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Purpose The focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability. Methods On September 17–18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10 days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments. Results In total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes. Conclusions SPINE20’s initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe.

Ehlers-Danlos is a connective tissue disorder characterized by hypermobile joints, hyperextensible skin, and increased bleeding tendency. We report a case involving endovascular repair of an intussusception of aortic dissection that occurred in an Ehlers-Danlos patient following surgical repair of an intercostal artery bleed. Given the rarity of Ehlers-Danlos, continued reporting of treatment outcomes is important for refining complication management in this population. Our experience lends support for endovascular rescue of failed aortic repair that may arise in Ehlers-Danlos patients and contributes to the otherwise small body of literature concerning endovascular intervention in this population overall.

Background To describe the key findings and lessons learned from an international pilot study that surveyed spinal cord injury programs in acute and rehabilitation facilities to understand the status of spinal cord injury care. Methods An online survey with two questionnaires, a 74-item for acute care and a 51-item for rehabilitation, was used. A subset of survey items relevant to the themes of specialized care, timeliness, patient-centeredness, and evidence-based care were operationalized as structure or process indicators. Percentages of facilities reporting the structure or process to be present, and percentages of indicators met by each facility were calculated and reported separately for facilities from high-income countries (HIC) and from low and middle-income countries (LMIC) to identify “hard to meet” indicators defined as those met by less than two-thirds of facilities and to describe performance level. Results A total of 26 acute and 26 rehabilitation facilities from 25 countries participated in the study. The comparison of the facilities based on the country income level revealed three general observations: 1) some indicators were met equally well by both HIC and LMIC, such as 24-hour access to CT scanners in acute care and out-patient services at rehabilitation facilities; 2) some indicators were hard to meet for LMIC but not for HIC, such as having a multidisciplinary team for both acute and rehabilitation settings; and 3) some indicators were hard to meet by both HIC and LMIC, including having peer counselling programs. Variability was also observed for the same indicator between acute and rehabilitation facilities, and a wide range in the total number of indicators met among HIC facilities (acute 59–100%; rehabilitation 36–100%) and among LMIC facilities (acute: 41–82%; rehabilitation: 36–93%) was reported. Conclusions Results from this international pilot study found that the participating acute and rehabilitation facilities on average adhered to 74% of the selected indicators, suggesting that the structure and processes to provide ideal traumatic spinal cord injury care were broadly available. Recruiting a representative sample of SCI facilities and incorporating regional attributes in future surveys will be helpful to examine factors affecting adherence to indicators.

Together, SARS-CoV-2 and M. tuberculosis have killed approximately 5.7 million people worldwide over the past 2 years. The COVID-19 pandemic, and the non-pharmaceutical interventions to mitigate COVID-19 transmission (including social distancing regulations, partial lockdowns and quarantines), have disrupted healthcare services and led to a reallocation of resources to COVID-19 care. There has also been a tragic loss of healthcare workers who succumbed to the disease. This has had consequences for TB services, and the fear of contracting COVID-19 may also have contributed to reduced access to TB services. Altogether, this is projected to have resulted in a 5-year setback in terms of mortality from TB and a 9-year setback in terms of TB detection. In addition, past and present TB disease has been reported to increase both COVID-19 fatality and incidence. Similarly, COVID-19 may adversely affect TB outcomes. From a more positive perspective, the pandemic has also created opportunities to improve TB care. In this review, we highlight similarities and differences between these two infectious diseases, describe gaps in our knowledge and discuss solutions and priorities for future research.

This case series looks at the role of intraoperative ultrasound in spine surgery for extradural pathologies.Ten cases of different pathologies were included. Following posterior laminectomy, intraoperative ultrasound was used to determine the adequacy of decompression. The surgical approach and extent of surgery was then determined on the basis of ultrasound observations. Postoperative magnetic resonance imaging was done to correlate the ultrasound findings.We found intraoperative ultrasound to be a useful tool that is easy to use and interpret in spine surgery. The adequacy of decompression was well visualized. The finding also correlated with the decompression achieved on a postsurgery magnetic resonance imaging scan.Intraoperative ultrasound is a useful tool in routine spine surgery. It is effective and easy to read to determine decompression for various pathologies including disk herniation, epidural abscess, tumors, and deformity and reconstructive surgeries. This simple tool can help plan surgeries.

The epidemiological international landscape of traumatic spinal cord injury (SCI) has evolved over the last decades along with given inherent differences in acute care and rehabilitation across countries and jurisdictions. However, to what extent these differences may influence neurological and functional recovery as well as the integrity of international trials is unclear. The latter also relates to historical clinical data that are exploited to inform clinical trial design and as potential comparative data.Epidemiological and clinical data of individuals with traumatic and ischemic SCI enrolled in the European Multi-Center Study about Spinal Cord Injury (EMSCI) were analyzed. Mixed-effect models were employed to account for the longitudinal nature of the data, efficiently handle missing data, and adjust for covariates. The primary outcomes comprised demographics/injury characteristics and standard scores to quantify neurological (i.e., motor and sensory scores examined according to the International Standards for the Neurological Classification of Spinal Cord Injury) and functional recovery (walking function). We externally validated our findings leveraging data from a completed North American landmark clinical trial.A total of 4601 patients with acute SCI were included. Over the course of 20 years, the ratio of male to female patients remained stable at 3:1, while the distribution of age at injury significantly shifted from unimodal (2001/02) to bimodal distribution (2019). The proportional distribution of injury severities and levels remained stable with the largest percentages of motor complete injuries. Both, the rate and pattern of neurological and functional recovery, remained unchanged throughout the surveillance period despite the increasing age at injury. The findings related to recovery profiles were confirmed by an external validation cohort (n=791). Lastly, we built an open-access and online surveillance platform ("Neurosurveillance") to interactively exploit the study results and beyond.Despite some epidemiological changes and considerable advances in clinical management and rehabilitation, the neurological and functional recovery following SCI has remained stable over the last two decades. Our study, including a newly created open-access and online surveillance tool, constitutes an unparalleled resource to inform clinical practice and implementation of forthcoming clinical trials targeting neural repair and plasticity in acute spinal cord injury.

Background Scrub typhus was once thought to be a disease of rural origin and was confined to specific pockets in South Asia. Early diagnosis and treatment is extremely important as it is associated with high mortality if left untreated. Aim To delineate the clinical and molecular epidemiology of scrub typhus in patients presenting with acute febrile illness from various parts of India. Methods During the study period of 5 years (October 2013 to October 2018), a total of 1742 patients with acute febrile illness Results A total of 210 (12.1%) patients were diagnosed with scrub typhus. Of these, nested PCR was positive in only 85 patients. Sequencing and phylogenetic analysis showed that the predominant circulating genotypes were Gilliam and Karp. On multivariate analysis, acute respiratory distress syndrome, myocarditis, encephalitis/encephalopathy, jaundice and splenomegaly were significantly more common in those patients who were diagnosed with scrub typhus. A total of 14 patients diagnosed with scrub typhus succumbed to the illness. Conclusion Patients with fever, headache, pulmonary manifestations, CNS manifestations, myocarditis, transaminitis or thrombocytopenia presenting in the monsoon and post-monsoon season should be evaluated for scrub typhus irrespective of the geographical location in India.

Background and Purpose: Clot fragmentation and distal embolization during endovascular thrombectomy for acute ischemic stroke may produce emboli downstream of the target occlusion or in previously uninvolved territories. Susceptibility-weighted magnetic resonance imaging can identify both emboli to distal territories (EDT) and new territories (ENT) as new susceptibility vessel signs (SVS). Diffusion-weighted imaging (DWI) can identify infarcts in new territories (INT). Methods: We studied consecutive acute ischemic stroke patients undergoing magnetic resonance imaging before and after thrombectomy. Frequency, predictors, and outcomes of EDT and ENT detected on gradient-recalled echo imaging (EDT-SVS and ENT-SVS) and INT detected on DWI (INT-DWI) were analyzed. Results: Among 50 thrombectomy-treated acute ischemic stroke patients meeting study criteria, mean age was 70 (±16) years, 44% were women, and presenting National Institutes of Health Stroke Scale score 15 (interquartile range, 8–19). Overall, 21 of 50 (42%) patients showed periprocedural embolic events, including 10 of 50 (20%) with new EDT-SVS, 10 of 50 (20%) with INT-DWI, and 1 of 50 (2%) with both. No patient showed ENT-SVS. On multivariate analysis, model-selected predictors of EDT-SVS were lower initial diastolic blood pressure (odds ratio, 1.09 [95% CI, 1.02–1.16]), alteplase pretreatment (odds ratio, 5.54 [95% CI, 0.94–32.49]), and atrial fibrillation (odds ratio, 7.38 [95% CI, 1.02–53.32]). Classification tree analysis identified pretreatment target occlusion SVS as an additional predictor. On univariate analysis, INT-DWI was less common with internal carotid artery (5%), intermediate with middle cerebral artery (25%), and highest with vertebrobasilar (57%) target occlusions ( P =0.02). EDT-SVS was not associated with imaging/functional outcomes, but INT-DWI was associated with reduced radiological hemorrhagic transformation (0% versus 54%; P Conclusions: Among acute ischemic stroke patients treated with thrombectomy, imaging evidence of distal emboli, including EDT-SVS beyond the target occlusion and INT-DWI in novel territories, occur in about 2 in every 5 cases. Predictors of EDT-SVS are pretreatment intravenous fibrinolysis, potentially disrupting thrombus structural integrity; atrial fibrillation, possibly reflecting larger target thrombus burden; lower diastolic blood pressure, suggestive of impaired embolic washout; and pretreatment target occlusion SVS sign, indicating erythrocyte-rich, friable target thrombus.

Factor VIII replacement products have improved the care of patients with hemophilia A, but the short half-life of these products affects the patients' quality of life. The half-life of recombinant factor VIII ranges from 15 to 19 hours because of the von Willebrand factor chaperone effect. BIVV001 (rFVIIIFc-VWF-XTEN) is a novel fusion protein designed to overcome this half-life ceiling and maintain high sustained factor VIII activity levels. Data are lacking on the safety and pharmacokinetics of single-dose BIVV001.In this phase 1-2a open-label trial, we consecutively assigned 16 previously treated men (18 to 65 years of age) with severe hemophilia A (factor VIII activity,1%) to receive a single intravenous injection of recombinant factor VIII at a dose of 25 IU per kilogram of body weight (lower-dose group) or 65 IU per kilogram (higher-dose group). This injection was followed by a washout period of at least 3 days. The patients then received a single intravenous injection of BIVV001 at the same corresponding dose of either 25 IU or 65 IU per kilogram. Adverse events and pharmacokinetic measurements were assessed.No inhibitors to factor VIII were detected and no hypersensitivity or anaphylaxis events were reported up to 28 days after the injection of single-dose BIVV001. The geometric mean half-life of BIVV001 was three to four times as long as that of recombinant factor VIII (37.6 hours vs. 9.1 hours in the lower-dose group and 42.5 vs. 13.2 hours in the higher-dose group); the area under the curve (AUC) for product exposure was six to seven times as great in the two dose groups (4470 hours vs. 638 hours × IU per deciliter in the lower-dose group and 12,800 hours vs. 1960 hours × IU per deciliter in the higher-dose group). After the injection of BIVV001 in the higher-dose group, the mean factor VIII level was in the normal range (≥51%) for 4 days and 17% at day 7, which suggested the possibility of a weekly interval between treatments.In a small, early-phase study involving men with severe hemophilia A, a single intravenous injection of BIVV001 resulted in high sustained factor VIII activity levels, with a half-life that was up to four times the half-life associated with recombinant factor VIII, an increase that could signal a new class of factor VIII replacement therapy with a weekly treatment interval. No safety concerns were reported during the 28-day period after administration. (Funded by Sanofi and Sobi; ClinicalTrials.gov number, NCT03205163.).

Multicenter prospective cohort.To discern neurological- and functional recovery in patients with a traumatic thoracic spinal cord injury (TSCI), conus medullaris syndrome (CMS), and cauda equina syndrome (CES).Specialized spinal cord injury centers in Europe.Lower extremity motor score (LEMS) and spinal cord independent measure (SCIM) scores from patients with traumatic TSCI, CMS, and CES were extracted from the EMSCI database. Scores from admittance and during rehabilitation at 1, 3, 6, and 12 months were compared. Linear mixed models were used to statistically analyse differences in outcome, which were corrected for the ASIA Impairment Scale (AIS) in the acute phase.Data from 1573 individuals were analysed. Except for the LEMS in patients with a CES AIS A, LEMS, and SCIM significantly improved over time for patients with a TSCI, CMS, and CES. Irrespectively of the AIS score, recovery in 12 months after trauma as measured by the LEMS showed a statistically significant difference between patients with a TSCI, CMS, and CES. Analysis of SCIM score showed no difference between patients with TSCI, CMS, or CES.Difference in recovery between patients with a traumatic paraplegia is based on neurological (motor) recovery. Regardless the ceiling effect in CES patients, patients with a mixed upper and lower motor neuron syndrome (CMS) showed a better recovery compared with patients with a upper motor neuron syndrome (TSCI). These findings enable stratifications of patients with paraplegia according to the level and severity of SCI.

A number of trials have examined the peripheral analgesic effect of opioids, known to have an anti-nociceptive effect at the central and/or spinal cord level. This study aimed to evaluate the efficacy of buprenorphine added to 2% lignocaine with adrenaline 1:80,000 in providing postoperative analgesia after lower third molar surgery. Sixty patients were randomized to three groups: group A received lignocaine 2% with adrenaline 1:80,000 for inferior alveolar nerve block (IANB), along with intramuscular (IM) injection of 1 ml saline; group B received buprenorphine mixed with lignocaine 2% with adrenaline 1:80,000 for IANB (0.01 mg buprenorphine/ml lignocaine with adrenaline), along with 1 ml saline IM; group C received lignocaine 2% with adrenaline 1:80,000 for IANB, along with 0.03 mg buprenorphine IM. Mean postoperative pain scores (visual analogue scale; when the patient first felt pain) were 6.0 for group A, 1.0 for group B, and 4.4 for group C. The mean duration of postoperative analgesia was 3.5 h in groups A and C and 12 h in group B. The mean number of postoperative analgesics consumed was 5.8 in groups A and C and 3.9 in group B. The addition of buprenorphine (0.03 mg) to 2% lignocaine with adrenaline 1:80,000 significantly reduced the severity of postoperative pain and prolonged the duration of analgesia, thereby decreasing the need for postoperative analgesics.

To assess the influence of financial constraints on access to different components of spinal cord injury (SCI) management in various socio-economic strata of the Indian population. Indian Spinal Injuries Centre (ISIC). One hundred fifty SCI individuals who came for follow-up at ISIC between March 2009 and March 2013 with at least 1 year of community exposure after discharge were included in the study. Socio-economic classification was carried out according to the Kuppuswamy scale, a standard scale for the Indian population. A self-designed questionnaire was administered. No sample was available from the lower group. There was a statistically significant difference (P

To conduct an extensive literature and toxicological database review on substitute compounds and available alternative medical products to replace polyvinyl chloride (PVC) and/or di(2-ethylhexyl) phthalate (DEHP), and conduct a DEHP-medical inventory analysis at a large metropolitan neonatal intensive care unit (NICU).A systematic search for DEHP-free alternative products was performed using online databases. An informal audit of a large metropolitan NICU was undertaken in 2005 and 2006; 21 products were identified that could potentially contain DEHP. Availability of DEHP-free alternatives was determined through company websites and phone interviews.Two alternative approaches are available for replacing DEHP in NICU medical products: (1) replacement by DEHP-free plasticizers; and (2) replacement of PVC entirely through the use of other polymers. Both approaches seem to provide less harmful substitutes to DEHP, but support PVC-free polymers as the preferred alternative. However, significant data gaps exist, particularly for the alternative polymers. In all, 10 out of 21 (48%) products in the NICU audit were DEHP-free; six consisted of alternative polymers and four of alternative plasticizers. Of the remaining 11 products, only three were available without DEHP at the time of the audit.Because of significant data gaps, systematic toxicological testing of DEHP-free alternatives is imperative. Continued development of alternative products is also needed.

To report the course of ocular motor cranial nerve palsy due to herpes zoster.A retrospective chart review identified patients with ocular motor cranial nerve palsy occurring at the time of herpes zoster ophthalmicus. Patients were seen by a single neuro-ophthalmologist from 1994 to 2012.Twenty-one patients were identified; 3 were excluded because of incomplete follow-up. Nine (50%) had complete recovery and 8 (44%) had partial recovery but no diplopia in primary gaze (mean time = 10 weeks). One patient with complete ophthalmoplegia had persistent diplopia in primary position for recovery.Ophthalmoplegia secondary to herpes zoster ophthalmicus has good long-term prognosis for recovery.

Item does not contain fulltext STUDY DESIGN: A questionnaire survey. OBJECTIVES: To evaluate the need for the introduction of quantitative diagnostic criteria for the traumatic central cord syndrome (TCCS). SETTING: An online questionnaire survey with participants from all over the world. METHODS: An invitation to participate in an eight-item online survey questionnaire was sent to surgeon members of AOSpine International. RESULTS: Out of 3340 invited professionals, 157 surgeons (5%) from 41 countries completed the survey. Whereas most of the respondents (75%) described greater impairment of the upper extremities than of the lower extremities in their own TCCS definitions, symptoms such as sensory deficit (39%) and bladder dysfunctions (24%) were reported less frequently. Initially, any difference in motor strength between the upper and lower extremities was considered most frequently (23%) as a 'disproportionate' difference in power. However, after presenting literature review findings, the majority of surgeons (61%) considered a proposed difference of at least 10 points of power (based on the Medical Research Council scale) in favor of the lower extremities as an acceptable cutoff criterion for a diagnosis of TCCS. Most of the participants (40%) felt that applying a single criterion to the diagnosis of TCCS is insufficient for research purposes. CONCLUSION: Various definitions of TCCS were used by physicians involved in the spinal trauma care. The authors consider a difference of at least 10 motor score points between upper and lower extremity power a clear diagnostic criterion. For clinical research purposes, this diagnostic criterion can be considered as a face valid addendum to the commonly applied TCCS definition as introduced by Schneider et al. 01 september 2010

Caesarean section is one of the commonest major surgical procedures in public and private hospitals. The worldwide rise in the caesarean section rate during the last 50 years is cause for alarm and a matter of concern. This increase deserves international attention not only because of health consequences, resource administration and policies, but also because high caesarean section rates are not associated with low perinatal mortality rates. The present study is an analysis of indications of caesarean sections performed with no take-home baby ('fruitless' caesarean section) between April 1983 and March 2007. It was revealed that the caesarean section rate has increased from 15.47% of births in 1983 to 37.96% births in 2007, and 03.75% of these were fruitless. The overall perinatal mortality rate has reduced from 91.56 in 1983 to 51.20 in 2007, for various reasons. This analysis reveals a large increase in caesarean sections with many being fruitless. While the major causes of perinatal mortality were sepsis, prematurity and congenital anomalies which need to be addressed, it is also essential to review the indications of caesarean section, so as to prevent fruitless caesarean sections.

Tumor necrosis factor-related apoptosis inducing ligand (TRAIL) is normally expressed in the human immune system and plays a critical role in antitumor immunity. TRAIL interacts with the death receptors, DR4 and DR5, and activates intracellular apoptotic pathway in cancer cells. This discovery has resulted in a rapid development of cancer therapeutic agents that can activate this apoptotic pathway. These therapeutic agents include recombinant human TRAIL (rhTRAIL) and its agonistic monoclonal antibody (MAb) against DR4 and DR5. Phase I trials have established the safety and tolerability of these TRAIL agonists in patients. Phase II trials are currently evaluating the therapeutic efficacy of TRAIL agonists as single agents or in combination with established cancer therapeutics. This review outlines the advances and the challenges in the development of these TRAIL agonists as effective clinical cancer therapeutics.

Intrauterine infections are important causes of childhood blindness in both developed and developing countries. Chorioretinal scars are the most characteristic eye manifestation of a congenital or prenatal infection. The various ocular manifestations of congenital infections, summarized by the mnemonic TORCH, and recent additions to the "other" category (lymphocytic choriomeningitis virus and West Nile virus) are discussed.

Objective: To determine the usefulness of antepartum transabdominal amnioinfusion (APTA) in reducing perinatal morbidity and mortality due to oligohydramnios. Methods: In this case–control study of 100 pregnant women with oligohydramnios, 50 received APTA and 50 were treated conservatively. These controls were matched for age, parity, and pregnancy duration with the case patients. Results: There was a mean 4.02-cm increase in amniotic fluid index (AFI) after amnioinfusion. Only 18% of case patients required cesarean sections vs. 46% of controls. The perinatal mortality rate was 18% among controls and 4% among case patients, and the difference was significant. Conclusion: Antepartum amnioinfusion is a useful procedure to reduce complications resulting from decreased intra-amniotic volume. It is especially useful in preterm pregnancies, where the procedure allows for a better perinatal outcome by prolonging the duration of pregnancy.

✓The authors report on a 63-year-old man initially admitted to an outside hospital for altered mental status and respiratory distress. A head computed tomography scan disclosed a right frontal cystic mass, suspected to be a neoplasm. An open biopsy was performed at an outside institution, and on visualization of the cyst, an aneurysm was found incidentally. Postoperatively, an angiogram and magnetic resonance image confirmed the presence of a distal right M1 segment aneurysm. The patient was transferred to our institution where, in addition to the middle cerebral artery lesion, a right anterior choroidal artery aneurysm was found intraoperatively; the necks of both aneurysms were clipped successfully. A review of the literature revealed 14 additional cases of intracranial aneurysms associated with arachnoid cysts. Data in the present report highlight the importance of considering an intracystic aneurysm in the differential diagnosis when reviewing cases that involve a cystic mass with a mural nodule. The authors provide a comprehensive summary of documented cases of aneurysms associated with arachnoid cysts. In addition, they include a discussion of prevailing thoughts on the origin and evolution of arachnoid cysts.

Case report: We document a previously unreported association of Vogt-Koyanagi-Harada (VKH) syndrome with intracranial meningioma. A female patient with diminished vision, exudative retinal detachment, and headache was diagnosed with VKH syndrome, more precisely a Harada form of disease with intracranial meningioma, on the basis of exudative retinal detachment, typical fundus fluorescein findings, and magnetic resonance imaging. With intravenous steroid therapy, visual acuity improved and the detachment settled within a week. At 3 months, the detachment recurred but improved after retreatment. At I year, the tumour was unchanged in size. Comments: VKH syndrome may be associated with intracranial meningioma that may affect the patient's overall morbidity or mortality.

The present observational study was carried out at a rural referral healthcare, educational institute in India. The objectives were to study the trends of contribution of caesarean section (CS) for failure-to-progress to the overall CS rate and their relationship to variables such as age, parity, stage of labour, augmentation of labour, in order to look at the trends and the scope for reduction in the CS for failure-to-progress and also the reduction in fetomaternal morbidity either by early intervention or reducing CS rates. Over 16 years, a total of 7,309 caesarean operations were performed, (contributing to 22.5% of births) and 533 (7.3%) were for failure-to-progress. The rate of CS for failure-to-progress was reduced in 2002 (5.0%), compared with 1992 (10.5%). The age of these women were similar to overall cases. A majority (346, 64.9%) of Sections for failure-to-progress were performed between 37 and 40 weeks of pregnancy, 125 (23.5%) between 41 and 42 weeks and only 62 (11.6%) were preterm. Rates of CS for failure-to-progress were 16.3% in primigravida and 8.8% in multipara, a decade ago, compared with 7.0% in primigravida and 2.8% in multipara now. Among the primigravida, 66 (18.3%) were performed in latent phase, 217 (60.3%) in the active first stage and 77 (21.4%) in the second stage of labour. Among multigravida, 35 (20.2%) were in the latent phase, 68 (39.3%) in the active first stage and 70 (40.5%) in the second stage. The authors were not always involved in the decisions to proceed to CS but probably because of the discussions before the observational study was undertaken, everyone involved with the decision making became concerned. So it seems critical evaluation of each CS before decision (keeping in mind materno-fetal well-being rather than hours), separating imminent labour from latent phase and higher doses of oxytocin should lead to a reduction in CS for failure-to-progress. Efforts need to be continued and should involve further research and evidence-based management strategies.

The present study was conducted to analyse the changing trends in maternal deaths and the factors affecting them in a rural institution in India. Analysis of case records of maternal deaths over a period of 20 years, between April 1982 and March 2002 was performed in relation to the age, parity and disorders leading to death. It was revealed that the maternal mortality ratio has declined significantly, from 890.7 between April 1982 and March 1987 to 259.4 between April 1997 and March 2002. Most of the deaths were in young women (20-29 years) and primigravidae. Hypertensive disorders (27.4%) and haemorrhage (12.9%) were the leading direct causes, while anaemia (13.9%) was the main indirect cause. It was shown that from 1982-1987 to 1997-2002 there was a fall in the percentage of deaths due to hypertensive disorders, from 27.5% to 14.6%, peripartum sepsis from 13.7% to 7.3% and ruptured uterus from 3.9% to nil, but there was a rise in deaths due to septic abortions from 9.8% to 14.0% and haemorrhage from 7.8% to 17.1%. Deaths within 24 hours of admission decreased from 60.8% between 1982 and 1987 to 46.3% between 1997 and 2002. It appears that even with resource constraints, maternal mortality can be reduced by improving peripheral services and individualised evidence- based appropriate interventions at referrals. However, the problems of anaemia and septic abortions need to be examined further.

Various population studies have reported the association of rare S2 allele of apolipoprotein C3 (APOC3) SstI polymorphism with hypertriglyceridemia (HTG) and coronary artery disease (CAD). We were the first to report an association of S2 allele with high triglyceride (TG) levels in healthy volunteers from Northern India. Since HTG is suggested to be a predominant risk factor for CAD among Indians, we have elucidated the relationship of APOC3 SstI polymorphism with the lipid profile and CAD. A total of 158 patients with ≥ 70% stenosis in one or more coronary artery (angiographically proven CAD patients), 35 subjects with < 70% stenosis (NCAD) and 151 normal controls (free of heart disease) from Northern plains of India were recruited in the study. DNA samples were analyzed by polymerase chain reaction (PCR) followed by SstI digestion. Lipid profile was estimated by enzymatic kit. We found a strong association of S2 allele with high TG levels, which was more significant in patients. Prevalence of S2 allele in normal controls and CAD patients were comparable, despite the fact that mean TG level was significantly higher in patients. A greater insight into this observation revealed that the prevalence of high TG, if not coupled with other risk factors (like high total cholesterol, low HDL), was comparable in patients and controls. Thus, our study reveals that rare S2 allele may be employed as a susceptibility marker for high TG. However, high TG or S2 allele alone may not contribute to the etiology of CAD.

The US National Toxicology Program (NTP) is an interagency program whose mission is to evaluate agents of public health concern by developing and applying the tools of modern toxicology and molecular biology. Chemicals substances or physical agents selected for toxicology and carcinogenesis evaluations by the NTP are usually studied in a series of subacute (14-day exposure), subchronic (90-day exposure) and chronic (2-year exposure) studies in rodents. The NTP has published more than 500 reports of the findings and conclusions from its toxicology and carcinogenesis studies. In more specialized studies, the NTP also evaluates adverse effects on the structure and function of the immune, reproductive, nervous, and respiratory systems. The program attempts to evaluate and appropriately incorporate new technologies to improve the way we study the toxicity of chemicals. For example, the program has extensively evaluated several transgenic mouse models for their potential use as short-term cancer screens and has been a full participant in an international effort to examine their usefulness in pharmaceutical registration. Toxicogenomics, an emerging scientific field that examines the expression of thousands of genes simultaneously in response to chemical exposure, holds promise for future application to better understand the underlying mechanisms of chemical toxicity. A number of public health issues being addressed by the NTP are not only of national importance but also have global impact, such as the potential for endocrine disruptors to influence development and carcinogenesis and the safety of herbal medicines and dietary supplements. The program participates in the preparation of national and international toxicity testing guidelines and the findings from NTP studies are widely used for risk assessments by international organizations and federal agencies. The NTP maintains databases that contain toxicity, and health and safety information on a large number of chemicals. These databases are available from the NTP web site (http://ntp-server.niehs.nih.gov) and are accessed over 100000 times a month from around the world.

Every year, half a million babies are born with malformations, one-third of these life-threatening. The present study aims at analysing trends of perinatal mortality (PM) due to major congenital malformations (MCM) at a rural institute, for preventive possibilities. Records of all perinatal deaths due to MCM over 24 years were analysed. Perinatal deaths (PD) due to MCM were 346; overall 8.3% of PD (287 (82.94%) stillbirths; 59 (17.06%) neonatal deaths). There was a decreasing trend of contribution of MCM to PM: 9.52% in Block A to 6.95% in Block H; 26.87% of PD were due to nervous system anomalies: 3.76% in Block A to 2.02% in Block H. PM due to congenital heart disease increased from 0.87% in Block A to 6.94% in Block H. It is essential that a system exists to diagnose MCM at a gestation when abortion is possible. Research for prevention of anomalies needs to be continued.

programme in India C Purandare, A Bhardwaj, M Malhotra, H Bhushan, S Chhabra, P Shivkumar a Indian College of Obstetrics and Gynaecologists, Federation of Obstetrics and Gynaecological Societies of India, Mumbai, India b Avni Health Foundation, Mumbai, India c Maternal Health Division, Ministry of Health and Family Welfare, Government of India, New Delhi, India d Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, India Correspondence: A Bhardwaj, Avni Health Foundation, Mumbai, India. Email avnihealth@yahoo.com

The present study was undertaken at a rural medical institute in India to analyse the trends in maternal mortality due to sepsis and the factors associated with change, if any. During the study period of 20 years, a total of 37,155 women delivered, 192 deaths occurred and forty deaths (20.83%) were due to sepsis and it's sequlae. It was revealed that there is a definite decrease in the proportion of deaths due to sepsis, to 10% in the last five years from 35% in earlier years. The change seems to be due to the advocacy of clean deliveries and reduction in case fatality because of alterations in medication and earlier surgical intervention. However the percentage contribution of septic abortion has remained the same. Septic abortion continues to exist inspite of all the current laws and discussion about the availability of a liberal law, which permits abortion almost on request. Most of the women who had died due to septic abortion were married (65%). Deaths due to septic abortion, are persisting even in married women and it is a matter of concern for health providers, policy makers and governments.

Meckel's diverticular perforation is a rare cause of acute abdomen during pregnancy. We report the case of a 24-year-old woman at 24 weeks of gestation who presented with abdominal pain for 4 days accompanied with abdominal distension, tenderness and guarding in right lower quadrant. Ultrasonography was inconclusive. The patient underwent exploratory laparotomy with the clinical suspicion of appendicular perforation peritonitis. Intraoperatively, a perforated Meckel's diverticulum was detected. Owing to gross contamination of the peritoneal cavity, a diverticulectomy with ileostomy was performed. She had a normal full-term vaginal delivery, and ileostomy was reversed 1 month after delivery. The physiological and anatomical changes in pregnancy can make a straightforward clinical diagnosis difficult. A high index of suspicion is required to prevent delay in diagnosis and surgical intervention, which could prove detrimental to the mother and fetus.

The list of experimental therapies that have been developed in animal models to improve functional outcomes after spinal cord injury is extensive. Though preclinical trials have shown a good potential for cellular therapies in spinal cord injury, there is no documentary proof as of now that any form of cellular therapy definitely improves outcome in management of human spinal cord injury. The adverse effects of many such therapies are well-documented. There is a need to conduct proper clinical trials. Some early-stage spinal cord injury clinical trials have recently been done and some have been started. However, some experimental therapies have been introduced into clinical practice without a clinical trial being completed. Undue hype by the media and claims by professionals have a profound psychological effect on the spinal cord injured and interferes in their rehabilitation. While we know that the future holds a good promise, this should not prevent patients from aggressively pursuing rehabilitation since we are not sure when a clinical breakthrough will be achieved.

Purpose To study the intra- and inter-observer reliability of pediatric ophthalmologists in grading retinal hemorrhages in abusive head trauma. Methods Pediatric ophthalmologists attending the 2009 annual meeting of the American Association for Pediatric Ophthalmology and Strabismus participated in an onsite survey. The participants were required to compare a collection of fundus photographs of patients with abusive head trauma to two standardized photographs, A and B. Participants graded photographs as normal (no retinal hemorrhages), better than A but not normal, same as A, between A and B, same as B, or worse than B. The survey was divided into four parts: part 1 consisted of 20 photographs to be graded; part 2 was a questionnaire about participant's professional experience; part 3 consisted of 20 photographs to be graded (including 15 graded in part 1 but reordered); and part 4 asked about the criteria used to grade the photographs. Results Of the 95 participants, 92 (97%) were licensed physicians with a mean of 14 years in practice. The intra-rater reliability was found to be high, with overall average of 85% pre- and post-agreement on the common pictures. Kendall's coefficient of concordance was used as the statistical measure of inter-rater reliability and had a high value (0.82). Conclusions Pediatric ophthalmologists showed high intra- and inter-observer reliability in grading retinal hemorrhages in abusive head trauma.

The superficial ulnar artery (SUA) is a rare anatomical variant that usually arises either in the axilla or the arm and runs a superficial course in the forearm, enters the hand, and participates in the formation of superficial palmar arch. During the routine dissection of cadavers in the department of anatomy, whilst preparing the specimen for medical students, an unusual bilateral branch of the axillary artery was found in one of the cadavers: a rare variant of the artery known as SUA, which originates from the 2nd part of the axillary arteries of both sides. The SUA is a known anatomical variant, but the bilateral high origin from the 2nd part of the axillary artery is extremely unusual. Its occurrence is of great clinical importance to the surgical and radiological departments.

BACKGROUND Silent corticotroph adenomas (SCAs) are clinically nonfunctioning pituitary adenomas (NFPAs) with positive staining for corticotropin (ACTH) by immunohistochemistry. Whether SCAs behave more aggressively than NFPAs without ACTH immunoreactivity (ACTH negative) remains controversial. OBJECTIVE To compare characteristics and outcomes of SCAs with ACTH-negative NFPAs and to identify predictors of aggressive outcome. Primary composite endpoint included the first of any of the following events: progression, recurrence, or death. METHODS We reviewed all cases of SCAs and all ACTH-negative macroadenomas operated on between April 1995 and December 2007 by 1 neurosurgeon. RESULTS Our retrospective cohorts included 33 SCAs followed for 42.5 months (median) (range, 6.7-179.0 months) and 126 ACTH-negative patients followed for 42 months (range, 6-142 months). SCA were younger (mean ± SD; 49.6 ± 14.1) than ACTH-negative patients (55.6 ± 12.8, P = .02). Tumor diameter was similar (2.8 ± 1.0 cm); cavernous sinus invasion was present in 45.5% of SCAs and 30.2% of ACTH-negative NFPAs (P = .09). Postoperative tumor residual was detected in 53.1% of SCAs and 49.6% of ACTH-negative patients. Radiation was administered in 40.6% of SCAs at 16 months (range, 3-149 months) and 33.3% of ACTH-negative patients at 13 months (range, 3-94) postoperatively. Progression of residual tumor occurred in 24.2% of SCAs and 11.1% of ACTH-negative patients (P = .08); recurrence was similar (6.0% SCAs vs 5.5% ACTH-negative patients). Cumulative event-free survival rates were not significantly different between the 2 groups (P = .3). Age, sex, tumor size, cavernous sinus invasion, or SCA subtypes were not associated with outcome. CONCLUSION SCA patients were younger, but exhibited similar postoperative tumor regrowth rates as ACTH-negative macroadenomas while using a similar adjuvant radiation protocol. Long-term follow-up is warranted because predictors of regrowth are currently lacking.

Temporomandibular joint dislocations are extremely rare in children and only four such cases have been reported in the literature so far. However, a case of recurrent bilateral mandibular dislocation is even rare to occur and a report of one such case is presented in this article.

Tuberculosis (TB) has become a global epidemic again with emergence of HIV/AIDS and multi-drug resistant strains of TB. Female genital tuberculosis (GT) is typically a disease of young women and its occurrence in post menopausal women is rare. Amongst the genital disorders, GT is the most baffling especially because of its various presentations. So GT is notorious for evading diagnosis. A series of cases of females GT between the age 25 yrs to 40 yrs is being reported with women having spectrum of clinical features, creating diagnostic dilemma and so final diagnosis by histopathology after laparotomy. So a high degree of suspicion aided by intensive investigations may be required for the diagnosis of GT. Medical therapy is the main treatment, however some do need surgery. Research needs to be continued for early establishment of timely diagnosis of GT and modalities of effective therapies.

Growing evidence highlights a role for mitochondrial dysfunction and oxidative stress as underlying contributors to Parkinson’s disease (PD) pathogenesis. DJ-1 (PARK7) is a recently identified recessive familial PD gene. Its loss leads to increased susceptibility of neurons to oxidative stress and death. However, its mechanism of action is not fully understood. Presently, we report that DJ-1 deficiency in cell lines, cultured neurons, mouse brain and lymphoblast cells derived from DJ-1 patients display aberrant mitochondrial morphology. We also show that these DJ-1-dependent mitochondrial defects contribute to oxidative stress-induced sensitivity to cell death since reversal of this fragmented mitochondrial phenotype abrogates neuronal cell death. Reactive oxygen species (ROS) appear to play a critical role in the observed defects, as ROS scavengers rescue the phenotype and mitochondria isolated from DJ-1 deficient animals produce more ROS compared with control. Importantly, the aberrant mitochondrial phenotype can be rescued by the expression of Pink1 and Parkin, two PD-linked genes involved in regulating mitochondrial dynamics and quality control. Finally, we show that DJ-1 deficiency leads to altered autophagy in murine and human cells. Our findings define a mechanism by which the DJ-1-dependent mitochondrial defects contribute to the increased sensitivity to oxidative stress-induced cell death that has been previously reported.

The present study was done to show the incidence of polycystic ovarian syndrome (PCOS) in rural young women with menstrual irregularities and the correlation with different variables. During the study period, 19,339 women had attended as a gynaecological outpatient unit. A total of 9,096 (47%) of them were of 15-34 years age, of whom 1,182 (13%) had menstrual disturbances. Out of the 1,182 young women, 216 were the study subjects as per inclusion-exclusion criteria, but only 200 could be studied. After complete clinical, ultrasonographic and biochemical evaluation, it was revealed that PCOS is common in rural young women of low socioeconomic class. Such women presenting with menstrual irregularities need to be investigated for the presence of other endocrine disorders which may be present with or without PCOS. PCOS was diagnosed in 100 (50%) women. Of the 100 without PCOS, five had thyroid disorders and of the other 95, 49 (51%) had polycystic ovaries on sonography. Significantly more study objects had a family history of hypertension, diabetes and menstrual irregularities in their mothers. A state of hyperinsulinaemia indicated by a low fasting glucose to insulin ratio was present, even in non-obese women with PCOS.

S. Chhabraa, D.P. Agarwalb, S. Vasishtc, K. Luthraa, R. Narangc, S.C. Manchandac, L.M. Srivastavad and N. Dasa,∗ Department of Biochemistry, All India Institute of Medical Sciences, New Delhi, India Institute of Human Genetics, University of Hamburg, Germany Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India Department of Biochemistry, Sir Ganga Ram Hospital, New Delhi, India

This study covers issues on advanced unwanted pregnancies in rural single women in South-east Asia, with reference to age, education, occupation, person responsible (i.e. baby's father) and reasons for delay in seeking assistance. It describes single women with pregnancy beyond the time for abortion, as set by the Indian abortion law. The study involved 314 girls/women and was set in the Mahatma Gandhi Institute of Medical Sciences, Sevagram, India. The girls/women were admitted, provided with free facilities and had their babies looked after by hospital staff until given up for adoption, or otherwise. The outcomes of the study showed that most individuals (71.01%) were rural, less-literate, working girls. In 94.26% of cases, the baby's father was known; 24 (7.64%) reported rape (13 by a known person). A total of 66 individuals (21.02%) did not inform their parents about the pregnancy for up to 5 months. Five (1.59%) went to unqualified medical practitioners and 16.56% to private practitioners who did not give their services. A total of 47 (14.96%) had waited for the person responsible for their pregnancy before seeking assistance. There was a total of 315 babies born to 310 mothers (five twins); four absconded undelivered; 13 absconded after delivery (two with their babies, 11 leaving babies). The study found that pregnancies were often caused by rape and girls/women with no knowledge of abortion laws, shyness, fear, lack of desired privacy, lack of resources, misleading management at periphery all went beyond 20 weeks. Mostly, the babies were not accepted--the girls married the babies' fathers, but left their babies. Emergency contraception for unprotected sexual intercourse is essential.

Prospective Pilot Study.To determine the safety and feasibility of autologous olfactory mucosal transplantation into the spinal cord in chronic spinal cord injured using the technique developed by Carlos Lima et al.Spinal Injury Center, New Delhi.Five chronic, motor complete, traumatic spinal cord injury (SCI) patients with neurological level C5-T12 underwent the procedure. Participants were assessed at baseline and at 6 monthly intervals. Safety and tolerability were evaluated through monitoring for any adverse events and tests including magnetic resonance imaging (MRI) evaluation. Efficacy assessment was done through neurological, functional and psychological evaluation, electrophysiological studies and urodynamics.Surgery was tolerated well by all American Spinal Injury Association (ASIA) Impairment Scale (AIS) A participants. The only AIS B participant lost sensory scores significantly after surgery but is gradually regaining it. MRI evaluation revealed a syrinx in one participant and increase in length of myelomalacia in four participants. There were no other adverse findings on MRI evaluation. There was no significant improvement in any of the neurological, electrophysiological or urodynamic efficacy variables. Statistically significant improvement was seen in functional scores as evaluated by Spinal Cord Independence Measure, Beck Depression Inventory scores and life impact scores on International Spinal Cord Injury Scale.The procedure is relatively safe and feasible in AIS A participants with thoracic level injuries at 18 month follow-up. No efficacy could be demonstrated which could be attributed to the procedure.

Plasma cell tumours represent autonomous proliferation of plasma cells and can manifest as multiple myeloma, monoclonal gammopathy of undetermined significance, variants of plasma cell myeloma or plasmacytoma.We report 12 cases of plasma cell tumours, which were initially diagnosed as plasmacytoma on fine needle aspiration cytology (FNAC). The patients were further subjected to bone marrow examination, serum electrophoresis, urine examination for Bence-Jones proteins, and x-ray examination of the skeleton.The cytological smears from all cases were cellular and showed numerous plasma cells in varying degrees of maturity. Subsequent to investigations, five cases were labelled as multiple myeloma with secondary extramedullary plasmacytoma, three as solitary bone plasmacytoma and two as primary extramedullary plasmacytoma. In the remaining two cases, bone marrow and urine examination findings were not available, so a conclusive diagnosis of multiple myeloma or solitary plasmacytoma could not be made.The study highlights the role of FNAC in the diagnosis of plasma cell tumours. Subsequent work-up and follow-up of these patients is important to rule out the presence of multiple myeloma.

The authors report an unusual case of persistent tunica vasculosa lentis in a patient with minimal retinopathy of prematurity (ROP). A 3-month-old male infant who had been born at 31 weeks’ gestation presented with a significant amount of persistent tunica vasculosa lentis and arteriolar tortuosity with minimal ROP and no plus disease. After weekly observation and no surgical intervention, the arteriolar tortuosity lessened but the tunica vasculosa lentis persisted. Persistent tunica vasculosa lentis can be mistaken for iris vascular engorgement, suggesting plus disease and high-risk prethreshold ROP. Differentiation between tunica vasculosa lentis and iris vascular engorgement, as well as correct diagnosis of plus disease, is critical when considering laser treatment for high-risk prethreshold ROP.

To estimate the maternal morbidity and mortality in caesarean section for non-progress of labour, a study was conducted over a period of 16 years at Mahatma Gandhi Institute of Medical Sciences, Sevagram among 533 cases of non-progress of labour for which caesarean section was performed. A total of 34975 women delivered including 7309 cases by caesarean section. Sixteen years records divided into 4 blocks, one each of 4 years were analysed. There was no maternal mortality but 8.25% women had intra-operative complication and 42.21% had postoperative morbidity. Timely intervention can save complication of prolonged labour as well as complications for which caesarean section was done for non-progress of labour.

Aim: To discover the extent of sexual violence during pregnancy, its correlation to various variables and effects, and to consider future possibilities for creating awareness in health providers, health seekers and communities for prevention. Methods: Two thousand pregnant women were interviewed using a semi-structured, pre-designed, pre-tested questionnaire with some open-ended questions in the local language. Results: Of 2000 women, 1959 (97.95%) reported that they had had sex with their partners during the current pregnancy. Of the 2000, 615 (30.7%) women had not wished to have sex during the pregnancy, but had been forced to do so. Conclusion: Women suffer with recurrent marital rape during pregnancy with considerable after effects. This sexual violence takes place irrespective of education or socioeconomic status.

This article describes an unusual case of meningococcal endogenous endophthalmitis presenting as anterior uveitis. This case re-emphasizes the importance of early diagnosis of endogenous endophthalmitis, which can lead to good visual recovery. J Pediatr Ophthalmol Strabismus 2007;44:309-310. AUTHORS The authors are from Children’s Memorial Hospital, Chicago, IL. Originally submitted March 1, 2006. Accepted for publication March 29, 2006. Address correspondence to Marilyn B. Mets, MD, Division Head and Professor of Ophthalmology, Children’s Memorial Hospital, 2300 N. Children’s Plaza, Chicago, IL 60614.

Summary Globally, women suffer due to violence. Violence during pregnancy is being increasingly recognised as a clinical as well as public health problem. The objectives of the present study were: to find out the extent and causes of violence during pregnancy; the relation of violence with, age, education, occupation; and to study the immediate effects of violence during pregnancy. A total of 2,000 pregnant women (health seekers or their friends or relatives) irrespective of age and socioeconomic status, were interviewed using a pre-designed, semistructured, pre-tested questionnaire in local language, with some open-ended questions. Out of the 2,000 pregnant women interviewed, 952 (47.6%) had been physically hit or slapped or kicked, at some time during pregnancy, many repeatedly. Though more teenagers (65.63%) and illiterate women (70.32%) were assaulted, those with a postgraduate education (41.08%) had also suffered. A total of 71.7% had been hit by their husbands ‐ 32.4% were hit on the back and 161 (16.9%) on abdomen. Of the women who were assaulted during pregnancy, 30.25% had also suffered violence when non-pregnant. The present study reveals that violence is a common problem during pregnancy. While attempts need to be made to prevent this, it is essential that the healthcare providers who manage these women are aware of the possibility.