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Obesity increases the risk of developing type 2 diabetes, hypertension, and hyperlipidemia. We sought to determine the impact of obesity maintenance, weight regain, weight loss maintenance, and magnitudes of weight loss on future risk and time to developing these cardiometabolic conditions. This was a retrospective cohort study of adults receiving primary care at Geisinger Health System between 2001 and 2017. Using electronic health records, patients with ≥3-weight measurements over a 2-year index period were identified and categorized. Obesity maintainers (OM) had obesity (body mass index ≥30 kg/m²) and maintained their weight within ±3% from baseline (reference group). Both weight loss rebounders (WLR) and weight loss maintainers (WLM) had obesity at baseline and lost5% body weight in year 1; WLR regained ≥20% of weight loss by end of year 2 and WLM maintained ≥80% of weight loss. Incident type 2 diabetes, hypertension, and hyperlipidemia, and time-to-outcome were determined for each study group and by weight loss category for WLM. Of the 63,567 patients included, 67% were OM, 19% were WLR, and 14% were WLM. The mean duration of follow-up was 6.6 years (SD, 3.9). Time until the development of electronic health record-documented type 2 diabetes, hypertension, and hyperlipidemia was longest for WLM and shortest for OM (log-rank test p0.0001). WLM had the lowest incident type 2 diabetes (adjusted hazard ratio [HR] 0.676 [95% confidence interval [CI] 0.617 to 0.740]; p0.0001), hypertension (adjusted HR 0.723 [95% CI 0.655 to 0.799]; p0.0001), and hyperlipidemia (adjusted HR 0.864 [95% CI 0.803 to 0.929]; p0.0001). WLM with the greatest weight loss (15%) had a longer time to develop any of the outcomes compared with those with the least amount of weight loss (7%) (p0.0001). In an integrated delivery network population, sustained weight loss was associated with a delayed onset of cardiometabolic diseases, particularly with a greater magnitude of weight loss.

To reveal the extent of obesity in a single healthcare system and provide a blueprint for other health systems to perform similar analyses, this study describes characteristics and weight change patterns of patients classified with overweight and obesity at a large integrated delivery network (IDN) in the South-Central United States. A descriptive, observational, retrospective study was conducted using electronic medical records and claims data. Patients were ���18 years old, body mass index (BMI) ���27 kg/m2, and continuously enrolled in the IDN plan for ���6 months before and ���12 months after the index date. Demographics, comorbidities, BMI, and weight were collected. Weight changes were assessed annually, and anti-obesity medications (AOM) use was also captured. A total of 36,430 eligible patients were identified. A subset of 22,712 patients was continuously enrolled for the entire study period (mean age: 57.2) and were primarily white (83.3%) and commercially insured (54.3%). Most patients were categorized as overweight (40.1%) or obesity class I (32.5%) at baseline. At years 1 and 4 post-index, patients who maintained index weight (��3%) was 56.2% and 37.0%, respectively, whereas weight gain (���3% increase) was 23.7% and 33.3%, respectively. AOM use (1.1%) primarily consisted of phentermine-hydrochloride (n = 114, 0.5%) and orlistat (n = 115, 0.5%). An increasing proportion of patients gained weight over time, combined with low AOM use, emphasizing the need for weight-loss interventions in this population. Findings from this study provide a foundation for health systems to perform similar analyses.

Introduction: According to the Global Health Organisation thalassemia is the most prevalent genetic disorder which immensely affect the life of about 100,000 infants in over 60 countries. In India, thalassemia major is also the most prevalent genetic disorder. As indicated by the national statistics report, 22,000 patients of thalassemia major exist in our country. Thalassemia major is a chronic disease which has a long treatment regimen thus putting the affected children and their caregivers through a variety of challenges both physically and mentally. Objective: To assess the health promotion practices and coping behaviors among parents/caregivers of children suffering from Thalassemia Major. Materials and Methods: A descriptive study was conducted in the thalassemia clinic, APC, PGIMER, Chandigarh. Data was collected from 70 parents of thalassemic children with age group of 4 to 17 years on Socio Demographic Profile, clinical profile, Coping Health Inventory of Parents (CHIP) and Health Promotion Practices (HPP). Results: The study showed that 51.9% caregivers of thalassemic children reported that they considered the items enlisted in CHIP to be moderately helpful, 45.2% reported them to be extremely helpful while according to 2.9% of the subjects, they were minimally helpful. All the subjects were in the “always” level of the HPP i.e. caregivers were following health promotion practices. This study also revealed that majority of parents (61%) did not receive any genetic counselling during their first pregnancy. Conclusion: The study concluded the association between major study variables like Health Promotion practices (HPP) and Coping Health Inventory Of Parents (CHIP) analysed by Pearson correlation. The results revealed that there was low positive correlation between HPP and CHIP i.e. +0.078. Keywords: Health Promotion Practices, coping behaviors, Caregivers, Children, Thalassemia major.

Aims Little is known about the impact of weight loss on developing comorbidities in patients with obesity in real-world settings. Understanding health benefits and associated comorbidities with weight loss are critical to addressing the global obesity health epidemic. This study aimed to determine health outcomes associated with weight loss in individuals with obesity, and to better understand the relationship between disease burden (i.e., prior comorbidities, healthcare utilization) and weight loss in individuals with obesity. Electronic health records (EHRs) represent an important resource to investigate these impacts. Materials and methods We conducted a case-control study using deidentified EHR-derived information from 204,921 patients seen at the Cleveland Clinic between 2000-2018. Patients were ≥20 years of age with BMI ≥30 kg/m2 and ≥7 weight measurements, over ≥3 years. Thirty outcomes were investigated, including chronic and acute diseases, as well as psychological and metabolic disorders. Weight change was investigated three, five, and ten years prior to an event. Results Weight loss was associated with reduced incidence of many outcomes (e.g., type 2 diabetes, non-alcoholic steatohepatitis/non-alcoholic fatty liver disease, obstructive sleep apnea, hypertension) (P 10% was associated with increased incidence of certain outcomes including stroke and substance abuse. However, many outcomes that increased with weight loss were attenuated by disease burden adjustments. Conclusions This study provides the most comprehensive real-world evaluation of health impacts of weight change to date. After comorbidity burden and healthcare utilization adjustments, weight loss was associated with an overall reduction in risk of many adverse outcomes. This article is protected by copyright. All rights reserved.

OBJECTIVE Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk. METHODS A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk. RESULTS A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup). CONCLUSIONS Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.

BackgroundAntimicrobial therapy is essential for the treatment of enteric fever, the infection caused by Salmonella serovars Typhi and Paratyphi A. However, an increase in resistance to key antimicrobials and the emergence of MDR and XDR in Salmonella Typhi poses a major threat for efficacious outpatient treatments.ObjectivesWe recently identified tebipenem, an oral carbapenem licensed for use for respiratory tract infections in Japan, as a potential alternative treatment for MDR/XDR Shigella spp. Here, we aimed to test the in vitro antibacterial efficacy of this drug against MDR and XDR typhoidal Salmonella.MethodsWe determined the in vitro activity of tebipenem in time–kill assays against a collection of non-XDR and XDR Salmonella Typhi and Salmonella Paratyphi A (non-XDR) isolated in Nepal and Bangladesh. We also tested the efficacy of tebipenem in combination with other antimicrobials.ResultsWe found that both XDR and non-XDR Salmonella Typhi and Salmonella Paratyphi A are susceptible to tebipenem, exhibiting low MICs, and were killed within 8–24 h at 2–4×MIC. Additionally, tebipenem demonstrated synergy with two other antimicrobials and could efficiently induce bacterial killing.ConclusionsSalmonella Paratyphi A and XDR Salmonella Typhi display in vitro susceptibility to the oral carbapenem tebipenem, while synergistic activity with other antimicrobials may limit the emergence of resistance. The broad-spectrum activity of this drug against MDR/XDR organisms renders tebipenem a good candidate for clinical trials.

Obesity is a chronic disease that poses serious health and societal burdens. Although guidelines exist for obesity management in primary care, evaluating the success of obesity treatment programs is hampered by lack of established, robust quality measures. This study aimed to develop, and test for feasibility, measures for operational tracking, quality performance, and patient-centered care in the context of a national collaborative to develop a model for obesity management in the US primary care setting. The authors developed and evaluated 7 measures used to track the care of patients with overweight or obesity (n = 226,727 at baseline) receiving care within 10 health care organizations (HCOs). Measure categories included: (1) operational tracking (obesity/overweight prevalence and prevalence of obesity-related complications); (2) quality performance (obesity diagnosis, change in weight over time, anti-obesity medication prescriptions, and assessment of obesity-related complications); and (3) patient-centered care (patient-reported outcomes). Measures were tested for feasibility, variability across HCOs, ability to detect differences over time, and value to the HCOs. All measures were feasible to collect, provided value to the participating HCOs, and demonstrated variation and ability to detect differences over time (eg, rates of documented diagnosis of obesity classes 1, 2, and 3 increased from 29%, 46%, and 66%, respectively, at baseline to 35%, 53%, and 71% at study end). This study confirmed the feasibility and perceived value of 7 operational, performance, and patient-centered measures collected in primary care practices in 10 HCOs over an 18-month period.

Background Adenylate kinase (AK) deficiency is a rare red cell enzymopathy associated with moderate to severe congenital nonspherocytic hemolytic anemia, along with mental and psychomotor retardation (in exceptional cases). Only ten mutations have been detected in the AK1 gene to date. In this study, we aimed to diagnose the unexplained issue of haemolytic anaemia and offer antenatal screening to the family. Methods Genomic DNA was isolated from whole blood by a standard protocol. Targeted next-generation sequencing (t-NGS) was performed to identify pathogenic variants in the patient and control samples. A chronic villus sample was collected at 11 weeks of gestation from the mother, and molecular testing was performed. Genetic confirmation was concluded by Sanger DNA sequencing. Bioinformatics tools predicted the pathogenicity of the variant. Results t-NGS revealed a homozygous variant (c.301C > A, p. Gln101Lys) in the AK1 gene in the patient and heterozygosity in the fetus and parental samples. The prediction tools SIFT, Polyphen2, Provean, PMUT, Mutation taster, and Mutation Assessor, confirmed the damaging effect of the variant on the AK1 protein structure Conclusion We have presented a novel mutation in the AK1 gene (p. Gln101Lys) associated with adenylate kinase deficiency. It is the first prenatal diagnosis of AK deficiency in India, where heterogeneity is exceptionally high.

Aims: To compare the sensitivity of 2 microscopic methods for the diagnosis of Mycobacterium tuberculosis (M.tb) along with culture and drug susceptibility testing to first line drugs. Settings and design: The cross-sectional study comprises 200 suspected cases of pulmonary tuberculosis both clinically and radiologically in KIMS, Bangalore over a period of 2 years. Materials and Methods: Samples (sputum/BAL fluid) were collected, processed and stained by Ziehl Neelson (ZN) and Fluorescent methods. Culture and drug susceptibilty testing was done for Streptomycin, Isoniazid, Rifampicin and Ethambutol by Mycobacterium growth indicator tube (MGIT) method after decontamination. Statistical analysis: Fischer’s test Results: 1. Out of 200 samples: 1.120 were male and 80 were female; 2. 18 were positive by Ziehl Neelson, 21 by Fluorescent and 28 by culture; 3. Majority of the patients belonged to age group 41-50 years (23%); 4. InMGIT, 26 were M.tb and 2 were Non-tubercular mycobacteria; 5. Out of 26 M.tb isolates, 4 were resistant to streptomycin, 6 to isoniazid, 2 to rifampicin and 9 to ethambutol. Conclusion: 1. The sensitivity of Fluorescent staining (64.28%) is higher than that of Ziehl-Neelson (51.7%); 2. In MGIT, 26 were M.tb and 2 were Non tubercular mycobacteria; 3. 2 were Multi-drug resistant- tuberculosis (MDR-TB) Key Messages: This study made us aware of the need for prompt detection, identification and appropriate treatment of Tuberculosis due to the rising incidence of MDR-TB. Keywords: Mycobacterium tuberculosis, Mycobacterium growth indicator tube, ZiehlNeelson, Fluorescent.

The biggest task for a paediatric dentist is the restoration in a young child who has severely damaged anterior teeth and suffered from multiple tooth loss due to severe early childhood caries. Early loss of anterior teeth has a major effect on the psychology and behaviour of children. The aim of this paper is to describe the rehabilitation of deciduous anterior teeth with a fixed, aesthetic and functional appliance (modified Groper’s Appliance). Such appliances are considered to be elective and their placement is normally at the demand of parents. Keywords: Numerous tooth, Maxillary incisors.

Pancreatic ductal adenocarcinoma (PDAC) manifests aggressive tumor growth and early metastasis. Crucial steps in tumor growth and metastasis are survival, angiogenesis, invasion, and immunosuppression. Our prior research showed that chemokine CXC- receptor-2 (CXCR2) is expressed on endothelial cells, innate immune cells, and fibroblasts, and regulates angiogenesis and immune responses. Here, we examined whether tumor angiogenesis, growth, and metastasis of CXCR2 ligands expressing PDAC cells are regulated in vivo by a host CXCR2-dependent mechanism. C57BL6 Cxcr2(−/−) mice were generated following crosses between Cxcr2(−/+) female and Cxcr2(−/−) male. Cxcr2 ligands expressing Kirsten rat sarcoma (KRAS-PDAC) cells were orthotopically implanted in the pancreas of wild-type or Cxcr2(−/−) C57BL6 mice. No significant difference in PDAC tumor growth was observed. Host Cxcr2 loss led to an inhibition in microvessel density in PDAC tumors. Interestingly, an enhanced spontaneous and experimental liver metastasis was observed in Cxcr2(−/−) mice compared with wild-type mice. Increased metastasis in Cxcr2(−/−) mice was associated with an increase in extramedullary hematopoiesis and expansion of neutrophils and immature myeloid precursor cells in the spleen of tumor-bearing mice. These data suggest a dynamic role of host CXCR2 axis in regulating tumor immune suppression, tumor growth, and metastasis.

OBJECTIVE To estimate the causal effect of obesity on job absenteeism and the associated lost productivity in the United States, both nationwide and by state. METHODS We conducted a retrospective pooled cross-sectional analysis using the 2001 to 2016 Medical Expenditure Panel Survey and estimated two-part models of instrumental variables. RESULTS Obesity, relative to normal weight, raises job absenteeism due to injury or illness by 3.0 days per year (128%). Annual productivity loss due to obesity ranges from $271 to $542 (lower/upper bound) per employee with obesity, with national productivity losses ranging from $13.4 to $26.8 billion in 2016. Trends in state-level estimates mirror those at the national level, varying across states. CONCLUSIONS Obesity significantly raises job absenteeism. Reductions in job absenteeism should be included when calculating the cost-effectiveness of interventions to prevent or reduce obesity among employed adults.

Coronavirus disease 2019 (COVID-19) is a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of April 17, 2020, the total number of cases all over the world read as 2,182,823 positive cases with 145,551 deaths and 547,679 recovered cases. In India, the total number of affected cases has alarmingly increased up to 13,430, crossing the 10 thousand mark with 11,214 active cases and 1768 recovered cases. There have been multiple studies and reviews published regarding the nature of the disease, its clinical symptoms and their progression, as well as findings on chest radiography, computed tomography, and positron emission computed tomography. A systematic literature search of the PubMed database was performed on April 8, 2020, using the suitable keywords and publications on novel coronavirus infection were also searched for in the WHO database. Only those articles published in the year 2020 were included. Data were collected, extracted, and tabulated for systematic reviewing from 26 original articles and 4 case series. The typical radiological findings on computed tomography for COVD 19 were ground-glass opacity with and without consolidation, isolated consolidation, air bronchogram, crazy paving, and interlobular septal thickening with subpleural lines. With the progression of the disease, other atypical radiological findings are noted, such as pulmonary atelectasis, peribronchial thickening, pleural effusion, pericardial effusion, mediastinal lymphadenopathy, reverse halo or atoll sign, and tree in bud appearance with bronchiectasis. Computed tomography proved as a useful tool for screening COVID 19 cases to delineate the status and severity of lung pathology.

On April 10, 2020, the FDA approved selumetinib (KOSELUGO, AstraZeneca) for the treatment of pediatric patients 2 years of age and older with neurofibromatosis type 1 who have symptomatic, inoperable plexiform neurofibromas. Approval was based on demonstration of a durable overall response rate per Response Evaluation in Neurofibromatosis and Schwannomatosis criteria and supported by observed clinical improvements in plexiform neurofibroma–related symptoms and functional impairments in 50 pediatric patients with inoperable plexiform neurofibromas in a single-arm, multicenter trial. The overall reponse rate per NCI investigator assessment was 66% (95% confidence interval, 51–79) with at least 12 months of follow-up. The median duration of response was not reached, and 82% of responding patients experienced duration of response ≥12 months. Clinical outcome assessment endpoints provided supportive efficacy data. Risks of selumetinib are consistent with MAPK (MEK) inhibitor class effects, including ocular, cardiac, musculoskeletal, gastrointestinal, and dermatologic toxicities. Safety was assessed across a pooled database of 74 pediatric patients with plexiform neurofibromas and supported by adult and pediatric selumetinib clinical trial data in cancer indications. The benefit–risk assessment for selumetinib in patients with inoperable plexiform neurofibromas was considered favorable.

BACKGROUND: After a dramatic increase in prevalence over several decades, obesity has become a major public health crisis in the United States. Research to date has consistently demonstrated a correlation between obesity and higher medical costs for a variety of U.S. subpopulations and specific categories of care. However, by examining associations rather than causal effects, previous studies likely underestimated the effect of obesity on medical expenditures. OBJECTIVE: To estimate the causal effect of obesity on direct medical care costs at the national and state levels. METHODS: This study is a pooled cross-sectional analysis of retrospective data from the 2001-2016 Medical Expenditure Panel Surveys. Adults aged 20-65 years with a biological child living in the household were included in the study sample. Primary outcomes were individual-level medical expenditures due to obesity, overall, as well as separately by type of payer and category of medical care. Results were reported at the national level and separately for the 20 most populous states. The expenditure estimates were obtained from 2-part models of instrumental variables in which the respondent's body mass index (BMI) was instrumented using the BMI of their biological child. RESULTS: Adults with obesity in the United States compared with those with normal weight experienced higher annual medical care costs by $2,505 or 100%, with costs increasing significantly with class of obesity, from 68.4% for class 1 to 233.6% for class 3. The effects of obesity raised costs in every category of care: inpatient, outpatient, and prescription drugs. Increases in medical expenditures due to obesity were higher for adults covered by public health insurance programs ($2,868) than for those having private health insurance ($2,058). In 2016, the aggregate medical cost due to obesity among adults in the United States was $260.6 billion. The increase in individual-level expenditures due to obesity varied considerably by state (e.g., 24.0% in Florida, 66.4% in New York, and 104.9% in Texas). CONCLUSIONS: The 2-part models of instrumental variables, which estimate the causal effects of obesity on direct medical costs, showed that the effect of obesity is greater than suggested by previous studies, which estimated only correlations. Much of the aggregate national cost of obesity-$260.6 billion-represents external costs, providing a rationale for interventions to prevent and reduce obesity. DISCLOSURES: Novo Nordisk financed the development of the study design, analysis, and interpretation of data, as well as writing support of the manuscript. Cawley, Biener, and Meyerhoefer received financial support from Novo Nordisk to conduct the research study on which this manuscript is based. Smolarz and Ramasamy are employees of Novo Nordisk. Ding and Zvenyach have no conflicts to declare. Our research has been presented as a poster at the 2020 Academy Health Annual Research Meeting (Virtual), July 28-August 6, 2020.

Background Metabolic syndrome (MetS) is highly prevalent worldwide, and its individual components obesity, diabetes, and hypertension have been identified as risk factors to develop severe coronavirus disease 2019 (COVID‐19); however, data on MetS and clinical outcomes in COVID‐19 are scarce. This study aims to determine association between MetS and severe disease outcomes, that is, mortality, need for mechanical ventilation, and intensive care unit (ICU) requirement among patients with COVID‐19. Methods This is a retrospective multihospital cohort study on 1871 patients with confirmed COVID‐19 diagnosis. Patient data including demographics, comorbidities, body mass index (BMI), smoking, laboratory data, and the clinical course of hospitalization were collected. Multivariable regression was performed adjusting for age, sex, race, insurance, smoking, and comorbidities. Results A total of 1871 patients (median age 66 [interquartile range, IQR 54‐75]; 965 (51.6%) males; 1494 (80%) African Americans; median BMI 29.4 kg/m2 [IQR 25‐35.8]; 573 (30.6%) patients with MetS) were included. Patients with MetS had increased mortality (odds ratio [OR], 1.40; 95% CI, 1.11‐1.75; P = .004), higher ICU admission (OR, 1.68; 95% CI, 1.36‐2.08; P, Highlights Metabolic syndrome (MetS) is a vital prognostic indicator of outcomes in coronavirus disease 2019.Patients with MetS had worse clinical outcomes compared with the ones without MetS.Patients with MetS had a higher need for intensive care unit irrespective of their age, sex, or race.Need for mechanical ventilation was higher for all patients with MetS except Caucasians.Females, younger patients (

Acute gastric dilatation is the radiological finding of a massively enlarged stomach as seen on plain film X-ray or a computerized tomography scan of the abdomen. It is a rare entity with high mortality if not treated promptly and is often not reported due to a lack of physician awareness. It can occur due to both mechanical obstruction of the gastric outflow tract, or due to nonmechanical causes, such as eating disorders and gastroparesis. Acute hyperglycemia without diagnosed gastroparesis, such as in patients with diabetic ketoacidosis, may also predispose to acute gastric dilatation. Prompt placement of a nasogastric tube can help deter its serious complications of gastric emphysema, ischemia, and/or perforation. We present our experience of 2 patients who presented with severe hyperglycemia and were found to have acute gastric dilation on imaging. Only one of the patients was treated with nasogastric tube placement for decompression and eventually made a full recovery.

Hepatocellular carcinoma (HCC) is an aggressive tumour with unpredictable outcome. It is fourth most common cause of cancers in India. However, information on HCC is inadequate in India. Therefore, the purpose of study is to determine overall survival for patients diagnosed with HCC and association between various predictive factors and survival.Retrospectively 59 patients of HCC presenting to the radiotherapy out-patient department of our institute from April 2015 to April 2018 were included in the study.The median overall survival (OS) was 5 months ranging from 0 to 13 months. Majority of patients were in advance stage (III/IV). All patient died by 13 months. None of the possible predictive factors were found to be significantly associated with survival (p 0.05) by univariate analysis. However, age 59 years, male gender, KPS ≤ 60, AFP ≥ 400, cirrhosis, multifocality, tumour size 10 cm, advance stage (IIIB/IV), Child-Pugh score B/C, CLIP score ≥ 4, and raised bilirubin level had poorer survival compared to other predictive factors. Median survival was better in patient treated with TACE followed by sorafenib + palliative care group (9 months) then sorafenib + palliative care and palliative care alone group (5 and 4 months respectively). Although results were not statistically significant (p = 0.133). Amongst all possible variables, highest hazard was found with multifocal lesion (2.058) and results were statistically significantly (p = 0.045, 95% confidence interval: 0.922 to 4.590) as compared to unifocal lesion with median survival period of 7 vs 9.5 months by Kaplan-Meier survival curve analysis using log rank test.Multifocality was independent predicator for poor survival in HCC. Further clinical studies are necessary to improve the outcomes of patients with high risk features.

BACKGROUND: Obesity imposes a substantial economic burden on the United States. The short-term value of nonsurgical weight loss (WL) and nonsurgical sustained WL (i.e., WL not resulting from bariatric surgery) is poorly understood. OBJECTIVES: To assess short-term (1 year) effect of nonsurgical WL and sustained nonsurgical WL (i.e., approximately 2 years) on per-patient-per-month (PPPM) total all-cause health care costs among adults with obesity in the United States. METHODS: In this retrospective cohort study, we analyzed data from the IBM MarketScan Explorys Claims-EMR Data Set from January 1, 2012, through June 30, 2018. Adults aged 18-64 years with a body mass index (BMI) measurement ≥ 30 kg/m2 on the index date and BMI measurements at 12, 24, and 36 months were classified into weight-gain (≥ 3%), no-weight-change (within ± 3%), and WL (≥ 3%-≤ 5%, > 5%-≤ 10%, and > 10%-≤ 20%) cohorts based on the change from first to second BMI measurements (baseline), and sustained nonsurgical WL based on WL during baseline and 5%- ≤ 10% WL cohort (7.7%), and > 10%- ≤ 20% WL cohort (2.8%). Compared with the no-weight-change cohort, adjusted mean ΔPPPM all-cause health care cost from baseline to first year of follow-up was lower in all WL cohorts (≥ 3%- ≤ 5% WL: -$57.36, > 5%- ≤ 10% WL: -$135.35 [P 10%- ≤ 20% WL: -$193.54 [P 10%- ≤ 20% sustained WL (1.8%). Adjusted mean ΔPPPM all-cause health care cost was lower in all sustained WL groups (-$26.38, -$157.41 [P 10%- ≤ 20% WL, respectively). Greater nonsurgical WL and sustained nonsurgical WL were generally associated with larger reduction in short-term all-cause health care costs. Results stratified by index obesity class were mixed, due to small samples. CONCLUSIONS: Substantial all-cause health care cost savings were observed 1 year after nonsurgical WL and after sustained (on average for 2 years) nonsurgical WL in adults with obesity, with greater nonsurgical WL and sustained nonsurgical WL associated with greater cost savings. Comprehensive solutions to chronic weight management, including improved access to antiobesity medications in combination with lifestyle interventions, could be valuable to patients, employers, and payers. DISCLOSURES: This study was sponsored by Novo Nordisk, which also purchased the data. Blanchette is an employee of Novo Nordisk. Smolarz and Ramasamy are employees of Novo Nordisk and hold equity in Novo Nordisk. Ding, Fan, and Weng were employees of Novo Nordisk at the time this study was conducted. The findings from this study were previously presented at Obesity Week 2019; November 3-7, 2019; Las Vegas, NV.

Purpose: To provide real-world data on the world-wide-web for patient and doctor awareness. Methods: From December 2017 to January 2020, consecutive patients with choroidal melanoma (CM), iris ciliary body melanoma (ICM), and ocular surface squamous carcinoma (OSSC) had specific outcomes recorded at each return visit. Each result was anonymized, entered in an online portal, and sent to a unique software program where it was used to create real-world data of number of patients, mean vision, local tumor control, eye salvage, systemic metastases, and length of follow-up for our eye cancer center. Results: A HIPAA compliant, internet-based software program was developed and linked to public access web page to collect and analyze near-real-time data pertaining to the treatment, vision, life, and follow-up time of patients. During this period, CM radiation plaque tumor control was 99.7%, median vision 20/25 (mean 20/50) and eye salvage 95.8%. ICM tumor control was 99.1% and the median vision 20/20 (mean 20/20). OSSC tumor control was 100% and the most common vision was 20/20 (mean 20/25). Rates of primary enucleation as treatment were 4.2% for CM, 2.8% for ICM, and 0% for OSSC. All patient results were updated by the ophthalmic oncology fellow at each patient visit as to reflect near-real-time outcomes at our center. Conclusion: Prospective data collection of returning patients was found to be a simple method to reflect patient care outcomes. This method of reporting doctor outcomes offers a measure of transparency for patients and an opportunity to compare results with other clinical practices.

Attachment retained removable partial denture facilitates to replace the cosmetic and functional requirement to rehabilitate long edentulous span, distal extension situation and abutments with different path of insertion. Selection of attachment system is based on the distribution of forces to improve function and maintain health of remaining alveolar ridge and teeth. This clinical report describes a multidisciplinary approach to treat a long span distal extension condition using over denture with ceka attachment. Keywords: Proprioception, Bone preservation, Retention, Masticatory efficiency, Preventive prosthodontics.

Introduction: Adenomyosis is a common gynaecological condition that affects women of reproductive age group (20%-60%). The cardinal clinical features of adenomyosis are menorrhagia, dysmenorrhea and uterine enlargement. Classically, it was thought and compared with ultrasonography; MRI enables more accurate diagnosis of the disease when adenomyosis is suspected. Objective: To evaluate the clinical profile associated with adenomyosis, frequency distribution and to determine the prevalence of adenomyosis in patients undergoing hysterectomy for other indications, as well as to correlate clinical examination with histopathological examination. Methodology: It is a retrospective observational study which included 100 patients who underwent abdominal hysterectomy or vaginal hysterectomy for various indications. Age, parity, presenting complaints, elicited signs, indication for hysterectomy, and HPE report of the specimens were analyzed. All cases diagnosed as Adenomyosis and Endometriosis was excluded. Results: Among 100 women who underwent hysterectomy, Adenomyosis was found in 24 cases (24%). Menorrhagia (91.7%), chronic pelvic pain (83.3%), dysmenorrhea (79.2%), dyspareunia (16.7%) is the classic presentation. More common in multiparous women and begins later in reproductive life (mean age- 45yrs). (45.8%) had bulky uterus on per vaginal examination. Adenomyosis was present in 10 of 23 patients (43.47%) diagnosed as dysfunctional uterine bleeding; 6 of 24 (25%) with fibroid; 4 of 21 (19.04%) with prolapse; 2 of 14 (14.28%) with ovarian mass; 2 of 10 (20%) with pelvic inflammatory disease. Conclusion: The prevalence of unsuspected adenomyosis is found to be 24% in this study. Adenomyosis is common in women presenting with chronic pelvic pain, menorrhagia and dysmenorrhea. It is also common in multiparous women with bulky uterus and mean age being 45 years. In women with completed family and had failed medical therapy given for undiagnosed Adenomyosis the choice of thera

BACKGROUND Most cases of ACS (Acute Coronary Syndrome) are caused by rupture of an atherosclerotic plaque in a coronary artery, resulting in the formation of a thrombus. Atherosclerosis results from an over balance between radical generating, compared with radical scavenging systems, a condition called oxidative stress. Bilirubin had some role in mechanism of ACS. We wanted to evaluate the association between raised total bilirubin level and GGT levels with different subsets of acute coronary syndrome. METHODS The present descriptive cross-sectional study was conducted at Narayan Medical College and Hospital from July 2019 to April 2020. Total serum bilirubin was measured in the laboratory by spectrophotometry method. Gamma glutamyl transferase levels were measured in all the patients using a standardized photometric method. RESULTS In our study the mean value of triglyceride is 159.86 ± 42.36 with range 60 - 246. Total bilirubin 2.23 ± 0.827, with range 1 - 4. The value of gamma glutaraldehyde was 56.67 ± 26.48 with range 22 - 104. On studying the correlation of serum bilirubin and serum triglyceride in our study subjects, we found very mild correlation with an R square of 0.028. On finding correlation of GGT and serum triglyceride in our study subjects. We found almost no correlation with R square 0. When we do multivariate analysis of effect of serum bilirubin, GGT on total cholesterol level we found that there is very mild correlation with R square 0.031. CONCLUSIONS In our study there was very mild correlation between serum bilirubin and gamma glutamyl transferase with marker of acute coronary syndrome such as serum triglyceride level and total cholesterol level but the association was significant. KEYWORDS Acute Coronary Syndrome, Triglyceride, Bilirubin, Gamma Glutaraldehyde

Guillain- Barre Syndrome is serious health problem, that occurs when the body`s defence system mistakenly attacks parts of the nervous system. In about 50% of people with these syndrome symptoms begin about 5 days to 3 weeks after a mild infection symptoms include weakness and pin and needle sensation or loss of sensation. It is form of polyneuropathy that cause one episode of increasing muscle weakness. Weakness is more prominent than abnormal sensation reflex. Usually weakness begins both legs and moves up the body. In GBS, the body`s immune system attacks the myelin sheath which surround the axon of many nerves and enable nerve impulses to travel quickly. It may lead to life threatening complication in particular if respiratory muscles are affected or if the autonomic nervous system is involved. Worldwide, the annual incidence is about 0.6- 4.0 occurrences per 1,00,000 people. Electromyography and nerve conduction studies can help confirm the diagnosis. Plasmapheresis or immunoglobulin given intravenously may speed recovery. GBS as such is not correlated with any disease which is described in Ayurveda but pathology of GBS is Vata dominating disorder along with association of Pitta and Kapha dosha. As a precipitating factor produced functions of GI biofire plays an important role by producing Ama like reactive species in genesis of this disease. So at the management of GBS through Ayurveda anti-Vata and anti-Ama measures kept in mind while prescribing the drug.

On August 16, 2018, the U.S. Food and Drug Administration approved lenvatinib (Lenvima, Eisai Inc.) for first-line treatment of patients with unresectable hepatocellular carcinoma (HCC). Approval was based on an international, multicenter, randomized, open-label, noninferiority trial (REFLECT; NCT01761266) conducted in 954 patients with previously untreated metastatic or unresectable HCC. Patients were randomized (1:1) to receive lenvatinib (12 mg orally once daily for patients with a baseline body weight ≥60 kg and 8 mg orally once daily for patients with a baseline body weight Implications for Practice This article describes the U.S. Food and Drug Administration's review of data from a single trial, REFLECT, that supported the approval of lenvatinib, as a single agent, for the first-line treatment of unresectable hepatocellular carcinoma (HCC). REFLECT was an open-label, noninferiority trial that randomized 954 patients with HCC who were ineligible for liver-directed therapy with no prior systemic therapy for HCC to lenvatinib or sorafenib. REFLECT demonstrated that lenvatinib-treated patients had similar survival, more responses, and longer time to progression than those receiving sorafenib. Serious side effects were more common among lenvatinib-treated patients. Lenvatinib is an effective treatment for patients with previously untreated HCC.

A 10-year-old boy with autoimmune hemolytic anemia (AIHA) was treated at a local setup with repeated blood transfusions and steroids considering an idiopathic etiology. After 7 months of unresponsiveness, the child started developing recurrent fever with night sweats and pain in the abdomen which was diagnosed as tuberculosis on account of granulomatous necrotizing lesion on computed tomography (CT)-guided lymph node biopsy and treated for the same. Four months later, when the child presented to our center in anemic heart failure, work-up with positron emission tomography-CT and excisional biopsy of mesenteric lymph node led to the diagnosis of advanced Hodgkin's lymphoma with B symptoms. AIHA in pediatric age group, unlike in adults, is usually secondary. Our report stresses on a thorough evaluation of AIHA as it can mask a malignancy for a long duration and alter its course if treated with steroids, making the patient resistant to further chemotherapy.

BACKGROUND Diabetes is the most important risk factor for chronic kidney disease. Because of this, clearance of many oral hypoglycaemic drugs from our body is hampered and time of exposure to these drugs increases. Therefore, patients of diabetes need to be assessed frequently for the development of diabetic nephropathy and the dosage of oral hypoglycaemic drugs should also be modified accordingly. So, the purpose of this study was to evaluate the doses of prescribed OHAs in newly diagnosed diabetic nephropathy patients. METHODS A hospital based observational study was conducted at Narayan Medical College and Hospital, Sasaram, Bihar, India. A total of 600 diagnosed patients of diabetic nephropathy of age more than 18 years visiting for the 1 st time in OPD of general medicine / nephrology department were included in the study after obtaining an informed consent. The results were expressed as a percentage of the assessed population. RESULTS Only about 38% of the total study population was taking doses of Oral Hypoglycaemic Agents (OHAs) according to their GFR status. 62% were taking wrong doses of OHAs with their respective renal function. CONCLUSIONS Treatment of diabetes in a CKD patient is more difficult than in non-CKD patient. GFR status should be monitored on regular basis in patients of diabetes with CKD. A significant number of these patients are still treated with wrong dosage of OHAs for their respective renal function. KEYWORDS Wrong Dose of OHA, Diabetic Nephropathy, Oral Hypoglycaemic Drugs

Background Azithromycin and trimethoprim-sulfamethoxazole (SXT) are widely used to treat undifferentiated febrile illness (UFI). We hypothesized that azithromycin is superior to SXT for UFI treatment, but the drugs are noninferior to each other for culture-confirmed enteric fever treatment. Methods We conducted a double-blind, randomized, placebo-controlled trial of azithromycin (20 mg/kg/day) or SXT (trimethoprim 10 mg/kg/day plus sulfamethoxazole 50 mg/kg/day) orally for 7 days for UFI treatment in Nepal. We enrolled patients >2 years and, We compared azithromycin with trimethoprim-sulfamethoxazole for 7 days in the treatment of undifferentiated febrile illness in Nepal. Despite similar fever clearance time and treatment failure in the 2 arms, significantly fewer complications and relapses were noted in the azithromycin arm.

Cardiac hypertrophy is the underlying cause of heart failure and is characterized by excessive oxidative stress leading to collagen deposition. Therefore, understanding the signalling mechanisms involved in excessive extracellular matrix deposition is necessary to prevent cardiac remodelling and heart failure. In this study, we hypothesized that hesperetin, a flavanone that elicits the activation of Nrf2 signalling and thereby suppresses oxidative stress, mediated pathological cardiac hypertrophy progression. A cardiac hypertrophy model was established with subcutaneous injection of isoproterenol in male Wistar rats. Oxidative stress markers, antioxidant defense status, and its upstream signalling molecules were evaluated to discover the impacts of hesperetin in ameliorating cardiac hypertrophy. Our results implicate that hesperetin pretreatment resulted in the mitigation of oxidative stress by upregulating antioxidant capacity of the heart. This curative effect might be owing to the activation of the master regulator of antioxidant defense system, known as Nrf2. Further, analysis of Nrf2 revealed that hesperetin enhances its nuclear translocation as well as the expression of its downstream targets (GCLC, NQO1, and HO-1) to boost the antioxidative status of the cells. To support this notion, in vitro studies were carried out in isoproterenol-treated H9c2 cells. Immunocytochemical analysis showed augmented nuclear localization of Nrf2 implicating the action of hesperetin at the molecular level to maintain the cellular redox homeostasis. Thus, it is conceivable that hesperetin could be a potential therapeutic candidate that enhances Nrf2 signalling and thereby ameliorates pathological cardiac remodelling.

Despite minimally invasive neck dissection (MIND) being popular technique, there is a paucity of literature emphasizing its safety and efficacy. In this meta-analysis, we compared the efficacy and safety of MIND over CND techniques in treating oral/head and neck cancer. We systematically searched PubMed, MEDLINE, Embase, from database inception to January, 2019 for the relevant studies comparing MIND and CND. Two independent reviewers performed quality check and data were extracted for primary outcomes to assess length of hospital stay, duration of surgery, intraoperative blood loss and retrieved lymph nodes. Drainage volume and duration, length of incision, satisfaction of scar and safety were the secondary outcomes. We analyzed the outcomes using standard mean differences (SMDs) and the relative risk that were pooled using random effect meta-analysis. Out of 144 studies, 17 met the final inclusion criteria. MIND technique has shown better overall efficacy with outcomes compared to CND except with duration of surgery (SMD 1.82, 95% CI 0.47-3.17). Lesser hospital stay, better nodal yield and less intra-operative blood loss was observed with MIND over CND. Duration and volume of wound drainage was comparably less in MIND with smaller length of incision. Postoperative complications were less and tolerable with MIND approach with superior cosmetic outcomes. MIND via endoscopic or robotic approach is safe and efficacious with equitable oncological outcomes in terms of lymph nodes yield compared to CND, but it requires longer surgery duration.

To document the clinical presentation, complications, management strategy and post-operative outcomes of extensive cholesteatomas. Cholesteatoma is a well demarcated cystic lesion derived from an abnormal growth of keratinizing squamous epithelium in the temporal bone. Cholesteatomas commonly involve the middle ear, epitympanum, mastoid antrum and air cells and can remain within these confines for a considerable period. Bony erosion is present confined to ossicular chain and scutum initially, but as the cholesteatoma expands, erosion of the otic capsule, fallopian canal and tegmen can occur. Erosion of the tegmen tymapani or tegmen mastoideum may lead to development of a brain hernia or cerebrospinal fluid leakage. Invasion of jugular bulb, sigmoid sinus, internal carotid artery are noticed in extensive cholesteatoma and are quite challenging and requires expertise. Neurosurgical intervention should be considered along with the otological management in the same sitting in all possible cases. A retrospective review of 12 patients were carried out to assess the clinical presentation, complications, surgical management and postoperative outcomes of extensive cholesteatomas presenting at our centre between January 2017 and December 2019. CT or MRI findings, extent of cholesteatoma intra-operatively along with the status of major neurovascular structures and disease clearance, and the post-operative outcomes including morbidity and mortality were noted. All patients underwent canal wall down mastoidectomy with or without ossiculoplasty. Post operatively all patients were treated with intravenous antibiotics and if required intravenous steroids. Amongst the 12 patients of extensive cholesteatoma (EC), all of them (100%) presented with foul smelling, purulent ear discharge. 9 (75%) patients presented with otalgia. 4 (33.33%) patients had temporal headache. 10 (83.33%) patients complained of hard of hearing. 7 (58.33%) patients gives history of vertigo at the time of presentation. In 8 (66.66%) patients there was tegmen plate erosion noticed in CT scan. In 3 (25%) patients, the disease was invading the sigmoid sinus and in 1 (8.33%) patient jugular bulb was involved. In 3 (25%) cases of EC, blind sac closure was performed. In two patients who developed cerebellar abscess, drainage procedure was performed. 2 (16.66%) patients developed sigmoid sinus thrombosis, 1 (8.33%) patient had petrositis.

A survey was conducted in selected villages of Prayagraj district to evaluate the disease incidence of Fusarium (Fusarium udum) wilt and cyst nematode (Heterodera cajani) of pigeon pea (Cajanus cajan). Soil and roots were collected from the rhizosphere of infested pigeonpea plants. The maximum wilt incidence was recorded (57.6%) in Dari village followed by Pump House (56%), Pahlu ka Purwa (51.2%) and the lowest incidence of wilt was recorded in Chaka (12.8%), Naini (11.2%) and Jhusi (9.6%) in the year 2016. For cyst nematode, soil samples was collected from selected fields, the soil was mixed thoroughly and 500 g of the soil was processed following Cobb’s sieving and decanting method where cyst and J2’s were separated in separate mesh size sieves. It was observed that infestation of Heterodera cajani was very high in Jari (51%) followed by Naini (41%). The minimum infestation of Heterodera cajani was found in Meza village which was responsible for wilt disease in pigeonpea concluding that Fusarium wilt of pigeonpea is a major problem in Prayagraj district of U.P. India.

Aim: The authors hereby present a case of giant frontal-ethmoid sinus osteoma which is not so rare but in the present case, the size and orbital involvement of this tumor make it a unique case. Introduction: Paranasal sinus osteoma most commonly presents in frontal sinuses. Their growth is slow, and patients usually seek physician’s advice only for cosmetic reasons. Case Description: A 20-year-old female presented to us with the complaint of proptosis of left eye near medial canthus for last 6 months. After investigations, she was diagnosed with frontal-ethmoid sinus osteoma, which was excised by endoscopic approach. There was dense, compact bone and broad trabeculae of mature bone i.e. compact osteoma which was confirmed on histopathology. Conclusion: Paranasal sinus osteomas are slow-growing bony tumors, which are amenable to complete cure provided adequate preoperative planning and conscientious surgical technique is used.

To determine the diagnostic cut-offs and the prevalence of sarcopenia in India. Indians have lower muscle strength and muscle mass than Caucasians. The prevalence of ‘probable sarcopenia’, ‘sarcopenia’, and ‘severe sarcopenia’ is 14.6%, 3.2%, and 2.3%, respectively; corresponding values are higher using well-established Western cut-offs. Indigenous and not Western cut-offs should be used to define sarcopenia in Indians. Comprehensive data on diagnosis and prevalence of sarcopenia in India are lacking. The present study was undertaken to determine cut-offs for low muscle strength (MS) and low muscle mass (MM), and find out the prevalence of sarcopenia in Indians. Apparently healthy individuals aged ≥ 20 years with no prior history of any co-morbidities were recruited from community by door-to-door survey. Participants eligible for study underwent blood sampling. Individuals identified as having biochemical abnormalities that could potentially affect MS and MM were excluded. Enrolled participants underwent DEXA. Muscle mass, MS, and physical performance were expressed as appendicular skeletal muscle index (ASMI), dominant handgrip strength (HGS), and usual gait speed (GS), respectively. Cut-offs for low MS and MM were defined as HGS and ASMI 2SD

Summary Objective In shared medical appointments (SMAs), multiple patients with a similar clinical diagnosis are seen by a multidisciplinary team for interactive group sessions. Very few studies have specifically studied SMAs and weight loss in patients with obesity. This study compared weight loss outcomes and anti‐obesity medication (AOM) access between patients with obesity managed through (SMAs) versus individual appointments. Methods Retrospective study of adults seen for obesity between September 2014 and February 2017 at Cleveland Clinic Institute of Endocrinology and Metabolism. Percent weight loss from baseline was compared between two propensity score‐matched populations: patients who attended ≥1 SMA and patients managed with individual medical appointments. Results From all eligible patients identified (n=310 SMA, n=1,993 non‐SMA), 301 matched pairs were evaluated for weight loss. The SMA group (n=301) lost a mean of 4.2%, 5.2% and 3.8% of baseline weight over 6, 12 and 24 months; the non‐SMA group (n=301) lost significantly less weight (1.5%, 1.8% and 1.6%, respectively) (paired t‐test, P

Background: Typhoid and paratyphoid fever (enteric fever) is a common cause of non-specific febrile infection in adults and children presenting to health care facilities in low resource settings such as the South Asia. A 7-day course of a single oral antimicrobial such as ciprofloxacin, cefixime, or azithromycin is commonly used for its treatment. Increasing antimicrobial resistance threatens the effectiveness of these treatment choices. We hypothesize that combined treatment with azithromycin (active mainly intracellularly) and cefixime (active mainly extracellularly) will be a better option for the treatment of clinically suspected and culture-confirmed typhoid fever in South Asia. Methods: This is a phase IV, international multi-center, multi-country, comparative participant-and observer-blind, 1:1 randomised clinical trial. Patients with suspected uncomplicated typhoid fever will be randomized to one of the two interventions: Arm A: azithromycin 20mg/kg/day oral dose once daily (maximum 1gm/day) and cefixime 20mg/kg/day oral dose in two divided doses (maximum 400mg bd) for 7 days, Arm B: azithromycin 20mg/kg/day oral dose once daily (max 1gm/day) for 7 days AND cefixime-matched placebo for 7 days. We will recruit 1500 patients across sites in Bangladesh, India, Nepal, and Pakistan. We will assess whether treatment outcomes are better with the combination after one week of treatment and at one- and three-months follow-up. Discussion: Combined treatment may limit the emergence of resistance if one of the components is active against resistant sub-populations not covered by the other antimicrobial activity. If the combined treatment is better than the single antimicrobial treatment, this will be an important result for patients across South Asia and other typhoid endemic areas. Clinicaltrials.gov registration: NCT04349826 (16/04/2020)

Background: HCC is an aggressive tumour with unpredictable outcome. It is fourth most common cause of cancers in India. However, information on HCC is inadequate in India.Therefore purpose of study is to determine overall survival for patients diagnosed with hepatocellular carcinoma (HCC) and association between various predictive factors and survival. Results: The median overall survival (OS) was 5 months ranging from 0-13 months. Majority of patients were in advance stage (III/IV). All patient died by 13 months. None of the possible predictive factors were found to be significantly associated with survival (P > 0.05) by univariate analysis. However age < 59 yrs, male gender, KPS ≤ 60, AFP ≥ 400, cirrhosis, multifocality, tumour size > 10 cm, advance stage (IIIB/IV), child pugh score B/C, CLIP score ≥ 4 and raised bilirubin level had poorer survival compared to other predictive factors. Median survival was better in patient treated with TACE followed by sorafenib + palliative care group (9 month) then sorafenib + palliative care and palliative care alone group (5 and 4 months respectively). Although results were not statistically significant (p: 0.133). Amongst all possible variables, highest hazard was found with multifocal lesion (2.0577) and results were statistically significantly (p 0.0451, 95 % confidence interval : 0.9225 to 4.5900 ) as compared to unifocal lesion with median survival period of 7 vs 9.5 months by Kaplan-Meier survival curve analysis using log rank test. Conclusion: Multifocality was independent predicator for poor survival in HCC. Further clinical studies are necessary to improve the outcomes of patients with high risk features.

Epidemiologic data regarding health care acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) from Nepal are negligible. We conducted a prospective observational cohort study in the intensive care unit (ICU) of a major tertiary hospital in Nepal between April 2016 and March 2018, to calculate the incidence of VAP, and to describe clinical variables, microbiological etiology, and outcomes. Four hundred and thirty-eight patients were enrolled in the study. Demographic data, medical history, antimicrobial administration record, chest X-ray, biochemical, microbiological and haematological results, acute physiology and chronic health evaluation II score and the sequential organ failure assessment scores were recorded. Categorical variables were expressed as count and percentage and analyzed using the Fisher’s exact test. Continuous variables were expressed as median and interquartile range and analyzed using Kruskal-Wallis rank sum test and the pairwise Wilcoxon rank—sum test. 46.8% (205/438) of the patients required intubation. Pneumonia was common in both intubated (94.14%; 193/205) and non-intubated (52.36%; 122/233) patients. Pneumonia developed among intubated patients in the ICU had longer days of stay in the ICU (median of 10, IQR 5–15, P< 0.001) when compared to non-intubated patients with pneumonia (median of 4, IQR 3–6, P< 0.001). The incidence rate of VAP was 20% (41/205) and incidence density was 16.45 cases per 1,000ventilator days. Mortality was significantly higher in patients with pneumonia requiring intubation (44.6%, 86/193) than patients with pneumonia not requiring intubation (10.7%, 13/122, pKlebsiella and Acinetobacter species were the dominant organisms from both VAP and non-VAP categories. Multi-drug resistance was highly prevalent in bacterial isolates associated with VAP (90%; 99/110) and non-VAP categories (81.5%; 106/130). HAP including VAP remains to be the most prevalent hospital-acquired infections (HAIs) at Patan hospital. A local study of etiological agents and outcomes of HAP and VAP are required for setting more appropriate guidelines for management of such diseases.

Background Typhoid fever is a major public health problem in low-resource settings. Vaccination can help curb the disease and might reduce transmission. We have previously reported an interim analysis of the efficacy of typhoid conjugate vaccine (TCV) in Nepali children. Here we report the final results after 2 years of follow-up. Methods We did a participant-masked and observer-masked individually randomised trial in Lalitpur, Nepal, in which 20 019 children aged 9 months to younger than 16 years were randomly assigned in a 1:1 ratio to receive a single dose of TCV (Typbar TCV, Bharat Biotech International, India) or capsular group A meningococcal conjugate vaccine (MenA). Participants were followed up until April 9, 2020. The primary outcome was blood culture-confirmed typhoid fever. Cases were captured via passive surveillance and active telephone surveillance followed by medical record review. The trial is registered at ISRCTN registry, ISRCTN43385161 and is ongoing. Findings From Nov 20, 2017, to April 9, 2018, of 20 119 children screened, 20 019 participants were randomly assigned to receive TCV or MenA vaccine. There were 75 cases of blood culture-confirmed typhoid fever included in the analysis (13 in the TCV group and 62 in the MenA group) over the 2-year period. The protective efficacy of TCV against blood culture-confirmed typhoid fever at 2 years was 79·0% (95% CI 61·9–88·5; p Interpretation The final results of this randomised, controlled trial are in keeping with the results of our published interim analysis. There is no evidence of waning protection over a 2-year period. These findings add further support for the WHO recommendations on control of enteric fever. Funding Bill & Melinda Gates Foundation.

Gestational trophoblastic diseases, which include molar pregnancy, have an increased risk of complications associated with the thyroid gland. This condition is mainly caused by elevated levels of beta-human chorionic gonadotropin produced during pregnancy, which is exaggerated in molar pregnancy and can lead to thyrotoxicosis. Hence, it is important to recognize the signs and symptoms of hyperthyroidism among women of childbearing age to prevent complications such as thyroid storm. Medical management of thyroid storm before surgery is critical to prevent adverse maternal outcomes. Here, we report a rare case of impending thyroid storm induced by molar pregnancy.

Despite recent advances in typhoid fever control, asymptomatic carriage of Salmonella Typhi in the gallbladder remains poorly understood. Aiming to understand if S. Typhi becomes genetically adapted for long-term colonisation in the gallbladder, we performed whole genome sequencing on a collection of S. Typhi isolated from the gallbladders of typhoid carriers. These sequences were compared to contemporaneously sampled sequences from organisms isolated from the blood of acute patients within the same population. We found that S. Typhi carriage was not restricted to any particular genotype or conformation of antimicrobial resistance genes, but was largely reflective of S. Typhi circulating in the general population. However, gallbladder isolates showed a higher genetic variability than acute isolates, with median pairwise SNP distances of 21 and 13 SNPs (p = 2.8x10-9), respectively. Within gallbladder isolates of the predominant H58 genotype, variation was associated with a higher prevalence of nonsense mutations. Notably, gallbladder isolates displayed a higher frequency of non-synonymous mutations in genes encoding hypothetical proteins, membrane lipoproteins, transport/binding proteins, surface antigens, and carbohydrate degradation. Specifically, we identified several gallbladder-specific non-synonymous mutations involved in LPS synthesis and modification, with some isolates lacking the Vi capsular polysaccharide vaccine target due to the 134Kb deletion of SPI-7. S. Typhi is under strong selective pressure in the human gallbladder, which may be reflected phylogenetically by long terminal branches that may distinguish organisms from chronic and acute infections. Our work shows that selective pressures asserted by the hostile environment of the human gallbladder generate new antigenic variants and raises questions regarding the role of carriage in the epidemiology of typhoid fever., Author summary Salmonella Typhi is the bacterium that causes typhoid. Salmonella Typhi is infamous for being able to be carried in the gallbladder, with Typhoid Mary being the best-known example of a typhoid carrier. Despite having new tools for typhoid control, we have made little progress in understanding this disease process. Aiming to understand if Salmonella Typhi is adapted for long-term survival in the gallbladder, we sequenced the genomes of 24 Salmonella Typhi isolated from the gallbladders of typhoid carriers. We compared these genomes to Salmonella Typhi from acute typhoid patients within the same population. The carriage of Salmonella Typhi was not restricted to any specific genotype or resistance to antibiotics, but reflective of the organisms causing acute disease. However, gallbladder isolates had higher genetic variability than acute isolates, with a higher frequency of mutations changing the amino acid sequences of hypothetical proteins, membrane lipoproteins, transport/binding proteins, surface antigens, and carbohydrate degradation. We identified several gallbladder-specific mutations involved in polysaccharide synthesis on the bacterial surface. Our work shows that selective pressures asserted by the hostile environment of the human gallbladder generates genetic variation, which is not observed in acute isolates, raising questions regarding the role of carriage in the epidemiology of typhoid.

Aim To study the long-term efficacy and safety of Ozurdex as anti-inflammatory monotherapy in the management of tuberculosis-associated intermediate uveitis (TBIU). Methods Retrospective analysis of eyes with TBIU that received Ozurdex as anti-inflammatory monotherapy with a follow-up of at least 1 year. Results 13 eyes (2 pseudophakic) of 11 patients were included. Mean BCVA improved from 0.65 to 0.11 at 3 months (p = .0005) and remained 0.11 at 1 year. Mean central foveal thickness improved from 452.87µ to 187.25µ at 3 months (p = .0009) and 184.62µ at 1 year in 8 eyes with CME. Mean vitreous haze improved from 2.38 to 0.11 at 3 months with no recurrences at 1 year. Mean IOP increased from 13.15mmHg to 15.53mmHg (p = .013) at 2 months and reduced to 12.46mmHg by 1 year. None required antiglaucoma medication. One eye underwent cataract surgery. The mean follow-up was 18.4 months. Conclusion Ozurdex is safe and efficacious in TBIU as anti-inflammatory monotherapy in conjunction with antitubercular therapy.

Background Inborn errors of immunity remain underdiagnosed in developing countries. Despite several limitations and challenges, there has been significant progress in diagnosing and managing these conditions. Objectives To study the clinical & laboratory profile of children with inborn errors of immunity in a tertiary care center in South India. Methods Case records of children diagnosed to have inborn errors of immunity over a period of 36 months at KLE Prabhakar Kore Hospital in South India were reviewed in detail. The details included clinical history, examination findings, laboratory parameters, and genetic tests. Results A total of forty-six children with a mean age of 3.04±4.07 years were diagnosed with inborn errors of immunity. The male-to-female ratio was 3.6:1. A positive history of consanguineous marriage was present in 32.7%. Immunodeficiency affecting cellular and humoral immunity(n=8): 6 had SCID, 1 had DOCK-8 deficiency, 1 had CARD 11 deficiency; Combined immunodeficiency with associated or syndromic features(n=5): 3 had Wiskott Aldrich syndrome, 1 had Ataxia telangiectasia and Hyper IgE syndrome; Predominant antibody deficiencies(n=5): 4 had CVID and 1 had CARD11 deficiency; Diseases of Immune dysregulation(n=15): 9 Children had familial hemophagocytic lymphohistiocytosis, 5 had autoimmune lymphoproliferative syndrome, and one T-CRD (T cell receptor immunodeficiency); Congenital defects of phagocyte number/function(n=9): 4 had CGD, 3 had severe congenital neutropenia (Kostman syndrome) and 2 had LAD; Defects in intrinsic and innate immunity(n=2): 1 had IRF8 gene deletion and another had Osteopetrosis; Autoinflammatory disorders(n=1): 1 had Familial periodic fever; Bone marrow failure(n=1): 1 child had Fanconi anaemia. Conclusions From a single-center, 46 children with inborn errors of immunity could be identified by chart review suggesting a high index of suspicion for the diagnosis of inborn errors of immunity. Children presenting with repeated infections, with a background of consanguinity, atypical courses of infections, poor response to conventional treatment should be evaluated for inborn errors of immunity. We can improve the outcome if transplant is made affordable and accessible as most patients are from lower socioeconomic groups. Awareness about these disorders may improve the diagnosis of these conditions and help in appropriate management. There is a need to share experience and data on these rare conditions and build support groups to guide patients and families afflicted with these ominous disorders.

Typhoid Vi-conjugate vaccines (Vi-TCV) have been developed to control typhoid fever in children in endemic regions. Previously, in a human challenge model of typhoid, Vi-TCV was administered prior to deliberate ingestion of Salmonella Typhi by healthy adult volunteers in the UK. Vi-specific antibody-dependent neutrophil phagocytosis (ADNP) was associated with protection against enteric fever in this model, but it is not known if ADNP is induced by vaccination of children. We measured ADNP in a cohort of Nepalese children receiving a Vi-TCV in a field study to investigate whether functional antibody responses were also present in children in an endemic setting. Furthermore, we investigated relationships between the functional antibody measures and other properties of the antibody response, including Vi-IgG and IgA titres, and Fc region glycosylation. Antibody-dependent neutrophil phagocytosis significantly increased in children aged 9 months to 15 years between the day of vaccination and 28 days following administration of Vi-TCV (D28). The magnitude of ADNP was also comparable with the levels of ADNP induced by plasma from vaccinated UK adults. Neither IgG nor IgA antibody titres significantly correlated with ADNP scores at D28; however, increased vaccine-induced ADNP was associated with decreased levels of IgG1 sialylation. These data suggest that vaccination with Vi-TCV produces functional antibody responses in children, which associate with specific glycosylation patterns of the Fc region.

Kidney stones, also referred to as renal calculi, are solid masses made from crystals. It's vital to detect the precise and accurate position of urinary calculus for surgical operations. Since the ultrasound images contain speckle noise, therefore it's difficult to detect the urinary calculus manually and hence it's required to use automated techniques in detection of kidney stones in ultrasound images. Ultrasound imaging is one among the available imaging techniques used for diagnosis of kidney abnormalities, which can be like change in shape and position and swelling of limb; there also are other kidney abnormalities like formation of stones, cysts, blockage of urine, congenital anomalies, and cancerous cells. This challenge can be overcome by employing suitable image processing techniques. This paper proposes an image processing technique to identify kidney stones automatically without human intervention. This report also presents the literature review and comparative study of varied algorithms available within the existing literature for urinary calculus detection in human bodies.

Perfect diet and nutrition are important factors in the promotion and maintenance of health throughout the entire course of life. Malnutrition is both a cause and a consequence of ill health. Geriatric population with long term medical and psyco-social problems are chronically underweight and so are vulnerable to acute illness. Even people who are well-nourished eat and drink less if they are ill or injured. Although this may only be short lived as a part of an acute problem. If it persists the person can become undernourished to an extent that it precipitates other medical conditions. Issues related to geriatric nutrition are extricable linked to certain broader issues facing the geriatric population. This article provides an overview of geriatric nutrition and related issues faced by this group of people. This review summarizes the changes in diet associated with senior group of people. Keywords: Diet, Nutrition, Malnutrition, Ill-health, Acute illness, Geriatric.

Two sibling patients aged 16 & 18 years reported at this tertiary hospital with symptoms of bilateral painless diminution of vision noticed for previous 4 & 2 years respectively. Refractive corrections did not result in tangible visual improvements. Unaided visual status of counting fingers at 1 metre (OD) & ½ metre (OS) in the 16 years old female and ½ metre (OD) and 4 metres (OS) in the 18 years old male patient foretold a similar clinical handicap. Anterior segment evaluations revealed overt superonasal subluxation of lens in the female patient while an inferior temporal zonular dehiscence, phacodonesis & a propensity for ectopia lentis were observed in the male sibling. Intra ocular pressures of 15 mmHg (OD) & 17 mmHg (OS) in the male and 14 & 16 mmHg respectively in the female patient as on Applanation tonometry ruled out glaucomatous aetiology for poor vision. Similarly, all biometric evaluations of the globe in both patients were within normal range. Posterior segment evaluation employing fundus photography noted oval hyperaemic disc with blurred margins and absent cup with tessellated background. Optical coherence tomographic picture was unremarkable except for a pigment epithelial defect in one of the eyes. Facial contour expressed striking features of Crouzon syndrome with Brachycephaly, prominent parrot beak nose, maxillary hypoplasia, telecanthus & low set of ears. In addition, a high arched palate, irregular dentition and a vacant expression noticed in multiple cranio facial dysostosis highlighted the quintessential features of the syndrome. General examination revealed stunted growth and poor nutritional status in both patients. Height of 140 cm in female sibling was equal to the arm span with an Upper lower segment ratio of 0.59. There were no deformities in the extremities and no characteristic skin changes. General physical changes in male sibling were less prominent. Psychological assessment of the cases revealed a subnormal Intelligence quotient (IQ of 82) in the female but an average normal in the male. Pure tone audiometry revealed normal hearing status for both patients. X-ray chests and Echocardiographic assessments ruled out cardio-vascular malformations. A multi-disciplinary approach, involving an Internist, Paediatrician, Clinical Psychologist, Neurosurgeon and Otorhinolaryngologist conferred the diagnosis of Crouzon syndrome.