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The current version of the Declaration of Helsinki states that ‘the benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best current proven intervention(s) … ’. This wording implies that it is acceptable for patients to be assigned to receive an unproven new intervention and to be denied a best current proven intervention. We assert that patients being invited to participate in controlled trials cannot, ethically, be expected to forego proven beneficial forms of care. Patients being treated in controlled trials should not knowingly be disadvantaged compared with similar patients being treated in usual clinical care, where they have access to beneficial care. In this article, we have tried to separate for discussion ‘the withholding of effective care from trial participants’, ‘informed consent to treatment’, ‘blinding’ and ‘use of placebos’.

Recent years have seen a paradigm shift in the management of patients with diabetes mellitus. Rather than good glycaemic control being the sole primary aim, the therapeutic focus has broadened to consider potential additional cardiovascular and renal benefits. Sodium-glucose co-transporter 2 inhibitors, such as empagliflozin, canagliflozin and dapagliflozin, have gained increasing prominence, with evidence suggesting significant improvement in outcomes in patients with established cardiovascular and renal disease. Here, we discuss the benefits and relative risks of these novel agents and highlight important clinical issues of relevance to general physicians.

Purpose To describe the use of glycerine in improving media clarity in cases with edematous cornea. Methods Retrospective case-series including patients with posterior segment pathologies needing surgical invention and having corneal edema. Each case was studied for the role of topical application of glycerine instead of viscoelastic agents and the course of surgery. The cases were followed up for minimum 3-months duration. Results Six cases with corneal edema having posterior segment pathology underwent surgery with intraoperative topical application of glycerine. The corneal edema was seen to clear with progression of surgery and was maintained until the end of surgery. Procedures like vitreoretinal surgery, identification of break, internal limiting membrane peeling, intraocular lens explantation, scleral indentation, DSEK graft removal, and subretinal band removal could be performed in these cases. Conclusion Intraoperative glycerine use during vitreoretinal surgeries is helpful in improving the corneal clarity and maintaining it till the end of surgery.

Background Postpartum depression (PPD) has been associated with adverse health outcomes including maternal suicide. Mode of delivery has been suggested to be a risk factor for PPD, but no large cohort study has examined the association between mode of delivery and PPD. We aimed to examine the association between mode of delivery and risks of PPD at 1 and 6 months after childbirth. Methods In a nationwide study of 89,954 mothers with a live singleton birth, we examined the association between mode of delivery and risks of PPD. PPD was measured by the Edinburgh Postnatal Depression Scale (≥13) at 1 and 6 months after childbirth. Odds ratios (ORs) with 95% confidence intervals (CIs) of PPD were calculated using multivariable logistic regression analyses after adjustment of antenatal physical, socioeconomic, and mental factors. Results Among 89,954 women, 3.7% and 2.8% had PPD at 1 and 6 months after childbirth, respectively. Compared with unassisted vaginal delivery, cesarean section (CS) was marginally associated with PPD at 1 month, but not at 6 months; adjusted ORs were 1.10 (95% CI, 1.00-1.21) and 1.01 (95% CI, 0.90-1.13), respectively. The association with PPD at 1 month was evident in women with antenatal psychological distress: adjusted OR was 1.15 (95% CI, 1.03-1.28). The observed associations were attenuated after adjusting for infant feeding method. Conclusions Women who had antenatal psychological distress and underwent CS delivery may be regarded as a target for monitoring PPD.

PURPOSE To present a new technique to treat refractory retinal detachment secondary to optic disc pit. METHODS An interventional case report. RESULTS A 25-year-old man with congenital optic disc pit had two failed vitrectomies involving laser around the optic disc, internal limiting membrane peel and flap to plug the disc pit, and gas tamponade to reattach the retina. With all options running out, a further vitrectomy with autologous retinal transplant and silicone oil tamponade was carried out to treat the refractory serous retinal detachment; the silicone oil was removed at 6 weeks after the last procedure. The retina remained successfully attached at 6 months post-surgery with the patient maintaining his baseline visual acuity. CONCLUSION The use of autologous retinal transplant is a new approach to treat refractory retinal detachment secondary to congenital optic disc anomalies, and adds to our options of dealing with this complex condition when first-line approaches have failed.

Transient loss of consciousness (TLOC) is a frequent cause of referral to an emergency room. In view of the impact on treatment and the patients’ daily life activities (e. g. profession, driving license), an accurate and timely diagnosis is of uttermost importance. This article provides key features and suggests a practical step-by-step approach of how to differentiate syncope, epileptic and psychogenic non-epileptic seizures as the commonest causes of nontraumatic TLOC.

Background Early initiation of breastfeeding (EIBF) within 1 h of birth is crucial in preventing newborn deaths and plays a vital role in early infant nutrition. Promoting and supporting breastfeeding is an integral part of midwifery. The objective of the study was to improve the EIBF rate in neonates born through a Cesarean Section (CS) from 0% to 50% within six months through a quality improvement (QI) process and to assess the maternal experience of EIBF in operation theatre (OT). Methods Six Plan-Do-Study-Act (PDSA) cycles were conducted to test the change ideas proposed by the team members for a month to improve EIBF. Participants of the study were the stable term newborns delivered by CS under spinal anesthesia. Results The EIBF rate improved from 0% to 88% after the sixth PDSA cycle. The effect was sustained for six months. Mothers of 51 neonates (98%) who received EIBF reported that their newborns were breastfed successfully, and it was not physically tiring to feed immediately in the OT. Conclusions A quality improvement (QI) initiative was able to improve and sustain the improved EIBF rate after CS. Early skin-to-skin contact to be initiated with EIBF for better neonatal outcomes.

Purpose To highlight a case of chorioretinitis sclopetaria, with concomitant macular hole formation and orbital emphysema, caused by a commercial-grade pressure washer. Patient A 19-year-old male presented to the emergency department with a left eye injury, incurred after being sprayed with a commercial-grade pressure washer. He endorsed ipsilateral blurred vision, pain, and linear floaters. Left eye visual acuity was 20/40. Dilated fundus exam showed inferior vitreous hemorrhage, retinal whitening, and pre-, intra-, and sub-retinal hemorrhages, consistent with chorioretinitis sclopetaria. Optical coherence tomography revealed a full-thickness macular hole. Computed tomography scan of the orbits showed subcutaneous and post-septal orbital emphysema. Two months following injury, vitreous and retinal hemorrhages and macular hole resolved. Five months following injury, visual acuity improved to 20/20. Discussion Chorioretinitis sclopetaria is defined as a full-thickness chorioretinal disruption resulting from a high-velocity projectile passing adjacent to or into the orbit without penetrating the globe. Chorioretinal deformation and ocular comorbidities are influenced by the velocity of the missile and its spatial relationship to the orbit. While this pattern of injury is typically associated with indirect trauma to the globe by a BB or a bullet, this is the first report of chorioretinitis sclopetaria precipitated by a high-velocity liquid missile.

In this report, we present a series of two unusual cases of elapid snakebite with acute neuroparalysis, that after initial response to standard anti-snake venom therapy, developed recurrence of disabling quadriparesis with dysautonomia, that on detailed evaluation turned out to be immune-mediated polyradiculoneuropathy (GB syndrome). Both the cases then responded to therapy with intravenous immunoglobulins. These cases bring out the rare immune-mediated late complication of snake venom, which if recognized and treated in time, can significantly reduce the morbidity and mortality.

Purpose To describe with multimodal imaging including the use of ultra-widefield optical coherence tomography (OCT) imaging a distinct phenotype of autosomal recessive nanophthalmos associated with a novel mutation of the MFRP gene (membrane-type frizzled-related protein). Methods Case report and review of the relevant literature. Patients Single patient followed by the Weill Cornell Medicine Department of Ophthalmology Retina and Glaucoma Services. Results A patient with a novel homozygous mutation in the MFRP gene (c.472C>T) presented with nanophthalmos, optic disc drusen, foveal hypoplasia, and extensive peripheral retinoschisis, which was revealed to be multilevel retinoschisis on ultra-wide field OCT. Unlike other reported cases, the findings associated with this novel mutation did not include foveoschisis nor clinically obvious retinitis pigmentosa. The patient underwent prophylactic peripheral laser iridotomy in both eyes. Conclusion Here we present a patient with nanophthalmos, optic disc drusen, and foveal hypoplasia associated with extensive peripheral retinoschisis imaged by ultra-widefield OCT, but not foveal retinoschisis or prominent retinitis pigmentosa. The findings may expand the clinical spectrum of MFRP-associated nanophthalmos.

Neurofibromatosis (NF) is an inherited neuroectodermal abnormality that primarily affects the growth of neural tissues, and Riccardi classified it into eight types. Segmental neurofibromatosis, which is a rare form of neurofibromatosis, is classified as type 5. We report a case for very unusual presentation of segmental NF with unilateral lisch nodules and uncommon sites involving the scalp. Moreover, we could find only one case report of segmental NF with lisch nodules in the literature and could not find any case report involving the scalp.

Background and objectives Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs. Methods According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: (“regional anesthesia” OR “nerve block”) AND (“complications” OR “nerve lesion” OR “nerve damage” OR “nerve injury”). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed. Results Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000. Conclusions Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.

BACKGROUND/PURPOSE To describe the association between autosomal dominant Best disease and peripapillary angioid streak-like changes. METHODS Case report of two siblings. RESULTS A 76-year-old Caucasian male was referred for evaluation of bilateral macular changes and worsening visual distortion over the preceding 2 years. Best corrected visual acuity (BCVA) measured 20/30 in the right eye and 20/80 in the left eye. Funduscopic examination revealed multifocal yellow lesions in the posterior pole that were hyper-autofluorescent on short-wavelength excitation and corresponded with subretinal hyperreflective material on optical coherence tomography. The posterior pole examination was interesting due to the juxtapapillary involvement of the vitelliform lesions as well as the presence of bilateral peripapillary angioid streak-like changes despite no history of conditions associated with angioid streaks. On further workup, an electro-oculogram revealed reduced Arden ratios and a known heterozygous missense mutation in BEST1 (c.903T>G; p.D301E) was found. The patient's 69-year-old younger brother was brought in and found to have a remarkably similar phenotype, including the presence of angioid streak-like changes associated with the same BEST1 mutation. CONCLUSIONS These two cases demonstrate the possibility of late-onset multifocal vitelliform disease due to dominantly inherited BEST1. A consistent phenotype in this family with macular lesions extending into the peripapillary region, associated with angioid streak-like changes, suggests susceptibility of this region to changes in dominant BEST1-vitelliform macular dystrophy.

Background Coma is one of the frequently encountered clinical conditions in any intensive care unit (ICU), which is responsible for considerable morbidity and mortality. Therefore, this study was designed to look at the clinical and EEG profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG). Methods In all 102 patients of unresponsive coma (GCS ≤ 8), who remained in poor sensorium despite 48 h of optimum treatment in ICU, were included in the study. All patients underwent 1 h of electroencephalography (EEG) monitoring with a portable EEG machine. All EEGs were screened according to Salzburg Consensus Criteria (SCC) for Nonconvulsive Status Epilepticus (NCSE). Patients with evidence of NCSE were administered parenteral Antiepileptic Drugs (AED). A repeat EEG was done after 24 h of baseline to ascertain the effect of AED. The primary outcome was the recognition of patients with NCSE on the basis of established EEG criteria. The secondary outcome measure was the Glasgow outcome scale (GOS) at the time of discharge. Results Out of 102 cases enrolled, 12 (11.8%) cases were detected to have NCSE on portable EEG. The mean age of patients with NCSE was 52.2 years. In terms of gender distribution, 2/12 (17%) were female, and 10/12 (83%) were male (M: F = 5:1). Median GCS was 6 (range 3–8). Looking at CNS infections, 4/12 (33.3%) had evidence of some form of CNS infection in the NCSE group, compared to 16/90 (18%) in the group without NCSE. This difference was statistically significant (P-value 2 points) after administration of AED’ was noted with good clinical outcomes (GOS 5). In five of these 12 cases, death was the final outcome (GOS 1). Conclusions NSCE should be considered in the differential diagnosis of all unresponsive comatose ICU patients. In resource-limited settings, where continuous EEG monitoring may not be feasible, bedside portable EEG testing can be used to diagnose patients with NCSE. Treating NCSE reverses epileptiform EEG changes and improves clinical outcomes in a subset of comatose ICU patients.

DRESS is a potentially life-threatening severe cutaneous adverse reaction (SCAR). Historically, it was most frequently linked with phenytoin and was initially described as phenytoin hypersensitivity syndrome; however, it was later found to be caused by various other medications, with the commonest been aromatic anticonvulsants, allopurinol and sulfonamides. The severity of this entity is related to systemic involvement, which can result in multiorgan failure and death. The diagnosis of DRESS, especially in the early stages, remains challenging and elusive due to its heterogeneous clinical presentation and the complex course of the disease with different patterns depending on the causal drug. The most important step in the management of DRESS is early diagnosis and immediate cessation of the suspected offending drug along with oral steroids or immunosuppressants to control the disease. We describe the varying presentation and management of six adults with DRESS from a tertiary care hospital, observed over a two-year period with a brief review of the literature.

Classic Toxic Epidermal Necrolysis (TEN) in Lupus Erythematosus (LE) is rare and that caused by oxcarbazepine is even rarer. It can be triggered/induced by various insults, the most prominent being drugs. Herein, we describe a young female, a diagnosed case of LE with lupus nephritis, with recent-onset central nervous system vasculitis (incidentally detected on neuroimaging while she was being evaluated for a recent-onset behavioural change), who within a month of exposure to the drug developed an extensive exfoliating skin rash with mucosal lesions, which on histopathological evaluation showed TEN in LE, triggered by Oxcarbazepine, which was commenced for seizure prophylaxis. She was managed with pulse methylprednisolone, followed by intravenous immunoglobulin (IVIg), after which she made a satisfactory recovery. It is highlighted that TEN in LE patterns must be recognized in an emergency and Acute Syndrome of Apoptotic Panepidermolysis (ASAP) concept applied promptly without awaiting diagnoses. Further, many common drugs possibly trigger this pathology making the rara-avis not rare anymore!

Multicentric reticulohistiocytosis, also called as lipoid dermato-arthritis is a rare form of non-Langerhans cell histiocytosis characterised by nodular and papular skin lesions containing characteristic bizarre multinucleate giant cells with ground glass cytoplasm. The disease commonly involves the skin, mucosa, synovium, and internal organs with cutaneous nodules and progressive erosive arthritis being the most common presenting features. We report a case of a 61-year-old male presenting with multiple swellings over distal part of fingers for 6 years without involvement of joints. A diagnosis of multicentric histiocytosis was made based on typical histopathological features of sheets of histiocytes and multinucleate giant cells with ground glass eosinophilic cytoplasm. The disease has a low incidence and about 300 cases have been reported so far in literature. The present case is being reported as it is uncommon for the disease to present in absence of arthritis.

Background Mobile phones in hospital settings have been identified as an important source of cross-contamination because of the low frequency with which mobile phones are cleaned by health workers and cyclical contamination of the hands and face. The aim of this study was to investigate whether the mobile phones of the anesthesia team at a teaching hospital are potential reservoirs of nosocomial bacteria. In addition, differences in device sanitization and hand hygiene habits between attending and resident anesthesiologists were correlated with mobile phone colonization. Methods A prevalence study was conducted over a 6-month period from 2017 to 2018 that involved the collection of samples from the mobile phones of the anesthesiology team and culturing for surveillance. A questionnaire was administered to assess the mobile phone sanitization and hand washing routines of the anesthesia team in specific situations. Results Bacterial contamination was detected for 86 of the 128 mobile phones examined (67.2%). A greater presence of Micrococcus spp. on devices was correlated with a higher frequency of mobile phone use (p = 0.003) and a lower frequency of sanitization (p = 0.003). The presence of bacteria was increased on the mobile phones of professionals who did not perform handwashing after tracheal intubation (p = 0.003). Conclusion Hand hygiene and device sanitization habits were more important than the use behavior, as a higher presence of bacteria correlated with poorer hygiene habits. Furthermore, handwashing is the best approach to prevent serious colonization of mobile devices and the possible transmission of pathogens to patients under the care of anesthesiologists.

Absract Background Obstetrics as a speciality has a very long association with the transfusion services and poses its own set of immunohematological (IHL) challenges. A study was carried out to evaluate the spectrum of IHL issues in obstetrics in our setup and to suggest a way forward. Methods This study was carried out in a transfusion services setup catering to antenatal care (ANC) clientele in two tertiary-level health care setups. Samples were collected from all ANC patients requiring transfusion and patients reporting for Indirect Coombs Test (ICT). Data included ICT positive cases with implicated alloantibodies, those requiring specialised procedures and the foetal outcome. The results were described using descriptive statistics by frequencies and percentages. Results A total of 4683 eligible samples were included in the study, out of 21,893 antenatal patients visiting our setup during study period. One hundred thirty-six ANC patient samples were found to be ICT positive. The most common single alloantibody was anti-D (n = 77, 57.5%). Double antibody positivity was found in 28 patients. Multiple alloantibodies were found in 1 patient. Up to 48% of these allo-anti D cases necessitated specialised procedures. Conclusion The IHL issues of obstetrics faced in our setup are no less than that in Indian population. We have much higher frequency of double alloantibody in our ANC population. The authors propose that all multiparous ANC patients, especially with a history of transfusion, irrespective of Rh D status should be screened for irregular alloantibodies to circumvent these issues and the last-minute rush for provision of compatible units.

A fetus with features of hydrops was given intra-uterine transfusion at 27 weeks and 31 weeks of gestation. Mother had been alloimmunized with anti-D and anti-C antibodies. At birth, laboratory investigations revealed bone marrow suppression along with features of hemolytic anemia. The neonate was started on a combination of phototherapy and intravenous immunoglobulin. During the course, the neonate was transfused with one unit of packed red cells (top-up transfusion). Neonatal hyperbilirubinemia responded to phototherapy and the bone marrow activity spontaneously resumed after 3 weeks of life. In neonates with anemia at birth who have history of multiple intra-uterine transfusions, early-onset hypoproliferative anemia should be considered.

Introduction Subtotal cholecystectomy (STC) is an alternative to total cholecystectomy (TC) in patients with severe inflammation/adhesions around the hepatocystic triangle. This study aimed to evaluate the safety profile of STC. Methods We retrospectively reviewed all patients who had STC at our unit between February 2009 and August 2019. STC was divided into two types, reconstituting (R-STC) and fenestrating (F-STC), depending on whether the gall bladder remnant was closed or left open. Patients who had cholecystectomy for gall bladder malignancy or as part of another operation were excluded from the study. Results A total of 5,664 patients underwent cholecystectomy during the study period. Of these, 97 (1.7%) underwent STC. The laparoscopic to open conversion rate was high at 48.8% (47 cases), as was the overall postoperative complication rate (45.4%, 44 cases). No patient suffered iatrogenic bile duct injury. Nineteen patients (19.6%) suffered postoperative bile leak. This was significantly higher in patients who had STC in the acute setting (41% vs 13% for elective STC cases; p=0.04). There was no significant difference in rate of bile leak or other complications between R-STC and F-STC types. The 90-day readmission rate was 8.2% (8 cases). No mortalities were recorded within 90 days post STC. Conclusions STC seems to be an effective technique to avoid bile duct injury in difficult cholecystectomy cases. However, the perioperative morbidity associated with STC is relatively high. Surgeons should be aware of the risks of STC and take appropriate steps to minimise them.

Purpose To describe central serous chorioretinopathy (CSCR) cases presenting as uveal effusion syndrome, providing new insights into "pachychoroid spectrum" diseases. Methods Clinical charts, color fundus photographs, fluorescein angiography, indocyanine green angiography, optical coherence tomography, ultrasound imaging, cerebral magnetic resonance imaging and biometry of four eyes of three patients were assessed. A literature review was conducted. Results The three patients had peripheral choroidal detachment and inferior bullous retinal detachment associated with CSCR features detected using multimodal imaging, including fluorescein and indocyanine green angiography. The choroid was thick in the three patients, and uveal effusion occurred after steroid treatment in all cases. Subretinal fluid drainage and deep sclerectomy with flaps of 4x4 mm in both inferior quadrants were performed in 3 eyes of 2 patients with good outcomes. One patient was treated with photodynamic therapy. All three patients developed a typical leopard-spot pigmentary pattern in the fundus. Conclusion A severe presentation of highly exudative CSCR may occur in rare cases with a peripheral choroidal detachment mimicking uveal effusion syndrome. These severe cases highlighted the role of choroidal thickening and hyperpermeability, choroidal vein dilation and possible scleral thickening in both entities.

In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.

Background Acute respiratory infections (ARIs) are responsible for considerable morbidity and mortality among children all over the world. Many of the etiologic agents of the infections especially viral go undiagnosed for lack of requisite facility and the cost factors. We have used a commercially available platform for diagnosis of ARIs in children receiving inpatient and outpatient services in a tertiary care centre. Methods The framework of the study was prospective and observational. In this study, clinical samples of children suffering from ARIs were subjected to real-time multiplex PCR targeting both viral and bacterial pathogens. Results Of 94 samples received at our centre (49 male and 45 female), the positivity for respiratory pathogens was detected in 50 (53.19%) samples. Clinical symptoms of patients and age distribution have been elaborated in text. A single pathogen (n = 29/50), two pathogens (15/50) and three pathogens (n = 6/50) were detected by multiplex RT-PCR. Of 77 isolates detected, maximum numbers were of human rhinovirus (HRV) (n = 14) (18.18%) Streptococcus pneumoniae (n = 14) (18.18%) followed by Staphylococcus aureus (n = 10) (12.98%). Conclusion The epidemiology of ARIs considering viral etiologies is poorly understood due to less number of studies especially in Indian subcontinent. The advent of latest advanced molecular methods has made it possible to identify common respiratory pathogens and has contributed to cover the gap in existing knowledge.

Many systemic diseases go along with dermal involvement. Only a few of systemic diseases show characteristic skin derangements directly leading to the diagnosis of the underlying disease. Ten of these entities are described within this article. Some of these are autoimmune diseases, such as systemic lupus erythematodes, dermatomyositis or the anti-synthetase-syndrome. Others are genetic diseases with benign or malignant neoplasias (Peutz-Jeghers-syndrome, neurofibromatosis, tuberous sclerosis, Birt-Hogg-Dubé-syndrome, Cowden-syndrome). Other genetically based diseases with typical skin manifestations are characterised by vascular malformations (Pseudoxanthoma elasticum and Osler-Weber-Rendu syndrome) or metabolic and structural organ defects (Morbus Fabry, cystic fibrosis). Being familiar with the typical skin-appearance of these diseases will allow physicians and general practitioners to make a timely diagnosis.

Background Injury surveillance is the cornerstone of any prevention program. However the same pertaining to women’s boxing is meager. We hence intended to analyse the incidence, pattern and characteristics of injuries in female boxers during the 4th Elite Women’s National Boxing Championship, 2019, in India. Methods A total of 235 female Indian boxers participated in the tournament. Injuries from the competition injury database maintained in accordance with the injury code proposed by the Australian Sports Injury Data Dictionary were compiled to observe the pattern and analysed. The outcomes measured were incidence in terms of injury rate and injury risk and injury pattern in terms of site, nature, mechanism, severity and time of injury. Results The injury rate was observed to be 43.98 injuries per 1000 athlete bouts of exposure (95% confidence interval [CI]: 33.71-54.07) and 293.21 injuries per 1000 athlete hours of competition (95% CI: 225.94-360.47). The most commonly injured site was head, face and neck regions. Most injuries were bruises/contusions followed by cuts and epistaxis. No concussions were reported. Conclusion This study observed that women are less prone to injuries than their male counterparts, even though a logical comparison is difficult because of the lack of data and standardization in women's boxing.

Peripartum cardiomyopathy (PPCM) is a rare pregnancy-associated dilated cardiomyopathy occurring in the last month of pregnancy and five months postdelivery, which presents with features of cardiac failure. Diagnosis is based on characteristic echocardiographic findings and elevated cardiac biomarkers and has significant mortality and morbidity when undiagnosed and untreated. Atypical presentations in earlier gestations are rare and associated with risk factors. Here we present a case of PPCM diagnosed in the second trimester in a post in vitro fertilization (IVF) twin pregnancy to emphasize the importance of considering the diagnosis of PPCM in all cases of unexplained cardiac failures during pregnancy in previously healthy patients, especially in the presence of risk factors.

This review describes major mass gatherings in the MENA region and the public health implications of these events, and provides recommendations for public health officials of the host country. Through our search of the literature for peer-reviewed publications, we identified relevant 77 papers; all were related to the annual Hajj. Using the information obtained from the literature review, the Eastern Mediterranean Public Health Network (EMPHNET) and the Centers for Disease Control and Prevention (CDC) developed and conducted 2 workshops on Public Health Surveillance during Mass Gatherings for field epidemiology training programmes and ministry of health focal points from 10 countries. The main potential public health concerns associated with mass gatherings include: infectious diseases (e.g. respiratory disease, gastro-intestinal tract disease, foodborne disease), injuries, traffic accidents, heat-related illnesses, insect stings, non-communicable diseases and terrorism.

Souissi, MA, Elghoul, Y, Souissi, H, Masmoudi, L, Ammar, A, Hamdi chtourou, and Souissi, N. The effects of three corrections strategies of errors on the snatch technique in 10-12-year-old children: A randomized controlled trial. J Strength Cond Res XX(X): 000-000, 2020-Sports movement correction is one of the major problems for motor control and learning. Therefore, the purpose of the present study was to determine which of the 3 strategies, i.e., the self-observation method with direct instructions (SO-DI), self-observation alone (SO), or the direct instruction (DI), would be useful for correcting errors during the snatch technique. Forty-eight children with 2 months of experience were randomly assigned to one of 4 training conditions: SO-DI, SO, DI, or control. In this study, the experience lasted 15 sessions. Subjects completed the test sessions before (T0) and after (T1) 12 training sessions and a retention test session after 2 weeks (T2). The Kinovea version 0.8.15 software was used to measure the kinematic parameters of weightlifting performance. After the training intervention, the data showed that the SO-DI group registered a greater improvement in all kinematic parameters compared with the SO, DI, and control groups, and this benefit was present 2 weeks later in the retention test (e.g., the horizontal displacement of the bar in the first pull with respect to the starting position [T1 vs. T0: +32.57 ± 6.69%, d = 1.87, p < 0.001; T2 vs. T0: 25.07 ± 11.55%, d = 1.32, p < 0.001] and the horizontal displacement of the bar between the receiving position and the reference line [T1 vs. T0: 24.34 ± 29%, d = 1.17, p < 0.01; T2 vs. T0: 25.53 ± 30.4%, d = 0.99, p < 0.01]). The results of the present study could have practical implications for physical education teachers because, even if practice is required to improve the technique, the effectiveness of the learning process is essential to enhance learner self-efficacy and motivation.

Non-obstructive azoospermia is reported to affect 1 in 100 men, and despite advances in surgical practice, the succesful sperm retrieval rate for microdissection testicular sperm extraction surgery (mTESE) is only 46%. This article reviews the potential causes for mTESE failure and provides a management strategy to guide the clinicians on how to treat this challenging cohort of patients.

Background: The purpose of this study was to compare the safety and clinical outcomes of transcarotid (TC) and transapical access (TA) transcatheter aortic valve implantation (TAVI) patients whom the transfemoral approach (TF) was not feasible. Methods: The analysis included consecutive patients with severe symptomatic aortic stenosis treated from 2017 to 2020 with TC-TAVI or TA-TAVI in two high-volume TAVI centers. The approach was selected by multidisciplinary heart teams after analyzing multislice computed tomography of the heart, aorta and peripheral arteries, transthoracic echocardiography and coronary angiography. Results: One hundred and two patients were treated with alternative TAVI accesses (TC; n = 49 and TA; n = 53) in our centers. The groups were similar regarding age, gender, New York Heart Association class, and echocardiography parameters. Patients treated with TC-TAVI had significantly higher surgical risk. The procedural success rate was similar in both groups (TC-TAVI 98%; TA-TAVI 98.1%; p = 0.95). The rate of Valve Academic Research Consortium-2 defined clinical events was low in both groups. The percentage of new-onset rhythm disturbances and permanent pacemaker implantation was similar in TC and TA TAVI (4.1% vs. 11.3%; p = 0.17 and 10.2% vs. 5.7%; p = 0.39, respectively). In the TA-TAVI group, significantly more cases of pneumonia and blood transfusions were observed (11% vs. 0%; p = 0.01 and 30.2% vs. 12.2%; p = 0.03). The 30-day mortality was similar in TC and TA groups (4.1% vs. 5.7%; p = 0.71, respectively). Conclusion: Both TC and TA TAVI are safe procedures in appropriately selected patients and are associated with a low risk of complications.

Background: Cardiac magnetic resonance imaging (CMR) remains underutilized as an exercise imaging modality, mostly because of the limited availability of MR-compatible exercise equipment. This study prospectively evaluates the clinical feasibility of a newly developed MR-conditional pedal ergometer for exercise CMR Methods: Ten healthy volunteers (mean age 44 ± 16 years) and 11 patients (mean age 60 ± 9 years) with known or suspected coronary artery disease (CAD) underwent rest and post-exercise cinematic 3T CMR. Visual analysis of wall motion abnormalities (WMA) was rated by 2 experienced radiologists, and volumes and ejection fractions (EF) were determined. Image quality was assessed by a 4-point Likert scale for visibility of endocardial borders. Results: Median subjective image quality of real-time Cine at rest was 1 (IQR 1–2) and 2 (IQR 2–2.5) for post-exercise real-time Cine (p = 0.001). Exercise induced a significant increase in heart rate (62 [62–73] to 111 [104–143] bpm, p < 0.0001). Stroke volume and cardiac index increased from resting to post-exercise conditions (85 ± 21 to 101 ± 19 mL and 2.9 ± 0.7 to 6.6 ± 1.9 L/min/m 2 , respectively; both p < 0.0001), driven by a reduction in end-systolic volume (55 ± 20 to 42 ± 21 mL, p < 0.0001). Patients (2/11) with inducible regional WMA at high-resolution post-exercise cine imaging revealed significant coronary artery stenosis in subsequently performed invasive coronary angiography. Conclusion: Exercise-CMR using our newly developed 3T MR-conditional pedal ergometer is clinically feasible. Imaging of both cardiac response and myocardial ischemia, triggered by dynamic stress, is rapidly conducted while the patient is near their peak heart rate.

Background: Cardiac amyloidosis (CA), following a non-invasive diagnosis, constitutes an increasingly prevalent heart failure (HF) etiology. This study aims to determine which echocardiography findings help to diagnose cardiac amyloidosis in patients with left ventricular hypertrophy (LVH) admitted for decompensated HF. M ethods: The present study is a retrospective observational study on a cohort of 85 LVH patients admitted for HF decompensation, in which 99m Tc-DPD scanning was performed to rule out transthyretin CA. The echocardiographic findings obtained were compared between CA and non-CA groups. Results: From a total number of 85 patients, 49 (57.6%) met the CA criteria and 36 (42.3%) were ruled out for the disease. Interventricular septum thickness (16 ± 3 mm vs. 14 ± 3 mm), left ventricular posterior wall thickness (14 ± 3 mm vs. 11 ± 2 mm), left ventricular mass (259 ± 76 g vs. 224 ± 53 g), left ventricular telediastolic diameter (48 ± 7 mm vs. 53 ± 6 mm), left ventricular telediastolic indexed volume (51 ± 18 cm 3 /m 2 vs. 59 ± 16 cm 3 /m 2 ), tricuspid annular plane systolic excursion (16 ± 5 mm vs. 20 ± 4 mm), right atrial area (27.4 ± 8.4 cm 2 vs. 22.2 ± 5.7 cm 2 ) and strain relative apical sparing (2.2 ± 0.9 vs. 1.03 ± 0.4; p = 0.04) were significantly associated with the diagnosis of CA. Conclusions: In patients with LVH admitted for HF decompensation, there are several echocardiographic features (LVH, reduced left ventricular cavity size, strain relative apical sparing, right atrial dilation, and altered right ventricular function) that are associated with the diagnosis of cardiac amyloidosis.

Background: In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), the treatment strategy for non-infarct-related artery (non-IRA) remains controversial. Quantitative flow ratio (QFR) is a new angiography-based physiological assessment index. However, there is little evidence on the practical clinical application of QFR. Methods: Two hundred and twenty-nine patients with STEMI and MVD were recruited for this study. Patients were randomly assigned to either receive QFR-guided complete revascularization (QFR-G-CR) of non-IRA or receive no further invasive treatment. The primary (1o) endpoint analyzed included death due to all causes, non-fatal myocardial infarction (MI), and ischemia-induced revascularization at 12 months post-surgery. Secondary (2o) endpoints included cardiovascular death, unstable angina, stent thrombosis, New York Heart Association (NYHA) class IV heart failure (HF), and stroke at 1 year post surgery. Massive bleeding and contrast-associated acute kidney injury (CAKI) were used as safety endpoints. Results: Around the 12 month follow up, the 1o outcome was recorded in 11/115 patients (9.6%) in the QFR-G-CR population, relative to 23/114 patients (20.1%) in the IRA-only PCI population (hazard ratio [HR]: 0.45; 95% confidence interval [CI]: 0.22–0.92; p = 0.025). Unstable angina in 6 (5.2%) and 16 (14.0%) patients (HR: 0.36; 95% CI: 0.14–0.92; p = 0.026), respectively. No marked alterations were found in the massive bleeding and CAKI categories. Conclusions: In conclusion, STEMI and MVD patients can benefit from QFR-G-CR of non-IRA lesions in the initial stages of acute MI. This can help reduce incidences of major adverse cardiovascular events and unstable angina, relative to IRA treatment only. Chinese Clinical Trial Registration number: ChiCTR2100044120.

Background: Current guidelines recommend electrical cardioversion (ECV) in patients with atrial fibrillation (AF) after at least 3 weeks of adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without prior transesophageal echocardiography (TEE). However, in clinical practice in some centres, TEE is performed before ECV in patients with AF. The aim of the study was to evaluate prevalence of thromboembolic and hemorrhagic complications in patients with AF treated with NOACs and undergoing ECV without prior TEE. Methods: This observational, multicentre study included consecutive patients with AF treated with NOACs who were admitted for ECV without prior TEE. Thromboembolic events and major bleeding complications were investigated during a 30-day follow-up. Results: In the study group there were 611 patients, mean age was 66.3 ± 9.2 years, 40% were women. 52 (8.5%) patients had a low thromboembolic risk, 148 (24.2%) patients had an intermediate thromboembolic risk and 411 (67.2%) patients had a high thromboembolic risk. In the study group 253 (41.4%) patients were treated with rivaroxaban, 252 (41.2%) patients were treated with dabigatran and 106 (17.3%) patients were treated with apixaban. Reduced doses of NOACs were administered to 113 (18.9%) patients. In the entire study group, there were no thromboembolic events or major bleeding complications during the in-hospital stay and the 30-day follow-up. Conclusions: In this “real-world” study of AF patients treated with NOACs, it was proved that ECV is safe without a preceding TEE, regardless of the risk of thromboembolic complications and of the type of NOAC used.

Investigating the prognostic value of the Murray law-based quantitative flow ratio (μQFR) on the clinical outcome after treatment of in-stent restenosis (ISR) with a drug-coated balloon (DCB).Patients participating in a previous randomized clinical trial for DCB-ISR were post-hoc analyzed. The primary endpoint was vessel-oriented composite endpoint (VOCE), defined as cardiac death, target vessel-related myocardial infarction, and ischemia-driven target vessel revascularization. μQFRs at baseline and after DCB angioplasty was calculated, and its prognostic value as a predictor of VOCE was explored in Cox regression.A total of 169 lesions in 169 patients were analyzed. At one-year follow-up, 20 VOCEs occurred in 20 patients. Receiver-operating characteristic curve analysis identified a post-procedural μQFR of ≤ 0.89 as the best cut-off to predict VOCE (area under curve [AUC]: 0.74; 95% confidence interval [CI]: 0.67-0.80; p0.001), superior to post-procedural in-stent percent diameter stenosis (DS), which reported an AUC of 0.61 (95% CI: 0.53-0.68; p = 0.18). Post-procedural μQFR was significantly lower in patients with VOCE compared with those without (0.88 [interquartile range: 0.79-0.94] vs. 0.96 [interquartile range: 0.91-0.98], respectively; p0.001). After correction for potential confounders, post-procedural μQFR ≤ 0.89 was associated with a 6-fold higher risk of VOCE than lesions with μQFR0.89 (hazard ratio: 5.94; 95% CI: 2.33-15.09; p0.001).Post-procedural μQFR may become a promising predictor of clinical outcome after treatment of DES-ISR lesions by DCB angioplasty.

Background Many epidemiological studies have reported the association between various social factors and health status in mothers during and after pregnancy. However, little is known about their joint and longitudinal impact. We therefore examined the association of lack of social support and trust during pregnancy and at 2.5 years postpartum with health status in mothers. Methods To adequately address time-varying exposure, marginal structural models were fitted to a pseudopopulation constructed by inverse probability weighting. The model included records of 90,071 mothers participating in the Japan Environment and Children's Study. Social support and trust were measured using a 9-item questionnaire (Q1-9). Mental and physical health were measured using Mental and Physical Component Summary scores from the 8-item Short-Form Health Survey. Results For the Mental Component Summary, the magnitude of the effect estimate was largest when participants lacked close friends/neighbors (Q4) at only 2.5 years postpartum (= -6.23), followed by a lack in emotional support (Q2) at the same time point (= -4.94). For the Physical Component Summary, effect estimates were negligible. The magnitude of the effect estimates of lack of social support and trust tended to be larger when there was a lack at only 2.5 years postpartum than at both time points. Conclusions These findings suggest that, after childbirth, a loss in social support, particularly in a concrete or instrumental aspect, carries high risk, especially for mental health. Our results highlight the importance of supporting mothers for more than a few years after pregnancy.

BackgroundDevelopmental dysplasia of the hip (DDH) is a cluster of hip development disorders that affects infants. The incidence of DDH-related dislocation (DDH-dislocation) is reportedly 0.1-0.3%; however, the nationwide incidence of DDH-dislocation in Japan has not been previously reported. The primary aim of this study was to report the nationwide incidence of DDH-dislocation in Japan using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), and to examine its regional variation across Japan.MethodsThis was a retrospective birth cohort study using the NDB. Data on patients born between 2011 and 2013 and assigned DDH-dislocation-related disease codes during 2011-2018 were extracted. Among these, patients who underwent treatment for DDH-dislocation between 2011 and 2018 were defined as patients with DDH-dislocation.ResultsAcross the 2011, 2012, and 2013 birth cohorts, 2367 patients were diagnosed with DDH-dislocation, yielding the nationwide incidence of 0.076%. Region-specific incidence rates were almost similar across Japan. Secondary analyses revealed that 273 (11.5%) patients were diagnosed at the age of ≥1 year. The effect of birth during the cold months on the incidence of DDH-dislocation was significant (relative risk [RR]=1.89, 95% confidence interval [CI]: 1.75-2.06). The risk of DDH-dislocation among girls was approximately seven times higher than that among boys.ConclusionsThis is the first study to report the nationwide incidence of DDH-dislocation in Japan, which was estimated at 0.076%. The regional variation was trivial and unlikely to be clinically significant. Thus, the incidence rates were approximately equal across all regions in Japan.

Background Anger has been suggested as a risk factor for stroke. Perceived social support (PSS) may relieve anger, thus reducing the risk of stroke; however, evidence supporting this is limited. We aimed to examine whether PSS modifies the risk of stroke associated with anger expression. Methods A cohort study was conducted among 1,806 community residents aged 40-74 years who received a cardiovascular risk survey including anger expression in 1997. A Cox proportional hazards model was applied to the participants with low and high PSS to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) of the risks of total stroke and its subtypes based on total anger expression after adjusting for known stroke risk factors. Results The median follow-up duration was 18.8 years, with 51 incident strokes. Among the participants with low PSS, anger expression had a positive association with the total stroke risk: The multivariable HR per SD increment of total anger expression was 1.43 (95% CI, 1.13-1.82). In contrast, no association was identified among those with high PSS. The corresponding HR was 0.83 (95% CI, 0.49-1.40), with a significant interaction between low and high PSS (p = 0.037). Similar associations regarding the risk of ischemic stroke were found. Conclusions We found an increased risk of stroke associated with anger expression among the participants with low PSS, but not among those with high PSS. Our results suggest that PSS might mitigate the risk of stroke associated with anger.