Smoking Status and Outcomes following Lung Resection

BACKGROUND

 Surgical resection is the gold standard treatment for the management of early-stage lung cancer. Several modifiable factors may significantly influence postoperative morbidity and mortality. We examined the outcomes of patients following lung resection based upon preoperative smoking status to quantify the impact on postoperative outcomes.

METHODS

 Data from consecutive lung resections from January 1, 2012 to June 11, 2021 were included. Biopsies for interstitial lung disease and resections for emphysematous lung or bullae were excluded. Patients were divided into three cohorts: current smokers (those who smoked within 4 weeks of surgery), ex-smokers (those who stopped smoking prior to 4 weeks leading up to surgery), and nonsmokers (those who have never smoked). Patient's preoperative variables, postoperative complications, length of stay, and mortality were examined.

RESULTS

 A total of 2,426 patients were included in the study. A total of 502 patients (20.7%) were current smokers, 1,445 (59.6%) were ex-smokers and 479 patients (19.7%) nonsmokers. Of those smoking immediately prior to surgery 36.9% developed postoperative complications. Lower respiratory tract infections (18.1%) and prolonged air leak (17.1%), in particular, were significant higher in smokers. 90-day mortality (5.8%) was higher in the current smokers when compared with ex- and nonsmokers (5.3 and 1%, respectively). Median length of hospital stay, readmissions, and cost of hospital stay was also higher in the current smoker cohort.

CONCLUSION

 Smoking immediately prior to surgery is associated with an increase in morbidity, mortality, and length of stay. Not only does this have a significant individual impact, but it is also associated with a significant financial burden to the National Health Service.

Correlation of palatal anatomic characteristics with dermatoglyphic heterogeneity in different growth patterns

AIM AND OBJECTIVE

The study aimed to explore the correlation between dermatoglyphic patterns and quantitative palatal anatomic variables in individuals with different growth patterns.

MATERIALS AND METHOD

A cross-sectional study was conducted involving 126 healthy patients aged 17-25 years. Participants were divided into three groups based on growth patterns: average, vertical, and horizontal. Dermatoglyphic patterns were recorded using an optical fingerprint sensor, and palatal characteristics were measured using digital software. Palatal characteristics, including intercanine width, intermolar width, and palatal depth, were measured using digital software. The results were statistically analyzed.

RESULTS

Significant differences were observed in ridge counts among the three growth patterns. The average growth pattern showed lower ridge counts compared to the vertical and horizontal growth patterns. Dermatoglyphic patterns, such as double loops and tented arches, were significantly higher in the horizontal growth pattern. Weak correlations were found between certain dermatoglyphic patterns and palatal characteristics, with simple arch patterns showing a negative correlation with inter-canine width and symmetrical whorl patterns showing a positive correlation with palatal depth. Loop patterns, spiral patterns, double loop patterns, symmetrical whorl, and simple arch patterns were significant predictors of growth patterns.

CONCLUSION

This study revealed distinct dermatoglyphic patterns and ridge counts among individuals with different growth patterns. Weak correlations were observed between dermatoglyphic patterns and palatal characteristics. However, the predictive value of dermatoglyphics for skeletal malocclusion requires further investigation. Understanding the relationships between dermatoglyphic patterns and craniofacial growth can provide valuable insights into genetic and developmental factors affecting dental and orthodontic conditions.

A comparative study of uncomplicated acute non-A-E hepatitis with acute viral hepatitis and acute onset autoimmune hepatitis

BACKGROUND AND AIMS

Non-A-E hepatitis (NAEH) not leading to acute liver failure (ALF) is poorly documented. The objective was to compare clinical and laboratory features of uncomplicated acute NAEH with acute viral (AVH) and autoimmune hepatitis (AIH) and histopathology in NAEH and AIH.

METHODS

Cases of hepatocellular jaundice were included. These were grouped into AVH, AIH and NAEH based on clinical, laboratory and, when indicated, liver biopsy findings. NAEH and AIH were followed up at three months.

RESULTS

Of 336 patients with hepatocellular jaundice, 15 (5%) were NAEH, 25 (7%) acute AIH and 45 (14%) AVH. Among NAEH patients, seven (46.7%) were males with a mean age of presentation 39 years. Jaundice (100%) was the most common presentation of NAEH. Peak bilirubin was 10.7 mg/dL. Peak aspartate and alanine aminotransferase (AST, ALT) were 512 and 670 U/L. Five (33.3%) patients had positive anti-nuclear antibody and one had anti-smooth muscle antibody. Mean immunoglobulin G (IgG) levels were 1829. On liver biopsy, all had ballooning degeneration, four (26.7%) had mild and three (20%) moderate interface hepatitis, four (26.7%) mild lymphoplasmacytic infiltrate, one (6.7%) rosette formation, bridging necrosis in none and stage 1 fibrosis in one. Comparing NAEH with AIH, AIH showed significantly older age at presentation, female predisposition, past history of jaundice, lower ALT, more autoantibodies, higher IgG, higher grade interface hepatitis, lymphoplasmacytic infiltrate, rosette formation and higher bilirubin, AST at three months. NAEH and viral hepatitis had similar features.

CONCLUSION

Etiology of NAEH is unlikely to be autoimmune and is probably viral, unidentified as yet. Uncomplicated NAEH likely has self-limiting course even without specific treatment.

Upfront tofacitinib in patients with biological-naïve ulcerative colitis - An Indian multicentric experience

OBJECTIVES

Tofacitinib is a Janus Kinase inhibitor used for treating moderate to severe ulcerative colitis (UC), mainly after the failure of biological therapy. There is a paucity of data on the outcome of tofacitinib in biological-naïve UC patients. The present study was aimed at analyzing the safety and efficacy of tofacitinib in biological-naïve Indian patients with UC.

METHODS

The present study retrospectively evaluated consecutive patients with biological-naïve moderate-to-severe active UC from six tertiary care centers in India receiving tofacitinib from September 2020 to September 2022. Clinical remission or response assessment was based on partial Mayo score (PMS) calculated at baseline and weeks eight, 16 and 24.

RESULTS

Total 47 cases (57.4% male, median age: 32 years) were included. After eight weeks of therapy, 33 (70.2%) achieved clinical remission and eight (17.0%) had a primary failure. The baseline serum albumin at treatment initiation was the only independent predictor of remission at eight weeks (Odds ratio: 11.560, 95% CI: 1.478 - 90.404), but not at 16 weeks. By 24 weeks, 59.6% (28/47) of the patients were in remission and 29.8% (14/47) had stopped tofacitinib either due to failure (27.6%) or adverse events (AEs) (2.1%). Among the 47 patients, 10 (21.2%) cases developed AEs during follow-up, including two tuberculosis (4.2%), one cytomegalovirus (CMV) colitis (2.1%) and one herpes zoster (2.1%). Four patients with infection required temporary drug discontinuations. One required permanent discontinuation (mania).

CONCLUSION

Upfront tofacitinib is effective in biologic-naïve Indian patients with moderate-severe UC. Further randomized studies are required to validate the study findings.

The Association of Incidental Radiation Dose to the Heart Base with Overall Survival and Cardiac Events after Curative-intent Radiotherapy for Non-small Cell Lung Cancer: Results from the NI-HEART Study

AIMS

Cardiac disease is a dose-limiting toxicity in non-small cell lung cancer radiotherapy. The dose to the heart base has been associated with poor survival in multiple institutional and clinical trial datasets using unsupervised, voxel-based analysis. Validation has not been undertaken in a cohort with individual patient delineations of the cardiac base or for the endpoint of cardiac events. The purpose of this study was to assess the association of heart base radiation dose with overall survival and the risk of cardiac events with individual heart base contours.

MATERIALS AND METHODS

Patients treated between 2015 and 2020 were reviewed for baseline patient, tumour and cardiac details and both cancer and cardiac outcomes as part of the NI-HEART study. Three cardiologists verified cardiac events including atrial fibrillation, heart failure and acute coronary syndrome. Cardiac substructure delineations were completed using a validated deep learning-based autosegmentation tool and a composite cardiac base structure was generated. Cox and Fine-Gray regressions were undertaken for the risk of death and cardiac events.

RESULTS

Of 478 eligible patients, most received 55 Gy/20 fractions (96%) without chemotherapy (58%), planned with intensity-modulated radiotherapy (71%). Pre-existing cardiovascular morbidity was common (78% two or more risk factors, 46% one or more established disease). The median follow-up was 21.1 months. Dichotomised at the median, a higher heart base Dmax was associated with poorer survival on Kaplan-Meier analysis (20.2 months versus 28.3 months; hazard ratio 1.40, 95% confidence interval 1.14-1.75, P = 0.0017) and statistical significance was retained in multivariate analyses. Furthermore, heart base Dmax was associated with pooled cardiac events in a multivariate analysis (hazard ratio 1.75, 95% confidence interval 1.03-2.97, P = 0.04).

CONCLUSIONS

Heart base Dmax was associated with the rate of death and cardiac events after adjusting for patient, tumour and cardiovascular factors in the NI-HEART study. This validates the findings from previous unsupervised analytical approaches. The heart base could be considered as a potential sub-organ at risk towards reducing radiation cardiotoxicity.

A potential biomarker of radiosensitivity in metastatic hormone sensitive prostate cancer patients treated with combination external beam radiotherapy and radium-223

PURPOSE

The ADRRAD trial reported the safety and feasibility of the combination of external beam radiotherapy and radium-223 in the treatment of de novo bone metastatic prostate. This study aimed to determine if any biomarkers predictive of response to these treatments could be identified.

EXPERIMENTAL DESIGN

30 patients with newly diagnosed bone metastatic hormone sensitive prostate cancer were recruited to the ADRRAD trial. Blood samples were taken pre-treatment, before cycles 2 to 6 of radium-223, and 8 weeks and 6 months after treatment. Mononuclear cells were isolated and DNA damage was assessed at all timepoints.

RESULTS

DNA damage was increased in all patients during treatment, with bigger increases in foci observed in patients who relapsed late compared to those who relapsed early. Increases in DNA damage during the radium-223 only cycles of treatment were specifically related to response in these patients. Analysis of hematology counts also showed bigger decreases in red blood cell and hemoglobin counts in patients who experienced later biochemical relapse.

CONCLUSIONS

While some patients responded to this combination treatment, others relapsed within one year of treatment initiation. This study identifies a biomarker based approach that may be useful in predicting which patients will respond to treatment, by monitoring both increases in DNA damage above baseline levels in circulating lymphocytes and decreases in red blood cell and hemoglobin counts during treatment.

A surgical case report of an epiploic hernia - A mobile right colon herniating through the foramen of Winslow

INTRODUCTION

An Epiploic Hernia is an extremely rare type of abdominal hernia with <0.1 % incidence where the bowel or other intra-abdominal contents herniate through the Foramen of Winslow. A case of an Epiploic hernia in a middle-aged female is presented here.

PRESENTATION OF CASE

A woman in her 60s was admitted to a tertiary level hospital with severe right sided intermittent upper abdominal pain associated with nausea, bloating and constipation. The symptoms were thought to be due to biliary colic and managed conservatively. Since the symptoms persisted and a computed tomography scan of abdomen was organized. CT scan showed that the caecum was in the upper left quadrant. A laparoscopy was performed and demonstrated that her right colon was mobile herniating through the Foramen of Winslow into the lesser sac. The hernia was reduced, and the bowel was viable. The patient was discharged with no complications.

DISCUSSION

There have been case reports of small bowel as the content of the hernia with lesser occurrences of caecum, ascending colon, transverse colon, gall bladder, omentum, or Meckel's diverticulum. A caecal herniation through the Foramen of Winslow is reported only with an incidence of 0.02 %. <10 % of these Epiploic hernias are diagnosed preoperatively making it a potentially life-threatening condition if not treated promptly due to high risk of bowel strangulation and mortality of up to 50 %.

CONCLUSION

A high index of suspicion is needed for the diagnosis of this internal hernia and radiological investigation is fundamental in making this diagnosis for allowing prompt surgical treatment.

Impact of Extremes of BMI on Outcomes following Lung Resection

BACKGROUND

 Body mass index (BMI) has been shown to be an independent predictor of survival following lung resection surgery. This study aimed to quantify the short- to midterm impact of abnormal BMI on postoperative outcomes.

METHODS

 Lung resections at a single institution were examined between 2012 and 2021. Patients were divided into low BMI (<18.5), normal/high BMI (18.5-29.9), and obese BMI (>30). Postoperative complications, length of stay, and 30- and 90-day mortality were examined.

RESULTS

 A total of 2,424 patients were identified. Of these patients, 2.6% (n = 62) had a low BMI, 67.4% (n = 1,634) had a normal/high BMI, and 30.0% (n = 728) had an obese BMI. Overall postoperative complications were higher in the low BMI group (43.5%) when compared with normal/high (30.9%) and obese BMI group (24.3%) (p = 0.0002). Median length of stay was significantly higher in the low BMI group (8.3 days) compared with 5.2 days in the normal/high and obese BMI groups (p < 0.0001). Ninety-day mortality was higher in the low (16.1%) compared with the normal/high (4.5%) and obese BMI groups (3.7%) (p = 0.0006). Subgroup analysis of the obese cohort did not elucidate any statistically significant differences in overall complications in the morbidly obese. Multivariate analysis determined that BMI is an independent predictor of reduced postoperative complications (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.94-0.97; p < 0.0001) and 90-day mortality (OR, 0.96; 95% CI, 0.92-0.99; p = 0.02).

CONCLUSION

 Low BMI is associated with significantly worse postoperative outcomes and an approximate fourfold increase in mortality. In our cohort, obesity is associated with reduced morbidity and mortality following lung resection surgery, confirming the existence of the obesity paradox.

Association between multilingualism and cognitive performance among older adults in rural southern India

Objectives

Recent studies have shown that multilingualism may play an important role in enhancing cognitive health. The process of language acquisition constitutes a form of natural brain training, which in turn is hypothesized to increase neuroplasticity and hence, maintains the cognitive reserve. The study aimed to analyze the relationship between the number of languages known to an individual and its effect on cognitive functioning in both healthy and cognitively impaired study participants.

Materials and Methods

This study utilized cross-sectional (baseline) data from Srinivasapura Aging, Neuro Senescence and COGnition study, which is an ongoing community-based, longitudinal aging cohort study conducted in a rural setting in southern India. A total of 3725 participants were considered for the study. The participants were separated into two groups, namely, monolinguals (participants knowing one language) and multilingual (participants knowing more than one language). The cognitive performance of the participants was assessed using the Clinical Dementia Rating (CDR) Scale. In addition, bivariate analyses and binary logistic regression analyses were carried out.

Results

The result of CDR scores with respect to language category shows that, among the monolingual participants, 86.5% were healthy individuals and 13.5% were with mild cognitive impairment (MCI). Similarly, among the multilingual, 94.3% were healthy and 5.7% were with MCI. The odds ratio value derived from logistic regression (0.69 95% CI (0.5-0.9)) that an individual has a higher chance of developing cognitive impairment if he/she is a monolingual.

Conclusion

This study highlights that knowing more than one language might have a profound positive impact on cognitive health, thereby reducing the likelihood of developing cognitive decline.

A case of giant colonic lipoma removed endoscopically using a modified hybrid technique

Colonic lipomas are benign adipose tumors and are mostly asymptomatic. They may cause symptoms when their size becomes more than 2 cm. Giant colonic lipoma (GCL) is a rare finding in endoscopy which presents with or without macroscopic ulceration and may lead to iron deficiency anaemia (IDA). The choice of treatment of symptomatic large colonic lipomas has been controversial. Here we are presenting a case of GCL presenting with occult bleeding causing iron deficiency anaemia (IDA). It was removed endoscopically using a combination of noradrenaline, endoloop ligation, and snare cautery technique (modified hybrid technique). Successful removal of the GCL lead to the resolution of IDA. This case report highlights that even GCL can be removed endoscopically, thus surgery can be prevented. Clinical Significance: GCL is an unusual cause of anemia. Modified hybrid endoscopic removal technique improves safety.

25 The efficacy of pre-operative multidisciplinary meetings for surgical management of strabismus

Informal discussion regarding surgical management plans between strabismus surgeons is common but this limits potentially valuable multi-disciplinary input and learning opportunities. We evaluate the effectiveness of virtual multidisciplinary meetings to provide a platform for discussion of pre-operative strabismus surgical cases.Weekly virtual MS Teams meetings are held on Monday mornings for one hour, attended by the three paediatric consultants, paediatric fellow, all trainees on the paediatric firm and orthoptists. The meetings are recorded and available for reference to the content and for those not present.Presentations for upcoming surgery cases are prepared and presented by the fellow, with discussion from participants regarding examination findings and surgical options. Cases are anonymised to allow multicentre collaboration. The agreed management plan is documented in the patient's medical notes, and outcomes of challenging cases are discussed.The management plan is formalised during the MDT. Where required, additional tests are arranged. There are opportunities for all participants to constructively challenge decisions. Trainees of all levels are actively engaged by presenting, listening to the rationale behind surgical plans, with the opportunity to ask and respond to questions.Patients are informed that their case has been presented in the MDT to obtain multiple opinions, which gives them additional confidence. Orthoptists can see the impact of the measurements they provide, and how differing tests can change management plans.This MDT has been a positive change to our surgical strabismus patient pathway. Knowledge and teamwork have been strengthened using this innovative virtual discussion method.

Simulation CT Features and Radiation Cardiotoxicity in Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Radiation cardiotoxicity is a significant clinical dilemma in non-small cell lung cancer (NSCLC) radiation therapy (RT). Baseline cardiovascular (CV) status may influence the risk of cardiotoxicity, and may be ascertainable from the appearance of the heart on simulation computed tomography (CT). We examined the association of CT features with incidental heart dose and risk of cardiac events in NSCLC.

MATERIALS/METHODS

Patients treated with curative-intent RT between 2015 and 2020 at a regional center were identified. Clinical notes were interrogated for baseline patient and CV health details, and follow-up CV events. Cardiac events were verified by a cardiologist. A deep learning-based auto-segmentation tool was applied, allowing extraction of a pre-specified list of volume parameters in a programming environment. CAC was graded as none, mild, moderate and severe in patients with a non-contrast scan. The craniocaudal relationship of the PTV and heart (Feng atlas) were annotated.

RESULTS

A total of 478 patients were included, with a median age of 70 and Charlson Index of 5. The median mean heart dose was 6.3 Gy (IQR 2.7-11.4). The median lung V20 was 20.0% (IQR 14.8-27.1). Cardiovascular risk factors were common, with most patients having 2 (39%) or 3 (31%). A history of previous cardiac events was common, including myocardial infarction (14%), arrhythmia (11%) or heart failure (9%). A total of 6.9% and 7.1% patients developed a new atrial arrhythmia (AA) or heart failure (HF) after completing RT. The volume metrics with the highest AUC for AA and HF events were the left atrium (LA) (AUC 0.67, p = 0.0002) and left ventricle:right ventricle (LV:RV) ratio (AUC 0.66, p = 0.0021). Kaplan-Meier analysis for cardiac events dichotomizing at the optimal cut-point for maximum sensitivity and specificity demonstrated significantly different rates for both AA (LA 109cc, HR 3.35, 95% CI 1.64-6.83, p = 0.0009) and HF (LV:RV ratio 1.61, HR 2.37, 95% CI 1.19-4.74, p = 0.0143). Only 2 patients with non-contrast scans developed a myocardial infarction, both had mild CAC. The incidence of pooled cardiac events was not significantly different between patients with no (n = 2/21, 9.5%), mild (n = 10/38, 26.3%), moderate (n = 8/53, 15.1%) and severe (n = 7/24, 29.2%) CAC (p = 0.3916). Where the inferior border of the PTV was above the superior border of the heart, mean heart dose was significantly lower than compared with overlap of levels (1.9 Gy v 9.7 Gy, p<0.0001), and this was true for 3DCRT (n = 139, p<0.001), IMRT (n = 94, p<0.001) and VMAT (n = 145, p<0.001) patients.

CONCLUSION

LA volume and LV:RV volume ratio are predictive for the development of AA and HF respectively. CAC grade did not differentiate patients by risk of cardiac events. Where the craniocaudal level of the PTV doesn't overlap with the level of the heart, the cardiac dose is likely to be very low. Several simulation CT features are associated with cardiac events following treatment for NSCLC and prospective evidence of cardiac risk could enable medical optimization prior to RT.

AN INCREASED RISK OF HORMONAL DISORDERS, PRIMARILY DIABETES, IN INDIVIDUALS WITH Β -THALASSEMIA MAJOR: A RETROSPECTIVE ANALYSIS

β-Thalassemia major is an inherited blood condition marked by a serious anemia and a lifetime need for blood transfusions. The effects of β-thalassemia major on endocrine health, notably the risk of diabetes, remain largely unstudied, despite the fact that its haematological components are established. The purpose of this systematic analysis was to examine the incidence of reduced metabolism of glucose in β--thalassemia major. The articles were under the inclusion requirements, after which the data was retrieved. The main outcome was determined to be every prevalence (P) of DM (diabetes mellitus) in β-thalassemia major. In order to examine the percentage of aberrant glucose metabolism (GM) with individuals among β-thalassemia major, the P with the 95% CI (Confidence Interval) was utilized. In this retrospective investigation, we looked at a cohort of people with β-thalassemia major diagnoses to determine the incidence and risk of hormonal diseases, particularly diabetes. A specialist thalassemia facility treated 315 individuals with β-thalassemia major, and their medical records were examined. Age, gender, age at which a main diagnosis of β-thalassemia was made, the length of transfusion treatment, and concomitant diseases were gathered as part of the demographic and clinical data. Our research, which included 17 studies and 1500 cases altogether, showed that with β -thalassemia major had a considerably greater frequency of diabetes than people in general. With a mean beginning age of 30 years, diabetes was identified in 28% of the research cohort's participants. The combined meta-analysis showed that each year had a rather stable level of DM P in β-thalassemia major. In people with major β-thalassemia, the P of impaired fasting glucose (IFG), DM, and impaired glucose tolerance (IGT) was 17.22% (95% CI: 8.44%-26.02%), (6.57 (95% CI: 5.31%- 7.79%) and 12.47 % (95% CI: 5.97%-18.95%), respectively. Our research suggests that people with β-thalassemia major have a high chance of acquiring diabetes, particularly if they get extended transfusion treatment. For prompt diagnosis and care, early detection of diabetes and other hormonal problems in this group is crucial. In β-thalassemia major, there is a high frequency of endocrine problems, including improper GM. To stop growth and endocrine issues, treatment and preventative measures can be required.

17 Development of a questionnaire to study fear and anxiety factors affecting patients and their families undergoing strabismus surgery

Patients and their Families undergoing Strabismus Surgery. The aim of this study was to develop a questionnaire to identify perioperative fear and anxiety factors affecting pediatric strabismus surgery patients.First, we reviewed the literature to determine precipitants of fears and anxieties experienced by pediatric patients. Subsequently, we developed a questionnaire for pediatric patients undergoing strabismus surgery. This was a two part questionnaire, consisting of a 16-piece section for patients and a 22-piece section for parents. Finally, we piloted this questionnaire to validate its clinical use.Common anxiety factors for children include pain, minor clinical procedures requiring needles, separation from parents and engaging with medical professionals. We used this information to develop a two part questionnaire for patients and parents. The questionnaire elicited positive and negative aspects of the patient journey, corroborated fears reported in the literature, and identified anxiety inducing factors specific to strabismus patients.There is a lack of evidence regarding fear and anxiety specific to pediatric ophthalmology surgeries. Strabismus surgery carries unique fear inducing factors. Interventions which may alleviate the stress of pediatric surgery, therefore greatly benefit patient experience and surgical outcomes, and should be considered in the care of pediatric patients. Patient educational material is known to provide a sense of control to patients, helping to alleviate such fear.Evidenced by the literature and the pilot questionnaire, there still exists anxiety inducing factors in pediatric surgery. Investigation into patient fears regarding pediatric strabismus surgery is needed to better understand how clinical staff can support patients perioperatively.

Patient-Level and Endpoint-Specific Clinico-Dosimetric Analysis of the Cardiac Base as a Mediator of Radiation Cardiotoxicity in Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Cardiac disease is a dose-limiting toxicity in non-small cell lung cancer (NSCLC) radiation therapy. Radiation dose to the cardiac base is associated with poor overall survival in several clinical studies, but has not been validated in a non-dose escalated cohort, or with individual patient delineations. In this study we examined the impact of cardiac base dose on overall survival (OS) and cardiac events (CEs), and interrogated the relationships of the substructures comprising the heart base with OS and CEs.

MATERIALS/METHODS

Patients with stage I-III NSCLC treated with curative-intent radiation therapy between 2015 and 2020 at a regional cancer center were identified. Clinical notes were examined for baseline patient, tumor and cardiac details, and both cancer and cardiac outcomes. Three cardiologists verified CEs. Cardiac delineations were completed using a validated deep learning-based autosegmentation tool. Cox and Fine and Gray regressions were undertaken for the risk of death and CEs respectively, accounting for pre-specified evidence-based dose metrics and clinically relevant cardiac covariates.

RESULTS

Most patients received 55 Gy/20# (n = 461/478, 96%) without chemotherapy (58%), planned with VMAT (51%) or IMRT (20%). Pre-existing cardiovascular morbidity was common, with 78% having ≥2 risk factors, and 46% having >1 established cardiac disease. The median follow-up was 21.1 months. Dichotomized at the median, higher heart base Dmax was associated with poorer survival on Kaplan-Meier analysis (21.6 months (95% CI 19.3-24.9) versus 29.4 months (95% CI 21.6-36.6), p = 0.021), and remained significant when statistically compared in published multivariate models. In a multivariate analysis for pooled acute CEs, heart base Dmax was associated with CEs (HR 1.75, 95% CI 1.01-1.06, p = 0.04), but this was not the case for individual CEs. Using Fine and Gray models to account for the competing risk of death, left main coronary maximum dose was associated with atrial fibrillation (p = 0.024), proximal right coronary artery V15 (p = 0.023) and mean dose (p = 0.032), and the right atrium mean dose (p = 0.029) were associated with heart failure. No dose-volume metrics were significantly associated with acute coronary syndrome. None of the constituent base substructures dose were significantly associated with death.

CONCLUSION

Dose to the heart base was associated with increased mortality and an increased pooled cardiac event rate. Accounting for endpoint-specific clinical covariates, only select constituent substructures of the heart base were associated with CEs and no substructures were independently associated with survival. Together, these findings are suggestive of possible interplay between the constituent base substructures in their mediation of radiation cardiotoxicity.

Trends of surgical-care delivery during the COVID-19 pandemic: A multi-centre study in India (IndSurg Collaboration)

Context

The COVID-19 pandemic and subsequent lockdowns adversely affected global healthcare services to varying extents. To accommodate its added burden, emergency services were affected along-with elective surgeries.

Aims

To quantify and analyze the trends of essential surgeries and bellwether procedures during the waxing and waning of the pandemic, across various hospitals in India.

Settings and Design

Multi-centric retrospective study.

Methods and Material

A research consortium led by World Health Organization (WHO) Collaboration Center (WHOCC) for Research in Surgical Care Delivery in Low-and Middle-Income countries, India, conducted this study with 5 centers. All surgeries performed during April 2020 (Wave I), November 2020 (Recovery I), and April 2021 (Wave II) were compared with those performed in April 2019 (pre-pandemic period).

Statistical Analysis Used

Microsoft Excel 2019 and SPSS Version 20.

Results

The total number of surgeries reduced by 77% during Wave I, which improved to a 52% reduction in Recovery I compared to the pre-pandemic period. However, surgeries were reduced again during Wave II to 68%, but the reduction was less compared to Wave I. Emergency and essential surgeries were affected along with the elective ones but to a lesser extent.

Conclusions

The present study has quantified the effects of the pandemic on surgical-care delivery across a timeline and documented a reduction in overall surgical volumes during the peaks of the pandemic (Wave I and II) with minimal improvement as the surge of COVID-19 cases declined (Recovery II). The surgical volumes improved during the second wave compared to the first one which may be attributable to better preparedness. Cesarean sections were affected the least.

Pulse parameter optimizer: an efficient tool for achieving prescribed dose and dose rate with electron FLASH platforms

Purpose. Commercial electron FLASH platforms deliver ultra-high dose rate doses at discrete combinations of pulse parameters including pulse width (PW), pulse repetition frequency (PRF) and number of pulses (N), which dictate unique combinations of dose and dose rates. Additionally, collimation, source to surface distance, and airgaps also vary the dose per pulse (DPP). Currently, obtaining pulse parameters for the desired dose and dose rate is a cumbersome manual process involving creating, updating, and looking up values in large spreadsheets for every treatment configuration. This work presents a pulse parameter optimizer application to match intended dose and dose rate precisely and efficiently.Methods. Dose and dose rate calculation methods have been described for a commercial electron FLASH platform. A constrained optimization for the dose and dose rate cost function was modelled as a mixed integer problem in MATLAB (The MathWorks Inc., Version9.13.0 R2022b, Natick, Massachusetts). The beam and machine data required for the application were acquired using GafChromic film and alternating current current transformers (ACCTs). Variables for optimization included DPP for every collimator, PW and PRF measured using ACCT and airgap factors.Results. Using PW, PRF,Nand airgap factors as parameters, a software was created to optimize dose and dose rate, reaching the closest match if exact dose and dose rates are not achievable. Optimization took 20 s or less to converge to results. This software was validated for accuracy of dose calculation and precision in matching prescribed dose and dose rate.Conclusion. A pulse parameter optimization application was built for a commercial electron FLASH platform to increase efficiency in dose, dose rate, and pulse parameter prescription process. Automating this process reduces safety concerns associated with manual look up and calculation of these parameters, especially when many subjects at different doses and dose rates are to be safely managed.

Effects of high bilirubin level in pregnancy in Crigler-Najjar syndrome type 2: An extremely rare but important clinical entity to recognize

Crigler-Najjar is a rare genetic autosomal recessive disorder caused by deficiency of enzyme Uridine 5-Diphosphate Glucuronosyl Transferase (UDP-GT). We report the case of a 24-year-old female with two consecutive pregnancies with a high level of total bilirubin level of 15.1 mg/dl and a direct bilirubin level of 0.8 mg/dl during the first pregnancy. As she was diagnosed case of Crigler Najjar type 2, she was on phenobarbitone 60 mg daily. With careful monitoring, she continued with the same dose. We concluded that even with high bilirubin level (15.1 mg/dl) in pregnancy, no adverse effects to the baby and mother were seen.

Outcomes and complications of Titanium elastic nailing for forearm bones fracture in children: our experience in a district general hospital in the United Kingdom

Intramedullary Titanium elastic nailing (TENS) is successfully used for irreducible and displaced forearm bone fractures in children. The purpose of this study was to report the potential complications and functional outcomes associated with paediatric forearm fractures treated with TENS nails. We retrospectively reviewed 65 children with displaced forearm bone fractures treated by TENS nailing with a mean follow-up of 5.84 months (4-12). Data detailing patient demographics, fracture characteristics, associated fractures, injury surgery interval, grade of the operating surgeon, methods of fixation, time to union, the timing of removal of the nail, and complications were collected and analysed. The mean age in our study was 9.13 years. 92% had fractures of both radius and ulna, 83.3% had fixation of both bones, and 16.7% had single bone fixation only. Open reduction was required in 38.5% of cases. The average time to fracture union was 10.34 weeks (6-20). The average time of implant removal was 20.12 weeks (9-32). We observed an overall complication rate of 41.5%. We noted a higher (56% vs 32.5%, p=0.059) complication rate in open reduction cases. According to the Price criteria, we had excellent to good results in over 98% of patients despite a slightly higher complication rate. Titanium elastic nailing is a safe, reliable method of internal fixation for irreducible or unstable fractures of both bones of the forearm in children. Open reduction of fracture was associated with higher complications. Despite higher overall complications, we noted excellent functional results in most cases.

Characterization of Circulating Tumor Cells Using Imaging Flow Cytometry in Liver Disease Patients

Background

Hepatocellular carcinoma (HCC) is asymptomatic at an early stage which delays its timely diagnosis and treatment. Circulating tumor cells (CTCs), derived from a primary or secondary tumor, may help in the management of HCC. Here, we evaluate and characterize CTCs in liver disease patients.

Methods

In total, 65 patients, categorized into liver cirrhosis (LC) (n = 30) and HCC (n = 35), were enrolled. Using ImagestreamX MkII imaging flow cytometer, CTCs were detected and characterized using biomarker expression of EpCAM, CK, AFP, CD45, and DRAQ5 in LC and HCC patients.

Results

CTCs were detected in 33/35 (94%) HCC patients and in 28/30 (93%) LC patients. In the HCC group, the number of biomarker-positive CTCs was higher in BCLC stage D when compared with others. EpCAM + CK was the most expressed biomarker on CTCs in LC versus HCC (83.3% vs. 77.14%), followed by AFP (80% vs. 65.71%), EpCAM (30% vs. 28.57%), and CK (16.6% vs. 14.28%). The EpCAM cell area was significantly associated (P value = 0.031) with the CTC-positive status. The combination biomarker expression of CTCs cell area (EpCAM, CK, and AFP) performed well with the area under the curve of 0.92, high sensitivity, and specificity in detecting early-stage and AFP-negative HCC as well as in AFP-negative LC cases.

Conclusion

Enumeration and cell area of CTCs may be used as a biomarker for early detection of HCC and guiding treatment.

Electrosurgical unit in GI endoscopy: the proper settings for practice

INTRODUCTION

Electrosurgical unit (ESU) is integral to the endoscopy unit. The proper knowledge of the Mode with setting is essential for good therapeutic outcomes and the safety of the patients.

AREAS COVERED

ESU generates high-frequency electric current, which could perform cutting and coagulation for various therapeutic interventions. We review the proper settings for common endoscopic interventions like hemostasis, polypectomy, sphincterotomy, and advanced procedures like endoscopic ultrasound-guided cysto-gastrostomy, bile duct drainage, and endoscopic Ampullectomy. We review the various waveforms of ESU in practice in endoscopy, including special conditions like patients with pacemakers.

EXPERT OPINION

Knowledge of the waveforms' duty cycle and crest factor is necessary. A high-duty cycle and lower crest factor lead to a good cutting effect on the tissue. Endocut is the most commonly used Mode in ESU in endoscopic practices like sphincterotomy and polypectomy. Endocut I mode (effect 1-2, duration 3, interval 3) is used for endoscopic sphincterotomy, while Forced Coag mode (Effect 2, 60 W) controls post-sphincterotomy bleeding. Endocut Q mode (Effect 2-3, duration 1, interval 3) is used for cutting the polyp, while Forced Coag mode (Effect 2, 60 W) is used before cutting for pre-coagulation of the stalk.

LAPAROSCOPIC APPROACH TO A GIANT RUPTURED SPLENIC CYST: A CHALLENGING CASE REPORT

Splenic cysts are rare; their absence of an epithelial wall determines whether they're real cysts or pseudocysts. Spontaneous nonparasitic actual tumors are those that develop early in life at the anterior pole of the splenic and are typically epidermoid, dermoid, or endodermal. Surgical therapy is suggested for symptomatic, large (more than 5 cm) cysts or complicated. Inhaling splenic excision is a substitute for surgery, depending on the quantity, location, connection to the hilus, and dimension of the tumors. With an emphasis on less invasive treatments that preserve the spleen, laparoscopic methods have already established themselves as the accepted method for treating numerous disorders, including splenic cysts. They describe the effective decapsulation of a massive epidermoid spleen tumor under a prolonged, partially endoscopic technique. Laparoscopy, an operation commonly referred to as surgery with minimally invasive or keyhole surgery, is a technique that makes many tiny incisions in the belly to carry out different surgical procedures.

Critical reflections on the concept and impact of "scaling up" in Global Mental Health

The field of Global Mental Health (GMH) aims to address the global burden of mental illness by focusing on closing the "treatment gap" faced by many low- and middle-income countries (LMICs). To increase access to services, GMH prioritizes "scaling up" mental health services, primarily advocating for the export of Western centred and developed biomedical and psychosocial "evidence-based" approaches to the Global South. While this emphasis on scalability has resulted in the increased availability of mental health services in some LMICs, there have been few critical discussions of this strategy. This commentary critically appraises the scalability of GMH by questioning the validity and sustainability of its approach. We argue that the current approach emphasizes the development of mental health services and interventions in "silos," focusing on the treatment of mental illnesses at the exclusion of a holistic and contextualized approach to people's needs. We also question the opportunities that the current approach to GMH offers for the growth of mental health programmes of local NGOs and investigate the potential pitfalls that scalability may have on NGOs' impact and ability to innovate. This commentary argues that any "scaling up" of mental health services must place sustainability at the core of its mission by favouring the growth and development of local solutions and wider forms of support that prioritize social inclusion and long-lasting mental health recovery.

Evaluation of the impact of continuous Kangaroo Mother Care (KMC) initiated immediately after birth compared to KMC initiated after stabilization in newborns with birth weight 1.0 to < 1.8 kg on neurodevelopmental outcomes: Protocol for a follow-up study

BACKGROUND

Preterm birth or low birth weight is the single largest cause of death in newborns, however this mortality can be reduced through newborn care interventions, including Kangaroo Mother Care (KMC). Previously, a multi-country randomized controlled trial, coordinated by the World Health Organization (WHO), reported a significant survival advantage with initiation of continuous KMC immediately after birth compared with initiation of continuous KMC a few days after birth when the baby is considered clinically stable. Whether the survival advantage would lead to higher rates of neurodevelopmental morbidities, or the immediate KMC will also have a beneficial effect on cognitive development also, has not been investigated. We therefore propose to test the hypothesis that low-birth-weight infants exposed to immediate KMC will have lower rates of neurodevelopmental impairment in comparison to traditional KMC-treated infants, by prospectively following up infants already enrolled in the immediate KMC trial for the first 2 years of life, and assessing their growth and neurodevelopment.

METHODS

This prospective cohort study will enroll surviving neonates from the main WHO immediate KMC trial. The main trial as well as this follow-up study are being conducted in five low- and middle-income countries in South Asia and sub-Saharan Africa. The estimated sample size for comparison of the risk of neurodevelopmental impairment is a total of 2200 children. The primary outcome will include rates of cerebral palsy, hearing impairment, vision impairment, mental and motor development, and epilepsy and will be assessed by the age of 3 years. The analysis will be by intention to treat.

DISCUSSION

Immediate KMC can potentially reduce low-birth-weight-associated complications such as respiratory disease, hypothermia, hypoglycemia, and infection that can result in impaired neurocognitive development. Neuroprotection may also be mediated by improved physiological stabilization that may lead to better maturation of neural pathways, reduced risk of hypoxia, positive parental impact, improved sleep cycles, and improved stress responses. The present study will help in evaluating the overall impact of KMC by investigating the long-term effect on neurodevelopmental impairment in the survivors.

TRIAL REGISTRATION

Clinical Trials Registry-India CTRI/2019/11/021899. Registered on 06 November 2019. Trials registration of parent trial: ACTRN12618001880235; Clinical Trials Registry-India: CTRI/2018/08/015369.

Determinants of Short-term Mortality in Liver Cirrhosis with Acute Kidney Injury: A Prospective Observational Study

Background: Acute kidney injury (AKI) occurs in 20-50% of patients with cirrhosis and is associated with a poor prognosis. The aim of the study is to identify the baseline factors affecting mortality in these patients at 30 and 90 days. Methods: We enrolled 117 patients with cirrhosis and AKI and followed them up prospectively. Results: Distribution of International club of ascites AKI stages was: 26 (22.03%) stage 1, 59 (50%) stage 2, and 33 (28%) stage 3. Mortalities at 30 and 90 days were 27 (22.8%) and 33 (27.9%) respectively. On multivariate analysis, variables affecting mortality at 30 days were serum creatinine level>2 mg% at 48 hours after AKI development (adjusted OR 7.93, P=0.02) and leukocytosis (total leucocyte count>11000/mm3 ) at admission (adjusted OR 6.54, P=0.002). Only leukocytosis at admission was a predictor of 90 days mortality (adjusted OR 4.76, P=0.01). Though not statistically significant, patients not responding to standard medical treatment had 3 times higher mortality at 30 days, while the maximum AKI stages (2 and 3) had eight times higher mortality at 90 days. Conclusion: In cirrhosis, AKI increases short-term mortality. High serum creatinine at 48 hours affects mortality at 30 days, while leukocytosis at baseline predicts mortality at 30 and 90 days. Progression to a higher AKI stage impacts prognosis.

A cost analysis of treating postoperative periprosthetic femoral fractures following hip replacement surgery in a UK tertiary referral centre

AIM

This study aims to evaluate costs associated with periprosthetic femoral fracture (PFF) treatment at a UK tertiary referral centre.

METHODS

This study included 128 consecutive PFFs admitted from 02/04/2014-19/05/2020. Financial data were provided by Patient Level Information and Costing Systems. Primary outcomes were median cost and margin. Secondary outcomes were length of stay, blood transfusion, critical care, 30-day readmission, 2-year local complication, 2-year systemic complication, 2-year reoperation and 30-day mortality rates. Statistical comparisons were made between treatment type. Statistical significance was set at p<0.05.

RESULTS

Across the cohort, median cost was £15,644.00 (IQR £11,031.00-£22,255.00) and median loss was £3757.50 (£599.20-£8296.20). The highest costs were ward stay (£3994.00, IQR £1,765.00-£7,013.00), theatre utilisation (£2962.00, IQR £0.00-£4,286.00) and overheads (£1705.10, IQR £896.70-£2432.20). Cost (£17,455.00 [IQR, £13,194.00-£23,308.00] versus £7697.00 [IQR £3871.00-£10,847.00], p<0.001) and loss (£4890.00 [IQR £1308.00-£10,009.00] versus £1882.00 [IQR £313.00-£3851.00], p = 0.02) were greater in the operative versus the nonoperative group. There was no difference in cost (£17,634.00 [IQR £12,965.00-£22,958.00] versus £17,399.00 [IQR £13,394.00-£23,404.00], p = 0.98) or loss (£5374.00 [IQR £1950.00-£10,143.00] versus £3860.00 [IQR -£95.50-£7601.00], p = 0.21) between the open reduction and internal fixation (ORIF) and revision groups. More patients required blood transfusion in the operative versus the nonoperative group (17 [17.9%] versus 0 [0.0%], p = 0.009). There was no difference in any clinical outcome between the ORIF and revision groups (p>0.05).

CONCLUSION

PFF treatment costs are high with inadequate reimbursement from NHS tariff. Work is needed to address this disparity and reduce hospital costs. Cost should not be used to decide between ORIF and revision surgery.

1147 MORPHO-FUNCTIONAL EVALUATION OF 3MG/KG ICV-STZ RAT SHOWED SPORADIC ALZHEIMER'S LIKE PATHOLOGY WITH PROGRESSIVE DEMENTIA

Background

Intracerebroventricular streptozotocin (ICV-STZ) injection is among the best animal models to simulate sporadic Alzheimer’s disease (sAD). Abnormality in brain insulin signalling, neurodegeneration, neuroinflammation, cholinergic damage, mitochondrial dysfunction, genetic abnormality, respiratory problem, oxidative stress, gliosis, sleep disturbances are associated with cognitive abnormalities seen in ICV-STZ injected rats. Available experimental evidence has used varying doses of STZ (&lt;1 to 3mg/kg) and studied its effect for different study durations, ranging from 14-21 (short), 30-42 (mild), 90-105 (moderate) and 250-270 (long) days. These studies indicated that 3mg/kg of body-weight is the optimum dose for inducing sAD in the rodents. However, studies on the pathological process with related the morphological and functional abnormalities reported were illusive.

Objective/Method

Hence in the present study, we have investigated the morpho-functional changes after 3mg/kg ICV-STZ treatment with a follow-up of two months in 54 male Wistar rats (ethical no. 937/IAEC/PhD-2016).

Results

Exhibited a spatial, episodic and avoidance memory decline and increase in anxiety (p&lt;0.05) in ICV-STZ group progressively with time from 15th day to 60th day post-injection. Morphometry showed hippocampal atrophy with CA1, CA3 layer thinning (p ≤0.01) and loss of neurons (p&lt;0.0001) associated with third ventricular enlargement (p= 0.007) in ICV-STZ rats versus sham, along-with extracellular amyloid plaque in AD rats with Congored staining. In addition, spine morphometry with Golgi-Cox impregnation of mossy fibre showed a reduction of spine density in AD group versus control and sham group (p&lt;0.0001). Finally, immunohistochemistry of GSK3ß, PI3K and mtCOX-1 antigen in coronal sections revealed an increase in mean intensity of GSK3ß and decrease in PI3K and mtCox-1 in brain areas associated with limbic system in ICV-STZ group on 60th day.

Conclusion

These findings suggest progressive dementia and anxiety in 3mg/kg STZ treated rats, which may be due to hippocampal atrophy, amyloidopathy, ventricular enlargement, synaptic dysfunction and deficits in energy homeostasis of brain.

1145 RTMS TREATMENT IMPROVED COGNITIVE DYSFUNCTION THROUGH ADULT NEUROGENESIS IN ICV-STZ RAT MODEL OF SPORADIC ALZHEIMER'S DISEASE

Background

Intracerebroventricular streptozotocin injection at 3mg/kg of b/w causes phenotypes similar to that of sporadic Alzheimer’s disease (sAD) from 14th day post-injection. On the other hand, the body of evidence indicated that impairment in the sAD is the major contributor for cognitive decline. Taken together, we tested the adult neurogenesis hypothesis in streptozotocin model of sAD in female Wistar rats after extremely low magnetic stimulation (MF: 17.96, 50Hz, 2hr/day, 21days).

Method

33 rats were randomly divided into three groups viz. Sham+MF, AD and AD+MF. Consequently, animals were first induced AD with stereotaxic manipulation and then they were exposed to low frequency magnetic field stimulation, followed by terminal cognitive behavioural tasks brain tissue being isolated for both biochemical and subcellular expression experiments (ethical no. 12/IAEC-1/2017).

Results

Showed reduction in latency to the goal quadrant (p= 0.002) and transfer latency (p= 0.045) in AD+MF group versus AD. Even, Dirichlet distribution of time spent in 4 quadrants indicated un-uniform in all the groups except AD group (p= 0.067, LRS= 7.35). Further, cell count in CA3 and DG exhibited increase in cell density in AD+MF group (p&lt;0.05). However, we found significant reduction in SOD1 activity after MF treatment (p= 0.035) but no change in GSH level in hippocampus and frontal cortex. Interestingly, these changes in AD+MF animals are associated with increase in density of BrdU+/Nestin+ cells in granular layer (p= 0.002) and hilus region (p= 0.0005) of DG along with increase in expression of L-type Ca2+ channels as compared to AD group.

Conclusion

This experimental evidence suggests that non-invasive brain stimulation can promote adult neurogenesis by activating L-type ca2+ channels in the hilus, which intern helps in retention of long-term memory even after sAD.

A Case of Acute Severe Ulcerative Colitis Triggered by COVID-19 Infection

Ulcerative colitis is a chronic inflammatory bowel condition. One of the theories for its etiopathogenesis is gastrointestinal infections. Although COVID-19 primarily affects the respiratory tract, gastrointestinal involvement is also common. We have reported a case of a 28-year-old male who presented with bloody diarrhea, diagnosed with acute severe ulcerative colitis, triggered by COVID-19 infection after known triggers were excluded.

An interdisciplinary effort to understand chemical organizations at the origin of life

This backstory features the perspectives of three group leaders of a Franco-Indian collaboration on the origin of life, involving efforts to engineer evolvable chemical systems. The researchers explain how they overcame the difficulties to bring empiricist and theorist cultures together and the importance of such synergy for the future of origin of life research.

Prevalence of neuropsychiatric conditions and cognitive impairment in two parallel, aging study cohorts from rural and urban India

INTRODUCTION

With the rising proportion of the elderly in India, the burden of neuropsychiatric conditions and cognitive impairment is escalating.

METHODS

Baseline data of cognitively healthy subjects ≥45 years of age, from two longitudinal, aging cohorts in rural (n = 3262) and urban (n = 693) India, were used to calculate prevalence of depression, early-life stressful events, stroke, head injury, and cognitive impairment.

RESULTS

Depression prevalence was significantly higher in rural than urban subjects, with female preponderance in both groups. Early life stressor (parental death) and head injury were significantly more common in rural than in urban India, whereas stroke was more in urban India. There was no significant difference in overall prevalence of cognitive impairment between the rural and urban cohorts; however, women had higher prevalence than men in rural, whereas this was reverse in urban subjects. Depression and stroke were significantly associated with cognitive impairment in the rural cohort.

DISCUSSION

Longitudinal assessment of these neuropsychiatric conditions, with parallel cognitive monitoring, will help identify their causal relationship with dementia.

Management of dog bite wounds: Our protocol and experience with early surgical intervention

Dog bites injuries are a significant cause of morbidity and mortality. Conventionally, it was suggested to leave the wounds open due to probable increased risk of infections and occurrence of rabies with suturing.Recent publications indicate that primary closure does not necessarily affect the chances of infection but definitely helps in improving the quality of scar. We are presenting our experience and protocol for primary closure of all dog bite wounds. From March 2020 to February 2021, 10 consecutive patients of all ages coming to the emergency of our hospital with category 3 dog bite that penetrated the epidermis and dermis and presenting within 48 hours of injury were included. Every patient was administered first dose of anti rabies vaccine (ARV) (zero dose) for active immunisation and was also given injection tetanus intramuscularly. Mean age of patients in our study was 20.9 with range from 2 years to 90 years. Only 2/10 patients developed infections which were managed conservatively with drainage of abscess and antibiotics. Rest all patients recovered without complications. Primary closure of dog bite wounds when associated with debridement, sufficient irrigation, povidine iodine cleansing and antibiotic administration resulted in improved cosmetic appearance without increase in the rate of infection.

Analytical review on the biocompatibility of surface-treated Ti-alloys for joint replacement applications

INTRODUCTION

With the advancement of joint replacements such as total hip replacement (THR), Titanium (Ti) and its alloys are widely used as implant materials. The bearing surface of Ti improves the longevity of implants. In this perception, researchers design a Ti-alloy that increases the wear and corrosion resistance to enhance osteogenesis and mechanical stability.

AREAS COVERED

: This paper is dedicated to finding the major causes of the failure of THR. Further, this paper provides an overview of the application of metallic alloys and their influencing factors that influence biocompatibility. The most contributing part of this paper focuses on the post-treatment impact on Ti-alloys biocompatibility.

EXPERT OPINION

This paper revealed and discussed that Ti alloys' biocompatibility for orthopedic applications mainly depends on antibacterial activities that decide tissue-implant compatibility. Therefore, performing surface treatment enhances the biocompatibility of Ti alloys. It was also observed that more water contact angle (WCA) induces bacterial growth and enhances cell adhesion. In contrast, the treated surface increases the antibacterial activities at lower WCA. Surface heat treatment with sintering or micro-arc oxidation achieves suitable antibacterial or antimicrobial activities.

Correlation of arterial PaCO2 to end tidal CO2 in children undergoing laparoscopic abdominal surgery: An observational study

Background and Aims

The reliability of end tidal carbon dioxide (ETCO2) as a measure of arterial carbon dioxide (PaCO2) in pediatric laparoscopy is unclear. We evaluated the correlation of arterial to end tidal P(a-ET) CO2 during pediatric laparoscopy at two hours of pneumoperitoneum as the primary objective. We also compared P(a-ET) CO2 and alveolar to arterial oxygen gradient P(A-a) O2 and haemodynamics at fixed time points during surgery.

Material and Methods

A cross-sectional study was conducted in 25 children undergoing laparoscopic abdominal surgery. Arterial blood gases were drawn at T0, baseline, T10: ten minutes, T1h: 1 hour, T2h: 2 hours of pnuemoperitoneum and T 10d: 10 mins after deflation. The P(a-ET) CO2, P(A-a) O2, were measured from the blood gas and ETCO2 and FiO2 values on the monitor. The Pearson's correlation coefficient, the Wilcoxon rank test and Chi square test were used for statistical analysis.

Results

At T2h moderate correlation of P(a-ET) CO2 (r = 0.605, P = 0.001) with 40% children documenting accurate P(a-ET) CO2, -1 to +1 mm Hg was seen. Moderate correlation was also seen at T0, T10, T 10d but poor correlation at T 1h. The P(A-a) O2 increased progressively with surgery and did not correlate with P(a-ET) CO2. Heart rate was stable, but systolic blood pressures at T 10 and diastolic at T10, T 1h, T 2h were higher than baseline.

Conclusion

Moderate correlation was seen between PaCO2 and ETCO2 at 2 h of pnuemoperitoneum and at T0, T 10, and T 10d. P(A-a) O2 increased with surgery but did not correlate with P(a-ET) CO2.

Pattern of liver function test variations in COVID-19 infection & its clinical significance: A study from a dedicated COVID-19 tertiary care centre from India

Background & objectives

Coronavirus disease 2019 (COVID-19) affects respiratory, gastrointestinal, cardiovascular and other systems disease. Studies describing liver involvement and liver function test (LFT) abnormalities are sparse from our population. This study was undertaken to estimate the LFT abnormalities in patients with COVID-19 in a tertiary care set up in India.

Methods

In this retrospective study conducted at a tertiary care centre in Mumbai, India, all consecutive patients with proven COVID-19 by reverse transcriptase-PCR from March 23 to October 31, 2020 were enrolled. Of the 3280 case records profiled, 1474 cases were included in the study. Clinical characteristics, biochemical parameters and outcomes were recorded.

Results

Overall 681 (46%) patient had deranged LFTs. Hepatocellular type of injury was most common (93%). Patients with deranged LFTs had more probability of developing severe disease (P<0.001) and mortality (P<0.001). Advanced age (P<0.001), male gender (P<0.001), diabetes mellitus (P<0.001), lower oxygen saturation levels at admission (P<0.001), higher neutrophil-lymphocyte ratio (P<0.001), history of diabetes mellitus and cirrhosiss were associated with deranged LFTs. Acute liver injury was seen in 65 (4.3%) cases on admission and 57 (3.5%) cases during hospital stay. On multivariate analysis for predicting mortality, age >60 yr serum creatinine >2 mg%, PaO₂/FiO₂ ratio ≤200 and raised AST >50 IU/l (OR: 2.34, CI: 1.59-3.48, P<0.001) were found to be significant.

Interpretation & conclusions

In COVID-19, LFT abnormalities were common, and derangement increased as severity progressed. The presence of deranged LFT worsens the clinical outcome and predicts in-hospital mortality.