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Objective: To describe the proportion of women presenting with undiagnosed anaemia at confinement and to explore associations between anaemia and socio economic factors, dietary pattern and compare maternal and neonatal outcome among term mothers with anaemia compared to non-anaemic pregnant women at a tertiary care centre in Sri Lanka. Method: A comparative cross-sectional study was performed by recruiting anaemic and non-anaemic term mothers who delivered at the Teaching Hospital Peradeniya during the period March 2018-March 2019. Pregnant mothers whose haemoglobin level was less than 10.5 g/dl were considered as anaemic and compared with the mothers whose haemoglobin level was above this level. With written consent, demographic data, etiological factors, maternal and neonatal outcomes of term mothers were evaluated by an interview and blood samples were withdrawn to carry out anaemia related investigations. Results: Among 2854 pregnancies, a total of 234 (8.19%) term pregnant mothers were anaemic and they were and compared with 199 non-anaemic mothers. Out of the anaemic mothers (Hb < 105 g/l), 133 (56.76%) had moderate anaemia, 100 (42.79%) had mild anaemia and 1 mother (0.45%) had severe anaemia. Low monthly family income was significantly associated with the incidence of anaemia. Anaemia was also associated with low weekly consumption of red meat (OR 8.994; 95% CI, 5.74 - 14.09, p < 0.05) and high weekly tea intake (OR 0.217; 95% CI 0.144 - 0.327, p < 0.05). Among anaemic mothers, 215 (67.44%) had low serum ferritin (

Background. Patients with cervical spinal injury with quadriplegia are at an increased risk of developing serious gastrointestinal complications. We report an unusual case of spontaneous rectosigmoid perforation in a quadriplegic patient. Case Presentation. A 58-year-old man with diabetes mellitus and hypertension presented to the emergency department following a fall from 25 feet of height. He sustained a fifth cervical vertebral fracture with quadriplegia and neurogenic shock. One week later, he developed progressive abdominal distension with tachycardia, low blood pressure, and respiratory distress. His abdomen was soft but had impaired liver dullness. Imaging showed evidence of visceral perforation. He underwent an emergency laparotomy and was found to have a perforation of the antemesenteric border of the rectosigmoid junction with fecal contamination. The perforation was repaired primarily, and a temporary loop ileostomy was created. The patient received intensive care for 4 days, and thereafter, the recovery was uneventful. He was later transferred to the spinal unit for further management. The intraoperative findings, histology, and subsequent colonoscopy did not reveal any underlying cause for the perforation. Conclusions. Clinical signs and symptoms are generally absent in patients following spinal cord injury, and the diagnosis of serious gastrointestinal pathology can be difficult and challenging. We believe that ischemia at the rectosigmoid junction precipitated by multiple factors was the possible reason for the spontaneous perforation.

GOALS The goal of this study was to evaluate the impact of inpatient outcomes of gastrointestinal bleeding (GIB) related to percutaneous coronary intervention (PCI). BACKGROUND With all-cause mortality increasing in patients undergoing PCIs, outcomes for GIB associated with PCI may be adversely impacted. STUDY Using the National Inpatient Sample (2007 to 2012), we performed a nested case-control study assessing inpatient outcomes including incidence and mortality for PCI-related GIB hospitalizations. Multivariate logistic regression analyses were performed to determine significant predictors for GIB incidence and mortality. RESULTS A total of 9332 (1.2%) of PCI hospitalizations were complicated by GIB with the age-adjusted incidence rate increasing 13% from 2007 (11.3 GIB per 1000 PCI) to 2012 (12.8). Patients ≥75 years of age experienced the steepest incline in GIB incidence, which increased 31% during the study period. Compared with non-GIB patients, mean length of stay (9.4 d vs. 3.3 d) and median cost of care ($29,236 vs. $17,913) was significantly higher. Significant demographic risk factors for GIB included older age and comorbid risk factors included gastritis or duodenitis, and Helicobacter pylori infection.In total, 1044 (11%) of GIB patients died during hospitalization with the GIB mortality rate increasing 30% from 2007 (95 deaths per 1000 GIB) to 2012 (123). Older age had the strongest association with inpatient mortality. CONCLUSIONS Inpatient incidence and mortality for PCI-related GIB has been increasing particularly with a large increase in incidence among older patients. A multidisciplinary approach focused on risk-stratifying patients may improve preventable causes of GIB.

Magnetoencephalography (MEG) is a noninvasive neuroimaging tool that is increasingly becoming useful for presurgical delineation of epileptogenic zones and eloquent cortex in both lesional and non-lesional pediatric cases. During the past 10 yrs, the use of MEG in pediatric epilepsy research has increased. This paper starts with a review of the use of MEG in pediatric epilepsy. We then describe the protocol used for epilepsy patients at the pediatric MEG facility in Boston Children’s Hospital and present two case studies of intractable epilepsy obtained in our laboratory -cortical dysplasia and tuberous sclerosis complex -to illustrate our methodology in localizing epileptiform generators. In both cases, we are able to localize generators of interictal spikes in the irritative zone just outside the lesion. We also present results on localization of the somatosensory cortex based on our pediatric MEG system to illustrate the utility of MEG for identification of the eloquent cortex. We complete this review by considering advantages and limitations of MEG in children with epilepsy, its future developments and research applications. Application of MEG in pediatric epilepsy will accelerate during the coming years as different types of pediatric whole-head MEG systems and more advanced data analysis methods become available to the researchers and clinicians. These advances will lead to greater use of MEG as a complement to clinical electroencephalography, with improved noninvasive delineation of the epileptogenic zone.

Non-alcoholic fatty liver disease (NAFLD), the most common cause of liver disease, affects approximately 75 to 100 million Americans. Patients with concurrent NAFLD and type 2 diabetes mellitus have a higher risk of progressing to advanced fibrosis and non-alcoholic steatohepatitis compared to non-diabetics. Lifestyle modifications, including weight loss, remain the mainstay of treatment for NAFLD, as there are no medications currently indicated for this disease state. Anti-diabetic pharmacologic therapies aimed at improving insulin sensitivity and decreasing insulin production have been studied to determine their potential role in slowing the progression of NAFLD. In this review, we focus on the evidence surrounding anti-diabetic medications and their ability to improve disease progression in patients with NAFLD.

Disturbances of the autonomic nervous system (ANS) are common in neuropsychiatric disorders. Disease specific alterations of both sympathetic and parasympathetic activity can be assessed by heart rate variability (HRV), whereas electrodermal activity (EDA) can assess sympathetic activity. In posttraumatic stress disorder (PTSD), parasympathetic HRV parameters are typically decreased and EDA is increased, whereas in major depressive disorder (MDD) and dissociation, both parasympathetic and sympathetic markers are decreased. ANS abnormalities have also been identified in psychogenic nonepileptic seizures (PNES) by using HRV, indicating lower parasympathetic activity at baseline. In addition to reviewing the current literature on ANS abnormalities in PTSD, MDD, and disorders with prominent dissociation, including borderline personality disorder (BPD), this article also presents data from a pilot study on EDA in patients with PNES. Eleven patients with PNES, during an admission to our epilepsy monitoring unit (EMU), were compared with 9 with generalized tonic-clonic seizures (GTCS). The area under the EDA curve, the number of EDA responses lasting longer than 2 seconds, and the number of EDA surges during sleep (sympathetic sleep storms) were calculated on ictal and interictal days by an automated algorithm. EDA changes in PNES patients did not follow a systematic pattern of sympathetic hyperarousal (like EDA after GTCS) but were more variable. How specific PNES semiologies, and/or underlying neuropsychiatric disorders, may influence ictal and interictal EDA patterns, and lead to a novel diagnostic biomarker remains to be evaluated in future larger studies.

Tuberous sclerosis complex (TSC) is a rare disorder of tissue growth and differentiation, characterized by benign hamartomas in the brain and other organs. Up to 90% of TSC patients develop epilepsy and 50% become medically intractable requiring resective surgery. The surgical outcome of TSC patients depends on the accurate identification of the epileptogenic zone consisting of tubers and the surrounding epileptogenic tissue. There is conflicting evidence whether the epileptogenic zone is in the tuber itself or in abnormally developed surrounding cortex. Here, we report the localization of the epileptiform activity among the many cortical tubers in a 4-year-old patient with TSC-related refractory epilepsy undergoing magnetoencephalography (MEG), electroencephalography (EEG), and diffusion tensor imaging (DTI). For MEG, we used a prototype system that offers higher spatial resolution and sensitivity compared to the conventional adult systems. The generators of interictal activity were localized using both EEG and MEG with equivalent current dipole (ECD) and minimum norm estimation (MNE) methods according to the current clinical standards. For DTI, we calculated four diffusion scalar parameters for the fibers passing through four ROIs defined: (i) at a large cortical tuber identified at the right quadrant, (ii) at the normal appearing tissue contralateral to the tuber, (iii) at the cluster formed by ECDs fitted at the peak of interictal spikes, and (iv) at the normal appearing tissue contralateral to the cluster. ECDs were consistently clustered at the vicinity of the large calcified cortical tuber. MNE and ECDs indicated epileptiform activity in the same areas. DTI analysis showed differences between the scalar values of the tracks passing through the tuber and the ECD cluster. In this illustrative case, we provide evidence from different neuroimaging modalities, which support the view that epileptiform activity may derive from abnormally developed tissue surrounding the tuber rather than the tuber itself.

This study presents effects of intravenous laser blood irradiation (ILBI) in a transient immunodeficiency patient with juvenile idiopathic arthritis (JIA) treated with an interleukin-6 receptor inhibitor (Tocilizumab). Biological agents induce JIA remission, but some patients do not respond favorably to this final therapeutic line of defense. ILBI was performed in a 16-year-old male patient, with JIA and transient immunodeficiency. When ILBI was introduced, the patient was receiving disease-modifying drugs, steroids, tocilizumab, and physical therapy. Because the disease was not well controlled, ILBI was applied in addition to other ongoing therapies. The patient underwent 1 session daily, and 10 successive sessions per month, repeated every 3 months, for 7 months. Patient evaluation was performed before ILBI was started and at 3, 6, 9, and 12 months after ILBI initiation, using the ACR Pediatric response. The outcome was evaluated using Pediatric 50, 70, and 90 responses and compared to initial status, after 3, 6, 9, and 12 months. At the end of study, the titre of IgA and IgG levels returned to normal. Synergistic anti-inflammatory effect of ILBI was evident, if applied additionally in combination with tocilizumab, in a patient with a therapy-resistant severe form of JIA and related subacute transient immunodeficiency.

Sublingual laser blood irradiation (SLBI) was applied into a randomized, single-blind, placebo-controlled study in juvenile idiopathic arthritis (JIA), aimed at inducing disease remission. 105 children with JIA, without an adequate response to classical treatment, were administrated a disease modifying drug (Methotrexate) and were randomly assigned to three groups. Group I (36 patients) received SLBI with the Weberneedle Lasershower Mouth Applicator with three wavelengths (635 nm, 536 nm, and 405 nm), 5 mW maximum output power each, in continuous mode, simultaneously, for 20 minutes daily, 7 successive sessions per month, repeated every 7 weeks, for three times. Group II (36 patients) received placebo SLBI. Group III (33 patients) received only treatment with Methotrexate. Evaluation was performed using American College of Rheumatology Pediatric criteria (ACR Pedi) at study enrollment and at 8, 16, 24, and 48 weeks. At the end of study, there was an improvement of the ACR Pedi 30 by 86.11% in SLBI group compared to only 61.11% in Group II, respectively, and 60.6% in Group III (P=0.001), with significant statistical differences. SLBI has reduced the pain, lowered the number of articulations with movement limitation, increased the quality of life, and made it possible to avoid the administration of biological agents.

A patient who had a small bowel mesentery perforation following insertion of a suprapubic catheter (SPC) is described. He had no bowel complaints immediately following the procedure, but presented 10 weeks later with insidious onset bowel obstruction due to the kink caused by the catheter. This complication occurred despite cystoscopy control and adequate bladder distension prior to the procedure. This isolated case illustrates the fact that regardless of the ease and frequency of SPC insertion, complications do occur.

This single-blind, placebo-controlled study assesses the efficacy of synergic administration of intravenous laser blood irradiation (ILBI) and etanercept in selected subtypes of juvenile idiopathic arthritis (JIA). Etanercept is a tumor necrosis factor alpha blocking agent with recognized importance in JIA. Laser radiation has immunomodulatory effects in animal and human studies. Fourteen patients (Group I) received ILBI and 9 patients (Group II) received placebo laser. ILBI was performed in addition to ongoing JIA medication, including etanercept. ILBI was administrated in 3 sets of 5 consecutive daily sessions, with a 7-week interval between every set of sessions. Evaluation was performed using ACR (American College of Rheumatology) Pediatric Criteria (ACR Pedi) at study enrollment and at 10 and 20 weeks, respectively. After 10 weeks, 85.7% of the patients in Group I fulfilled Pedi 30 criteria, compared to only 55.6% of the patients in Group II. After 20 weeks, all patients in both groups had a Pedi 30 response. In Group I, 92.8% of the subjects met the Pedi 50 response, compared to only 55.6% in the placebo group. One patient in Group I responded best, fulfilling Pedi 70 criteria. If applied synergistically, ILBI and etanercept would have an increased efficacy in promoting JIA remission.

The concept of surgically restoring the ventricle to a near-normal physiologic geometry has been the goal of successful treatment of advanced heart failure due to left ventricular aneurysms following transmural myocardial infarctions [1]. The resulting geometry after surgical restoration has concerned a number of surgeons since the first successful repair in 1958, but little attention was placed on the altered geometry until attempts were made to effect a more physiologic aneurysmorrhaphy in 1973. Substantial attention was focused on a concept of geometric reconstruction from within the left ventricle in 1985 [2]. A prosthetic patch was employed with the concept to redirect normal muscle bundles to their original orientation and position. Further refinements include use of improved materials for the repair, preservation, and bypass of the left anterior descending coronary artery, ablation of ventricular arrhythmias when indicated, and the absence of prosthetic material used in contact with the pericardial surface. The previous chapters have dealt with the innovations in surgical technique which has led to an evolution toward greater normalcy in the restored ventricular geometry.