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BACKGROUND Epidural steroid injections (ESIs) have been widely used for over 50 years in the treatment of back pain with or without radiculopathy. In this study, we intended to evaluate the effect of single caudal epidural steroid injection (CESI) in patients suffering from chronic lumbago-sciatica syndrome, resistant to conservative medical therapy. METHODS This was a retrospective study. CESI was performed on thirty-four patients suffering from chronic lumbago-sciatica syndrome, from April 2019 to March 2020. Single injection of caudal epidural steroid (40 mg Triamcinolone Acetonide) diluted with 10 ml. of sterile water was given guided by anatomic landmark, confirmed by “Whoosh” test and radiologically with dye. Patients were followed for 12 weeks using Numeric Rating Scale (NRS) for pain, Oswestry disability index (ODI) and North American spine society patient satisfaction index (NASS). Values were recorded before the injection and after the injection at 1 week, 3 week, 6 week and 12 week during follow-up. RESULTS Significant improvement in patient’s status was observed after CESI, as measured with NRS, ODI and NASS at one, three, six and twelve weeks as compared to pre injection (zero week) but no significant difference was observed at successive follow ups at first to third and third to six weeks. There was significant reversal of NRS and ODI Score from 6 week to 12 week follow-up. Sixty seven percent of patients were satisfied at the end of the follow-up and mild side-effects were reported in a few patients. CONCLUSIONS CESI is a safe, simple and cost-effective intervention procedure for the treatment of chronic lumbago-sciatica syndrome. It provides rapid pain relief and physical function improvement of the patient starting within a week. KEYWORDS Injections, Epidural, Sciatica, Low Back Pain

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

BACKGROUND Prolonged immobilization of the body following Spinal Cord Injury (SCI) is associated with certain metabolic changes in calcium (Ca) metabolism leading to hypercalciuria. This is associated with an increased risk of developing urinary calculi, urinary tract infection, & osteoporosis. Excretion of excess 24 hours urinary calcium in these cases can be reduced with weight bearing in the form of tilt table standing along with passive and active strengthening exercises. MATERIALS AND METHODS A prospective study was conducted on 18 patients with spinal cord injury hospitalized for post-acute rehabilitation program after observing all ethical formalities. Urinary calcium excretion was measured for 24 hours period before and after a structured weight bearing given on tilt table for 1 hour a day and passive and active upper limb strengthening exercise program given half an hour daily, for 2 weeks. RESULTS All the patients belonged to traumatic SCI with immobilization ranging from 2 to 8 months and the structured treatment program lead to significant reduction in hypercalciuria. The level of lesion, diagnosis and different periods of immobilization did not influence the outcome significantly. CONCLUSION This being a short term longitudinal study, the demographics differed from larger earlier studies. Majority of our patients (94%) were young males of 15-50 years age. Paraplegics constituted 72% of our patients while 28% were quadriplegics. The significant reduction in hypercalciuria after a standard regimen of tilt table standing coupled with exercises in all the cases established the value of the treatment. There was no correlation between the periods of immobilization to the change in urine calcium excretion in response to our treatment. It was a short term, small sample study and needs further validation with a larger study of longer duration to establish the efficacy of tilt table standing coupled with exercises.

BACKGROUND The study was undertaken to assess the effectiveness of autologous Platelet Rich Plasma (PRP) injection compared to local ultrasonic therapy for treatment of plantar fasciitis in terms of improvement in pain and function. MATERIALS AND METHODS This prospective, randomized, controlled study was conducted in Physical Medicine and Rehabilitation department of a tertiary care centre. 61 patients were randomly allocated in to either ultrasonic therapy (Group 1, n=30) or PRP group (Group 2, n=31). All patients were assessed for pain in Visual Analogue Scale (VAS) and for pain and function on Foot Ankle Disability Index (FADI) scale at baseline and three, six and twelve weeks after treatment. A p-value of less than 0.05 was considered significant. RESULTS Out of 61 subjects enrolled, 59 completed 12 weeks follow-up (29 in group 1, 30 in group 2). In both groups, statistically significant improvement was seen at three weeks on both VAS and FADI scales, but the observed improvement persisted upto 12 weeks follow-ups only in PRP treated group. There was no adverse event reported. CONCLUSION Local injection of autologous PRP proved to be a promising form of treatment. It is both safe and effective in relieving pain and improving function and superior to local ultrasonic therapy for treatment of plantar fasciitis.

Objective Chronic symptomatic sinus node dysfunction (SND), the most common bradyarrhythmia, can be effectively managed by permanent cardiac pacing. Yet the care pathway and barriers to adoption of pacing therapy are not well understood – particularly in low volume implanting countries. The IMPROVE Brady study is a quality improvement initiative being conducted at centers in South Asia, Latin America, and Russia. We assessed the rates of SND diagnosis and pacemaker treatment for SND in the South Asia cohort. Methods The prospective study enrolled patients with heart rate of ≤50 beats per minute presenting with symptoms including syncope, dizziness, and/or dyspnea from ten centers in India and Bangladesh. Patients were followed to identify the proportion diagnosed with SND and subsequently treated with pacemaker therapy. Results A total of 508 patients meeting criteria were enrolled and followed on average for 8.3 ± 8.0 months. Patients were on average 58 years of age, 77% were male, and 91% had completed at least primary education. An SND diagnosis was made in 368 (72%) of patients, with the majority (80%) of diagnoses occurring within 1 month of enrollment. Of the patients with an SND diagnosis, 63 (17%) were treated with a pacemaker. Reasons for not receiving treatment were: subject refusal or deferred decision (45%), unaffordability (34%), physician determined – not-indicated (20%), and other (1%). Older age, female gender, history of hypertension, lower resting heart rate, and syncopal or pre-syncopal symptoms were associated with a higher probability of implant. Conclusions In a care pathway assessment for the diagnosis and treatment of symptomatic SND in South Asia only 1 in 6 patients received pacemaker indicated therapy, largely due to patient refusal and physician decision. Phase II of the study will be aimed to improve this treatment rate.

BACKGROUND Removal of a part of a limb through one or more bones termed amputation is done for various causes. Properly performed amputation is a reconstructive procedure. Effective postoperative rehabilitation reduces disability and helps in proper shaping of the residual limb leading to final prosthetic fitment. The aim of the study is to compare effect of rigid dressing and Immediate Postoperative Prosthesis (IPOP) using a simple and cheap pylon developed by the first author with soft dressing in respect of stump maturation and function in lower limb amputees. MATERIALS AND METHODS Fifty one patients with lower limb amputations were included in the study and randomised into two groups. Twenty four patients completed follow-up in the study group of rigid dressing with early postoperative prosthetic fitting while twenty patients completed with soft dressing. Stump maturation as measured by girth and volumetric assessment and complications of residual pain and phantom pain were compared at six weeks and twelve weeks with baseline data. Statistical Analysis- Done with SPSS for Windows version 17. Independent-T test was used for comparison of continuous variables and Chi-square and Fischer exact test was used for comparison of dichotomous responses. Settings and Design- The study was done in a multispecialty teaching hospital of a metro city. It was a well-structured comparative study done after addressing all safety and ethical issues. RESULTS Stump maturation was significantly better and the stump complications reduced in the study group. CONCLUSION Rigid dressing with IPOP has proven to be significantly superior to soft dressing in terms of maturation of stump and residual complications in lower limb amputations.

Introduction: Carpal Tunnel Syndrome (CTS) is one of the most common entrapment neuropathy with significant affection of hand function. Diagnosis is based on clinical, electrophysiological findings and ultrasonographic findings. Treatment may be nonsurgical or surgical. Of the nonsurgical methods, local glucocorticoid injection has yielded promising results in mild to moderate CTS. Use of different doses of steroid for CTS ranging from 12 mg to 40 mg with comparable results has been reported in the literature. To the best of our knowledge, efficacy of low dose steroid injection has not been evaluated in a comprehensive manner. Aim: To assess the efficacy of a low dose local steroid injection in CTS patients utilising clinical, electrophysiological and ultrasonographic parameters. Materials and Methods: Fifty five diagnosed patients of mild and moderate CTS, on the basis of electrophysiologic findings, were recruited for the study. Clinical evaluation was done in terms of grip strength and pain status. For baseline electrophysiological evaluation, nerve conduction studies were performed. This included Sensory Nerve Action Potentials (SNAPs), Sensory Distal Latency (SDL), Motor Distal Latency (MDL) and sensory and motor Conduction Velocity (CV) of median nerve as assessment parameters. Cross Sectional Area (CSA) of median nerve and bowing of flexor retinaculum was assessed using ultrasonography. Single dose of 20 mg methylprednisolone acetate was injected into the carpal tunnel under all aseptic precautions. Pain status was assessed at one week after the procedure. Overall, efficacy of the intervention was assessed using all the assessment parameters at one and three months after intervention. Statistical analysis was done using SPSS version 17 and p-value of

In this study 30 patients with osteo-arthritis (OA) knee (total 55 knees) were given weekly injections of high molecular weight (HMW) hyaluronic acid (HA) for 3 weeks. The subjective parameter was Western Ontario and McMaster Universities Index of Osteoarthritis (WOMAC) score which improved from 97.67±21.4 at baseline to 61.03±24.8 at six months follow-up (p=0.0001). Also the mean range of motion (ROM) of the involved knees was 125.73± 10.8 degrees at baseline and it increased to 132.64±5.2 degrees after six months (p=0.0001) of injection treatment. The objective parameter of disease modification was MRI based semi-quantitive Whole-organ Magnetic Resonence Imaging Score (WORMS) score. The mean of total WORMS score in medial femorotibial joint (MFTJ) and patellofemoral joint (PFJ) improved from baseline (28.382±10.446; 22.64±5.969) to final follow up (27.46±10.32; 21.76± 6.182) which was quite significant (p=0.0321; p=0.0294) and implies a reduced rate of cartilage destruction after injection HA though there is no regrowth of cartilage as such.

Introduction: Periarthritis (PA) shoulder characterised by pain and restricted range of motion has a plethora of treatment options with inconclusive evidence. Platelet Rich Plasma (PRP) is an emerging treatment option and its efficacy needs to be examined and compared with other routine interventions. Aim: To assess the efficacy of PRP injection and compare it with corticosteroid injection and ultrasonic therapy in the treatment of PA shoulder. Materials and Methods: Patients with PA shoulder (n=195) were randomised to receive single injection of PRP (2 ml) or corticosteroid (80 mg of methylprednisolone) or ultrasonic therapy (seven sittings in two weeks; 1.5 W/cm2 , 1 MHz, continuous mode). All participants were also advised to perform a home based 10 minute exercise therapy. The primary outcome measure was active range of motion of the shoulder. Secondary outcome measures used were Visual Analogue Scale (VAS) for pain and a shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) for function. Participants were evaluated at 0, 3, 6 and 12 weeks. Chi-square test, one way and repeated measures of ANOVA tests were used to determine significant differences. Results: PRP treatment resulted in statistically significant improvements over corticosteroid and ultrasonic therapy in active as well as passive range of motion of shoulder, VAS and QuickDASH at 12 weeks. At six weeks, PRP treatment resulted in statistically significant improvements over ultrasonic therapy in VAS and QuickDASH. No major adverse effects were observed. Conclusion: This study demonstrates that single injection of PRP is effective and better than corticosteroid injection or ultrasonic therapy in treatment of PA shoulder.

Congenital muscular torticollis is a common congenital problem. It is considered to be amenable to treatment which may be conservative or surgical. There are as yet no fixed guidelines as to the methodology or the timing of treatment. It is certainly advised to be prudent in selecting the appropriate treatment which should neither be too conservative nor over-invasive. We are reporting a series of 15 cases in which we did a unipolar release of the sternocleidomastoid muscle at the lower attachment. Retrospective analysis of 15 consecutive patients is done. During the postoperative period the parents were advised to regularly continue with the stretching exercises, focus on activities on the opposite side of the face and use a semi-rigid cervical collar, specially designed for active correction of these cases. We got very satisfactory postoperative results in most of our patients except one who had resistant deformity due to advanced age. In conclusion we would like to bring the focus back to unipolar release which is shifting unduly in favour of a bipolar release. This would also reduce the chances of the complication of accessory nerve injury. We have used the scoring system developed by Cheng et al and modifi ed by Shim in which the present cases showed improvement of 7 points with p-value of less than 0.0001

Introduction: Paretic upper limb in stroke patients has a significant impact on the quality of life. Modified Constraint Induced Movement Therapy (mCIMT) is one of the treatment options used for the improvement of the function of the paretic limb. Aim: To investigate the efficacy of four week duration mCIMT in the management of upper extremity weakness in hemiparetic patients due to stroke. Materials and Methods: Prospective single blind, parallel randomized controlled trial in which 30 patients received conventional rehabilitation programme (control group) and 30 patients participated in a mCIMT programme in addition to the conventional rehabilitation programme (study group). The mCIMT included three hours therapy sessions emphasizing the affected arm use in general functional tasks, three times a week for four weeks. Their normal arm was also constrained for five hours per day over five days per week. All the patients were assessed at baseline, one month and three months after completion of therapy using Fugl-Meyer Assessment (FMA) score for upper extremity and Motor Activity Log (MAL) scale comprising of Amount of Use (AOU) score and Quality of Use (QOU) score. Results: All the 3 scores improved significantly in both the groups at each follow-up. Post-hoc analysis revealed that compared to conventional rehabilitation group, mCIMT group showed significantly better scores at 1 month {FMA1 (p-value

There is a need for appropriate classification to describe gross motor function status in a child with cerebral palsy (CP). It was hypothesised that: greater the number of limbs involved, higher would be the Gross Motor Function Classification System (GMFCS) level; and, there would be spectrum of GMFCS level for each of the topographical types of the cerebral palsy. A cross-sectional study of 182 children of both sexes in the age group of 7 months to 30 years having spastic CP who attended CP clinic from 2008 to 2009 in tertiary care hospital were assessed for topographical diagnosis and GMFCS levels. Topographical distribution showed diplegia (42%), quadriplegia (30%), hemiplegia (23%), triplegia (4%) and monoplegia (1%). GMFCS levels were almost evenly distributed, level II (26%) was most common followed by level V (23%). Statistical analysis was done using Cramer's ratio and Pearson's Chi-square test. Cramer's ratio of 0.277 showed fairly weak correlation between GMFCS levels and topographical CP types. Pearson's Chi-square (12) =41.7, p=0.000 indicates that there is significant difference between expected and observed values of number of limbs involved in GMFCS levels, further substantiating the weak correlation. These results mean that GMFCS in different topographical groups have different distributions. It was also observed that GMFCS had weak correlation with the number of limbs involved, thus reflecting that the GMFCS is a better indicator of gross motor function impairment than the traditional topographical categorisation of CP that specifies the number of limbs involved.

Deformities of the hands and feet in Parkinson's disease (PD) may be mistaken for other more commonly occurring conditions. A case report of a 62 years old lady with Parkinsonism having such deformities is presented here.

Gram-negative organisms are a rare cause of infective endocarditis. Escherichia coli, the most common cause of urinary tract infection and gram-negative septicemia involves endocardium rarely. In this case report, we describe infection of native mitral valve by E. coli following septicemia of urinary tract origin in a diabetic male; subsequently, he required prosthetic tissue valve replacement indicated by persistent sepsis and congestive cardiac failure.

Introduction: Lateral epicondylitis or Tennis Elbow is one of the most common causes of upper extremity pain with various treatment options. Platelet-rich plasma (PRP) offers a new option for the treatment of lateral epicondylitis. This study was conducted with an aim to compare the efficacy of PRP versus methyl-prednisolone local injection in patients with lateral epicondylitis. Materials and Methods: Sixty five patients with lateral epicondylitis were included in the study and randomized into two groups. Group A was treated with single injection of 1ml PRP with absolute platelet count of at least 1 million platelets/ mm3 . Group B was treated with single injection of 1ml (40mg) methylprednisolone. Pain, grip strength and functional improvements were assessed using visual analogue scale, dynamometer and quick Disabilities of the Arm, Shoulder and Hand scale respectively at baseline, 15 days, 1 month and 3 months. Results: Sixty patients completed the follow up. All assessment parameters improved significantly in both the Groups at each follow up compared to baseline. At the end of three months group A showed significantly better improvement as compared to Group B. Conclusion: PRP and methyl-prenisolone both are effective in the treatment of lateral epicondylitis. However, PRP is a superior treatment option for longer duration efficacy.

Conrad misses the key point of our argument: The bills we highlight are fundamentally flawed because they are based on a series of false premises about how agencies use science to make policy. Taken together, these bills pervert the idea of a more “transparent, participatory, or accountable” regulatory process by sidelining independent science and scientists and creating redundant bureaucratic hoops that hamstring the ability of agencies to protect the public. Simply tweaking their language cannot achieve the goal of improving the process. Conrad also misrepresents the true intent of these bills: to shut down or block regulations that sponsors, and those who support their campaigns, don't like. Collectively, the bills shift analysis and decision-making authority from subject-matter experts to politically motivated generalists. McClellan, who has worked closely with the chemical industry throughout his career, notes that there are highly qualified scientists in industry, government, and academia that can usefully contribute to the policy process. We agree. But we disagree that these bills take the right approach or can be made to do so with some minor modifications to the language. Evans calls attention to incidents of bias and misuse of statistics, which can occur in any study that requires technical analyses. He actually helps to make our point: The process of assessing science for the purpose of developing the best policies needs to be in the hands of independent scientists. Attempts to distort this process by including analysts who have an agenda are dangerous for society. Can the process be improved? Absolutely. But only by encouraging the full participation of the science community rather than solely through industry lobbying efforts. We must begin from a rational starting point by recognizing that while enormous public health, safety, and environmental benefits have come from regulatory processes, a better connection between truly independent science and the policy-making process will result in still greater benefits for the public and for industry. We and our colleagues in science organizations, academia, and civil society are ready to fully engage in making those improvements. Are elected officials willing to work with us?