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Hypoglycemia is a common complication in patients with chronic kidney disease (CKD), more so if they have diabetes as well. The occurrence of hypoglycemia in CKD is associated with considerable morbidity and mortality, both of which are treatable and preventable. This review summarizes the incidence and risk factors associated with hypoglycemia among patients with CKD. The meta-analysis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A search was done on PubMed, EMBASE, SCOPUS, Cochrane Library, Google Scholar, and Cumulative Index to Nursing and Allied Health Literature for cohort studies in English published between January 2000 and August 2019 using search terms related to hypoglycemia (low blood sugar), chronic kidney disease (chronic renal failure OR renal failure), and incidence (risk OR epidemiology OR risk factors). Summary measures were calculated using random-effects model. A total of 5 studies involving 311,817 persons were included in the meta-analysis. The pooled incidence of hypoglycemia in patients with CKD was 0.188 (confidence interval [CI] = 0.097–0.287). The incidence of hypoglycemia was significantly higher in patients with CKD than in patients without CKD (Relative risk [RR] = 1.89, 95% CI = 1.86–1.92, P < 0.0001). No heterogeneity was reported between the studies (I2 = 0%, P > 0.05), and publication bias was also found. Females, patients who had diabetes mellitus of long duration, and those on antidiabetic drugs such as insulin and sulfonylureas were at risk of developing hypoglycemia in CKD as per narrative review. The incidence of hypoglycemia in patients with CKD is high. Therefore, there is need to closely monitor affected individuals so that appropriate management protocols could be set up. Further probing of various risk factors for hypoglycemia in CKD patients is necessary for early detection and initiation of timely preventive and curative measures.

Klippel-Trénaunay-Weber syndrome (KTWS) is a rare condition characterized by a classic clinical triad. However, it can also have other features, such as cavocarus foot deformity, which is a rare presentation in a patient with KTWS. In this case report, we present our surgical technique of correcting such a complex deformity. Also, there are no other similar cases reported in the literature. An 18-year-old girl who is a known case of KTWS with a complaint of progressive unilateral left foot deformity. Her examination, revealed a rigid pes cavus with an equinus deformity in the left foot. Radiography of the left foot revealed marked cavus as well as hindfoot and forefoot varus. A successful surgical correction of the deformity was described in a stepwise fashion. The management of foot cavocarus deformity in KTWS patients is associated with high intra- and post-operative risk due to its complexity. Therefore, the management requires a multidisciplinary team approach.

Introduction and importance The two major etiologies of shoulder superior labral tears anterior to posterior (SLAP) are traumatic and degenerative processes. Bucket handle tears of the superior labrum represent one-third of labral lesions. However, in this article, we present a double bucket handle tear which has been reported once in the literature. Presentation of case A 25-year-old male presented with complaint of chronic pain in his right shoulder with a remote history of traumatic dislocation. Physical examination revealed a positive apprehension test. Shoulder magnetic resonance imaging (MRI) showed a superior labral tear with a Hill-Sach lesion. Arthroscopy showed a double bucket handle tear of superior labrum and mild biceps tendonitis along with Bankart lesion. The tear was resected and the Bankart lesion was repaired followed by supervised physical therapy. Good clinical outcomes in form of resolution of pain and shoulder instability at six months were obtained. Discussion SLAP tears are common shoulder lesion that is reported differently in the literature. Arthroscopic studies had reported the incidence between 3.9%-11.8. The diagnosis of such lesion relies on the clinical presentation and imaging. Knesek et al. classified SLAP lesions based on the integrity of the biceps anchor and the type of labral tear (Knesek et al., 2013). The standard treatment of symptomatic SLAP lesions is Arthroscopic debridement. However, non-operative management was described in the literature. Conclusion Double bucket handle injuries of the superior labrum are reported in literature once. These lesions can be treated with arthroscopic debridement and Bankart repair and followed by supervised physical therapy., Highlights • Superior labrum Anterior to posterior (SLAP) lesions are common cause of shoulder pain. • Various causes for SLAP lesions have been described including micro traumatic and non-traumatic (e.g., degenerative). • The incidence of SLAP tears varies among multiple arthroscopic studies. Snyder et al. reported an incidence of 3.9% to 11.8. • Most of patients with SLAP lesions present with concurrent shoulder injuries such as partial or complete rotator cuff tears. • MR arthrography is the best imaging Modality to evaluate the SLAP lesions. • Arthroscopic SLAP repair remains the gold standard treatment. However, management depends on patient age, functional status.

The photolysis of diclofenac (DCF), sulfamethoxazole (SMX), carbamazepine (CBZ), and trimethoprim (TMP) was investigated using a low-pressure (LP) mercury ultraviolet (UV) lamp (254 nm) and a combination of UV with hydrogen peroxide (H 2 O 2 ). For each experiment, 5 mg/L of each pharmaceutical was prepared in pure water and individually degraded by either UV alone or UV/H 2 O 2 . DCF and SMX were highly susceptible to UV treatment and completely degraded to below their LC–MS detection limit (1 μg/L) after only 8 min of UV irradiation. TMP and CBZ were more resistant to UV treatment, with only 58.2 and 25.2% degradation (after 1 h UV exposure). The combination of H 2 O 2 addition (up to 0.2 g/L) with UV significantly improved the removal rate of TMP and CBZ up to 91.2 and 99.7% of the initial concentration, respectively. A number of novel transformation compounds were identified as UV or UV/H 2 O 2 degradation products using LC–MS. The range and amount of these transformation compounds strongly depended on the applied treatment conditions. The toxicity of each pharmaceutical solution before and after treatment was also evaluated and all parent compounds were non-toxic at the tested concentration (i.e. 5 mg/L). DCF, in particular, but also CBZ and SMX, showed an increase in solution toxicity after treatment with UV only, indicating the presence of photolytic degradation products that are more toxic than the parent compounds. Treatment with UV/H 2 O 2 reduced the toxicity of all solutions to below the detection limit of the assay.

BACKGROUND Hypothyroidism is characterised by a low cardiac output due to the decreased heart rate and stroke volume. Systolic and diastolic functions are reduced at rest and during exercise, thus impairing quality of life. In particular, an increased risk of coronary heart disease events and mortality has been reported in young patients affected by subclinical hypothyroidism with TSH >10 mU/L. The aim of the study is to evaluate the cardiovascular system using electrocardiogram and echocardiogram among patients with clinical and subclinical hypothyroidism. MATERIALS AND METHODS A cross-sectional comparative study was conducted for a period of one year on 50 patients attending the Outpatient Medicine Department in our hospital. The 50 patients were made into 2 groups of 25 each, group I are patients with clinical hypothyroidism and group II are patients with subclinical hypothyroidism. The cardiac status of all the patients was assessed by doing ECG and a 2D echo was done to assess their systolic and diastolic function. RESULTS The systolic function was normal in both the groups except for a slight increase in the septal wall and posterior wall thickness of LV among the clinical hypothyroidism patients. There is no statistical significant difference in the diastolic parameters among the two groups (p >0.05), but it proves that there is a diastolic dysfunction, which would be in the starting stage in both the groups. Among the hypothyroid patients, 20% of them had mild pericardial effusion, which was detected through 2D echo, whereas none of the patients with subclinical hypothyroidism had pericardial effusion and this difference was found to be statistically significant (p

Background: Diabetes mellitus (DM), is a group of metabolic disorders in which there are high blood sugar levels over a prolonged period with great harmful consequences, including cardiovascular and neurological complications, diabetic retinopathy, and diabetic nephropathy. Therefore, the objective of this study was to find out the common complications and comorbidities among diabetic Saudi patients in Northern Saudi Arabia. Methodology: Records of 50 diabetic patients were retrieved from King Khalid Hospital, Hail, Saudi Arabia. Different complications and comorbidities were documented and investigated. Results: Peripheral neuropath, retinopathy, diabetic septic foot, and amputation were identified among 40%, 38%, 14%, and 4%, correspondingly. Out of the 50 patients, 12 (24%), 18 (36%) and 8 (16%) were detected with thyroid diseases, dyslipidemia and renal complications, respectively. Conclusion: Hypertension, peripheral neuropathy, dyslipidemia, retinopathy, kidney complications and diabetic septic food represent the major complications and/or comorbidities among diabetic Saudi patients in northern Saudi Arabia. These complications and/or comorbidities must be well thought-out in epidemiological studies, so as to display disease burden and quality of diabetes care.

© 2019, © 2019 Informa UK Limited, trading as Taylor & Francis Group. The degradation of diclofenac (DCF), trimethoprim (TMP), carbamazepine (CBZ), and sulfamethoxazole (SMX) by laccase from Trametes versicolor was investigated. Experiments were conducted using the pharmaceuticals individually, or as a mixture at different initial concentrations (1.25 and 5 mg/L each). The initial enzymatic activity of all the treated samples was around 430–460 U(DMP)/L. The removal of the four selected pharmaceuticals tested individually was more effective than when tested in mixtures under the same conditions. For example, 5 mg DCF/L was completely removed to below its detection limit (1 µg/L) within 8 h in the individual experiment vs. after 24 h when dosed as a mixture with the other pharmaceuticals. A similar trend was visible with other three pharmaceuticals, with 95 vs. 39%, 82 vs. 34% and 56 vs. 49% removal after 48 h with 5 mg/L of TMP, CBZ, and SMX tested individually or as mixtures, respectively. In addition, at the lower initial concentration (1.25 mg/L each), the removal efficiency of TMP, CBZ, and SMX in mixtures was lower than that obtained at the higher initial concentrations (5 mg/L each) during both the individual and combined treatments. Four enzymatic transformation products (TPs) were identified during the individual treatments of DCF and CBZ by T. versicolor. For TMP and SMX, no major TPs were observed under the experimental conditions used. The toxicity of the solution before and after enzymatic treatment of each pharmaceutical was also assessed and all treated effluent samples were verified to be non-toxic.

Purpose Refractive error (RE) is one of the most common ocular disorders among children worldwide. This study aimed to investigate the prevalence of RE and possible risk factors among school children in Riyadh. Methods This is a cross-sectional study using data collected at various schools. To achieve the aim of the study, we selected a random sample of 850 school children aged 6-15 years. The examination was based on the RESC protocol and included full visual assessment. Furthermore, a questionnaire was sent to the parents of the participants to ascertain information about lifestyle factors. We constructed a logistic regression model to evaluate the predictors of RE. Results Close to a third of the children had a RE. Of those identified as having the condition, 60% did not wear glasses (newly diagnosed). Nearly all the children (95.4%) in our sample reported using electronic devices, according to parents. No association was found between using electronic devices and having a RE (P = 0.26). Doing outdoor activities was associated with 52% lower odds of a RE (odds ratio = 1.52). Conclusion We found a higher prevalence of uncorrected RE than previously reported in other Saudi studies. About 60% of children who had RE were not wearing glasses, highlighting the need for a standardized school screening program for early detection and management. Outdoor activities were associated with a lower likelihood of having a RE. These findings might support initiatives to encourage outdoor activities among school children.

Summary Background Etrolizumab is a gut-targeted, anti-β7 integrin, monoclonal antibody. In an earlier phase 2 induction study, etrolizumab significantly improved clinical remission compared with placebo in patients with moderately to severely active ulcerative colitis. We aimed to evaluate the efficacy and safety of etrolizumab in patients with moderately to severely active ulcerative colitis who had been previously treated with anti-tumour necrosis factor (TNF) agents. Methods HICKORY was a multicentre, phase 3, double-blind, placebo-controlled study in adult (18–80 years) patients with moderately to severely active ulcerative colitis (Mayo Clinic total score [MCS] of 6–12 with an endoscopic subscore of ≥2, a rectal bleeding subscore of ≥1, and a stool frequency subscore of ≥1) previously treated with TNF inhibitors. Patients were recruited from 184 treatment centres across 24 countries in North America, South America, Europe, Asia, Oceania, and the Middle East. Patients needed to have an established diagnosis of ulcerative colitis for at least 3 months, corroborated by both clinical and endoscopic evidence, and evidence of disease extending at least 20 cm from the anal verge. In cohort 1, patients received open-label etrolizumab 105 mg every 4 weeks for a 14-week induction period. In cohort 2, patients were randomly assigned (4:1) to receive subcutaneous etrolizumab 105 mg or placebo every 4 weeks for the 14-week induction phase. Patients in either cohort achieving clinical response to etrolizumab induction were eligible for the maintenance phase, in which they were randomly assigned (1:1) to receive subcutaneous etrolizumab 105 mg or placebo every 4 weeks through to week 66. Randomisation was stratified by baseline concomitant treatment with corticosteroids, concomitant treatment with immunosuppressants (induction randomisation only), baseline disease activity, week 14 MCS remission status (maintenance randomisation only), and induction cohort (maintenance randomisation only). All patients and study site personnel were masked to treatment assignment. Primary endpoints were remission (Mayo Clinic total score [MCS] ≤2, with individual subscores of ≤1 and a rectal bleeding subscore of 0) at week 14, and remission at week 66 among patients with a clinical response (MCS with ≥3-point decrease and ≥30% reduction from baseline, plus ≥1 point decrease in rectal bleeding subscore or absolute rectal bleeding score of 0 or 1) at week 14. Efficacy was analysed using a modified intent-to-treat population. Safety analyses included all patients who received at least one dose of study drug during the induction phase. This study is registered at ClinicalTrials.gov , NCT02100696 . Findings HICKORY was conducted from May 21, 2014, to April 16, 2020, during which time 1081 patients were screened, and 609 deemed eligible for inclusion. 130 patients were included in cohort 1. In cohort 2,479 patients were randomly assigned to the induction phase (etrolizumab n=384, placebo n=95). 232 patients were randomly assigned to the maintenance phase (etrolizumab to etrolizumab n=117, etrolizumab to placebo n=115). At week 14, 71 (18·5%) of 384 patients in the etrolizumab group and six (6·3%) of 95 patients in the placebo group achieved the primary induction endpoint of remission (p=0·0033). No significant difference between etrolizumab and placebo was observed for the primary maintenance endpoint of remission at week 66 among patients with a clinical response at week 14 (27 [24·1%] of 112 vs 23 [20·2%] of 114; p=0·50). Four patients in the etrolizumab group reported treatment-related adverse events leading to treatment discontinuation. The proportion of patients reporting at least adverse event was similar between treatment groups for induction (etrolizumab 253 [66%] of 384; placebo 63 [66%] of 95) and maintenance (etrolizumab to etrolizumab 98 [88%] of 112; etrolizumab to placebo 97 [85%] of 114). The most common adverse event in both groups was ulcerative colitis flare. Most adverse events were mild or moderate. During induction, the most common serious adverse event was ulcerative colitis flare (etrolizumab ten [3%] of 384; placebo: two [2%] of 95). During maintenance, the most common serious adverse event in the etrolizumab to etrolizumab group was appendicitis (two [2%] of 112) and the most common serious adverse events in the etrolizumab to placebo group were ulcerative colitis flare (two [2%] of 114) and anaemia (two [2%] of 114). Interpretation HICKORY demonstrated that a significantly higher proportion of patients with moderately to severely active ulcerative colitis who had been previously treated with anti-TNF agent were able to achieve remission at week 14 when treated with etrolizumab compared with placebo; however, there was no significant difference between groups in remission at week 66 among patients with a clinical response at week 14. Funding F Hoffmann-La Roche.