45-6.21, P 0.0001)].Based on our study, carbamazepine, lamotrigine, gabapentin, pregabalin, clonazepam, lorazepam, and acetazolamide are the most common causative ASMs for SCARs in the Asian population.

Continued rise in incidence and prevalence of diabetes globally warrants an effective strategy for its prevention and control. Prevention of diabetes seems more logical to attempt seeing its health care burden, long dormancy, systemic affliction and poor general awareness. Pre-diabetes is the intermediate state of erratic glucose metabolism without overt features of diabetes. This state seems to be a crossroad having a possibility to either convert into clinical diabetes, remain dormant or return to normal glucose control depending upon the efforts made. Unfortunately, due to the paucity of apparent clinical symptoms, this state embedded with reversal possibility, remains unexplored. Ayurveda account of prameha purvarupa (subclinical features of diabetes) may be proposed as the foundation upon which clinic-based pre-diabetes identification and subsequent prevention may be explored. Knowing the symptoms for their reliable proximity with upcoming diabetes may turn to be sensible sensitizers prompting the people to abort the disease process in an effective and timely manner. Considering diabetes from its purvarupa to complications as disease continuum and exploring the opportunities to intervene in order to prevent, or manage the disease on the basis of shada kriyaa kaala therefore, has a huge translational potential warrants an urgent exploration.

BACKGROUND Acute kidney injury (AKI) in preterm neonates is associated with poor outcomes that may worsen in the setting of recurrent episodes of AKI. This study defines and studies the incidence, risk factors, and outcomes of recurrent AKI (rAKI). METHODS Retrospective chart review of the neonates born at a gestational age of ≤28 weeks admitted to the neonatal intensive care unit (NICU) between January 2014 and December 2018. We identified AKI based on the serum creatinine (Scr) concentrations using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. rAKI was defined as the occurrence of AKI after Scr from the prior AKI had returned to baseline. RESULTS Forty-nine of the 205 (24%) preterm neonates developed rAKI. An earlier diagnosis (

Background: Scrub typhus (ST) is a rickettsial infection caused by Orientia tsutsugamushi, which presents with flu like symptoms. This disease has been reported from all over India but with slight variations in its pattern. For decreasing the prevalence, preventing new incidences, and predicting the course of the ST, therefore, it is crucial to gain knowledge and perception of local risk components associated with the disease. The present study aimed to investigate the epidemiological distribution and potential risk factors of O. tsutsugamushi Infection in Eastern Uttar Pradesh (EUP), India. Methods: The serums of 211 samples were collected from the suspected cases along with the detailed information about the participants such as age, location, and place recorded in case history form (CRF). IgM estimation was performed using enzyme-linked immunosorbent assay (ELISA) assay. Results: A total of 58 samples (27.4%) out of 211 ones were found to be positive for IgM antibodies against O. tsutsugamushi bacterium. Furthermore, the results were correlated with epidemiological data such as gender, rural or urban background, pets, and occupation. The results showed that 76.7% of the study participants were from rural areas or had bushes around their houses, 88.3% of them had pets/cattle or frequent encounter with rodents at their houses, and 30.3% of them had no toilet facilities at home. Conclusions: It was concluded that the proximity to pets/cattle, having rodents in closer vicinity, residing in places surrounded by vegetation/farm/bushy areas, and following occupations involving field work increased the chances of getting bitten by mites/chiggers. Overall, Orientia tsutsugamushi prevalence increased in EUP, with respect to clinical features, disease presentation, and laboratory diagnosis can help our community to reduce the mortality caused by this infectious disease.

Type 2 diabetes is a chronic metabolic disease characterized by vascular complications, the prevalence of which varies widely. Determine the prevalence of microvascular and macrovascular complications in type-2 diabetes in North India and their correlation with various risk factors. Prospective observational study Tertiary referral centres A total of 6400 patients attending diabetes clinic were screened, out of which 6105 patients were enrolled during April 2018 to February 2021. Data were collected using a standardized electronic case record form. Prevalence estimates of microvascular and macrovascular complications were performed, and multivariate regression was applied for the analysis of correlation with known modifiable and non-modifiable risk factors. ROC analysis was done to find the best cut-offs for predictors of diabetic vascular complications. The mean age of the participants was 58.3 ± 9.1 years (57% males). The mean duration of diabetes was 11.3 ± 7 years and HbA1c was 8.4 ± 4%. Prevalent diabetic neuropathy was observed in 30.1%, nephropathy in 18.8% and retinopathy in 13.7%. Coronary artery disease (CAD) was prevalent in 15.7%, cerebrovascular accident (CVA) in 3.6% and foot complications in 2.9%. In the multivariate regression model, all microvascular complications significantly correlated with the longer duration of diabetes but the same was not observed for macrovascular complications. Obesity [BMI cut-off>26.4 kg/m2 (AUC 0.51, p=0.04) and waist circumference>94 cm (male) and >98 cm (female)] significantly predicted prevalent diabetic neuropathy and nephropathy. A BMI of >25.7 kg/m2 had a sensitivity of 55.2% (AUC 0.57), p

Objective Literature regarding utility of 68 Ga-DOTATATE PET/CT in insulinoma localization across various subgroups [benign/malignant/multiple endocrine neoplasia-1 (MEN-1) syndrome associated] remains scarce. In this study, the performance of 68 Ga-DOTATATE PET/CT was compared with contrast-enhanced computed tomography (CECT) and 68 Ga-NODAGA-Exendin-4 PET/CT (whenever available) in an endogenous hyperinsulinemic hypoglycemia (EHH) cohort. Design Retrospective audit. Patients EHH patients [N = 36, lesions (n) = 49, final diagnosis: benign sporadic insulinoma (BSI) (N = 20), malignant insulinoma (N = 4, n = 14), MEN-1 syndrome associated insulinoma (N = 9, n = 15), Munchausen syndrome (N = 2) and drug-induced hypoglycemia (N = 1)] having both preoperative imaging modalities (CECT and 68 Ga-DOTATATE PET/CT). Measurements Per-lesion sensitivity (Sn) and positive predictive value (PPV) for histopathological diagnosis of insulinoma. Results Sn and PPV of 68 Ga-DOTATATE PET/CT were 67.3% and 89.2%; 55% and 100%; 85.7% and 100%; and 66.7% and 77% for overall EHH, BSI, malignant, and MEN-1 syndrome associated insulinoma cohorts respectively. Despite having comparatively lower sensitivity in BSI cohort, 68 Ga-DOTATATE PET/CT localized a pancreatic tail lesion missed by other modalities. 68 Ga-DOTATATE PET/CT had comparatively higher sensitivity in malignant insulinoma than BSI cohort. 68 Ga-DOTATATE PET/CT also paved the way for successful response to 177 Lu-based peptide receptor radionuclide therapy (PRRT). In MEN-1 cases, lower PPV as compared with BSI was due to uptake in non-insulinoma pancreatic neuroendocrine tumours (Pan-NET). Conclusions 68 Ga-DOTATATE PET/CT has supplemental role in selected cases of BSI with negative and/or discordant results with CECT and 68 Ga-NODAGA-Exendin-4 PET/CT. In malignant insulinoma, 68 Ga-DOTATATE-PET/CT has an additional theranostic potential. Interference due to uptake in non-insulinoma Pan-NET in MEN-1 syndrome may hinder insulinoma localization with 68 Ga-DOTATATE-PET/CT.

Management of cancers of oral cancers has remained a major challenge in India and globally. Radiotherapy and chemotherapy are mostly employed for treatment which inflicts changes in oral mucosa and makes it vulnerable for bacterial colonization and eventual infections. This study aims at evaluating the changes in oropharyngeal flora (bacteria and yeast) in oral cancer patients treated by a combination of chemo-radiotherapy with the control groups comprising of non-cancerous patients living in the same environment. This prospective evaluation included Seventy-seven patients with oral squamous cell carcinomas in the study group. Whereas the control group comprised of twenty-five non-cancerous patients. Saliva samples were collected from patients with oral carcinomas and those of the control group for bacteriological examination, and were transported within 2 hours to the laboratory and immediately inoculated and incubated. The oral microflora samples collected were evaluated for the presence of bacteria in saliva in both study and control group of patients. We evaluated the change in salivary oral flora during chemo-radiotherapy treatment. A statistically significant increase in growth of normal as well as abnormal oral flora was observed post-radiation. Escherichia coli showed a significant decrease in post-RT and also near to significant in control. Various changes in salivary oral flora were observed during the course of chemo-radiotherapy in study and controls groups. This shows that there are some sensitive spots in the oral cavity where the occurrence of oral cancer is more.

Context Alveolar soft part sarcoma (ASPS) is a rare soft tissue tumor most commonly occurring in deep intramuscular plane of lower extremities of adolescents and young adults. It is a highly vascular, slow growing tumor with malignant potential having lung as the most common site of metastases at the time of presentation. Aims The aim is to review the imaging findings of ASPS and determine characteristic imaging features of this rare tumor. Materials and Methods Sixteen patients having histopathological diagnosis and preoperative imaging of ASPS attending the dedicated sarcoma clinic at our institute were included in the study. The demographic, clinical, and imaging data were retrieved from the case records and then evaluated for characteristic imaging features which may raise suspicion of ASPS. Results The patients ranged from 3 to 72 years of age and with a slight male preponderance. Of the eight CECTs evaluated, 62.5% tumors showed well-defined lobulated margins, 87.5% cases showed intense enhancement with presence of feeder vessels. On CEMRI of 10 patients, 70% had well circumscribed lobulated margins with intense enhancement and tortuous flow voids in most of them. All cases showed T2 hyperintense signal. Fourteen of 16 (87.5%) patients had metastatic disease with lung as the most common site (92.8%). Conclusion ASPS is a rare soft tissue sarcoma seen in children and young adults. Imaging may mimic a vascular malformation due to the presence of tortuous feeders. Misdiagnosis at an early stage may lead to later metastatic presentation of the disease, thus emphasizing the need to suspect it on imaging.

Contains fulltext : 249977.pdf (Publisher’s version ) (Closed access) BACKGROUND: It is important to evaluate whether a new treatment for heart failure with reduced ejection fraction (HFrEF) provides additive benefit to background foundational treatments. As such, we aimed to evaluate the efficacy and safety of empagliflozin in patients with HFrEF in addition to baseline treatment with specific doses and combinations of disease-modifying therapies. METHODS: We performed a post-hoc analysis of the EMPEROR-Reduced randomised, double-blind, parallel-group trial, which took place in 520 centres (hospitals and medical clinics) in 20 countries in Asia, Australia, Europe, North America, and South America. Patients with New York Heart Association (NYHA) classification II-IV with an ejection fraction of 40% or less were randomly assigned (1:1) to receive the addition of either oral empagliflozin 10 mg per day or placebo to background therapy. The primary composite outcome was cardiovascular death and heart failure hospitalisation; the secondary outcome was total heart failure hospital admissions. An extended composite outcome consisted of inpatient and outpatient HFrEF events was also evaluated. Outcomes were analysed according to background use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) or angiotensin receptor neprilysin inhibitors (ARNIs), as well as β blockers and mineralocorticoid receptor antagonists (MRAs) at less than 50% or 50% or more of target doses and in various combinations. This study is registered with ClinicalTrials.gov, NCT03057977. FINDINGS: In this post-hoc analysis of 3730 patients (mean age 66·8 years [SD 11·0], 893 [23·9%] women; 1863 [49·9%] in the empagliflozin group, 1867 [50·1%] in the placebo group) assessed between March 6, 2017, and May 28, 2020, empagliflozin reduced the risk of the primary outcome (361 in 1863 participants in the empagliflozin group and 462 of 1867 in the placebo group; HR 0·75 [95% CI 0·65-0·86]) regardless of background therapy or its target doses for ACE inhibitors or ARBs at doses of less than 50% of the target dose (HR 0·85 [0·69-1·06]) and for doses of 50% or more of the target dose (HR 0·67 [0·52-0·88]; p(interaction)=0·18). A similar result was seen for β blockers at doses of less than 50% of the target dose (HR 0·66 [0·54-0·80]) and for doses of 50% or more of the target dose (HR 0·81 [0·66-1·00]; p(interaction)=0·15). Empagliflozin also reduced the risk of the primary outcome irrespective of background use of triple therapy with an ACE inhibitor, ARB, or ARNI plus β blocker plus MRA (given combination HR 0·73 [0·61-0·88]; not given combination HR 0·76 [0·62-0·94]; p(interaction)=0·77). Similar patterns of benefit were observed for the secondary and extended composite outcomes. Empagliflozin was well tolerated and rates of hypotension, symptomatic hypotension, and hyperkalaemia were similar across all subgroups. INTERPRETATION: Empagliflozin reduced serious heart failure outcomes across doses and combinations of disease-modifying therapies for HFrEF. Clinically, these data suggest that empagliflozin might be considered as a foundational therapy in patients with HFrEF regardless of their existing background therapy. FUNDING: Boehringer Ingelheim and Eli Lilly and Company.

Medical literature continues to get enriched through various researches and observations related to SARS CoV-2 infection leading to COVID-19. Case reports play crucially to understand a novel clinical condition where much is yet to be known. Current pandemic is unique for the reason that its impacts upon front line health care workers (HCWs) are much higher than general population. In this situation, how an Ayurvedic physician has handled his own case leading to a cure from COVID-19 may furnish important information regarding mitigation and cure from the disease. This is also an unprecedented writing in medical literature as a physician reporting his own case is a rare phenomenon in medical history. This case report puts strongly the prophylactic and disease modifying potential of Ayurvedic interventions in COVID-19.

Sarcomas are a heterogenous group of cancers, traditionally with dismal outcomes. They were initially treated with histology agnostic chemotherapy-based regimens usually centered around anthracyclines. With the availability of molecular diagnostics especially next-generation sequencing, the advanced genomics of sarcomas was slowly unveiled. Precision medicine not only enables a better diagnosis in sarcomas but also allows in identifying better targets for treatment of sarcoma subtypes. GENSARC study proved that using correct molecular diagnostics, enabled in a better diagnosis and treatment of soft tissue sarcomas (STSs). Notable examples of targeted therapies with great success in sarcomas include imatinib and other tyrosine kinase inhibitors in gastrointestinal stromal tumors, neurotrophic tyrosine receptor kinase inhibitors infantile fibrosarcoma, and crizotinib in inflammatory myofibroblastic tumors. Thus, treatment of sarcomas has been gradually changing from traditional chemotherapy-based treatments to the modern targeted therapy. In this review, we hope to impress on the evolving role of precision medicine in sarcoma subtypes especially STS.

Background: Oral submucous fibrosis (OSMF) is a doubtlessly malignant disorder of the oral cavity. The surgical control of this situation involves excision of the fibrotic bands and interpositional grafts to keep the elevated oral opening. Various strategies and graft had been utilized with differing achievement rates. Aims and Objective: Through this study, an attempt was made to evaluate the efficacy of collagen membrane as wound dressing material for mucosal defect in oral submucous fibrosis. Materials and Methods: The study include 30 patients in the age group of 15 to 60 years with stage III or IVa of oral sub mucous fibrosis all of which underwent operation under general anesthesia to enhance their mouthopening by fibrotomy of bands and placement of collagen membrane by same surgeon. After surgery all the patients were accessed under parameter like hemostatic effect, pain relief, granulation tissue formation, epithelization, contracture and reactivity. All patients were given similar prescriptions for pain killer, antibiotics and postoperative instructions. All patients were examined postoperatively. Results: In this study various parameter were accessing the efficacy of collagen membrane on wound defects were recorded. In this 1st parameter hemostatic 28 patients had a score of good (93.3%) with bleeding stopping within 5 minutes after application of membrane and only 2 patients had a score of fair (6.66%). In pain relief analgesics were stopped on the day of 3rd after procedure 16 patients had a good (53.3%) score, 12 patients had a fair (40%) score while only 2 patients gad a poor (6.66%) score. All the patients had sufficient granulation tissue formation of entire wound therefore all the patients had score of good (100%) at the end of two weeks. Epithelization was noted in 28 patients who had score of good (93.3%) after 1 month. Contracture of the wound site at the end of 3 months were noted and rated as good in 20 patients (66.6%) while fair (33.3%) in 10 patients. No reactivity of any form was found in any of the subjects (100%). Conclusion: In our study we noticed that collagen membrane was found to be very effective in all the subjects and it provided us satisfactory results as intraoral wound dressing material.

Background Aggressive angiomyxoma (AAM) is a rare mesenchymal tumor predominantly affecting the pelvis and perineum of females. Due to its variable clinical presentation, it is often misinterpreted and treated as other pathologies like Bartholin gland cyst, vulvar abscess, and hernia. The tumor is locally infiltrative, making its complete surgical removal difficult. Aim The aim of the study is to highlight and illustrate the imaging and pathological features of AAM. Materials and Methods After obtaining clearance from the Institutional Ethics Committee, a retrospective study was conducted on patients with histopathological diagnosis of AAM, presenting to the dedicated sarcoma clinic between 2016 and 2019. The demographic, clinical, radiological, pathological, and treatment details were obtained from the institute's database. The magnetic resonance imaging (MRI) and computed tomography images were reviewed to assess different imaging parameters. Follow-up imaging was assessed for residual or recurrent mass in the pelvis or perineum and distant metastasis. Results A total of four patients were included with an age range of 28 to 50 years. The baseline MRI of these four patients shows pelvic mass extending into the perineum, infiltrating along the surrounding fascial planes with the characteristic laminated appearance on T2-weighted image and gradual intense enhancement following contrast administration. All patients had residual disease post-surgery and were put on hormonal therapy. Conclusion AAMs are locally aggressive, rarely metastasizing mesenchymal tumor that has a specific predilection for the perineum and pelvis of females. MRI features like laminated or striated appearance, post-contrast enhancement, and finger-like infiltrating projections should raise the suspicion of the diagnosis on baseline imaging.

The current coronavirus disease (COVID-19) pandemic is showing no signs of abatement and result in significant morbidity and mortality in the infected patients. Many therapeutic agents ranging widely between antivirals and anti-inflammatory drugs have been used to mitigate the disease burden. In the deluge of the drugs being used for COVID-19 infection, glucocorticoids (GCs) stand out by reducing mortality amongst in-hospital severe-to-critically ill patients. Health-care practitioners have seen this as a glimmer of hope and started using these drugs more frequently than ever in clinical practice. The fear of mortality in the short term has overridden the concern of adverse long-term consequences with steroid use. The ease of availability, low cost, and apparent clinical improvement in the short term have led to the unscrupulous use of the steroids even in mild COVID-19 patients including self-medication with steroids. The use of GCs has led to the increasing incidence of hyperglycemia and consequent acute complications of diabetic ketoacidosis and mucormycosis in COVID-19 patients. There is an urgent need to dissipate information about optimum management of hyperglycemia during steroid use. In view of this, the Endocrine Society of India has formulated this position statement about the diagnosis and management of hyperglycemia due to the use of GCs in patients with COVID-19 infection.

Introduction: Dental professionals are considered to be at high-risk for contacting blood-borne pathogen transmissions. Thus, making it necessary for dentists to be aware on prevention, transmission and management of viral hepatitis. Objective: One day training programs for upskilling dental fraternity were conducted on 11th November 2019 and 11thFebruary 2020. Program also evaluated the Knowledge, Attitude, and Practices (KAP) of dentists regarding infection control practices and oral manifestations of viral hepatitis. Methods: One-day training program viz. “Viral hepatitis in Dentistry” under project Programmed Approach to Knowledge And Sensitization on Hepatitis (PRAKASH) was organized and a cross-sectional study using 20-item-self-reported questionnaire was conducted among participating professionals from six states of India. Identifying information was removed during statistical analysis. Results: Total of 625 dental professionals were trained; of which 470 participated in the KAP study i.e. response rate was calculated to be 75% (470 out of 625). Females represented about 73.2% of the sample(n=470). Sample comprised of experts from all the branches of dentistry. Almost 97% of responders were from private dental institutes or clinics. Mean knowledge score was found to be 4.71 ± 2.04, however when compared with age, knowledge in older professionals > 25 years was higher at 5.00 + 2.10 than participants’ aged 25 years. Conclusion: Study raised concerns regarding poor knowledge about infection prevention control and management of viral hepatitis in dental settings. Limited interventions in terms of capacity building programs for dentists on viral hepatitis, highlight the necessity of continued education through such training programs.

Aims: The objective of the study was to assess the effectiveness of the one-day training program on liver care among nursing professionals using online training platform of ECHO (Extension for Community Healthcare Outcomes). The study also aimed to assess the impact of one-day training program on liver care on their attitude and practice at least after four months. Study Design: Pre-post design Place and Duration of Study: Institute of Liver and Biliary Sciences New Delhi and 26th March 2019 till 22nd February 2020. Methodology: A one-day training program titled “Approach to patients with liver diseases” on management of liver infections for nursing professionals was conducted. An online link for KAP and Pre-post knowledge assessment questionnaire consisting 32 (KAP) questions was shared with all registered participants. Same Knowledge questionnaire consisting 19 questions was shared with the participants after training. Four months after training impact assessment was conducted by sharing the online link with the participants of the conducted program. The data was extracted in MS excel. The continuous variable was presented as mean and standard deviation (SD) or median and Inter quartile range (IQR) as appropriate. The categorical variable was presented as frequency and percentages. Paired t-test was used to assess the difference in pre and post knowledge assessment. For performing the requisite analysis, knowledge score was divided as poor-to-moderate (

Metformin may exert anticancer effects through indirect (mediated by metabolic changes) or direct mechanisms. The goal was to examine metformin impact on metabolic factors in non-diabetic subjects and determine whether this impact varies by baseline BMI, insulin, and rs11212617 SNP in CCTG MA.32, a double-blind placebo-controlled randomized adjuvant breast cancer (BC) trial. 3649 subjects with T1-3, N0-3, M0 BC were randomized; pretreatment and 6-month on-treatment fasting plasma was centrally assayed for insulin, leptin, highly sensitive C-reactive protein (hsCRP). Glucose was measured locally and homeostasis model assessment (HOMA) calculated. Genomic DNA was analyzed for the rs11212617 SNP. Absolute and relative change of metabolic factors (metformin versus placebo) were compared using Wilcoxon rank and t-tests. Regression models were adjusted for baseline differences and assessed interactions with baseline BMI, insulin, and the SNP. Mean age was 52 years. The majority had T2/3, node positive, hormone receptor positive, HER2 negative BC treated with (neo)adjuvant chemotherapy and hormone therapy. Median baseline body mass index (BMI) was 27.4 kg/m2 (metformin) and 27.3 kg/m2 (placebo). Median weight change was −1.4 kg (metformin) vs +0.5 kg (placebo). Significant improvements were seen in all metabolic factors, with 6 month standardized ratios (metformin/placebo) of 0.85 (insulin), 0.83 (HOMA), 0.80 (leptin), and 0.84 (hsCRP), with no qualitative interactions with baseline BMI or insulin. Changes did not differ by rs11212617 allele. Metformin (vs placebo) led to significant improvements in weight and metabolic factors; these changes did not differ by rs11212617 allele status.

Supplemental Digital Content is available in the text., Background and Purpose: Chronic kidney disease with reduced estimated glomerular filtration rate or elevated albuminuria increases risk for ischemic and hemorrhagic stroke. This study assessed the effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) on stroke and atrial fibrillation/flutter (AF/AFL) from CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) and a meta-analysis of large cardiovascular outcome trials (CVOTs) of SGLT2i in type 2 diabetes mellitus. Methods: CREDENCE randomized 4401 participants with type 2 diabetes mellitus and chronic kidney disease to canagliflozin or placebo. Post hoc, we estimated effects on fatal or nonfatal stroke, stroke subtypes, and intermediate markers of stroke risk including AF/AFL. Stroke and AF/AFL data from 3 other completed large CVOTs and CREDENCE were pooled using random-effects meta-analysis. Results: In CREDENCE, 142 participants experienced a stroke during follow-up (10.9/1000 patient-years with canagliflozin, 14.2/1000 patient-years with placebo; hazard ratio [HR], 0.77 [95% CI, 0.55–1.08]). Effects by stroke subtypes were: ischemic (HR, 0.88 [95% CI, 0.61–1.28]; n=111), hemorrhagic (HR, 0.50 [95% CI, 0.19–1.32]; n=18), and undetermined (HR, 0.54 [95% CI, 0.20–1.46]; n=17). There was no clear effect on AF/AFL (HR, 0.76 [95% CI, 0.53–1.10]; n=115). The overall effects in the 4 CVOTs combined were: total stroke (HRpooled, 0.96 [95% CI, 0.82–1.12]), ischemic stroke (HRpooled, 1.01 [95% CI, 0.89–1.14]), hemorrhagic stroke (HRpooled, 0.50 [95% CI, 0.30–0.83]), undetermined stroke (HRpooled, 0.86 [95% CI, 0.49–1.51]), and AF/AFL (HRpooled, 0.81 [95% CI, 0.71–0.93]). There was evidence that SGLT2i effects on total stroke varied by baseline estimated glomerular filtration rate (P=0.01), with protection in the lowest estimated glomerular filtration rate (

PURPOSE: To assess the performance of shear wave ultrasound elastography (SWE) for non‐invasive grading of fibrosis in normal BMI patients with varied aetiology chronic liver disease. METHOD: Prospective SWE liver and spleen stiffness (LS, SS respectively) of 124 patients (94 men, mean age 45.4 ± 12.4 years, mean BMI 19.66 ± 1.49) with CLD of mixed aetiology, who underwent liver biopsy, between January 2019–20 was analysed using receiver operating curve (ROC) and classification analysis regression tree (CART) to determine fibrosis cut‐off values and nominal logistical regression to quantify fibrosis. RESULTS: Of 124 patients, 50 (40%) had non‐alcoholic steatohepatitis (NASH), 31 (25%) chronic hepatitis B (CHB) and 43 (35%) alcoholic liver disease (ALD) on biopsy. Overall mean LS and SS of the study population was 11.81 ± 5.9 and 16.88 ± 10.8 kPa, respectively. LS cut‐off value 14.9 kPa for F3‐F4 fibrosis on biopsy. On application of CART, LS value < 5.3 kPa was discriminative for NASH, 5.32 to 12.64 kPa for ALD, SS 30 kPa for ALD in our study population. CONCLUSION: SWE is a viable non‐invasive tool for assessment of liver fibrosis grading in a population of mixed aetiology CLD. LS values in conjunction with SS are promising predictors of F2‐F3 fibrosis with potential to discriminate select categories like CHB and NASH in such a population.

Background There is limited scientific evidence on the potential of spectral computed tomography (SCT) for differentiation of nodules in the cirrhotic liver. We aimed to assess SCT-generated material density (MD) parameters for nodule characterisation in cirrhosis. Methods Dynamic dual-energy SCT scans of cirrhotic patients performed over 3 years were retrospectively reviewed. They were classified as hepatocellular carcinoma (HCC), regenerative or indeterminate, according to the European Association for the Study of the Liver criteria. MD maps were generated to calculate the area under the curve (AUC) and cutoff values to discriminate these nodules in the hepatic arterial phase (HAP) and portal venous phase (PVP). MD maps included iodine concentration density (ICD) of the liver and nodule, lesion-to-normal liver ICD ratio (LNR) and difference in nodule ICD between HAP and PVP. Results Three hundred thirty nodules belonging to 300 patients (age 53.0 ± 12.7 years, mean ± standard deviation) were analysed at SCT (size 2.3 ± 0.8 cm, mean ± SD). One hundred thirty-three (40.3%) nodules were classified as HCC, 147 (44.5%) as regenerative and 50 (15.2%) as indeterminate. On histopathology, 136 (41.2%) nodules were classified as HCC, 183 (55.5%) as regenerative and 11 (3.3%) as dysplastic. All MD parameters on HAP and the nodule difference in ICD could discriminate pathologically proven HCC or potentially malignant nodules from regenerative nodules (p < 0.001). The AUC was 82.4% with a cutoff > 15.5 mg/mL for nodule ICD, 81.3% > 1.8 for LNR-HAP and 81.3% for difference in ICD > 3.5 mg/mL. Conclusion SCT-generated MD parameters are viable diagnostic tools for differentiating malignant or potentially malignant from benign nodules in the cirrhotic liver.

Ekta Gupta,1 Reshu Agarwal,1 Aayushi Rastogi,2 Nitiksha Rani,1 Ankur Jindal3 1Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India; 2Department of Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India; 3Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, IndiaCorrespondence: Ekta GuptaDepartment of Clinical Virology, Institute of Liver and Biliary Sciences, Sector D1, Vasant Kunj, New Delhi, 110070, IndiaTel + 91 11 46300000Fax + 91 11 26123501Email ektagaurisha@gmail.comPurpose: Limited literature on the prevalence of baseline resistance associated substitutions (BL-RAS) among HCV–HIV co-infected patients and their association with treatment outcomes is available especially from India. Hence, the present study aimed to study naturally occurring RAS among non-cirrhotic HCV–HIV co-infected patients and their impact on the response to anti-HCV therapy.Patients and Methods: In this retrospective study, archived blood samples of 80 HCV–HIV co-infected patients, before anti-HCV therapy initiation, were tested for substitutions at the drug acting sites (NS5a and NS5b) in the HCV genome by direct PCR sequencing.Results: BL-RAS were seen in 19 (23.7%) patients. As well as BL-RAS, all patients were given sofosbuvir (SOF) 400 mg+ daclatasvir (DCV) 60 mg for 12 weeks. Overall, sustained virological response (SVR) was achieved in 63 (78.8%) patients, in 13 with BL-RAS and in 50 without BL-RAS. All the SVR failure cases (n=17) were retreated with SOF (400 mg) +DCV (60 mg)+ ribavirin (RBV) for 24 weeks. SVR was eventually attained in 14 (82.3%) patients, in 4/6 (66.6%) with BL-RAS and in 10/11 (91%) without BL-RAS. On univariate analysis, age more than 30 years (OR: 11.6; 95% CI: 3.0– 45.5, p-value< 0.001) and female gender (OR: 8.6; 95% CI: 1.1− 69, p-value < 0.009) were found to be significant factors associated with the attainment of SVR.Conclusion: BL-RAS are common in HCV–HIV co-infected patients. The existence of BL-RAS, however, did not affect the attainment of SVR among non-cirrhotic, treatment naive HCV–HIV co-infected patients.Keywords: HCV–HIV co-infection, drug resistance, direct acting antiviral, resistance associated substitutions

Background There is sparse literature on trabectedin in advanced soft-tissue sarcomas from developing world. It would be interesting to know about use and outcomes of trabectedin in Indian patients. Method In a retrospective study, consecutive patients treated with trabectedin from 2016 to 2019 were analyzed. Patients with L-sarcomas were treated at a dose of 1.5 mg/m2, while those with translocation-related sarcomas were treated at a dose of 1.2 mg/m2 as a 24-hour infusion through peripherally inserted central catheter line. From July 2019, infusions were administered through an ambulatory elastomeric pump, while before that patients were admitted for 24 hours. We used SPSS version 23.0 for statistical calculation. Result A total of 20 patients received trabectedin with a total of 116 infusions. The median age was 46 years (range: 22–73 years). The male (n = 11, 55%) and female patients were almost equal (n = 9, 45%). Thirteen patients (65%) had Eastern Cooperative Oncology Group Performance Status 1. Majority of the patients had leiomyosarcoma (n = 8, 40%); remaining comprised of liposarcoma (3, 15%), translocation-related sarcomas excluding myxoid liposarcoma (n = 8, 40%) and others (n = 1,5%). Most common site was extremity (n = 11, 55%) followed by retroperitoneal (n = 3, 15%), visceral (n = 3, 15%), and others (n = 3,15%). Median number of previous lines received was 2 (range: 0–4). Median number of trabectedin cycles received was 4 (range: 1–17). Best response assessed was stable disease (n = 10, 50%), progressive disease (n = 6, 30%), partial response (n = 1, 5%), and not assessed in 3 patients. After a median follow-up of 19 months, median progression-free survival was 4 months. Conclusion In this heavily treated population (composed of L-sarcomas and translocation-related sarcomas) with many patients with poor performance status, the outcome with trabectedin is in synchrony with literature. However, the need of 24-hour admission might deter quality of life. Elastomeric pump seems to be a reasonable alternative to admission and can be a breakthrough in administering trabectedin, especially in developing countries.

In the SPRINT (Systolic Blood Pressure Intervention Trial), the number of strokes did not differ significantly by treatment group. However, stroke subtypes have heterogeneous causes that could respond differently to intensive blood pressure control. SPRINT participants (N=9361) were randomized to target systolic blood pressures of P =0.09). The interaction between baseline cardiovascular risk factor status and treatment arm on stroke risk did not reach significance ( P =0.05). Similar numbers of stroke subtypes occurred in the intensive BP control and standard control arms of SPRINT.

Viral Hepatitis (VH) is one of the most serious infections during pregnancy which not only creates complications for the mother but also transmits the infection to the newborn. Hence, clinicians should be aware about the diagnosis and management related to VH during pregnancy and modes to prevent it. Thus the present study aimed to assess the current knowledge about VH in pregnancy among clinicians. A cross-sectional study was conducted among physicians who attended National Seminar for Physicians on Viral Hepatitis in Pregnancy organized by PRAKASH. An online link to 25-item questionnaire was circulated with all the registered participants. The data was analysed using IBM-SPSS version-21. The statistical significance was considered to be

Kimura disease is a benign rare chronic inflammatory disorder of unknown etiology. The disease is mainly endemic in Asia, cases have been reported in Europe and America. The present case is of a 75 year Indian male who presented with cervical and axillary lymphadenopathy. Ultrasonography was done which showed multiple peritoneal lymph nodes. Peripheral smear showed eosinophilia. Cytomorphology and histopathology showed features of Hodgkin’s disease. S IgE level was raised. 5 years earlier patient had presented with similar complaints of generalized lymphadenopathy, raised IgE level, peripheral eosinophilia. FNAC of cervical lymph node done earlier showed cytomorphology of Reactive Lymphadenitis. Biopsy showed histology of Kimura’s disease.

Hypertension is an insidious disease which predisposes to cardiovascular complications and if not treated properly can lead to various serious complications. Economic limitations, having additional benefits with few or almost no side effects have made non‐pharmacological management of hypertension an attractive approach for dealing with hypertension, in developed and developing countries alike. A MEDLINE search was done for relevant references with emphasis on original studies, randomized controlled trials, and meta‐analyses for this review paper. Lifestyle modifications including changes in the dietary pattern, adopting special diets with low sodium, saturated fat and high calcium, magnesium and potassium and trying the new methods like time restricted meal intake which work in tandem with the circadian rhythm are opening new vistas in the field of non‐pharmacological management of hypertension. Lifestyle modifications that effectively lower blood pressure are increased physical activity, weight loss, limited alcohol consumption, relaxation techniques of Yoga, Acupuncture, Tai chi, mindfulness‐based stress‐reduction program, and Transcendental Meditation. Air pollution of the surrounding air is linked with poor health outcomes and is a major contributor to the global burden of disease. Fine particulate matter, Non‐pharmacological methods are an integral part of management of hypertension. It includes lifestyle changes in farm of special diets and reduction of salt, alcohol, and saturated fat. Reduction of weight, increased physical activity and time restricted meal has also been found effective. Some traditional methods like yoga, acupuncture, and transcendental meditation are helpful.

Background: Primary open-angle glaucoma (POAG), fundamentally results from impaired or suboptimal drainage of aqueous humor from the eye through the trabecular meshwork and/or uveoscleral pathways. Aim and Objectives: the purpose of our study was to compare the efficacy and safety of Brimonidine 0.2% plus Brinzolamide 1% versus Brimonidine 0.2% plus Timolol 0.5% in patients with Primary Open Angle Glaucoma. Materials and Methods: A total of 81 subjects including 84 eyes in group I (brimonidine plus timolol) and 78 eyes in group II (brimonidine plus brinzolamide) with open angle glaucoma were enrolled. The detailed glaucoma examination was done. IOP measurements at 9 am, 12 pm and 3 pm, during week 2, 4, 8 and 12 were used to assess efficacy. Adverse events were recorded. The statistical test used were Chi-square test, Unpaired t-test and Paired t-test. Results: Majority of patients in group I obtained an IOP reduction of >30% at 9.00 am 92.3%), 12.00 pm (91.3%) and 3.00 pm (86.2%) after 12 weeks of therapy. Majority of patients in group II obtained an IOP reduction of >30% at 9.00 am (86.8%), 12.00 pm (87.7%) and 3.00 pm (71.9%) after 12 weeks of therapy. Conclusion: Both drugs can thus be useful as second line therapy in the management of patients with POAG uncontrolled on monotherapy. Moreover, each drug has provided significant mean IOP reduction after three month of therapy at all visits and at all times. Keywords: Brinzolamide, Primary openangle glaucoma, Timolol.

Introduction: To relieve anxiety and fear is a major concern for pediatric anesthesiologist, and intranasal dexmedetomidine seems to be better alternative to midazolam to provide sedation and allay anxiety in children. Aims and Objectives: We compare the sedative effects, anxiety level, successful child–parental separation, and hemodynamic parameters of either intranasal dexmedetomidine or midazolam as a premedication in children undergoing pediatric surgery. Setting and Design: This is a prospective, randomized, double-blind study conducted on 60 patients belonging to the American Society of Anesthesiologists Physical Status Classes I and II, undergoing pediatric surgical procedures with the use of intranasal dexmedetomidine and midazolam as premedication. Materials and Methods: Sixty children were randomly allocated into two groups of 30 each: dexmedetomidine group received intranasal dexmedetomidine (1 μg.kg−1), and midazolam group received intranasal midazolam (0.2 mg.kg−1), 30 min before induction. The sedation score, anxiety score, and successful child–parent separation were recorded till 30 min of drug administration, and then, the child was taken to the operating room (OR). Statistical Analysis: The Statistical Software, namely Statistical Package for the Social Science 17.0, was used for the analysis of the data. A P < 0.05 was considered statistically significant. Results: Children premedicated with intranasal dexmedetomidine achieved significantly lower sedation score (P < 0.001), lower anxiety levels (P = 0.001), and easier child–parent separation (P = 0.003) than children who received intranasal midazolam. Conclusion: Intranasal dexmedetomidine was associated with lower sedation levels, lower anxiety levels, and easier child–parent separation at the time of transferring patients to the OR than children who received intranasal midazolam.

Gastric outlet obstruction is a pathophysiological entity characterized by mechanical impediment of gastric emptying, which may occur due to a variety of intrinsic or extrinsic causes affecting the antrum or pylorus or duodenum. The obstruction may be benign or malignant or secondary to a motility disorder. Imaging in gastric outlet obstruction identifies majority of these causes and may indirectly even point toward motility disorders. The advent of computed tomography imaging and its subsequent advances have allowed it to become the mainstay of evaluation of stomach, particularly in gastric outlet obstruction. In this pictorial review, a few causes of gastric outlet obstruction are exhibited.