Effect of endodontic treatment on endothelial dysfunction and subclinical atherosclerosis-a prospective intervention study

OBJECTIVE

The objective of this study is to investigate the effect of endodontic treatment on flow-mediated dilatation (FMD) and carotid intima-media thickness (c-IMT) in patients with apical periodontitis (AP).

MATERIAL AND METHOD

The study includes 32 young men having AP with a mean age of 25.78 years free from cardiovascular disease (CVD) and its risk factors, including periodontitis. All subjects underwent complete physical and dental examination, echocardiography, and ultrasound assessment of FMD on the brachial artery and c-IMT on the carotid artery at baseline and 12 months after the endodontic treatment. Data were analyzed using paired Student's t-test and Pearson's correlation coefficient (r) test using SPSS 26 version.

RESULTS

Endodontic treatment leads to the improvement of FMD significantly from a pooled baseline value of 4.84 ± 1.55% to 7.68 ± 2.08% (p < 0.05). The study also depicts a statistically significant difference between c-IMT (mean = 0.62 ± 0.11 mm) before treatment as compared to 12 months after treatment (mean = 0.59 ± 0.11 mm) (p < 0.05).

CONCLUSION

Endodontic treatment leads to improved FMD and decreased c-IMT suggesting that treating AP can be help revert the early stages of CVD.

CLINICAL RELEVANCE

AP could be a potential etiological factor of future CVD and should be treated as soon as diagnosed.

Dynamic assessment of oropharynx with ultrasonography as a screening tool for obstructive sleep apnea

Ultrasonography is an easily available and portable tool to assess the dynamic changes in the upper airway and surrounding soft tissue. This study aimed to evaluate the utility of oropharynx ultrasonography as a screening tool for obstructive sleep apnea (OSA). The study sequentially enrolled overweight individuals (body mass index >25 kg/m² ) and subjected them to OSA screening tools (Berlin questionnaire, Epworth Sleepiness Scale and STOP-Bang scores), ultrasonography of the oropharynx followed by overnight polysomnography. A total of 30 healthy individuals were also recruited as controls. Detailed dynamic and static ultrasonography measurements of the oropharynx and surrounding tissue were done. The diagnostic ability of various ultrasonography parameters to detect OSA was determined using receiver operating characteristic curve analysis. A total of 63 subjects were enrolled, with 33 in the OSA group and 30 in non-OSA overweight group. All baseline characteristics were similar in the two groups. Except for the dynamic measurements of oropharynx (Retropalatal% change-inspiration, retropalatal% change-Muller manoeuvre, retroglossal% change-inspiration, and retroglossal% change-Muller manoeuvre) all other parameters were similar in the OSA and non-OSA overweight subjects. The area under the receiver operating characteristic curve was highest for retropalatal% change-inspiration: 0.989, followed by retropalatal% change-Muller manoeuvre: 0.988. Both were also significant predictors of OSA with odds ratios of 0.338 (p = 0.003; 95% confidence interval [CI] 0.164-0.696) and 0.346 (p = 0.018; 95% CI 0.143-0.837), respectively. Ultrasonography provides a near complete picture of the dynamic changes and collapsibility of the oropharynx and can be an effective tool in screening for OSA.

Phenotyping patients with aortic stenosis using cluster analysis to determine mortality and suitability for transcatheter aortic valve replacement

Background

Current classification of aortic stenosis (AS) is based on guideline-recommended echocardiographic criteria. Heterogeneity of patients with AS is increasingly recognised. Clinical and demographic factors in addition to echocardiographic parameters can determine those who may derive the greatest benefit from transcatheter aortic valvular replacement (TAVR) and influence patient outcomes.

Purpose

Our study aims to define distinct AS echocardiographic and clinical phenotypes and to accurately identify patients most likely to die or benefit from TAVR.

Methods

Patients diagnosed with at least mild AS between 2009 and 2021 (pre-TAVR) from a multicentre echocardiographic database at a quaternary referral centre included. Unsupervised clustering analysis was performed using K-means, partitioning around medoids, density-based spatial clustering, hierarchical clustering algorithms on 56 demographic, echocardiographic and clinical variables. Associations between AS clusters and clinical outcomes (all-cause mortality, cardiovascular death, AS-related death), and effect of TAVR on clinical outcomes were assessed using Cox proportional hazards models.

Results

Four AS clusters were identified amongst 2,456 patients with median follow up of 4.7 years (median age: 77 years, male: 66%).

Cluster 1 (n=542) had the lowest aortic valvular area (AVA, mean 0.89 cm2), highest peak velocity (Vmax) (4.3 m/s), mean gradient (45 mmHg), and the most bicuspid valves (12.7%). Cluster 2 (n=827) had 50% women, mostly in sinus rhythm and less severe echo findings. Cluster 3 (n=592) had predominantly males (85%) with a mean AVA of 1.65 cm2 and the most cardiovascular risk factors (hypertension, diabetes, hyperlipidaemia, stable angina, acute coronary syndrome, and atherosclerosis). Cluster 4 (n=495) had the highest left atrial size (mean 32 cm2), the most atrial fibrillation (82%), heart failure (80%), rheumatic heart disease (26%) and chronic kidney disease (55.8%), but only moderate AS (AVA 1.3 cm2, Vmax 3 m/s). All-cause mortality was highest in Cluster 4 (Hazard ratio (HR) 1.57, 95% CI: 1.33–1.85) and AS-related death was highest in Cluster 1 (HR 3.96, 95% CI: 2.61–5.99, Figure 1A). TAVR reduced AS-related death in only Cluster 1 (HR 0.22, 95% CI: 0.05–0.88, p=0.033, Figure 1B).

Conclusions

We demonstrated that phenotypic classification via a combination of demographics, echocardiography and comorbidities can significantly improve management of AS. This personalised approach can be implemented to identify patients most likely to die and most likely to benefit from TAVR.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of Australia (ID: 102578)National Health and Medical Research Council of Australia (ID: 1191044)

Testosterone and estradiol in men with acute ischemic stroke: A North Indian case control

Background: One intriguing aspect of stroke is its higher incidence in men as compared to women. Endogenous sex hormones, testosterone and estradiol, may be responsible for this difference. This research aims to study serum testosterone and estradiol levels in men with acute ischemic stroke (AIS) and to correlate these levels with National Institutes of Health Stroke Scale (NIHSS) score and infarct size in computed tomography (CT). Methods: 100 male patients with AIS and 100 age-matched controls were included in this case-control study. Patients with hemorrhagic stroke, taking hormonal preparations, or suffering from chronic illnesses like tuberculosis (TB), cancer, etc. were excluded. Complete history was obtained including presence of established risk factors and physical examination was done in cases and controls with informed written consent. Severity of stroke in cases was assessed by the NIHSS. CT scan of brain was performed within 72 hours of patient's admission to hospital. The infarct size was measured in centimeters as the largest visible diameter of the infarct on CT scan. Fasting blood samples were obtained for routine investigations and estimating estradiol and testosterone levels. Results: Mean total testosterone level in cases (223.30 ± 143.44 ng/dl) was significantly lower than that of controls (515.34 ± 172.11 ng/dl) (P < 0.001), while estradiol levels had no significant statistical difference (P = 0.260). A significant inverse correlation was found between total testosterone levels and stroke severity (r = -0.581, P < 0.001) and also, total testosterone levels and infarct size (r = -0.557, P < 0.001). Estradiol levels in patients had no significant correlation with stroke severity (P = 0.618) or infarct size (P = 0.463). Conclusion: Low testosterone levels are associated with increased stroke severity and infarct size in men. Further studies are required to establish whether low testosterone is a cause or effect of ischemic stroke and also to explore the potential benefits of testosterone supplementation in men with AIS.

Clinical outcomes from antihypertensive therapies in moderate or severe aortic stenosis: a systematic review and meta-analysis

Background

Hypertension can negatively affect prognosis in moderate or severe aortic stenosis (AS), but antihypertensive therapy (AHT) is often avoided due to possible deleterious effects such as reduced coronary perfusion, left ventricular dysfunction and haemodynamic compromise.

Purpose

We systematically assessed and compared clinical outcomes in adults with moderate or severe AS treated with and without AHT.

Methods

Two independent reviewers performed screening, data extraction and risk of bias assessments from a systematic search of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and grey literature without language restrictions up to September 9, 2019. Conflicts were resolved by the third reviewer. Outcomes of interest included mortality, left ventricular (LV) mass index, systolic blood pressure, diastolic blood pressure, and LV ejection fraction. Meta-analysis with pooled effect sizes using random-effects model, were estimated in R.

Results

Of 3,024 citations, 30 studies (26,224 patients) were included in the qualitative synthesis and 23 studies in meta-analysis. AHT was associated with favourable clinical outcomes and was well tolerated. AHT was associated with lower risk of all-cause mortality (Risk Ratio (RR)=0.69, 95% CI: 0.53–0.90, p=0.01, Figure). The effect size appears to differ with type of aortic valve replacement (AVR). AHT was associated with lower risk of acute kidney injury post-transcatheter AVR (RR=0.13, 95% CI:0.05–0.35, p=0.007). Favourable outcomes such as improved haemodynamic and echocardiographic parameters were demonstrated in some studies, but when pooled in meta-analysis, the differences did not reach statistical significance. However, heterogeneity was significant across studies.

Conclusion

This is the first systematic review and meta-analysis to demonstrate that AHT is safe and has a clinical benefit in patients with advanced stages of AS with significant improvement in survival or reduction in mortality without haemodynamic compromise. Further studies are required to determine the best AHT for patients with moderate or severe AS.

Forest plot of AHT effect on mortality.

Funding Acknowledgement

Type of funding source: None

Effects of patient characteristics and comorbidities on temporal trends of low-flow, low-gradient aortic stenosis phenotypes

Background

Aortic stenosis (AS) is a common primary heart valve disease in the elderly. Low-flow, low-gradient (LFLG) AS is an increasingly important phenotype.

Purpose

To evaluate the temporal changes in incidence of severe AS phenotypes: paradoxical LFLG, classical LFLG and non-LFLG and explore risk factors that contribute to temporal trends.

Methods

We analyzed 25,507 consecutive transthoracic echocardiograms over 6½ years between 2013 and 2019 divided into deciles. LFLG-AS was defined as mean transvalvular pressure gradient &lt;40 mmHg and stroke volume index (SVi) &lt;35 mL/m2, aortic valve area (AVA) &lt;1 cm2 or indexed AVA &lt;0.6 cm2/m2, with either normal (paradoxical LFLG) or decreased (&lt;40%; classical LFLG) left ventricular ejection fraction. Trends and associations with patients characteristics and comorbidities were assessed over time in deciles.

Results

Of 891 cases that fulfilled severe AS criteria, there were 536 cases of LFLG-AS (85 classical and 451 paradoxical LFLG-AS). There was a statistically significant increase in incidence of paradoxical LFLG-AS between each time interval (p&lt;0.0001), while significant reduction in incidence of non-LFLG-AS (p=0.009) that was not seen with classical LFLG-AS (p=0.7) (Figure). More comprehensive echocardiographic assessment of relevant parameters over time assisted with identification of LFLG-AS cases. Intrinsic patient factors such as age and E/e' contributed towards the increasing trend of paradoxical LFLG-AS. There was a rising population aged over 70 years (p=0.01). Multivariate logistic regression analysis showed that age, sex, E/e', obesity, atrial fibrillation and heart rate were potential risk factors responsible for temporal trend towards rising paradoxical LFLG-AS incidence. There was also a gradual increase in number of patients with low transvalvular flow rate (&lt;200mL/s) over time (p=0.04).

Conclusion

The incidence of paradoxical LFLG-AS is rising in a hospital echocardiogram service. The parallel increase in LV filling pressure and age in AS patients suggests the increment in LFLG-AS is related to changes to the LV myocardium.

Subtypes of aortic stenosis over time

Funding Acknowledgement

Type of funding source: None

CHA2DS2-VASc and CHADS2 scores for risk stratification of major adverse cardiovascular events in the COMPASS trial

Background

The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial demonstrated that the combination therapy of rivaroxaban and aspirin reduced major adverse cardiovascular events (MACE) compared to aspirin alone in patients with chronic coronary artery disease (CAD) and/or peripheral artery disease (PAD).

Purpose

We assessed whether the CHA2DS2-VASc (congestive heart failure (CHF), hypertension, age ≥75 years, diabetes, stroke/transient ischemic attack (TIA)/thromboembolism, vascular disease, age 65–75 years, and sex category) and CHADS2 (CHF, hypertension, age ≥75 years, diabetes, stroke/TIA) scores used to predict the risk of stroke in patients with atrial fibrillation, can be used identify vascular patients at highest risk of recurrent events who may derive greatest benefits of treatment.

Methods

In COMPASS patients, the predictive accuracy of CHA2DS2-VASc and CHADS2 scores were assessed for MACE, bleeding and net clinical benefit using Cox proportional hazards model. Kaplan-Meier estimates of cumulative risk and absolute risk differences were used to examine the effects of rivaroxaban plus aspirin compared with aspirin alone over 30 months according to risk score categories.

Results

In 27,395 participants with CAD and/or PAD, a high CHA2DS2-VASc score (6–9) was associated with 3 times greater absolute risk of MACE compared to a low score (1–2) (hazard ratio=3.39, 95% CI: 2.54–4.51, p&lt;0.0001). The effects of combination therapy with rivaroxaban and aspirin on MACE, bleeding and net clinical benefit were consistent across CHA2DS2-VASc and CHADS2 score categories, with the greatest benefit in those with the highest risk scores (Figure 1). The greatest reduction in MACE with rivaroxaban and aspirin compared to aspirin only was observed in patients treated for 30 months with highest CHA2DS2-VASc score (6–9) (23 events per 1000 patients prevented) or highest CHADS2 score (3–6) (25 events per 1000 patients prevented). There was increased bleeding in patients with higher CHA2DS2-VASc and CHADS2 scores, but net clinical benefit was preserved across all risk categories and was greatest in those with the highest risk scores.

Conclusion

The CHA2DS2-VASc or CHADS2 scores can be used in patients with chronic CAD and/or PAD to identify patients who are at highest risk of MACE, and therefore likely to achieve the greatest benefit of dual pathway inhibition with the combination of rivaroxaban and aspirin compared with aspirin alone.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): This study was sponsored by Bayer AG.

WP1-22 DuraGen™ as an encapsulating material for neural stem cell delivery

Objectives

Achieving neural regeneration after spinal cord injury (SCI) represents a significant challenge. Neural stem cell (NSC) therapy offers replacement of damaged cells and delivery of pro-regenerative factors, but >95% of cells die when transplanted to sites of neural injury. Biomaterial scaffolds provide cellular protective encapsulation to improve cell survival. However, current available scaffolds are overwhelmingly not approved for human use, presenting a major barrier to clinical translation. Surgical biomaterials offer the unique benefit of being FDA-approved for human implantation. Specifically, a neurosurgical grade material, DuraGen™, used predominantly for human duraplasty has many attractive features of an ideal biomaterial scaffold. Here, we have investigated the use of DuraGen™ as a 3D cell encapsulation device for potential use in combinatorial, regenerative therapies.

Methods

Primary NSCs were seeded into optimised sheets of DuraGen™. NSC growth and fate within DuraGen™ were assessed using 3D microscopic fluorescence imaging techniques.

Results

DuraGen™ supports the survival (ca 95% viability, 12 days) and 3D growth of NSCs. NSC phenotype, proliferative capacity and differentiation into astrocytes, neurons and oligodendrocytes were unaffected by DuraGen™.

Conclusions

A ‘combinatorial therapy’, consisting of NSCs protected within a DuraGen™ matrix, offers a potential clinically translatable approach for neural cell therapy.

Identification and validation of two peptide markers for the recognition of Clostridioides difficile MLST-1 and MLST-11 by MALDI-MS

OBJECTIVES

Clostridioides difficile infection (CDI) has become the main cause of nosocomial infective diarrhoea. To survey and control the spread of different C. difficile strains, there is a need for suitable rapid tests. The aim of this study was to identify peptide/protein markers for the rapid recognition of C. difficile strains by matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS).

METHODS

We analysed 44 well-characterized strains, belonging to eight different multi-locus sequence types (MLST), using ultrahigh-resolution Fourier transform ion cyclotron resonance (FTICR) MS. The amino acid sequence of two peptide markers specific for MLST-1 and MLST-11 strains was elucidated by MALDI-TOF-MS/MS. The investigation of 2689 C. difficile genomes allowed the determination of the sensitivity and specificity of these markers. C18-solid-phased extraction was used to enrich the MLST-1 marker.

RESULTS

Two peptide markers (m/z 4927.81 and m/z 5001.84) were identified and characterized for MLST-1 and MLST-11 strains, respectively. The MLST-1 marker was found in 786 genomes of which three did not belong to MLST-1. The MLST-11 marker was found in 319 genomes, of which 14 did not belong to MLST-11. Importantly, all MLST-1 and MLST-11 genomes were positive for their respective marker. Furthermore, a peptide marker (m/z 5015.86) specific for MLST-15 was found in 59 genomes. We translated our findings into a fast and simple method that allowed the unambiguous identification of the MLST-1 marker on a MALDI-TOF-MS platform.

CONCLUSIONS

MALDI-FTICR MS-based peptide profiling resulted in the identification of peptide markers for C. difficile MLST-1 and MLST-11.

Development of novel gastroretentive salbutamol sulfate-loaded sodium alginate-pectin bubble beads prepared by co-axial needle air-injection method and in vivo clinical evaluation by ultrasound studies

In the present study, the salbutamol sulfate-loaded sodium alginate-pectin (SS-loaded SA-PEC) bubble beads have been optimized and evaluated for drug loading, in vitro drug release, in vivo floating behavior in the stomach, etc. Nine batches (F1-F9) of bubble beads with different SA and PEC contents were prepared by novel co-axial needle air-injection method and related to their percent drug loading efficiency (%DLE) and percent drug release at 4 h (%R_4h) as response factors. The multivariate analysis has shown the effect of SA/PEC ratio, total polymer content, as well as their interaction on %DLE and %R_4h. In the quantitative modeling, the satisfactory adjustment of the linear models (along with interaction terms) with the experimental data for both %DLE and %R_4h has confirmed the findings of the multivariate analysis. The optimized SS-loaded SA-PEC bubble beads based on 2D (contours), 3D, desirability, and overlay plots has exhibited %DLE of 87.35 ± 2.48% (n = 3 and error = 2.94%) and %R_4h of 85.79 ± 2.98% (n = 3 and error = 0.25%). The in vitro drug release studies have shown almost complete (≥85%) SS release from all the batches within 4-6 h in simulated gastric fluid (SGF) pH 1.2. The in vivo clinical findings by ultrasound studies have shown excellent floatation (>6 h) behavior of bubble beads in the upper gastrointestinal tract (GIT) and efficient stomach-specific gastroretention.

Effect of Transdermal Nitroglycerine on Doppler Velocity Waveforms of the Uterine, Umbilical and Fetal Middle Cerebral Arteries in Patients with Chronic Placental Insufficiency: A Prospective RCT

INTRODUCTION

Increase in Nitric Oxide (NO) may be important in vascular adaptation needed to accommodate increased uteroplacental blood flow as pregnancy advances. Hence, in certain conditions like Pregnancy Induced Hypertension (PIH) and Fetal Growth Restriction (FGR), NO donors may play an effective role in increasing uteroplacental perfusion. Transdermal route appears to be a safe and effective route.

AIM

To evaluate the effect of nitroglycerine patch on Doppler velocity waveforms of the uterine, umbilical and fetal middle cerebral arteries in patients with chronic placental insufficiency.

MATERIALS AND METHODS

A prospective randomized controlled clinical trial was conducted on eighty consecutive pregnant women with FGR with or without PIH and having evidence of altered waveform velocimetry in uterine, umbilical and fetal middle cerebral artery. They were divided into two groups- study and control group. Transdermal nitroglycerine patch (10 mg per 24 hours) was applied in study group for three consecutive days. Changes in various Doppler indices were noted after three days of patch application and compared between the two groups. Analysis was carried out using SPSS (Statistical Package for Social Studies) for Windows version 20.0 and online GraphPad software (Prism 5 for Windows) version 5.01.

RESULTS

A significant fall in the systolic and diastolic ratio (S/D), Pulsatility Index (PI) and Resistivity Index (RI) of the uterine (3.07±0.52, 1.04±0.14 and 0.54±0.10 respectively, p<0.001) and umbilical artery (3.73±3.30, 1.18±0.21and 0.64±0.07 respectively, p<0.001) was noted after three days of patch application. No such significant change was observed in the middle cerebral artery indices.

CONCLUSION

The therapeutic approach of NO donor administration via transdermal route in pregnant patients with chronic placental insufficiency, apparently improved both maternal and fetoplacental haemodynamics, thus may help in improving perinatal outcome.

Comparative evaluation of central venous pressure and sonographic inferior vena cava variability in assessing fluid responsiveness in septic shock

OBJECTIVE

Fluid infusion, the most critical step in the resuscitation of patients with septic shock, needs preferably continuous invasive hemodynamic monitoring. The study was planned to evaluate the efficacy of ultrasonographically measured inferior vena cava collapsibility index (IVC CI) in comparison to central venous pressure (CVP) in predicting fluid responsiveness in septic shock.

MATERIALS AND METHODS

Thirty-six patients of septic shock requiring ventilatory support (invasive/noninvasive) were included. Patients with congestive heart failure, raised intra-abdominal pressure, and poor echo window were excluded from the study. They were randomly divided into two groups based on mode of fluid resuscitation - Group I (CVP) and Group II (IVC CI). Primary end-points were mean arterial pressure (MAP) of ≥65 mmHg and CVP >12 mmHg or IVC CI <20% in Groups I and II, respectively. Patients were followed till achievement of end-points or maximum of 6 h. Outcome variables (pulse rate, MAP, urine output, pH, base deficit, and ScvO2 ) were serially measured till the end of the study. Survival at 2 and 4 weeks was used as secondary end-point.

RESULTS

Primary end-point was reached in 31 patients (15 in Group I and 16 in Group II). Fluid infusion, by either method, had increased CVP and decreased IVC CI with resultant negative correlation between them (Pearson correlation coefficient -0.626). There was no significant difference in the amount of fluid infused and time to reach end-point in two groups. Comparison in outcome variables at baseline and end-point showed no significant difference including mortality.

CONCLUSION

CVP and IVC CI are negatively correlated with fluid resuscitation, and both methods can be used for resuscitation, with IVC CI being noninferior to CVP.

Port Site Tuberculosis Presenting as Nonhealing Sinus After Laparoscopic Appendicectomy

With increasing use of laparoscopy for various surgical procedures, the occurrence of port site tuberculosis is seen more often as a postoperative complication. However, lack of awareness of this entity leads to prolonged morbidity and repeat surgical interventions. In case of nonhealing sinus following laparoscopic surgery, keeping this possibility in mind will lead to early diagnosis and treatment. In recent times, various diagnostic tests have come up for confirming the diagnosis of tuberculosis.

Dermatoglyphic variation among the Limboo of Sikkim, India

Variations in finger and palmar dermatoglyphic patterns are investigated among the Limboo (18-60 years, 150 males and 150 females), a little known population of Sikkim. The results for Limboo were compared with other North-East Indian populations. The most commonly occurring pattern was loop (males: 64.33%; females: 75.00%) followed by whorl (males: 31.00%; females: 21.33%) and finally arch (males: 4.67%; females: 3.66%). There were no significant differences between sexes in pattern types. The overall values of pattern intensity (P.I.I.), Dankmeijer's (D.I.) and Furuhata's (F.I.) indices were 14.08, 12.60 and 96.06 respectively. The P.I.I. was within the range for East Asian populations of North-East India. The D.I. was similar to those reported for Rajbanshi, Kalita, Rabha and Newar populations, while F.I. was higher than in other populations of Eastern Himalaya and North-East India. The most frequently occurring mainline formulae in all palm prints (left and right combined) were 7.5'.5.- followed by 9.7.5.- and finally 11.9.7.- (p>0.05) and these were similar to the reported values for other North-eastern populations of India. The mean values of total finger ridge count (TFRC) and absolute finger ridge count (AFRC) were greater among males (138.03; s=42.26 and 198.78; s=77.4) than females (137.91; s=44.15 and 194.47; s=86.71). The a-b ridge count was greater among females than males. Sex differences in AFRC and a-b ridge count were both statistically significant (p<0.05). The mean TFRC values were within ranges for populations of North-East India. Cluster analysis based on P.I.I., D.I. and F.I. shows affinity of the Limbo to some of the populations of Assam and North-East India.

Antenatal umbilical coiling index as a predictor of perinatal outcome

PURPOSE

To evaluate the relationship between sonographic measurements of umbilical cord coiling index during late second trimester of pregnancy and perinatal outcome.

METHODS

This prospective study was conducted on two hundred pregnant women with uncomplicated, singleton pregnancy between 20 to 24 weeks of gestation. The antenatal umbilical coiling index (UCI) was calculated by doing a transabdominal ultrasound at the time of induction into the study as the reciprocal of the pitch of one complete vascular coil. The patients were followed up till delivery and any adverse antenatal and/or perinatal event was noted.

RESULTS

The mean value for the UCI was noted to be 0.36 + 0.07 coils/cm with a 95% CI of 0.35-0.37. The values for the 10th and the 90th percentile were 0.26 and 0.46 coils/cm respectively. Accordingly the cases were divided into three groups- hypocoiled (UCI <10th percentile)-18, normocoiled (UCI between 10th-90th percentile)-162 and hypercoiled (UCI >90th percentile)-20. Hypocoiling was observed to be significantly associated with preterm labour pains (P value 0.0344), oligohydramnios (P value 0.0021), intrapartum foetal heart rate abnormalities (P value 0.0012), instrumental vaginal delivery (P value 0.0275) and low birth weight (P value 0.0344). Hypercoiling was found to be significantly associated with intrauterine growth restriction (P value 0.0323), foetal heart rate abnormalities during labour (0.0399) and low birth weight (P value 0.0095).

CONCLUSION

Abnormal umbilical coiling index in the form of either hypo- or hypercoiling is associated with several adverse antenatal and neonatal outcomes.

The usefulness of the Loewenstein Occupational Therapy Cognition Assessment in evaluating cognitive function in patients with stroke

OBJECTIVE

We wished to evaluate the usefulness of the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) in early detection of the Vascular Cognitive Impairment, No Dementia (VCIND) in patients with stroke. We also wanted to compare LOTCA with the Mini-Mental State Examination (MMSE).

PATIENTS AND METHODS

Thirty patients with stroke and cognitive impairment comprised the cognitive impairment group. Another 30 patients with stroke and no cognitive impairment served as the stroke control group, while 30 healthy individuals served as the normal control group.

RESULTS

The age, gender, and education level were comparable among three study groups. All subjects were assessed with both tests. Total LOTCA scores strongly and positively correlated with total MMSE scores in patients with cognitive impairment (r = 0.934, p < 0.001). The correlations were also present between every sub-items of LOTCA and those of MMSE (p < 0.01). In addition, total scores and sub-item scores in LOTCA were significantly lower in the cognitive impairment group compared with both stroke control and normal control groups (p < 0.01), especially, with regard to scores of thinking operations, orientation, and visuomotor organization. The sub-item scores in LOTCA, including thinking operations, visuomotor organization, attention, orientation, and spatial perception were significantly lower in the stroke control group compared with normal control group (p < 0.01), especially in thinking operations and visuomotor organization. There is a good agreement between LOTCA and MMSE.

CONCLUSIONS

Compared with MMSE, LOTCA can detect VCIND earlier and more comprehensively, and can, thus, be used clinically for VCIND detection.

Histopathologic changes following neoadjuvant chemotherapy in locally advanced breast cancer

AIMS

To compare the clinical and pathologic assessment of response to neoadjuvant chemotherapy and describe the various histopathologic changes observed.

MATERIALS AND METHODS

We studied a group of 40 patients with locally advanced breast cancer who had their initial workup in the form of clinico-imaging assessment of the size and pretreatment biopsy from the lesion. All the patients received two to six cycles of neoadjuvant chemotherapy, either cyclophosphamide 50 to 60 mg/m 2 IV, doxorubicin 40 to 50 mg/m 2 IV and 5-fluorouracil 500 to 800 mg/m 2 IV (CAF) or cyclophosphamide, epirubicin, and 5-fluorouracil (CEF). Clinical and pathologic assessment of response to chemotherapy was done based on the UICC guidelines.

RESULT

Complete clinical response (cCR) was seen in 10% cases (4/40), thirty percent patients had (12/40) partial response and 60% (24/40) had stable disease after neoadjuvant chemotherapy. Pathologic complete response (pCR) with no evidence of viable tumor was observed in 20% patients (8/40). Fifteen patients (37.5%) showed partial response and 42.5% patients (17/40) had a stable disease. No patient progressed during the course of chemotherapy. Changes in the tumor type were observed following chemotherapy, most common being the mucinous change. Histologic changes like dyscohesion, shrinkage of tumor cells, elastosis, collagenization, necrosis, lymphocytic reaction, giant cell response are some of the common observations seen following treatment with neoadjuvant chemotherapy.

CONCLUSION

Pathologic assessment of response to neoadjuvant chemotherapy is a better predictor than the clinical response. The chemotherapy drugs can be modified based on the response observed after 1-2 cycles of neoadjuvant, the response being based on both tumor and patient's responsiveness.

Is periprostatic nerve block a gold standard in case of transrectal ultrasound-guided prostate biopsy?

Introduction:

Controversy exists over the pain during prostate biopsy. Periprostatic nerve block (PNB) is a gold standard anesthetic technique during transrectal ultrasound (TRUS)-guided prostate biopsy. Recent studies showed that PNB alone is insufficient as analgesic. We compared the efficacy of tramadol and intraprostatic nerve block (INB) in addition to PNB.

Materials and Methods:

We conducted a prospective double blinded placebo controlled study at our institute in 150 consecutive patients. Patients were randomized into three groups. Group A received PNB with INB with 1% lignocaine. Group B received oral tramadol with PNB. Group C patients were administered PNB only with 1% lignocaine. Patients were asked to grade the pain level using 11 point linear visual analog scale (VAS) at the time of ultrasound probe insertion, at time of anesthesia, during biopsy, and 30 min after biopsy.

Results:

The study groups were comparable in demographic profile, prostate-specific antigen (PSA) levels, and prostate size. Group A recorded the minimum mean pain score of 2.66 during prostate biopsy which was significantly lower than group 3 (P < 0.001). Group B recorded significantly lower pain score at time of probe insertion and at anesthetic needle insertion than other two groups.

Conclusions:

PNB provides better pain control in TRUS-guided prostate biopsy but still there is need of additional analgesic in the form of tramadol or INB. Tramadol has advantage of oral intake and analgesic effect at time of probe insertion and at nerve block. Both tramadol and INB may be used in combination along with PNB.

Histopathologic changes following neoadjuvant chemotherapy in various malignancies

BACKGROUND

Various histopathological changes have been observed following neoadjuvant chemotherapy in individual tumors in the literature.

AIMS AND OBJECTIVES

To observe histopathologic changes seen after neoadjuvant chemotherapy in breast malignancies, squamous cell carcinomas, adenocarcinomas, and Wilms' tumor using breast cancer predominantly as the model.

MATERIALS AND METHODS

The present prospective study was carried out on 60 patients including 40 patients with carcinoma breast and 20 patients with other malignancies who received neoadjuvant chemotherapy.

RESULTS

Post neoadjuvant chemotherapy, mastectomy specimens revealed nuclear enlargement, nuclear shrinkage, necrosis, vacuolation of nucleus, vacuolation of cytoplasm, dyscohesion, and shrinkage of tumor cells with nuclear changes of nonviability like karyorrhexis, karyolysis, and pyknosis. Stromal reactions manifested as fibrosis, elastosis, collagenization, hyalinization, microcalcification, and neovascularization. Areas of necrosis included both vascular and avascular pattern. The stroma also revealed fibrinoid necrosis and mucinous change. Hyalinization of the blood vessel wall was a common finding. The most common inflammatory host response observed in the present study was lymphocytic; others included mixed inflammation, plasmacytic, prominent histiocytic, and giant cell types. Giant cell reaction was significantly correlated to all types of tumor responses (P < 0.05). Similar changes were also observed in other malignancies. A detailed review of the literature has also been done and presented.

CONCLUSION

The tumor grade decreases and differentiation improves, in addition to the retrogressive changes and increase in stromal component, as a result of chemotherapy in carcinoma breast as well as in other malignancies.

Comparative Evaluation of Periprostatic Nerve Block with and without Intraprostatic Nerve Block in Transrectal Ultrasound-Guided Prostatic Needle Biopsy

Purpose

Controversy exists over the pain during prostate biopsy. Periprostatic nerve block is a commonly used anaesthetic technique during transrectal ultrasound (TRUS)-guided prostate biopsy. The recent trend toward increasing the number of cores has become popular. This practice further increases the need for a proper anaesthetic application. We compared the efficacy of periprostatic nerve block with or without intraprostatic nerve block.

Materials and Methods

We conducted a prospective double-blinded placebo-controlled study at our institute with 142 consecutive patients. Patients were randomly assigned into 3 groups. Group 1 received periprostatic nerve block with intraprostatic nerve block with 1% lignocaine. Group 2 patients were administered periprostatic nerve block only with 1% lignocaine. Group 3 received no anaesthesia. Patients were asked to grade their level of pain by using an 11-point linear analogue scale at the time of ultrasound probe insertion, at the time of anaesthesia, during biopsy, and 30 minutes after biopsy.

Results

The study groups were comparable in demographic profile, prostate-specific antigen (PSA) level, and prostate size. The mean pain scores at the time of biopsy in groups 1, 2, and 3 were 2.70, 3.39, and 4.16, respectively. Group 1 recorded the minimum mean pain score of 2.70 during prostate biopsy, which was significantly lower than the scores of groups 2 and 3 (p<0.001). There were no significant differences in pain scores among the 3 groups during probe insertion, during anaesthesia, or at 30 minutes after biopsy (p>0.05).

Conclusions

Periprostatic nerve block with intraprostatic nerve block provides better pain control than does periprostatic nerve block alone in TRUS-guided prostate biopsy.

Comparative evaluation of periprostatic nerve block and diclofenac patch in transrectal ultrasound-guided prostatic needle biopsy

Background

The aim of the present study was to compare two analgesic techniques for transrectal ultrasound (TRUS)-guided biopsy: diclofenac patch versus periprostatic nerve block with 1% lidocaine.

Objectives

To study the efficacy of and compare diclofenac patch and periprostatic nerve block as analgesia in TRUS-guided prostate needle biopsy.

Patients and Methods

In total, 60 patients were prospectively randomized into three groups: those in whom a diclofenac patch was used (n = 20), those in whom periprostatic nerve block was used (n = 20), and a control group (n = 20). Prostate biopsy was performed after administration of analgesia according to group.

Results

The three groups were similar in terms of age, prostate volume, and PSA (prostate-specific antigen) levels. Pain scores were significantly lower in the nerve block group (P = 0.000) at the time of biopsy until 2 h postprocedure, but not at 4 h postprocedure (P = 0.068). No significant difference in pain score was observed in the diclofenac patch group at the time of biopsy (P = 0.106) as compared to the control group, but the diclofenac patch provided adequate pain relief 1 h (P = 0.000), 2 h (0.000), and 4 h (0.002) postprocedure. No significant difference was observed in pain score between the nerve block (P = 0.520) and control groups (0.057) at probe insertion. The pain score at 4 h was significantly lower in the patch group compared to the nerve block and control groups.

Conclusions

Periprostatic nerve block provides superior analgesia for TRUS-guided biopsy. Diclofenac patch is useful as an adjunct.

Evaluation of endothelial function and effect of glycemic control (excellent vs. poor / fair control) on endothelial function in uncontrolled type 2 diabetes mellitus

OBJECTIVE

To evaluate the endothelial functions before and after glycemic control in type II diabetes mellitus.

MATERIAL AND METHODS

It was an open, randomized and comparative study on 30 patients of type 2 diabetes mellitus. The study was of 12 weeks spread over 5 visits. The initial visit (visit 1) is for screening of patients. Other visits (visits 2 to 5) constituted the follow up of patients. The primary efficacy parameters included blood sugar (fasting and postprandial) done on each visit and glycosylated hemoglobin (HbA1c) done at visits 1 and 5. Based on glycosylated hemoglobin (HbA1c) only poorly controlled and fairly controlled patients were included in the study. Brachial artery flow mediated vasodilatation (FMD) was studied in all these patient at visits 1 and 5 to see the effect of glycemic control on endothelial functions. Results obtained were statistically analyzed with appropriate method.

RESULTS

There was a significant improvement in endothelial functions in patients with fair, good and excellent control of diabetes. During uncontrolled state (HbA1c 10.08 +/- 0.48%) FMD was lowest, i.e., 2.88 +/- 0.53 at 1st week which improved to 11.94 +/- 3.33 at 12th week with control of diabetes (HbA1c 6.74 +/- 0.16%). The FMD in patients who had fair control (HbAlc 8.45 +/- 0.30%) in the beginning was 6.74 +/- 2.43% and after excellent control in these patients FMD rises to 12.81 +/- 3.16%.

CONCLUSION

Our data showed that the endothelial functions improved sequentially with control of diabetes from fair to good to excellent glycemic control.

Benign vs malignant soft tissue neoplasms: limitations of magnetic resonance imaging

AIMS

Various features have been described in the literature to differentiate benign from malignant lesions. The aim of the present study was to study the accuracy of each of these features and that of magnetic resonance imaging (MRI) in diagnosing malignant lesions.

MATERIALS AND METHODS

Fifty-five consecutive patients presenting with neoplastic (both benign and malignant) lesions diagnosed clinically and on ultrasound were studied and their MRI features were compared with the findings on surgical exploration and histopathologic examination.

RESULTS

There were 32 (58%) benign and 23 (42%) malignant masses. Malignant masses were more common in patients older than 20 years (83%), and these had symptoms of less than 6 months duration (75%), as against benign lesions. The swelling was painful in 8 malignant masses and these were more common in the upper limbs (61%). Various features of malignant lesions were size more than 5 cm in 83%, change in signal intensity from homogenous on T1-weighted images to heterogenous on T2-weighted images in 74%, irregular margins in 74%, and heterogenous contrast enhancement in 91%. The accuracy of these features was 76%, 58%, 78%, and 60%, respectively. Most benign and malignant lesions were intramuscular in location. A significant number (38%) of benign lesions were located in the intermuscular facial plane. Definitive diagnosis was made in 42% of the lesions.

CONCLUSIONS

MRI is an excellent modality for evaluating soft tissue neoplasms; however, prediction of a specific diagnosis and differentiation of malignant and benign lesions is not always possible.

A new marker of carotid atherosclerosis in middle aged adults: cystatin C or microalbuminuria

OBJECTIVE

Cystatin C and microalbuminuria, the new markers of atherosclerosis, have been shown to predict cardiovascular outcome in older individuals. However there is limited data regarding their role in middle aged individuals with preserved renal functions. Hence this study.

METHODS

Patients aged 45 to 65 years irrespective of presence or absence of diabetes, hypertension or coronary artery disease were subjected to high resolution B mode ultrasonography for carotid artery intimal-medial complex thickness (IMT). Patients with maximal intimal-medial complex thickness greater than 800 microm at the far wall of the common carotid artery, excluding raised lesions and plaques, were selected for the study. Study participants were subjected to biochemical tests for serum cystatin-C, serum creatinine, glomerular filtration rate (GFR) and for presence of microalbuminuria. The relationship of carotid artery intimal-medial complex thickness with serum cystatin C and microalbuminuria was compared.

RESULTS

The mean carotid IMT of the study group was 928 +/- 117 microm. Carotid IMT was significantly associated with advancing age, raised systolic blood pressure, ESR, GFR, LDL cholesterol and microalbuminuria but not with cystatin C. Carotid IMT has significant association with systolic blood pressure but not with diastolic blood pressure. There was a statistically significant difference in ESR across tertiles (p < 0.05). There was a statistically significant difference in GFR across tertiles (p < 0.05) and an inverse relationship was found between GFR and IMT. Carotid IMT was positively and significantly correlated with microalbuminuria but there was no significant correlation of carotid IMT with serum cystatin C.

CONCLUSION

Microalbuminuria was found to be associated with carotid atherosclerosis in middle aged individuals. However cystatin C was not associated with carotid atherosclerosis in patients with preserved renal functions.

Free phenytoin concentration measurement in brain extracellular fluid: a pilot study

This article investigates the relationship between brain extracellular fluid free phenytoin concentration and plasma free phenytoin concentration in adults with acute brain injury. Daily cerebral microdialysate free phenytoin concentration was measured in eight adults with acute brain injury and compared with simultaneous measurement of plasma free phenytoin concentration. The group data revealed no significant correlation between microdialysate and plasma free phenytoin concentration (r = 0.34, p = 0.41). However, in two patients, with a sufficient number of samples for intra-individual analysis, there was a significant correlation between microdialysate and plasma free phenytoin concentration (r = 0.92, p < 0.001 and r = 0.88, p < 0.01). In vitro microdialysis relative recovery for phenytoin was 2.1%. In the context of acute brain injury, measurement of free plasma phenytoin concentration may not provide an accurate reflection of regional brain extracellular fluid free phenytoin concentration and may have limitations with respect to achieving reproducible brain extracellular fluid free phenytoin concentrations. This has implications for dosing regimens relying on plasma phenytoin levels.

Metastatic bilateral malignant ovarian tumors associated with pregnancy

OBJECTIVE

Krukenberg tumors in pregnancy are extremely rare. Only three cases have been reported, two of which were diagnosed postpartum.

CASE REPORT

A 20-year-old, primigravida with bilateral malignant ovarian tumors, who received no prior antenatal care, was presented with intestinal obstruction at 5 months' gestation. Pregnancy was preserved, and bilateral oophorectomy, omentectomy with resection of sigmoid colon growth, and colostomy were performed. The patient aborted spontaneously and postoperatively, and was treated with adjuvant chemotherapy.

CONCLUSION

Because platinum-based chemotherapy can be safely given during pregnancy, hysterectomy can be avoided in cases of bilateral malignant ovarian tumors if the uterus is not grossly involved, so allowing preservation of an existing pregnancy.

Infiltrative ophthalmopathy and primary hypothyroidism: a rare clinical manifestation of a common disease

The association of infiltrative ophthalmopathy with primary hypothyroidism is uncommon. We describe two such cases manifesting at different times during the course of primary hypothyroidism. The successful outcome of the present cases suggests that the timely addition of levothyroxine treatment alone or in combination with steroids is useful and effective in the management of hypothyroid Graves' ophthalmopathy.