Serum neurofilament light as a potential marker of illness duration in bipolar disorder

INTRODUCTION

Investigation on specific biomarkers for diagnostic or prognostic usage in mental diseases and especially bipolar disorder BD seems to be one outstanding field in current research. Serum neurofilament light (sNfL), a marker for neuro-axonal injury, is increased in various acute and chronic neurological disorders, but also neuro-psychiatric conditions, including affective disorders. The aim of our study was to determine a potential relation between a neuron-specific marker like sNfL and different clinical states of BD.

METHODS

In the current investigation, 51 patients with BD and 35 HC were included. Mood ratings with the Hamilton depression scale (HAMD) and the Young mania rating scale (YMRS) have been included. Illness duration was defined as the period from the time of diagnosis out of self-report and medical records. sNFL was quantified by a commercial ultrasensitive single molecule array (Simoa).

RESULTS

There was a significant positive correlation between the number of manic episodes in the past and sNfL, controlled for age and duration of illness. (R = 0.49, p = 0.03) Depressive episodes were not associated to sNfL values. (R = 0.311, p = n.s.) Patients with >3 years of illness duration showed significantly higher levels of sNfL (M18.59; SD 11.89) than patients with shorter illness duration (M = 12.38, p = 0.03) and HC (M = 11.35, p = 0.02). Patients with <3 years of illness and HC did not differ significantly in sNfL levels.

DISCUSSION

Interestingly, individuals with BD and HC did not differ in sNFL levels in general. Nevertheless, looking at the BD cohort more specifically, we found that individuals with BD with longer duration of illness (>3 years) had higher levels of sNfL than those with an illness duration below 3 years. Our results confirm previous reports on the relation of neuro-axonal injury as evidenced by sNfL and illness specific variables in bipolar disorder. Further studies are needed to clarify if sNfL may predict the disease course and/or indicated response to treatment regimes.

Variation of Acromiocoracoid and Acromioglenoid Distance in Bangladeshi People

This cross-sectional descriptive purposive study was done on 150 (70 right and 80 left) fully ossified dry human scapulae of Bangladeshi people to find out the variation in length of acromiocoracoid and acromioglenoid distance. Sample collection was carried out in the Department of Anatomy, Mymensingh Medical College, Bangladesh from January to December 2019. Any kind of damaged or broken scapulae were excluded to maintain standard measurement. Length of these distances was measured with the help of digital Vernier slide calipers. The mean±SD acromiocoracoid distance were 35.8±4.64 mm and 36.32±5.55 mm on right and left sided scapulae respectively and the mean±SD acromioglenoid distance were 27.69±3.43 mm on right sided scapulae and 28.18±3.26 mm on left sided scapulae. These data are important to compare Bangladeshi scapulae to those from various other races that could contribute to demographic studies of shoulder disease probability and management in Bangladeshi population.

Variation of Mid shaft Antero-posterior and Transverse Diameter of Femur in Bangladeshi People

Femoral morphometric variation is a dynamic system for different region, which is influenced by geographical, physiological and environmental factors, due to the adaptation, functional and remodeling responses of bones. This descriptive cross-sectional study was conducted on 150 (64 right and 86 left) fully ossified dry human femur of Bangladeshi people to find out the variation of mid shaft antero-posterior and transverse diameter of femur. Sample was collected in the Department of Anatomy, Mymensingh Medical College (MMC), Bangladesh from January 2019 to December 2019. All samples were assessed to eliminate fractured, pathologically damaged and remodeled bones. The diameters were measured with the help of digital Vernier slide calipers. The mean±SD mid shaft antero-posterior diameter of right and left femur were 25.03±2.86 mm and 25.54±2.65mm respectively. The mean±SD transverse diameter of right and left femur was 24.24±2.43mm and 24.54±2.38mm respectively. The knowledge of variations in the parameters of dry femora will help the orthopedicians for the treatment and management of femoral shaft fracture. These data also provide information about mid shaft diameter of femur of Bangladeshi people and to compare these data to those from various other races. Thus it could contribute for the design of well-fitting prosthesis which suits the Bangladeshi population. This value may be considered while making a best-fit femoral prosthesis.

Effects of tidal volume challenge on the reliability of plethysmography variability index in hepatobiliary and pancreatic surgeries: a prospective interventional study

BACKGROUND

The plethysmography variability index (PVI) is a non-invasive, real-time, and automated parameter for evaluating fluid responsiveness, but it does not reliably predict fluid responsiveness during low tidal volume (VT) ventilation. We hypothesized that in a 'tidal volume challenge' with a transient increase in tidal volume from 6 to 8 ml Kg- 1, the changes in PVI could predict fluid responsiveness reliably.

METHOD

We performed a prospective interventional study in adult patients undergoing hepatobiliary or pancreatic tumor resections and receiving controlled low VT ventilation. The values for PVI, perfusion index, stroke volume variation, and stroke volume index (SVI) were recorded at baseline VT of 6 ml Kg- 1, 1 min after the VT challenge (8 ml Kg- 1), 1 min after VT 6 ml Kg- 1 reduced back again, and then 5 min after crystalloid fluid bolus 6 ml kg- 1 (actual body weight) administered over 10 min. The fluid responders were identified by SVI rise ≥ 10% after the fluid bolus.

RESULTS

The area under the receiver operating characteristic curve for PVI value change (ΔPVI6-8) after increasing VT from 6 to 8 ml Kg- 1 was 0.86 (95% confidence interval, 0.76-0.96), P < 0.001, 95% sensitivity, 68% specificity, and with best cut-off value of absolute change (ΔPVI6-8) = 2.5%.

CONCLUSION

In hepatobiliary and pancreatic surgeries, tidal volume challenge improves the reliability of PVI for predicting fluid responsiveness and changes in PVI values obtained after tidal volume challenge are comparable to the changes in SVI.

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.

Relation between Vitamin D level and severity, symptomatology and cognitive dysfunction of Major Depressive Disorder - A sample of Egyptian patients

Introduction

Vitamin D helps in the regulation of neurotransmission and neuroprotection. Therefore, vitamin D deficiency might lead to inactivated receptors and may result in depression.

Objectives

The study assessed the relation between serum level of vitamin D and severity, symptomatology and cognitive dysfunction of Major Depressive Disorder (MDD) in a sample of Egyptian patients.

Methods

Serum levels of 25-hydroxy vitamin D were measured with electro-chemiluminescence binding assay technique in 75 patients with major depressive disorder. Patients were recruited from Psychiatry and Addiction Hospital, Kasr Al Ainy outpatient clinic. Patients were subjected to the Structured Clinical Interview for DSM-IV Axis I Disorders(SCID), Hamilton depression scale (HAM-D), Mini-mental status examination (MMSE), Wechsler memory subtests (story A and paired associate learning test (PALT) ), Benton visual retention test (BVRT) and Trail B test.

Results

94.6% of patients had vitamin D deficiency. There was no significant correlation between levels of vitamin D and severity of depression according to HAM-D. Regarding symptoms of depression, there was a statistically significant difference between levels of vitamin D, being more deficient with decreased concentration, decreased libido and menstrual disturbances. There was no statistically significant correlation between level of vitamin D and cognitive functions tests.

Conclusions

Major depressive disorder was associated with vitamin D deficiency but no statistical significant correlation could be established neither between levels of vitamin D and severity of depression nor between levels of vitamin D and cognitive dysfunction. Vitamin D level was statistically correlated with decreased concentration, decreased libido and menstrual disturbances.

Disclosure

No significant relationships.

Follow-up after emergency laparotomy suggests high one- and five-year mortality with risk stratified by ASA

INTRODUCTION

We investigated all-cause mortality following emergency laparotomy at 1 and 5 years. We aimed to establish a basis from which to advise patients and relatives on long-term mortality.

METHODS

Local data from a historical audit of emergency laparotomies from 2010 to 2012 were combined with National Emergency Laparotomy Audit (NELA) data from 2017 to 2020. Covariates collected included deprivation status, preoperative blood work, baseline renal function, age, American Society of Anesthesiologists (ASA) grade, operative time, anaesthetic time and gender. Associations between covariates and survival were determined using multivariate logistic regression and Kaplan-Meier analysis. We used patients undergoing laparoscopic cholecystectomy between 2015 and 2020 as controls.

RESULTS

ASA grade was the best discriminator of long-term outcome following laparotomy (n=894) but was not a predictor of survival following cholecystectomy (n=1,834), with mortality being significantly greater in the laparotomy group. Following cholecystectomy, 95% confidence intervals for survival at 5 years were 98-99%. Following laparotomy these intervals were: ASA grade 1, 79-96%; ASA grade 2, 69-82%; ASA grade 3, 44-58%; ASA grade 4, 33-48%; and ASA grade 5, 4-51%. The majority of deaths occurred after 30 days.

CONCLUSIONS

Emergency laparotomy is associated with a significantly increased risk of death in the following 5 years. The risk is strongly correlated to ASA grade. Thirty-day mortality estimation is not a good basis on which to advise patients and carers on long-term outcomes. ASA grade can be used to predict long-term outcomes and to guide patient counsel.

194 TIA IMAGING: ARE WE FOLLOWING NICE 2020 GUIDELINES?

Background

CT brain imaging is customary in clinical practice after Transient Ischemic Attack (TIA). However, NICE (2020) guidelines recommend MRI brain with diffusion weighted and blood-sensitive sequences; to be completed on the same day as the assessment. The purpose is to detect the ischemic territory, haemorrhage, or other pathology. The aim of this audit was to assess the diagnostic radiology investigations performed on patients, over the age of sixty-five years, presenting with TIA to a university teaching hospital.

Methods

We conducted a retrospective audit of all patients coded as TIA on the Hospital Inpatient-Enquiry (HIPE) system between July 2019 to July 2020. Data on brain imaging was accessed using the National Integrated Medical Imaging System (NIMIS) system. Hospital attendance records were accessed via the Emergency Department patient database. Data was analysed using Microsoft Excel.

Results

Eighty patients had brain imaging performed (n = 38 CT brain only; n = 1 MRI only; n = 41 CT and MRI). Of these patients, only three had an MRI brain completed within twenty-four hours where thirty-nine patients had an MRI scans outside of twenty-four hours. Forty-one patients had both a CT and MRI brain imaging performed. The median time to MRI brain was three days and one and a half hours and the median time to CT brain was two hours and forty-nine minutes.

Conclusion

This audit confirms duplication of TIA brain imaging and CT as the primary imaging tool for TIA which is not in keeping with best practice (NICE, 2020). This has implications for resources, radiation exposure and patient’s length of stay. Development of dedicated ambulatory care pathways for TIA must incorporate rapid MRI access as the primary imaging modality.

No IV hydration vs IV hydration in prevention of contrast-induced nephropathy: meta-analysis of randomized controlled trials

Background

Iodinated contrast is commonly utilized in modern medicine. However, it does not come free of risks. Incidence of contrast induced nephropathy is estimated to be 1% to 6% and can be as high as 50% in patients at high risk. IV hydration is routinely used to prevent Contrast-Induced Nephropathy (CIN). Recent randomized controlled trials (RCTs) suggested that no hydration is not inferior to hydration in prevention of CIN.

Objective

To evaluate the risk of forgoing IV hydration in patients undergoing procedures utilizing iodinated IV contrast.

Methods

We searched MEDLINE, COCHRANE, EMBASE databases for RCTs comparing no IV hydration to IV hydration in patients undergoing procedures utilizing IV iodinated contrast such as CT contrast and coronary interventions. Studies comparing any preventive measure to IV hydration were excluded. 6 RCTs were extracted that match our search criteria (1–6). 3 RCTs included patients undergoing percutaneous coronary intervention and 3 RCTs included patients with CKD stage III undergoing contrast CT. Outcome evaluated was the risk of Contrast-Induced Nephropathy in no IV hydration group compared to IV hydration group. Analysis was conducted initially using all 6 RCTs. Additional analysis was conducted using studies limited to contrast CT in patients with stage III chronic kidney disease (CKD) (3,5,6).

Results

A total of 1938 patients (972 in no IV hydration group vs 966 in IV hydration group) were analyzed from 6 RCTs. CIN occurred in 111 (11.4%) in no IV hydration group and in 62 (6.4%) in IV hydration group. Relative risk of CIN in no IV hydration group was 1.75 [95% CI 1.31–2.33, P=0.0001, I2=0%] (Figure 1).

In our analysis utilizing trials limited to contrast CT in patients with CKD stage III, a total of 1261 patients (634 in no hydration group vs 627 in IV hydration group) were analyzed from 3 RCTs. 2 trials utilized IV sodium bicarbonate and 1 used IV normal saline in IV hydration arm. CIN occurred in 21 (3.3%) who did not receive prophylactic IV hydration and in 17 (2.7%) received IV hydration. There was no increased risk of CIN in patients who did not receive IV hydration in patients with CKD stage III underwent contrast CT. Relative risk was 1.24 [95% CI 0.66–2.32, P=0.51, I2=0%] (Figure 2).

Conclusion

In patients with CKD stage III undergoing IV contrast CT scans, withholding IV hydration is not associated with increased risk of CIN compared to IV hydration. Nevertheless, this conclusion does not apply to patients undergoing coronary intervention. The difference in outcome could be explained by the population undergoing coronary interventions which is typically higher risk, and the dose of contrast which is typically higher in coronary interventions than in contrast CT.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Restrictive vs liberal blood transfusion strategy in patients with symptomatic coronary artery disease: meta-analysis from randomized controlled trials

Background

Anemia is common in patients with symptomatic coronary artery disease. Observational studies investigated blood transfusion threshold in symptomatic coronary artery disease but results were conflicting. Meta-analyses evaluating transfusion threshold utilized data mainly from observational trials but no meta-analysis, to our knowledge, used data solely from randomized clinical trials.

Objective

The goal of our study is to evaluate efficacy and safety outcomes in anemic patients presenting with symptomatic coronary artery disease using pooled data from randomized clinical trials.

Methods

We queried Medline, Embase and Cochrane data bases for randomized clinical trials comparing restrictive blood transfusion (defined as transfusion when hemoglobin is less than 8 gm/dl) vs liberal blood transfusion (transfusion when hemoglobin is less than 10 gm/dl) in patients presenting with symptomatic artery disease or acute coronary syndrome. We identified 3 randomized controlled trials; MINT, CRIT and REALITY trials. Data were pooled from 3 trials. Efficacy outcomes evaluated were all-cause mortality and New or recurrent myocardial infarction. Safety outcomes were congestive heart failure at 30-day follow up.

Results

A total of 820 patients were included in our meta-analysis; 420 patients in restrictive blood transfusion protocol and 400 in liberal blood transfusion protocol

There was no difference between two groups at 30-day follow up in all identified outcomes (all-cause mortality, new or recurrent myocardial infarction, and Congestive heart failure).

55 patients died (22/420 in restrictive group and 33/400 in liberal group). Risk ratio of all-cause mortality in restrictive group was 0.63 [95% CI (0.38–1.07), P=0.09, I2=30%].

15/420 in restrictive group and 16/400 in liberal group had new or recurrent myocardial infarction. Risk ratio of myocardial infarction in restrictive group was 0.91 [95% CI (0.46–1.80), P=0.78, I2=0%].

20/420 patients in restrictive group and 24/400 in liberal group had congestive heart failure with risk ratio of 0.80 [95% CI (0.19–3.37), P=0.30, I2=76%] in restrictive group.

Conclusion

Our meta-analysis showed similar outcomes between restrictive and liberal transfusion policies in patients presenting with symptomatic coronary artery disease of acute myocardial infarction. Our findings are consistent with available data about restricting transfusion in general population. Restricting blood transfusion might be cost-effective. Further studies are warranted to evaluate long term safety and efficacy of such approach.

Funding Acknowledgement

Type of funding sources: None.

Coronary computed tomography angiography vs.standard of care for evaluation of NSTE-ACS: a systematic review and meta-analysis

Background

Non-ST elevation acute coronary syndrome (NSTE-ACS) is one of the common cardiac emergencies that pose a diagnostic challenge, especially in the absence of EKG changes or elevation in cardiac markers. Coronary computed tomography angiography (CT) has an established role in the evaluation of stable chest pain with ESC giving it class I recommendation. The role of CCTA in the management of NSTE-ACS is less clear.

Purpose

To evaluate the hypothesis of CT efficacy in identifying and managing patients with NSTE-ACS in comparison to the standard of care (SOC).

Methods

We searched MEDLINE, EMBASE, and Cochrane Central for randomized controlled trials (RCT) that compared initial CT utilization vs SOC in patients presenting with acute chest pain with suspected or confirmed NSTE-ACS. SOC arm included initial evaluation and triaging by treating physician including but not limited to clinical observation, serial cardiac markers, stress testing, and invasive coronary angiography (ICA). Studies with follow-up data of 1 month or more were included. Outcomes evaluated were incidence of rehospitalization/ER visits post index visit, referral to ICA, and presence of significant lesion during ICA requiring revascularization.

Results

A total of 6,862 patients (3,663 in the CT arm and 3,199 in the SOC) were analyzed from 13 RCTs. No statistically significant difference was noted between two intervention arms with regards to repeat hospital visits [Odds ratio (OR): 1.02; 95% CI: 0.85–1.24; P=0.82; I2=0%], and referral to ICA (OR: 1.32: 95% CI: 0.95–1.83; P=0.10; I2=66). CT was however more likely to uncover significant lesions requiring revascularization compared to SOC arm (OR: 1.77; 95% CI: 1.32–2.37; P=0.0001; I2=23%].

Conclusion

Our meta-analysis showed that in patients with suspected NSTE-ACS, CT is associated with similar rates of ICA referral and re-admissions albeit being more likely to uncover hemodynamically significant lesions that require revascularization. These findings are consistent with the finding of the recently published VERDICT trial that showed comparable efficacy between coronary CT and ICA. Further studies evaluating the long term cardiovascular outcomes are warranted.

Funding Acknowledgement

Type of funding sources: None.

Polypill and its association with cardiovascular morbidity and mortality: meta-analysis from randomized controlled trials

Background

Polypill or fixed dose combination pill (containing antihypertensive and cholesterol lowering agents) has shown, in multiple studies, to increase adherence and improve blood pressure and cholesterol measurements in at risk underprivileged populations. However, its long term effect on mortality, cardiovascular and cerebrovascular outcomes in high risk groups is not well-established.

Objective

To assess mortality, cardiovascular and cerebrovascular outcomes in higher risk patients using polypill containing fixed dose of Aspirin, antihypertensive drugs and Statin compared to standard care or placebo.

Methods

We queried MEDLINE, COCHRANE, and EMBASE databases for randomized controlled trials (RCTs) comparing polypill containing Aspirin, Statin and at least 2 antihypertensive medications, to standard care or placebo in patients with increased risk of cardiovascular diseases. We looked for trials including data about mortality, coronary and cerebrovascular events. We excluded trials that did not include outcomes of interest. 5 RCTs matching our criteria were included in our meta-analysis; UMPIRE 2013, IMPACT 2014, Kanyini GAP 2015, PolyIran 2019, and TIPS-3 2021.

Results

12828 patients (6419 in polypill vs 6409 in standard care/placebo groups) with known all-cause mortality, coronary events and cerebrovascular events outcomes were analyzed from 5 RCTs. For cardiovascular mortality outcome, 12205 patients (6108 in polypill vs 6097 in standard care/placebo groups) were analyzed from 4 RCTs since 1 RCT lacked data about cardiovascular mortality outcome. There was no difference between both groups in all four outcomes.

Risk ratio of all-cause morality and cardiovascular mortality in polypill group was 0.89 [95% CI 0.76–1.03, P=0.11, I2=0%] and 0.77 [95% CI 0.48–1.26, P=0.31, I2=59%] respectively (Figure 1).

Risk ratio of coronary events in polypill group was 0.88 [95% CI 0.64–1.20, P=0.41, I2=40%]. Relative risk of cerebrovascular events was 0.73 [95% CI 0.36–1.48, P=0.38, I2=63%] (Figure 2).

Conclusion

Polypill, despite being a practical solution to non-adherence in at risk underprivileged groups, does not improve mortality or major cardiovascular or cerebrovascular outcomes compared to standard care or placebo. Further efforts need to be made towards aggressive preventative measures and encouraging adherence to medications in groups at risk.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Correlation between Length of Ala and Transverse Diameter of First Sacral Vertebral Body in both Sexes

Sacrum is a triangular bone formed by the fusion of five sacral vertebrae. It is situated near the lower end of the spinal column, where it joins both hip bones to form the posterio superior wall of the pelvic cavity. It is an important bone for identification of sex in human skeletal system. This cross sectional and descriptive study was done among 150 (59 male and 91 female) fully ossified dry human sacrum in Mymensingh Medical College, Mymensingh, Bangladesh from January 2017 to December 2017. The sex of sacrum was determined by previously measured different parameters. Sample collection was done by purposive sampling technique from anatomy department of Mymensingh Medical College and Community Based Medical College of Bangladesh, Mymensingh. The parameters included the length of ala and transverse diameter of first sacral vertebral body which were measured by digital vernier slide caliper and was expressed in mm. In present study the mean length of ala in male and female were 29.21±6.30mm and 30.77±5.56mm respectively. The mean transverse diameter of first sacral vertebral body in male and female were 48.10±4.83mm and 44.05±6.16mm respectively. Comparison of both length of ala and transverse diameter of first sacral vertebral body was done between male and female by unpaired student 't' test which was statistically significant. There was positive correlation between these two parameters and the differences were statistically highly significant in both sexes.

Rib fracture fixation in a patient on veno-venous ECMO for severe blunt thoracic trauma

Thoracic chest wall trauma is a common injury in patients admitted to hospital following injury and is associated with high mortality. British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines recommend consideration of rib fracture fixation in patients with flail chest wall injuries with respiratory compromise or uncontrollable pain. Veno-venous extracorporeal membrane oxygenation (ECMO) can be utilised in patients with severe respiratory dysfunction and we present the case of a patient who underwent rib fracture fixation while receiving ECMO. A 32-year-old male was admitted to our department following a 4.5m fall. He sustained significant thoracic injuries with multiple ribs fractures and a flail segment from the right fourth to ninth ribs. Treatment consisted of bilateral chest drains, ECMO support, tracheostomy and rib fracture fixation to the eighth and ninth ribs. The patient made a rapid recovery following surgery and ECMO support was ceased 2.5 days postoperatively. The case shows that a well-prepared, combined specialty surgical team can safely perform rib fixation for a patient on ECMO.

A Postmortem Study of Length & Depth of the Central Sulcus in Different Age & Sex Groups of Bangladeshi People

The central sulcus (CS) is a prominent landmark of the brain, separating the parietal lobe from the frontal lobe and the primary motor cortex from the primary somatosensory cortex. Variations in the morphology of the central sulcus are seen with respect to the length and depth of the central sulcus. This study was done to establish a normal standard of length and depth of central sulcus in different age and sex groups of Bangladeshi people. Interhemispheric age and gender differences of the central sulcus were done by cross sectional descriptive study which was performed into four categories- Group A (20 to 29 years), Group B (30 to 39 years), Group C (40 to 49 years) and Group D (50 years & above). The specimens were collected from morgue in the department of Forensic Medicine, Mymensingh Medical College, Bangladesh by purposive sampling technique. The length of central sulcus was measured by using thread and the depth was measured by using wooden stick at middle of the upper, middle and lower third of the central sulcus in superolateral surface. The mean length of central sulcus was 10.51±0.529cm to 9.78±0.996cm in male and 10.27±0.786cm to 8.83±0.379cm in female. Depth of the central sulcus was 1.333±0.100cm to 1.029±0.125cm in male and 1.173±0.144cm to 1.01±0.200cm in female. The difference in mean length & depth of the central sulcus for both left and right hemisphere between male and female was statistically non significant in all age groups. In present study the length and depth of the central sulcus showed gradual decreasing values with advancing age. Knowledge of morphometry of central sulcus is not only important during neurosurgery of brain but also holds tremendous significance in diagnosis and management of diseases of the cerebral cortex. The present study will help to increase the information pool on the length and depth of the central sulcus of Bangladeshi people which will minimize the dependency on foreign standards.

Impact of stereoacuity on simulated cataract surgery ability

BACKGROUND AND OBJECTIVES

There exists a long-standing perception that diminished stereoacuity has a detrimental effect on microsurgical ability and skills acquisition. This has potential implications on the enrolment of surgical trainees into ophthalmology and other microsurgery specialities. However, strong evidence in this area is lacking. This case-control study aims to establish the exact level of stereopsis impairment at which a statistical drop in surgical performance occurs.

METHODS

Fifty participants were enrolled from the University of Dundee Medical School and the NHS Tayside Foundation Doctor programme. Participants were assessed for their stereopsis level before completing an orientation module on an ophthalmic surgical simulator. They were then required to repeat a task four times. Automated and objective performance levels were recorded and analysed.

RESULTS

Nineteen (38%) had stereopsis lower than the defined normal of 60 seconds of arc (arcsec). Statistical analysis found no correlation between visual acuity and surgical performance. No statistical difference was found between performance scores and stereoacuities of 30, 60 and 120 arcsec. A statistically significant difference was discovered in the surgical performance of participants with a stereoacuity worse than 120 arcsec (total score = -69.85) as compared to the ones with a stereoacuity of 120 arcsec or better (total score = -42.23) with p = 0.010.

CONCLUSIONS

This study provides evidence of a specific level of stereopsis where statistical degradation of surgical performance occurs. The findings of this work may help formulate policy on stereoacuity standards required to commence microsurgical training.

Variation of Length of Calcarine Sulcus in Different Age & Sex Groups of Bangladeshi People

Calcarine sulcus, one of the major sulcus of occipital lobe of cerebral hemisphere which is intimately related with visual function. The detailed anatomy of this lobe is essential for the surgeons and radiologists for clinical investigation & surgery. The aim of the present study was to identify the variation of this sulcus of the occipital lobe. This study was done to establish a normal standard in length of calcarine sulcus in different age & sex groups of Bangladeshi people. Inter-hemispheric age and gender differences of this sulcus was done by cross sectional descriptive study which was performed into four categories: Group A (20 to 29 years), Group B (30 to 39 years), Group C (40 to 49 years) and Group D (50 years & above). The specimens were collected from morgue in the department of Forensic Medicine, Mymensingh Medical College, Mymensingh, Bangladesh by purposive sampling technique. The length of calcarine sulcus was measured by using thread. The mean length of calcarine sulcus was lowest to highest values 7.07±0.616cm to 7.86±0.792cm in male and 6.53±0.808cm to 7.62±0.806cm in female. The mean difference of the length of right calcarine sulcus between group A & D was statistically significant at p<0.05, but not significant in any other age & sex groups for both left and right hemisphere. In present study, the length of the calcarine sulcus showed gradual decreasing values with advancing age. For proper planning of neurosurgical procedures and radiological representation of visual functional areas, detailed knowledge on the variation of this sulcus is essential. Proper knowledge of calcarine sulcus can permit safer access to deep structures and reduce operative complications. The present study will also help to increase the information pool on the length of the calcarine sulcus of Bangladeshi people which will minimize the dependency on foreign standards.

Evidence of platelet dysfunction in congenital cyanotic heart disease: relevance to palliative systemic-pulmonary shunt and haemostatic parameters

Introduction

Platelets in congenital cyanotic heart disease (CCHD) were occasionally characterized by significantly enhanced expression of P-selectin in resting circulating platelets as well as their augmented activation in response to stimulating agents. P-selectin is present in the alpha granule membrane as well as Weibel-Palade body membrane of endothelial cells. It is translocated to platelet membrane after activation; thus, its expression on platelet surface is an indicator of platelet activation in vivo. The occurrence of the prothrombotic variant of GPIIIa in cyanotic children may be associated with enhanced activation of circulating platelets.

Purpose

To study the platelet functions in patients with CCHD by determination of Pselectin expression and the GPIIIa polymorphism and to correlate these findings with other clinical, radiological, and laboratory parameters in these patients.

Methods

This study included 47 patients, with cyanotic congenital heart disease with decreased pulmonary blood flow, attending the Pediatric Cardiology Clinic. They were divided into two groups: Group I: 31 patients with congenital cyanotic heart disease before cardio surgery Group II: 16 patients with congenital cyanotic heart disease 3–6 months after palliative or corrective cardio surgery, Group III: 12 age and sex matched normal children were included in the study as control group. They were subjected to Flow-cytometric evaluation of platelet activation by Pselectin expression: P-selectin expression was estimated using monoclonal antibody.-Typing of GPIIIa gene polymorphism was done.

Results

Statistically significant higher P-selectin levels were found in patients compared with controls being significantly higher in patients &lt;3 years of age. There was significant negative correlation between P-selectin level and O2 in patients. The incidence of prothrombotic variant A2 was described as phenotype positive. Statistically significant higher levels of P-selectine were found in positive phenotype patients than positive phenotype controls

Conclusion

Enhanced platelet activation may be an important contributor in the high thrombotic liability in congenital cyanotic heart disease. This may be attributed in part to genetic factors

Funding Acknowledgement

Type of funding source: None

Menthacarin induces calcium ion influx in sensory neurons, macrophages and colonic organoids of mice

AIMS

Menthacarin is a herbal combination that is clinically used for the treatment of functional gastrointestinal disorders (FGIDs). In several clinical studies, Menthacarin reduced visceral hypersensitivity-related symptoms. Pathogenesis of visceral hypersensitivity is multifactorial. This involves several cell types and different transient receptor potential ion channels (TRPs); these ion channels are highly conductive for calcium ions. Since transient changes in cytosolic calcium levels are crucial for many functions of living cells, we investigated if Menthacarin can induce calcium influx in sensory, largely nociceptive, neurons from dorsal root ganglia (DRG), peritoneal macrophages (PMs) and colonic organoids.

MAIN METHODS

We employed the calcium imaging technique on sensory neurons from DRG, PMs and colonic organoids isolated from mice. All cells were superfused by Menthacarin at several concentrations (600, 1200, 1800 μg/ml) during the experiments, followed by calcium ionophor ionomycin (Iono., 1 μM) as a positive control.

KEY FINDINGS

Menthacarin induced concentration-dependent calcium ion influx in all investigated cell types. Furthermore, repeated applications of Menthacarin induced tachyphylaxis (desensitisation) of calcium responses in sensory neurons and colonic organoids.

SIGNIFICANCE

Menthacarin-induced calcium influx into sensory neurons, macrophages and colonic organoids is probably related to its clinical desensitising effects in patients with FGIDs.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Invasive pulmonary aspergillosis: comparative analysis in cancer patients with underlying haematologic malignancies versus solid tumours

BACKGROUND

Invasive pulmonary aspergillosis (IPA) is commonly associated with haematologic malignancies but also occurs with solid tumours.

AIM

To compare the diagnostic approaches and therapeutic outcomes for IPA between patients with haematologic malignancies and solid cancers.

METHODS

A retrospective study was conducted evaluating consecutive cases of proven and probable IPA from 2004 to 2016. Patients >18 years of age with an underlying solid tumour, haematologic malignancy, or haematopoietic cell transplantation (HCT) within one year of IPA diagnosis were included.

FINDINGS

Of the 311 patients analysed, 225 had haematologic malignancies and 86 had solid tumours. Patients with solid tumours were more likely to have had chronic obstructive pulmonary disease (COPD) or other pulmonary diseases, have Aspergillus fumigatus infections, and have received radiotherapy before IPA occurrence than were those with haematologic malignancies (all P<0.01). Antifungal monotherapy and voriconazole-based therapy were more often prescribed in the solid group (87% vs 56%, P<0.0001, and 77% vs 53%, P=0.0002, respectively). The median duration of primary antifungal therapy was longer in the solid group (64 days vs 20 days, P<0.0001). Complete or partial response to antifungal therapy was recorded in 66% of the solid group and 40% of the haematologic group (P=0.0001). At 12 weeks, overall mortality was similar in both groups, but IPA-attributable mortality was higher in the haematologic group (30% vs 18%, P=0.04).

CONCLUSIONS

Monotherapy was more often prescribed in patients with solid tumours than in patients with haematologic malignancies. Patients with solid tumours had better antifungal therapy response and lower 12-week IPA-attributable mortality than did those with haematologic malignancies.

Kappa free light chains is a valid tool in the diagnostics of MS: A large multicenter study

OBJECTIVE

To validate kappa free light chain (KFLC) and lambda free light chain (LFLC) indices as a diagnostic biomarker in multiple sclerosis (MS).

METHODS

We performed a multicenter study including 745 patients from 18 centers (219 controls and 526 clinically isolated syndrome (CIS)/MS patients) with a known oligoclonal IgG band (OCB) status. KFLC and LFLC were measured in paired cerebrospinal fluid (CSF) and serum samples. Gaussian mixture modeling was used to define a cut-off for KFLC and LFLC indexes.

RESULTS

The cut-off for the KFLC index was 6.6 (95% confidence interval (CI) = 5.2-138.1). The cut-off for the LFLC index was 6.9 (95% CI = 4.5-22.2). For CIS/MS patients, sensitivity of the KFLC index (0.88; 95% CI = 0.85-0.90) was higher than OCB (0.82; 95%CI = 0.79-0.85; p < 0.001), but specificity (0.83; 95% CI = 0.78-0.88) was lower (OCB = 0.92; 95% CI = 0.89-0.96; p < 0.001). Both sensitivity and specificity for the LFLC index were lower than OCB.

CONCLUSION

Compared with OCB, the KFLC index is more sensitive but less specific for diagnosing CIS/MS. Lacking an elevated KFLC index is more powerful for excluding MS compared with OCB but the latter is more important for ruling in a diagnosis of CIS/MS.