Comparison of laparoscopic cholecystectomy in children at paediatric centres and adult centres: a systematic review and meta-analysis

INTRODUCTION

Paediatric laparoscopic cholecystectomy (LC) is performed by both paediatric and adult surgeons. The aim of this review was to compare outcomes at paediatric centres (PCs) and adult centres (ACs).

METHODS

A literature search was conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, for papers published between January 2000 and December 2020. Statistical analysis was performed using Stata® version 16 (StataCorp, College Station, TX, US).

RESULTS

A total of 92 studies involving 74,852 paediatric LCs met the inclusion criteria. Over half (59%) of the LCs were performed at ACs. No significant differences were noted in the male-to-female ratio, mean age or mean body mass index between PCs and ACs. The main indications were cholelithiasis (34.1% vs 34.4% respectively, p=0.83) and biliary dyskinesia (17.0% vs 23.5% respectively, p<0.01). There was no significant difference in the median inpatient stay (2.52 vs 2.44 days respectively, p=0.89). Bile duct injury was a major complication (0.80% vs 0.37% respectively, p<0.01). Reoperation rates (2.37% vs 0.74% respectively, p<0.01) and conversion to open surgery (1.97% vs 4.74% respectively, p<0.01) were also significantly different. Meta-analysis showed no significant difference in overall complications (p=0.92).

CONCLUSIONS

The number of LCs performed, intraoperative cholangiography use and conversion rates were higher at ACs whereas bile duct injury and reoperation rates were higher at PCs. Despite a higher incidence of bile duct injury at PCs, the incidence at both PCs and ACs was <1%. In complex cases, a joint operation by both paediatric and adult surgeons might be a better approach to further improve outcomes. Overall, LC was found to be a safe operation with comparable outcomes at PCs and ACs.

MRI in shoulder arthropathies: A short review

Arthropathies are a frequent cause of shoulder pain and comprise of a wide range of clinical entities that may pose a diagnostic challenge. Though history and clinical examination remain vital, imaging plays a pivotal role in accurate diagnosis. Magnetic resonance imaging (MRI) remains an invaluable tool for imaging evaluation of shoulder involvement by various arthropathies. With attention to characteristic imaging features, radiologist may be able to differentiate between various disease processes affecting the shoulder joint. In this article, we have provided a brief review of common and uncommon MRI manifestations of various arthropathies affecting the shoulder joint.

Landscaping tuberculosis multimorbidity: findings from a cross-sectional study in India

BACKGROUND

Multimorbidity, the concurrent presence of two or more chronic conditions is an emerging public health challenge. Till date, most of the research have focused on the presence and interaction of selected co-morbidities in tuberculosis (TB). There exist a critical knowledge gap on the magnitude of multimorbidity among TB patients and its impact on health outcomes.

METHODS

We undertook a cross-sectional study to assess the prevalence and patterns of multimorbidity among newly diagnosed TB patients in two states of India. A total of 323 patients were interviewed using a structured multimorbidity assessment questionnaire for primary care (MAQ-PC). MAQ-PC is already validated for Indian population and elicits 22 chronic conditions. We defined TB multimorbidity as the co-existence of TB with one or more chronic conditions and identified commonly occurring dyads (TB + single condition) and triads (TB + two conditions).

RESULTS

More than half (52%) of TB patients reported multimorbidity. Among dyads, depression, diabetes mellitus (DM), acid peptic disease (APD), hypertension, chronic alcoholism, arthritis and chronic back ache (CBA) were the most common co-occurring conditions while 'DM + arthritis', 'depression + APD', 'depression + DM' were the most commonly occurring triads among TB patients. Factors such as increasing age, low levels of education, alcohol abusers, drug-resistant TB and having health insurance were significantly associated with multimorbidity among TB patients.

CONCLUSIONS

Our findings suggest high prevalence of multimorbidity among newly diagnosed TB patients in India. The presence of concordant and discordant conditions with TB may increase the health complexity, thus necessitating appropriate care protocols. Given, the current situation, wherein TB and non-communicable diseases (NCD) services are delivered through collaborative framework between programmes, there is a need for addressing multimorbidity at the healthcare delivery level.

Review of management practices of sinogenic intracranial abscesses in children

OBJECTIVE

This study aimed to evaluate the management practices and outcomes in children with sinogenic intracranial suppuration.

METHOD

This was a retrospective cohort study in a single paediatric tertiary unit that included patients younger than 18 years with radiologically confirmed intracranial abscess, including subdural empyema and epidural or intraparenchymal abscess secondary to sinusitis. Main outcomes studied were rate of return to the operating theatre, length of hospital stay, death in less than 90 days and neurological disability at 6 months.

RESULTS

A cohort of 39 consecutive patients presenting between 2000 and 2020 were eligible for inclusion. Subdural empyema was the most common intracranial complication followed by extradural abscess and intraparenchymal abscess. Mean length of hospital stay was 42 days. Sixteen patients were managed with combined ENT and neurosurgical interventions, 15 patients underwent ENT procedures alone and 4 patients had only neurosurgical drainage. Four patients initially underwent non-operative management. The rates of return to the operating theatre, neurological deficits and 90-day mortality were 19, 9 and 3, respectively, and were comparable across the 4 treatment arms. In the univariate logistic regression, only the size of an intracranial abscess was found be associated with an increased likelihood of return to the operating theatre, whereas combined ENT and neurosurgical intervention did not result in improved outcomes.

CONCLUSION

Sinogenic intracranial abscesses are associated with significant morbidity and mortality. The size of an intracranial abscess has a strong association with a need for a revision surgery.

Household drug-resistant TB contact tracing in Tajikistan

BACKGROUND: Tajikistan has a high burden of rifampicin-resistant TB (RR-TB), with 2,700 new cases estimated for 2021 (28/100,000 population). TB is spread among household members through close interaction and children exposed through household contact progress to disease rapidly and frequently.METHODS: We retrospectively analysed programmatic data from household contact tracing in Dushanbe over 50 months. We calculated person-years of follow-up, contact tracing yield, number needed to screen (NNS) and number needed to test (NNT) to find one new case, and time to diagnosis.RESULTS: We screened 6,654 household contacts of 830 RR-TB index cases; 47 new RR-TB cases were detected, 43 in Year 1 and 4 in Years 2 or 3. Ten were aged <5 years; 46/47 had TB symptoms, 34/45 had chest radiographs consistent with TB, 11/35 were Xpert Ultra-positive, 29/32 were tuberculin skin test-positive and 28/47 had positive TB culture and phenotypic drug susceptibility results. The NNS to find one RR-TB case was 141.57 and the NNT was 34.49. The yields for different types of contacts were as follows: 0.7% for screened contacts, 2.9% for tested contacts, 17.0% for symptomatic contacts and 12.1% for symptomatic contacts aged below 5 years.CONCLUSION: RR-TB household contact tracing was feasible and productive in Tajikistan, a low middle-income country with an inefficient healthcare delivery system.

MDCT evaluation of distal radius fractures and their association with carpal and distal ulnar fractures

PURPOSE

The purpose of this study was to evaluate the characteristics of distal radius fractures (DRFs) in patients undergoing multi-detector computed tomography (MDCT) and their association with carpal and distal ulnar fractures.

METHODS

This retrospective study analyzed 120 patients, who underwent MDCT for evaluation of DRFs. Two radiologists independently evaluated the data for various fracture characteristics and for associated carpal and distal ulnar fractures.

RESULTS

Out of 120 DRFs, 74 were complete articular, 40 were partial articular and only 6 were extra-articular. Displacement was present in 99 fractures and intra-articular step off was present in 73 fractures. A total of 81 carpal bone fractures were identified in 46 (38.3%) patients, with more than one carpal bone fracture in 21 patients. Distal ulnar fractures were detected in 79 patients (65.8%), out of which 67 involved the ulnar styloid. DRFs with intra-articular step off were more frequently associated with carpal bone fracture (p value: 0.021), while displaced DRFs were more frequently associated with distal ulnar fracture (p value <0.001). Interobserver agreement for detection of carpal bone fractures (κ = 0.807) and distal ulnar fractures (κ = 0.923) was excellent.

CONCLUSION

Majority of DRFs in patients referred for MDCT were complete articular with high incidence of displacement and intra-articular step off. Associated carpal bone and distal ulna fractures were not uncommon.

Acute Epigastric Pain: Unexpected Urologic Findings on Computed Tomography

Mesenteric panniculitis is a relatively common condition encountered on cross-sectional imaging and is mostly asymptomatic. We present one such case where an underlying malignancy was brought to forefront due to associated mesenteric panniculitis presenting as acute abdomen.

Molecular surveillance detects high prevalence of the neglected parasite Mansonella ozzardi in the Colombian Amazon

Mansonellosis is an undermapped insect-transmitted disease caused by filarial nematodes that are estimated to infect hundreds of millions of people globally. Despite their prevalence, there are many outstanding questions regarding the general biology and health impacts of the responsible parasites. Historical reports suggest that the Colombian Amazon is endemic for mansonellosis and may serve as an ideal location to pursue these questions in the backdrop of other endemic and emerging pathogens. We deployed molecular and classical diagnostic approaches to survey Mansonella prevalence among adults belonging to indigenous communities along the Amazon River and its tributaries near Leticia, Colombia. Deployment of a loop-mediated isothermal amplification (LAMP) assay on blood samples revealed an infection prevalence of ∼40% for Mansonella ozzardi . This assay identified significantly more infections than blood smear microscopy or LAMP assays performed using plasma, likely reflecting greater sensitivity and the ability to detect low microfilaremias or occult infections. Mansonella infection rates increased with age and were higher among males compared to females. Genomic analysis confirmed the presence of M. ozzardi that clusters closely with strains sequenced in neighboring countries. We successfully cryopreserved and revitalized M. ozzardi microfilariae, advancing the prospects of rearing infective larvae in controlled settings. These data suggest an underestimation of true mansonellosis prevalence, and we expect that these methods will help facilitate the study of mansonellosis in endemic and laboratory settings.

Primary bedaquiline resistance in Karakalpakstan, Uzbekistan

BACKGROUND: Bedaquiline (BDQ) is widely used in the treatment of rifampicin-resistant TB (RR-TB). However, resistance to BDQ is now emerging. There are no standardised regimens for BDQ-resistant TB. This study aims to share experience in managing primary BDQ-resistant TB.METHODS: We performed a retrospective study of patients treated for RR-TB in Karakalpakstan, Uzbekistan, from January 2017 to March 2022. We identified patients with resistance to BDQ with no history of BDQ exposure. We describe baseline characteristics, treatment and follow-up of these patients.RESULTS: Twelve of the 1,930 patients (0.6%) had baseline samples resistant to BDQ with no history of BDQ exposure, 75% (9/12) of whom had been previously treated for TB. Ten (83.3%) were resistant to fluoroquinolones; respectively 66% and 50% had culture conversion by Month 3 and Month 6. The interim treatment outcomes were as follows: unfavourable treatment outcomes (3/12, 25%), favourable outcomes (2/12, 17%); the remaining seven (58%) were continuing treatment.CONCLUSIONS: A large proportion of the cases had previously been treated for TB and had TB resistant to quinolone. Both patients who had not experienced culture conversion by Month 3 had an unfavourable treatment outcome. Therefore, we recommend monthly monitoring of culture status for patients on treatment regimens for BDQ resistance.

Comparing the Effectiveness of Propranolol versus Atenolol in Inducing Clinical Clearance in the Treatment of Infantile Haemangioma: A Randomised Controlled Trial

Background

Despite the excellent clinical efficacy of oral propranolol in the management of infantile haemangiomas (IHs), there is a need to further evaluate other beta blockers that may be equally efficacious but result in lesser adverse effects. We compared the efficacy and short-term safety of atenolol, a hydrophilic cardio-selective beta blocker, with propranolol, in the treatment of IHs.

Materials and Methods

Sixty patients with complicated and/or cosmetically significant IHs were randomised into two groups, oral propranolol group (2 mg/kg/day) and the oral atenolol (1 mg/kg/day) group, respectively, for 9 months. Patients were assessed clinically, by the use of Doppler ultrasonography (USG) and measurement of serum hypoxia-inducible factor 1 alpha (HIF-1α).

Results

Twenty-two of 30 patients achieved complete clearance in the propranolol group (0.73; 95% CI = 0.54 to 0.87) compared with 13 of 25 patients in the atenolol group (0.52; 95% CI = 0.31 to 0.72). The mean time to achieve Physician Global Assessment Score 5 (PGA5) (25.00 ± 8.87 weeks) was significantly lesser in the propranolol group versus the atenolol group (31.69 ± 7.01 weeks; log-rank = 0.04). The two groups were comparable in terms of adverse effect profile, degree of volume reduction in USG and reduction in HIF-1α levels.

Conclusions

Propranolol (2 mg/kg/day) is better than atenolol (1 mg/kg/day) in inducing complete clinical clearance of IH although the results need to be reproduced in larger studies.

Ultrasound and magnetic resonance imaging of hands in systemic sclerosis: A cross-sectional analytical study of prevalence of inflammatory changes in patients with subclinical arthropathy

Objectives

Prevalence of synovitis, tenosynovitis, erosions, acro-osteolysis and bone marrow edema in systemic sclerosis is not extensively reported. We aimed to estimate the prevalence of changes in individual joints of hands in systemic sclerosis patients.

Method

A cross-sectional analytical study consisting of 34 adults (females, n = 32) with systemic sclerosis. Patients with clinical synovitis were excluded. All patients underwent ultrasound (US) and magnetic resonance imaging of bilateral hands.

Results

On US, synovitis, tenosynovitis, erosions, and acro-osteolysis were detected in 97%, 94%, 97%, and 29% patients. Grade I synovitis observed in 67% joints-first carpometacarpal joint (55%), first metacarpophalangeal joint (54%), distal radioulnar joint (50%), and intercarpal joints (47%) were commonly affected. Erosions were common in distal phalanges (first DP72% to fifth DP39%). On magnetic resonance imaging, synovitis, tenosynovitis, erosions, and bone edema were observed in 91%, 85%, 97%, and 85% patients. Grade I synovitis was seen in 70% joints, affecting intercarpal joint (70.6%) and third metacarpophalangeal joint (52.9%) commonly. Grade I erosions were seen in 61%, affecting distal phalanges (55.8%), capitate (60.3%), and lunate (55.8%). Grade I edema was commonly affecting lunate (39%) and capitate (26%). On magnetic resonance imaging, acro-osteolysis was present in 28% (97/340) distal phalanges. Fair agreement (0.21-0.40) was noted between US and magnetic resonance imaging for synovitis and erosions.

Conclusion

High prevalence of low-grade inflammation is found in systemic sclerosis patients on US and magnetic resonance imaging. Distal joint assessment in addition to proximal joints improves accurate estimation of prevalence of early arthropathy.

Low-grade myofibroblastic sarcoma of the mandible: A rare tumour of childhood

Low-grade myofibroblastic sarcoma is a rare and indolent tumour of soft tissue. This tumour is relatively common in the head and neck region followed by extremities. Primary low-grade myofibroblastic sarcoma of the mandible is very rarely reported and the occurrence of this tumour in a child is very unusual. A 7-year-old male child presented with a swelling in right angle of mandible. X-ray and computed tomography scan showed a lytic lesion. The lesion was excised and the tissue was sent for histopathological evaluation, which revealed a cellular spindle cell neoplasm arranged in fascicles. The tumour was partly circumscribed and lobulated. On immunohistochemistry (IHC), these tumour cells showed cytoplasmic positivity for vimentin, and smooth muscle actin showed 'tram-track' pattern of positivity. The case was diagnosed as low-grade myofibroblastic sarcoma. There are no definite clinical features or pathognomonic radiological appearances of this tumour that can differentiate this rare tumour from other commonly encountered gnathic bone tumours, such as osteosarcoma, inflammatory myofibroblastic tumour, etc., Histopathological diagnosis coupled with ancillary investigations such as IHC is important to establish a definite diagnosis and rule out the differentials. The exact biological behaviour of this tumour is not known.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Primary Osseous Leiomyosarcoma with Vertebral and Nodal Metastasis in a Young Woman: A Rare Case Report

Introduction. Primary leiomyosarcoma of bone is rarely described in the literature. In young patients, the clinical and radiological features may mimic relatively common tumours like osteosarcoma. Vertebral and nodal metastasis from osseous leiomyosarcoma is extremely uncommon. Case presentation. A 25-year-old female presented with progressively increasing pain and swelling of the right knee. Clinical and radiological features were suggestive of osteosarcoma. Pre-operative biopsy showed a malignant spindle cell tumour. The surgical resection specimen showed features of leiomyosarcoma of the right proximal tibia. On further evaluation, the patient was found to have an L3-L4 vertebral lesion and histopathological evaluation showed a similar tumour. After 11 months of initial presentation, the patient had axillary lymph node metastasis. Conclusion. Primary osseous leiomyosarcoma should be considered as a differential diagnosis even in young patients presenting with meta-diaphyseal expansile malignant bony lesions. Histology and ancillary studies can confirm the diagnosis.

Role of Shear-Wave Elastography in Achilles Tendon in Psoriatic Arthritis and Its Correlation with Disease Severity Score, Psoriasis Area and Severity Index

Purpose  The aim of this study was to compare accuracy of shear-wave elastography (SWE) with gray scale (GS) ultrasound and power Doppler (pD) for diagnosing Achilles tendinopathy in psoriatic patients with and without arthritis and correlation with achillodynia and disease severity score, psoriasis area and severity index (PASI).

Methods  A total of 100 Achilles tendons were evaluated where 56% were cases of psoriatic arthritis with achillodynia; 44% were controls of psoriasis without arthritis in this prospective study. Evaluation was done with GS, pD, SWE at proximal, mid, and distal third of the tendon. Qualitative (color maps) and quantitative data, elastic modulus, kilopascal (kPa), were generated. Pearson's correlation was done to see association between kPa, PASI and clinical symptoms, achillodynia, scored using visual analog scale (VAS).

Results  Significant negative correlation was seen between duration of arthritis, VAS and PASI with SWE values with r  = −0.34, −0.47, and −0.41, respectively. SWE could identify abnormal tendons in 71/100 (71%) in the overall study, 53/56 (94.6%) in cases, and 18/44 (40.9%) in control. The statistical significance was set at p  ≤ 0.05. In comparison, conventional ultrasound, GS, and pD together could identify 13/56 (23.21%) in cases and no abnormal tendon was identified in the control group.

Conclusion  SWE is a reliable, noninvasive, and valuable tool to detect early tendinopathy and monitor progression of disease.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Acquired bedaquiline resistance in Karakalpakstan, Uzbekistan

BACKGROUND: The WHO recommends the use of bedaquiline (BDQ) in longer, as well as shorter, multidrug-resistant TB (MDR-TB) treatment regimens. However, resistance to this new drug is now emerging. We aimed to describe the characteristics of patients in Karakalpakstan, Uzbekistan, who were treated for MDR-TB and acquired BDQ resistance during treatment.METHODS: We performed a retrospective study of routinely collected data for patients treated for MDR-TB in Karakalpakstan between January 2015 and December 2020. We included patients on BDQ-containing regimens with baseline susceptibility to BDQ who developed BDQ resistance at any point after treatment initiation. Patients resistant to BDQ at baseline or with no confirmed susceptibility to BDQ at baseline were excluded.RESULTS: Of the 523 patients who received BDQ-containing regimens during the study period, BDQ resistance was detected in 31 patients (5.9%); 20 patients were excluded-16 with no prior confirmation of BDQ susceptibility and 4 who were resistant at baseline. Eleven patients with acquired BDQ resistance were identified. We discuss demographic variables, resistance profiles, treatment-related variables and risk factors for unfavourable outcomes for these patients.CONCLUSION: Our programmatic data demonstrated the acquisition of BDQ resistance during or subsequent to receiving a BDQ-containing regimen in a patient cohort from Uzbekistan. We highlight the need for individualised treatment regimens with optimised clinical and laboratory follow up to prevent resistance acquisition.

Time-resolved hadronic particle acceleration in the recurrent nova RS Ophiuchi

Recurrent novae are repeating thermonuclear explosions in the outer layers of white dwarfs, due to the accretion of fresh material from a binary companion. The shock generated when ejected material slams into the companion star's wind can accelerate particles. We report very-high-energy (VHE, [Formula: see text]) gamma rays from the recurrent nova RS Ophiuchi, up to a month after its 2021 outburst, observed using the High Energy Stereoscopic System. The VHE emission has a similar temporal profile to lower-energy GeV emission, indicating a common origin, with a two-day delay in peak flux. These observations constrain models of time-dependent particle energization, favoring a hadronic emission scenario over the leptonic alternative. Shocks in dense winds provide favorable environments for efficient acceleration of cosmic-rays to very high energies.

Role of shear wave elastography of synovium to differentiate rheumatoid and tubercular arthritis

Background:

Synovitis is the underlying pathology in various arthritis, and sometimes, it is difficult to differentiate various arthritis clinically or even by imaging. The purpose of our study was to use shear wave elastography (SWE) to evaluate rheumatoid arthritis (RA) and tubercular (TB) arthritis and to differentiate them using synovial stiffness.

Methods:

The prospective study was performed on Supersonic Imagine Aixplorer Ultrasound (USG) machine using a linear array probe SL10-2 (2–10 MHz). A total of 29 participants, 15 of RA (ACR/EULAR criteria) and 14 of proven TB arthritis were included. Region of interest of 1 mm was applied on the hypertrophied synovium and quantitative SWE data in form of elasticity (kPa) and velocity (m/s) were measured. Discrete categorical data were presented as n (%). Mean values were recorded along with standard deviation and the range of values. To find a maximal cutoff value of elasticity and velocity - receiver operating characteristic curve were plotted.

Results:

The mean elasticity and velocity values were 54.81 ± 10.6 kPa and 4.2 m/s ± 0.42 for RA and 37 ± 10 kPa and 3.4 ± 0.47 m/s for TB group. Significant difference (P < 0.001) was seen in elastic modulus values between rheumatoid and TB group with cutoff of 43.6 kPa to differentiate the two groups (sensitivity – 86.7% and specificity – 80%). Similar significant (P < 0.001) results were seen with velocity values, with cutoff of 3.76 m/s (sensitivity – 86.7% and specificity – 80%).

Conclusion:

SWE shows the potential to be a useful adjunct to gray scale and color Doppler USG in differentiating various arthritis on the basis of elastic properties of the synovium. Elastic modulus and velocity are useful SWE quantitative parameters for synovial evaluation and can differentiate RA and TB arthritis.

Introducing Clinical Pathology Course to Fourth Year Medical Students as a Bridge between Pre-clinical and Clinical Medical Sciences

There isn't any vertical integration of pre-clinical and clinical sciences subjects in the existing Kathmandu University MBBS curriculum. Many of the graduates are not able to correlate the clinico-pathological aspects of various diseases as a result the rational use of investigations for diagnosing various diseases is compromised. There are few published examples of implementation of pathology instruction courses during the clinical years of medical training but it is not universally practiced. This lack of exposure to pathology may lead to poor understanding of laboratory testing and the role of pathologists in patient care. To set and implement an exemplary vertical integration of pre-clinical science with clinical science. A 12 credit hours clinical pathology education course comprising clinical hematology, cytopathology and histopathology was developed. Students belonging from the ongoing fourth year MBBS course of Birat Medical College were enrolled in the course. All of the interactive lecture sessions were delivered via an e-learning interface, using the Zoom platform as the main teaching methods. Evaluation of students' achievement of learning objectives was conducted through distributing pre and post-test online multiple-choice questionnaires. Chi-square tests were used to compare the variables between pre-test and post-test questionnaire responses. Results suggested that the designed clinical pathology course is valuable. The pretest and post-test questionnaire responses revealed the positive impact regarding the importance of introducing clinical pathology courses within the clinical year of MBBS undergraduate curriculum. Response rate to the online session was 100%. The point of agreement between the pre-test and post-test questionnaire responses were highly achieved after intervention of the clinical pathology course. A statistically significant result (p < 0.05) between all of the pre-test and post-test questionnaire responses was noted. There was a strong positive recommendation for incorporating clinical laboratory medicine courses within the MBBS clinical science curriculum. The improvement observed among fourth-year MBBS students on learning the importance of clinical pathology courses was encouraging. This experience thus contributed to set and implement an exemplary vertical integration of pre-clinical science with clinical science.

ADRENAL HISTOPLASMOSIS: AN EASTERN INDIAN PERSPECTIVE

CONTEXT

The clinical presentation of histoplasmosis is varied. Due to its propensity for adrenal involvement, histoplasmosis is an important differential diagnosis in any patient presenting with adrenal mass, bilateral in particular.

OBJECTIVE

Data on clinical presentation, pattern of adrenal involvement, radiological appearance and long-term follow-up of adrenal histoplasmosis are relatively sparse; hence we looked at it.

DESIGN

This record based single-centre retrospective study was conducted in one of the tertiary care hospitals, situated in eastern India catering the Gangetic delta.

SUBJECTS AND METHODS

Data on demographic characters, presenting manifestations, biochemical & hormonal parameters and radiological appearance of confirmed adrenal histoplasmosis cases (n=9), admitted between 2015-2019 have been retrieved. The treatment outcome and condition of patients after 1-4 years of follow-up has also been discussed.

RESULTS

Four out of the nine (44.4%) patients had predisposing immunocompromised conditions in the form of diabetes and/or chronic alcoholism while rest were immunocompetent. Seven out of nine patients (77.8 %) had signs and symptoms suggestive of adrenal insufficiency, while two (22.2%) presented with only pyrexia of unknown origin. All of them had bilateral adrenal mass, though the radiologically appearances were different. All patients received anti-fungal agents with/without hydrocortisone and/or fludrocortisone. One patient died (11.1%), while majority responded favourably to treatment. Adrenocortical function did not recover completely.

CONCLUSIONS

The possibility of adrenal histoplasmosis should always be considered in patients presenting with bilateral adrenal mass, irrespective of adrenal morphology. Treatment is effective, but many of them require supplemental hydrocortisone for quite a long period, if not lifelong. Mineralocorticoid deficiency, however, is not permanent.

Incidental Muscle Uptake of 177Lu-DOTATATE in Peripheral Vascular Disease

Somatostatin receptor (SSTR)-based imaging and therapy has emerged as well-established modality in neuroendocrine tumors. However, its role in inflammation imaging is still evolving. We present a 48-year-old male with metastatic neuroendocrine tumor who underwent lutetium-177-based somatostatin receptor-based therapy. The post-therapy scan showed a focal tracer uptake in the left calf muscle in addition to the expected tracer uptake at the primary and metastatic sites. Further, cross-sectional imaging and biochemical investigations revealed peripheral vascular disease (PVD). The incidental tracer uptake in the calf on post-therapy scan potentiates the role of somatostatin receptor scintigraphy in identifying macrophage-specific inflammatory reactions.

198 Immediate Post-Operative PDE5i Therapy Improves Early Erectile Function Outcomes after Robot-Assisted Radical Prostatectomy (RARP)

Aim

To assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function, continence, or safety outcomes.

Method

Data was prospectively collected from a single surgeon in one tertiary centre and retrospectively evaluated. 158 patients were treated with PDE5i therapy post RARP over a two-year period.

Results

There were no significant differences in pre-operative characteristics between the therapy groups. Patients that had bilateral nerve sparing had a mean drop in Erectile Function (EF) score by 5.4 compared to 8.8 in the unilateral group. Additionally, 34.9% of bilateral nerve sparing patients returned to baseline compared to 12.1% of unilateral. Drop in EF scores and percentage return to baseline for unilateral nerve sparing was respectively 9 and 11.1% of immediate (day 1-2), 7 and 14.8% of early (day 3-14) and 9.7 and 9.5% of late (day &gt;14) therapy (p = 0.9 and p = 0.6). For bilateral nerve sparing this was respectively 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p = 0.017 and p = 0.045). Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication, or readmission outcomes.

Conclusions

Immediate PDE5i therapy should be considered in patients following nerve sparing RARP in order to maximise functional outcomes, especially in those undergoing bilateral nerve spare.

81 VIRTUAL: Virtual Interactive Surgical Skills Classroom – An Ongoing Randomized Controlled Trial

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention, and Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed.

Results

Data collection will be completed in January 2021. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusions

To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the virtual classroom’s suitability as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

Malaria, COVID-19 and angiotensin-converting enzyme 2: what does the available population data say?

The etiopathogenesis of COVID-19 and its differential geographic spread suggest some populations are apparently 'less affected' through many host-related factors that involve angiotensin-converting enzyme 2 (ACE2) protein, which is also the entry receptor for SARS-CoV-2. The role of ACE2 has been well studied in COVID-19 but not in the context of malaria and COVID-19. We have previously suggested how malaria might intersect with COVID-19 through ACE2 mutation and here we evaluate the currently available data that could provide a link between the two diseases. Based on the existing global and Indian data on malaria, COVID-19 and the suggested ACE2 mutation, the association could not be examined robustly, neither accepting nor refuting the suggested hypothesis. We strongly recommend targeted evaluation of this hypothesis through carefully designed robust molecular epidemiological studies.

Early bone loss in Indian patients undergoing allogeneic hematopoietic cell transplantation

Background

There is a lack of prospective studies to address the issue of timing of bone mineral density (BMD) measurement and anti-resorptive therapy before and after allogeneic hematopoietic cell transplantation (allo-HCT), specifically in the younger population (age < 40 years). This study evaluated the incidence and risk factors of poor BMD in young Indian patients undergoing allogeneic hematopoietic cell transplant and the effect of anti-resorptive therapy in allogeneic transplant recipients who are at high risk for severe bone loss.

Methods

This was a single-center, prospective study conducted from 2016 to 2019. All patients aged ≥ 12 years undergoing allo-HCT were included in the study. Data regarding the risk factors for osteoporosis, underlying diagnoses, and HCT characteristics were recorded. BMD was measured by dual-energy X-ray absorptiometry (DXA) (HOLOGIC Discovery A) at the lumbar spine (LS), femoral neck (FN), and total hip (TH) at pre-HCT, day+100, and day+365 post-HCT. Patients with Z-score ≤ -2 at day+100 were given one dose (4 mg) of intravenous zoledronate. Patients with moderate to severe chronic graft-versus-host disease (GVHD) also received a dose of zoledronate if they had not received it earlier.

Results

The median age of our cohort was 24 years (IQR 18.5 - 39.5). Day+100 DXA was available for 25 (54.3%) patients, a paired day+100, and day+365 DXA was available for 15 patients. For pre-HCT, a Z-score ≤ -2 was seen in 30% of patients. For day+100 post-HCT, a Z-score ≤ -2 was seen in 44% of patients. Low body mass index was associated with a Z-score ≤ -2 (median 18 vs. 23 kg/m², P = 0.04). Despite a single dose of zoledronate in this cohort, the median Δ BMD (day+365 - day+100) loss at FN and LS was -0.8% to -3.7%, respectively. Seven (64%) of these patients also had moderate-severe chronic GVHD.

Conclusions

BMD below the expected range for age (Z-score ≤ -2) was present in one-third of young Indian patients undergoing allo-HCT in this single center study. Without intervention, up to half of the patients had a Z-score ≤ -2 at day+100 post-HCT. BMD loss at day+100 persisted at day+365 despite anti-resorptive therapy.

O43 Virtual: virtual interactive surgical skills classroom: a randomized controlled trial (protocol)

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on surgical skills experience and confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention. Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts.

Result

Change in confidence, time to completion and a novel granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusion

This will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and beyond.

Take-home Message

This is the first RCT assessing virtual basic surgical skill classroom training and serves as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

Barium esophagogram in various esophageal diseases: A pictorial essay

Recent years have seen a decline in number of barium procedures due to wider availability of cross sectional imaging modalities. Though use of barium esophagography/barium swallow has decreased in day to day clinical practice, it still remains a valuable test for structural and functional evaluation of esophagus. It can be performed as single or double contrast examination or as a multiphasic examination comprising upright double contrast views followed by prone single contrast views. This pictorial essay demonstrates imaging features of various esophageal diseases on barium esophagogram.

Revealing x-ray and gamma ray temporal and spectral similarities in the GRB 190829A afterglow

Gamma-ray bursts (GRBs), which are bright flashes of gamma rays from extragalactic sources followed by fading afterglow emission, are associated with stellar core collapse events. We report the detection of very-high-energy (VHE) gamma rays from the afterglow of GRB 190829A, between 4 and 56 hours after the trigger, using the High Energy Stereoscopic System (H.E.S.S.). The low luminosity and redshift of GRB 190829A reduce both internal and external absorption, allowing determination of its intrinsic energy spectrum. Between energies of 0.18 and 3.3 tera-electron volts, this spectrum is described by a power law with photon index of 2.07 ± 0.09, similar to the x-ray spectrum. The x-ray and VHE gamma-ray light curves also show similar decay profiles. These similar characteristics in the x-ray and gamma-ray bands challenge GRB afterglow emission scenarios.

The significance of urgent ultrasound scan for shoulder dislocation in patients above the age of 40: A prospective British Elbow and Shoulder Society pathway implementation study

BACKGROUND

The highlight of the British Elbow and Shoulder Society pathway for the management of traumatic anterior shoulder instability is early imaging in patients aged over 40 years to assess rotator cuff integrity and early repair, if indicated to optimise function. The senior author set up a protocol in our institute to streamline the diagnostic process for this cohort of patients. This was a retrospective analysis from a prospectively collected database to highlight the importance of early specialist imaging.

METHODS

Our protocol is to perform urgent ultrasound scans for all suitable patients above 40 years after first-time traumatic shoulder dislocation. Demographics, associated injuries, ultrasound scan results, operations and functional outcomes were collated.

RESULTS

One year following the introduction of our protocol, 40 patients with a mean age of 67 (range, 42-89; SD = 13.1) had ultrasound. The incidence of full-thickness rotator cuff tears was 57.5% (n = 23). Eleven patients with confirmed full-thickness rotator cuff tears underwent surgery. The mean age of surgical patients was significantly younger than the non-surgical group (p = 0.004).

DISCUSSION

The use of early diagnostic imaging demonstrated a high incidence of full-thickness rotator cuff tears in this cohort of patients. This allowed early surgical repair to optimise function.

Role of shear wave elastography in treatment follow-up of leprosy neuropathy

PURPOSE

Grayscale ultrasonography when complemented with shear wave elastography helps in better evaluation of treatment response of leprosy neuropathy and in guiding appropriate management of the patient. There is limited literature regarding the use of shear wave elastography in ulnar nerve neuropathy. Our purpose was to evaluate the role of shear wave elastography in assessing stiffness changes within the ulnar nerve during treatment of leprosy.

METHODS

This was a prospective study which included 30 patients diagnosed with leprosy neuropathy. Recruited patients were followed up, during the course of treatment, i.e. for 1 year. Serial ultrasonography of these patients was done at 0, 3, 6 and 12 months interval.

RESULTS

Significant (P < 0.05) decrease in elastography parameters was seen in transverse imaging plane between first and third, as well as first and fourth visits (mean stiffness and velocity pretreatment ~ 25.78 ± 18 kPa and 2.74 ± 0.98 m/s, mean stiffness and velocity post-treatment 15.67 ± 5.89 kPa and 2.24 ± 0.428 m/s). Although elastography parameters decreased during these visits in the long-axis imaging plane, they were not found to be statistically significant. However, gross morphology and cross-sectional area of the nerve did not change significantly across visits. Interestingly, elastography values were higher in patients with neuritis, though not statistically significant.

CONCLUSION

Shear wave elastography is a novel, upcoming modality in musculoskeletal imaging especially in the evaluation of peripheral neuropathy. It can act as an adjunct to grey-scale imaging, which can help in early diagnosis and in guiding treatment of leprosy neuropathy.

Primary elbow osteoarthritis presenting as ulnar nerve palsy with claw hand

A 59-year-old woman was referred with weakness, paraesthesia, numbness and clawing of the little and ring fingers for the last 2 years. MRI of the cervical spine was normal and nerve conduction velocity revealed abnormality of the ulnar nerve. Ultrasound and MRI showed medial osteophytes and effusion of the elbow joint with stretched and thinned ulnar nerve in the cubital tunnel. The patient underwent release and anterior transposition of the ulnar nerve with significant relief of symptoms.

31 Immediate Post-Operative Phosphodiesterase-5 Inhibitors (PDE5i) Therapy Improves Early Erectile Function Outcomes After Robot Assisted Radical Prostatectomy (RARP)

Introduction

To assess whether the timing of post-RARP PDE5i therapy affects early erectile function, continence, or safety outcomes.

Method

Data from 158 patients treated with PDE5is post-RARP was prospectively collected over two years from a single surgeon at one tertiary centre and retrospectively evaluated. Therapy was started: immediately (day 1-2) in 29%, early (day 3-14) in 37% and late (after day 14) post-op in 34%. EPIC-26 Erectile Function (EF) scores were collected pre-op and post-op after a median 43-day follow-up interval.

Results

Drop in EF scores and percentage return to baseline post unilateral nerve sparing (UNS) compared to bilateral nerve sparing (BNS) RARP was respectively 9 and 11.1% versus 3.5 and 42.9% of immediate therapy, 7 and 14.8% versus 5.5 and 35.5% of early and 9.7 and 9.5% versus 7.3 and 25% of late. Pad free and social continence was achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early and 26% and 54% for late.

Conclusions

Immediate post RARP PDE5i therapy may protect EF and should be considered clinically, with more benefits for BNS than UNS patients. Immediate or early, rather than late, PDE5i therapy improved early continence in BNS patients.

Diagnostic accuracy of CT and radiographic findings for novel coronavirus 2019 pneumonia: Systematic review and meta-analysis

PURPOSE

To evaluate pooled prevalence, sensitivity, and specificity of chest computed tomography (CT) and radiographic findings for novel coronavirus-2019 (COVID-19) pneumonia.

METHODS

We performed systematic literature search in PubMed and Embase to identify articles reporting baseline imaging findings of COVID-19 pneumonia. The quality of the articles was assessed using NIH quality assessment tool for case series studies. The pooled prevalence, sensitivity, specificity, and diagnostic odds ratio of imaging findings were calculated.

RESULTS

Fifty-six studies (6007 patients, age, 2.1-70 years, 2887 females, 5762 CT, 396 radiographs,) were included. The mean interval between onset of symptoms and CT acquisition was 1-8 days. On CT, the pooled prevalence of ground glass opacities (GGO), GGO plus consolidation, and consolidation only was 66.9% (95% CI 60.8-72.4%), 44.9% (38.7-51.3%), and 32.1 (23.6-41.9%) respectively. Pooled sensitivity and specificity of GGO on CT was 73% (71%-80%) and 61% (41%-78%), respectively. For GGO plus consolidation and consolidation only, the pooled sensitivities/ specificities were 58% (48%-68%)/ 58% (41%-73%) and 49% (20%-78%)/ 56% (30%-78%), respectively. The pooled prevalence of GGO and consolidation on chest radiograph was 38.7% (22.2%-58.3%) and 46.9% (29.7%-64.9%), respectively. The diagnostic accuracy of radiographic findings could not be assessed due to small number of studies.

CONCLUSION

GGO on CT has the highest diagnostic performance for COVID-19 pneumonia, followed by GGO plus consolidation and consolidation only. However, the moderate to low sensitivity and specificity suggest that CT should not be used as the primary tool for diagnosis. Chest radiographic abnormalities are seen in half of the patients.

Rare cause of paraparesis in a young man: cervico-dorsal neurenteric cysts associated with Klippel-Feil syndrome

Klippel-Feil syndrome is an entity presenting with short neck, low hairline and reduced range of motion of cervical spine. Neurenteric cyst is a congenital abnormality, in which mucus-secreting epithelium of the gastrointestinal tract is seen in the spinal axis. The association of a neurenteric cyst with Klippel-Feil syndrome has been reported very rarely. We report the case of a young man, affected by Klippel-Feil syndrome, who presented with bilateral paraplegia. Imaging of the spine revealed features suggestive of cervico-dorsal neurenteric cyst. Subsequently, surgical resection of the cysts was done, which resulted in resolution of the symptoms.

Consensus statement from the international consensus meeting on post-traumatic cranioplasty

Background

Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach.

Methods

The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP.

Results

The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations.

Conclusions

This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.