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Rationale & Objective Benefits of sodium-glucose co-transporter 2 inhibitors on kidney outcomes have been demonstrated in clinical trials. Among patients with type 2 diabetes and established cardiovascular (CV) disease enrolled in EMPA-REG Outcome Study (NCT01131676), empagliflozin added to standard of care (SoC) reduced the risk of incident or worsening nephropathy compared to SoC alone. This analysis evaluated the cost-effectiveness of empagliflozin versus SoC alone in the subpopulation with diabetic kidney disease (DKD) from the perspective of United States (US) commercial insurers and Medicare. Study Design Discrete event simulation model. Setting & Population Patients with DKD in a US healthcare system. Interventions Empagliflozin 10 or 25 mg with SoC versus SoC alone. SoC included glucose-lowering therapies and medications to treat CV risk factors. Outcomes Incremental cost-effectiveness ratios (ICERs, 2020 US dollars per quality-adjusted life-year [QALY] gained). Costs and QALYs were discounted 3.0%/year. Model, Perspective, & Timeframe: Cost-effectiveness analysis, commercial insurers and Medicare perspective, lifetime horizon. Results The ICER of empagliflozin with SoC versus SoC alone was $25,974/QALY. Empagliflozin added 0.67 QALYs and $17,322/patient over a lifetime horizon. Results were driven by fewer clinical events (including CV death, heart failure [HF] hospitalization, albuminuria progression, and a composite kidney outcome) experienced by patients receiving empagliflozin with SoC versus SoC alone. Results were sensitive to rates of CV death, non-fatal MI, and HF hospitalization, as well as to drug costs, and time horizon. Probabilistic sensitivity analyses indicated 91% of simulations falling below $50,000/QALY. Limitations The EMPA-REG Outcome Study was not powered to assess treatment benefits in a subgroup and excluded patients with estimated glomerular filtration rate Conclusion Based on EMPA-REG Outcome Study, this cost-effectiveness analysis suggests that for commercial insurers and Medicare, adding empagliflozin to SoC may be a cost-effective treatment option for patients with DKD.

Objectives To evaluate contemporary clinical presentations of priapism, their association with socioeconomic characteristics, and the role of prescribing providers in priapism episodes in a large cohort of patients managed at 3 major academic health systems. Methods We identified all consecutive patients presenting with ischemic priapism to the emergency departments of three major academic health systems (2014 –2019). Demographic characteristics, priapism etiologies, and clinical management were evaluated. Univariable and multivariable analyses were used to assess the contribution of socioeconomic characteristics and the role of prescribing providers in priapism episodes. Results We identified 102 individuals with a total of 181 priapism encounters. Hispanic race, lower income quartile, sickle-cell disease, and illicit drug use were associated with increased risk of recurrent episodes. Of ICI users, 57% received their prescriptions from non-urological medical professionals (NUMPs); the proportion with recurrent episodes was higher for NUMPs compared to urologists (24% vs 0%, P = 0.06) with no demographic differences identified between patients treated by either group. Conclusion Socioeconomic disparities exist among patients presenting with recurrent episodes of priapism, potentially highlighting systemic issues with access to care and patient education. With most patients who developed ischemic priapism from ICI being prescribed these medications by NUMPs, further investigation is required to elucidate the prescribing and counseling patterns of these providers. Increased awareness of disparities and complications may improve patient safety.

BACKGROUND Since the outbreak of coronavirus disease (Covid-19) many patients have presented with a variety of other symptoms along with primary respiratory symptoms. The increased reporting of these extra-pulmonary symptoms has made it necessary for the clinicians to establish a proper cause and relation between coronavirus disease 2019 (Covid-19) and extra-pulmonary symptoms. This study was undertaken to assess if the cause of elevated lipase levels in Covid-19 patients was due to acute pancreatitis. METHODS A retrospective observational study was performed at a local critical care ICU facility in Bathinda, India (MediWin Hospital, Bathinda, Punjab). RT - PCR, Rapid antigen test, CT scans were done to establish the Covid-19 status. Clinical signs and symptoms, CT scans were used to confirm the diagnosis of acute pancreatitis. MRI was preferred in patients with deranged renal function test. RESULTS Lipase test was done in 62 patients and the levels were found elevated in 52 patients. 40 patients were found to have symptoms of the spectrum of acute pancreatitis. 10 patients had symptoms along with signs of1 severe inflammatory response syndrome. Imaging was advised in these 10 patients with1 moderate to severe presentation of acute pancreatitis. 9 patients were advised CT scans which had no significant findings. 1 patient with deranged renal function test was advised2 MRI scan which showed mildly diffusely bulky pancreas. Mild peripancreatic fat stranding and fluid collection, suggestive of acute interstitial pancreatitis. It was associated with poor outcomes and lead to the patient’s death eventually. CONCLUSIONS Hyperlipasemia led to acute pancreatitis in 1 (1.6 %) patient. It was associated with poor outcome and caused eventual death of the patient. The prospects of a Covid-19 patient developing Hyperlipasemia due to acute pancreatitis were found to be statistically insignificant. KEY WORDS Coronavirus, Hyperlipasemia, Pancreatitis, Lipase, RT - PCR, Rapid Antigen Test.

Objective: The coronavirus disease (COVID-19) sparked from Wuhan city of China and rapidly developed into a pandemic. The critically ill patients of COVID-19 exhibit features of hyper inflammation, and the particular blood tests may be rewarding for prognosis. Our aim was to investigate the CBC, which includes total leukocyte, lymphocytes and granulocytes count, Hemoglobin, MCV, MCH, MCHC, RBCs and Platelet count, NLR etc. The current study was conducted to conclude the alteration in blood parameters and their association with the severity and mortality of COVID-19 patients. Methods: An observational cross-sectional study was conducted retrospectively, a total of 100 COVID-19 positive patients were examined: 50 were mild, 25 were moderate, 10 were severe, and 15 were critically diseased patients. Unfortunately, we recorded 6 deaths among the critical group. The overall mean age observed in our study was 48.94 years, where the mean age for critical individuals was 62.12 ± 14.35 years. Results: A significant association between the disease severity and elevation in blood parameters were observed. The total WBC's and Neutrophils count were significantly decreased (p value

Background COVID-19 pandemic has resulted in significant strain on healthcare resources and this requires diligent resource re-allocation. We aim to describe the incidence and outcomes of in-hospital cardiac arrest (IHCA) during this period as compared to non-pandemic period. Methods We conducted a retrospective study in a tertiary care hospital in Singapore. The study compared the incidence and outcomes of code blue activations over a 3-month period from March to May 2020 (COVID-19 period) with the same months in 2019 (pre-COVID-19 period). The primary outcome of the study was the rate of survival to hospital discharge for IHCA. The secondary outcomes included incidence of all code blue activation per 1000 hospital admissions, incidence of IHCA per 1000 hospital admissions. Outcomes The rate of survival to hospital discharge for IHCA was 5.88% in the COVID-19 period as compared to 10.0% in the pre-COVID-19 period [odds ratio (OR), 0.72; 95% confidence interval (CI), 0.26-1.95]. Compared to pre-COVID-19 period, there were more IHCA incidences per 1000 hospital admissions in the COVID-19 period (1.86 vs 1.03; OR, 1.81; 95% CI, 0.78-4.41). Conclusions The study observed a trend towards higher incidence of IHCA and lower rate of survival to hospital discharge during COVID-19 pandemic compared to pre-COVID-19 period.

Background The purpose of this study was to estimate prevalence of asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among patients admitted to obstetric inpatient units throughout the United States as detected by universal screening. We sought to describe the relationship between obstetric inpatient asymptomatic infection rates and publicly available surrounding community infection rates. Methods A cross-sectional study in which medical centers reported rates of positive SARS-CoV-2 testing in asymptomatic pregnant and immediate postpartum patients over a 1–3-month time span in 2020. Publicly reported SARS-CoV-2 case rates from the relevant county and state for each center were collected from the COVID Act Now dashboard and the COVID Tracking Project for correlation analysis. Results Data were collected from 9 health centers, encompassing 18 hospitals. Participating health centers were located in Alabama, California, Illinois, Louisiana, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, and Washington State. Each hospital had an active policy for universal SARS-CoV-2 testing on obstetric inpatient units. A total of 10 147 SARS-CoV-2 tests were administered, of which 124 were positive (1.2%). Positivity rates varied by site, ranging from 0–3.2%. While SARS-CoV-2 infection rates were lower in asymptomatic obstetric inpatient groups than the surrounding communities, there was a positive correlation between positivity rates in obstetric inpatient units and their surrounding county (P=.003, r=.782) and state (P=.007, r=.708). Conclusions Given the correlation between community and obstetric inpatient rates, the necessity of SARS-CoV-2–related healthcare resource utilization in obstetric inpatient units may be best informed by surrounding community infection rates., There was a significant positive correlation between SARS-CoV-2 positivity rates in obstetric inpatient units and their surrounding county and state. Healthcare resource utilization related to SARS-CoV-2 testing in obstetric inpatient units may be best informed by surrounding community infection rates.

Diagnostic evaluation for infertility in women should be conducted in a systematic, expeditious, and cost-effective manner to identify all the relevant factors with an initial emphasis on the least invasive methods for detecting the most common causes of infertility. The purpose of this committee opinion is to provide a critical review of the current methods and procedures for the evaluation of in fertile women, and it replaces the document of the same name, last published in 2015 (Fertil Steril 2015;103:e44-50). This guidance is intended for any provider evaluating women for infertility.

Migration is increasing at unprecedented rates worldwide, but inadequate mechanisms for granting citizenship or permanent residence have rendered many immigrants without legal status. We study the health of people without immigration status in Canada, building on a 2010 review on being without status and health. We employ an expanded definition of health, guided by the WHO Social Determinants of Health (SDoH) framework. Using a scoping review methodology, we reviewed literature from 2008 to 2018 on the SDoH of people without legal immigration status in Canada, selecting 33 articles for analysis. We found that structural determinants of health, such as stigmatization and criminalization, and intermediary determinants, such as fear of deportation and healthcare avoidance, produce ill health. We show how different social positions are produced by SDoH, finding immigration status to be the foundational determinant of health for people without status in Canada. We argue that lack of immigration status as a SDoH is missing from the WHO framework.

Introduction: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high mortality rate, though outcomes of the different lung compliance phenotypes are unclear. We aimed to measure lung compliance and examine other factors associated with mortality in COVID-19 patients with ARDS. Methods: Adult patients with COVID-19 ARDS who required invasive mechanical ventilation at 8 hospitals in Singapore were prospectively enrolled. Factors associated with both mortality and differences between high (

Background Multi-cancer early detection (MCED) next-generation-sequencing blood tests represent a potential paradigm shift in screening. Methods We estimated the impact of screening in the US and UK. We used country-specific parameters for uptake, and test-specific sensitivity and false-positive rates for current screening: breast, colorectal, cervical and lung (US only) cancers. For the MCED test, we used cancer-specific sensitivities by stage. Outcomes included the true-positive:false-positive (TP:FP) ratio; and the cost of diagnostic investigations among screen positives, per cancer detected (Diagcost). Outcomes were estimated for recommended screening only, and then when giving the MCED test to anyone without cancer detected by current screening plus similarly aged adults ineligible for recommended screening. Results In the US, current screening detects an estimated 189,498 breast, cervical, colorectal and lung cancers. An MCED test with 25–100% uptake detects an additional 105,526–422,105 cancers (multiple types). The estimated TP:FP (Diagcost) was 1.43 ($89,042) with current screening but only 1:1.8 ($7060) using an MCED test. For the UK the corresponding estimates were 1:18 (£10,452) for current screening, and 1:1.6 (£2175) using an MCED test. Conclusions Adding an MCED blood test to recommended screening can potentially be an efficient strategy. Ongoing randomised studies are required for full efficacy and cost-effectiveness evaluations.

Introduction: Despite adhering to criteria for extubation, up to 20% of intensive care patients require re-intubation, even with use of post-extubation high-flow nasal cannula (HFNC). This study aims to identify independent predictors and outcomes of extubation failure in patients who failed postextubation HFNC. Methods: We conducted a multicentre observational study involving 9 adult intensive care units (ICUs) across 5 public hospitals in Singapore. We included patients extubated to HFNC following spontaneous breathing trials. We compared patients who were successfully weaned off HFNC with those who failed HFNC (defined as re-intubation ≤7 days following extubation). Generalised additive logistic regression analysis was used to identify independent risk factors for failed HFNC. Results: Among 244 patients (mean age: 63.92±15.51 years, 65.2% male, median APACHE II score 23.55±7.35), 41 (16.8%) failed HFNC; hypoxia, hypercapnia and excessive secretions were primary reasons. Stroke was an independent predictor of HFNC failure (odds ratio 2.48, 95% confidence interval 1.83–3.37). Failed HFNC, as compared to successful HFNC, was associated with increased median ICU length of stay (14 versus 7 days, P

Various research studies have shown that exposure to radon gas is a cause of concern for health effects to the public. The present work has been carried out for the radiological risk assessment to the public due to the presence of radon isotopes in drinking water of Barnala district of Punjab, India, for the first time using scintillation-based radiation detector. A total of 100 samples were collected from different sources of water (canal and underground water) from 25 villages on grid pattern of 6 × 6 km2 in the study area for uniform mapping. In situ measurements were carried out to find out Rn-222 concentration in water samples. The measured values have been found to vary from 0.17 ± 0.01 to 9.84 ± 0.59 BqL−1 with an average value of 3.37 ± 0.29 BqL−1, which is well below the recommended limit of 100 BqL−1(WHO 2004). The annual effective dose due to ingestion and inhalation of radon has also been calculated for various age groups like infants, children and adults to understand the age-wise dose distribution. The calculated values suggest that there is no significant health risk to the general public from radon in water.

Objectives Cancer diagnoses at later stages are associated with a decrease in health-related quality of life (HRQOL). Health state utility values (HSUVs) reflect preference-based HRQOL and can vary based on cancer type, stage, treatment, and disease progression. Detecting and treating cancer at earlier stages may lead to improved HRQOL, which is important for value assessments. We describe published HSUVs by cancer type and stage. Methods A systematic review was conducted using Embase, MEDLINE®, EconLit, and gray literature to identify studies published from January 1999 to September 2019 that reported HSUVs by cancer type and stage. Disutility values were calculated from differences in reported HSUVs across cancer stages. Results From 13,872 publications, 27 were eligible for evidence synthesis. The most frequent cancer types were breast (n = 9), lung (n = 5), colorectal (n = 4), and cervical cancer (n = 3). Mean HSUVs decreased with increased cancer stage, with consistently lower values seen in stage IV or later-stage cancer across studies (e.g., − 0.74, − 0.44, and − 0.51 for breast, colorectal, and cervical cancer, respectively). Disutility values were highest between later-stage (metastatic or stage IV) cancers compared to earlier-stage (localized or stage I–III) cancers. Conclusions This study provides a summary of HSUVs across different cancer types and stages that can inform economic evaluations. Despite the large variation in HSUVs overall, a consistent decline in HSUVs can be seen in the later stages, including stage IV. These findings indicate substantial impairment on individuals’ quality of life and suggest value in early detection and intervention.

Background: Skin mycoses also called dermatophytosis is the most common fungal infection affects 20-25% of World population. Its prevalence varies place to place with climatic changes, time to time with age, sex and lifestyle of the population. Dermatophytoses could be caused by dermatophytes and non-dermatophytes, their frequency of isolation differs with geographical variation. Objectives: To study various clinical presentations of skin mycosis and compare KOH with culture in the diagnosis of dermatophytic infections in a tertiary care hospital. Material & Methods: A total of 98 skin scrapings collected from consecutive OPD patients from 1st June 2016 to 31st May 2017 examined using KOH and culture on modified Sabouraud’s dextrose agar medium. The isolated fungi were identified by morphology, lactophenol cotton blue, slide culture and biochemical tests. Results & Discussions: T. corporis (40.82%) was the most common clinical presentation followed by T. cruris (17.35%), T. pedis (15.31%), T. capitis (8.16%). Fungal infections were demonstrated in 52/98(53.06%). The male to female ratio of the positive cases was 15:9. The most affected age group in males 30-40yrs and females 40-50yrs. KOH positive were 43.87% (43/98). The samples which were positive in both KOH and culture were 17.35% (17/98), those positive in KOH and culture negative were 26.53% (26/98) and KOH negative and culture positive were 7.14% (7/98). Out of 24 positive cultures, 21 were dermatophytes and three were non-dermatophytes. The most common dermatophytes were T. mentagrophytes (62.5%) followed by T. rubrum (20.8%) and M. gypseum (4.33%). Conclusion: Skin mycoses is caused mainly by dermatophytes (T. mentagrophytes followed by T. rubrum) but non-dermatophytic infections do occur. Therefore, fungal culture is imperative for correct diagnosis and proper treatment.

Objective:Episodic memory impairment and hippocampal pathology are hallmark features of both temporal lobe epilepsy (TLE) and amnestic mild cognitive impairment (aMCI). Pattern separation (PS), which enables the distinction between similar but unique experiences, is thought to contribute to successful encoding and retrieval of episodic memories. Impaired PS has been proposed as a potential mechanism underling episodic memory impairment in aMCI, but this association is less established in TLE. In this study, we examined behavioral PS in patients with TLE and explored whether profiles of performance in TLE are similar to aMCI.Method:Patients with TLE, aMCI, and age-matched, healthy controls (HCs) completed a modified recognition task that relies on PS for the discrimination of highly similar lure items, the Mnemonic Similarity Task (MST). Group differences were evaluated and relationships between clinical characteristics, California Verbal Learning Test—Second Edition scores, and MST performance were tested in the TLE group.Results:Patients with TLE and aMCI demonstrated poorer PS performance relative to the HCs, but performance did not differ between the two patient groups. Neither the side of seizure focus nor having hippocampal sclerosis affected performance in TLE. However, TLE patients with clinically defined memory impairment showed the poorest performance.Conclusion:Memory performance on a task that relies on PS was disrupted to a similar extent in TLE and aMCI. The MST could provide a clinically useful tool for measuring hippocampus-dependent memory impairments in TLE and other neurological disorders associated with hippocampal damage.

Background: Understanding the reasons for HIV serostatus disclosure and nondisclosure and how these reasons differ by certain characteristics of the people living with HIV/AIDS (PLWHA) is important for effective HIV prevention intervention strategies. Objectives: This study was undertaken to investigate/identify the reasons for disclosure and nondisclosure of HIV serostatus by PLWHA, and to find out any association between the reasons for disclosure or nondisclosure and certain demographic and clinical characteristics, i.e. age, gender, WHO clinical stage and CD4 count of the study population. Methods: A cross-sectional study was conducted among all patients of 18-49 years with confirmed HIV infection registered at the antiretroviral therapy (ART) center of a tertiary care hospital in eastern Uttar Pradesh, India for one year, from July 2017 to June 2018. Results: The most common reason for disclosure of HIV serostatus was the presence of any family member at the time of collection of HIV test report (68.5%), and the most common reason for not disclosing the serostatus was stigmatization (68%). The reasons for disclosure was found to be associated with the WHO clinical stage of the respondents (p

Few studies demonstrate the safety and efficacy of postoperative pain regimens that exclude opioids altogether in patients undergoing robot-assisted radical prostatectomy (RARP). To reduce opioid use, we sought to develop an opioid-free regimen for RARP and determine perioperative outcomes before and after implementation. A retrospective, pre–post-interventional study was performed at a single institution between 8/2018 and 10/2019. An opioid-free pain regimen was developed and instituted on 3/7/2019, and all patients received preoperative counseling regarding pain expectations and management. Postoperative pain score was the primary outcome. Secondary outcomes included postoperative opioid use, length of stay, adverse events and unplanned health encounters within 30 days of discharge. Pearson’s chi-squared and Student’s t-tests were performed on categorical and continuous variables, respectively. Multivariable analysis was performed to determine risk factors for postoperative opioid use in the opioid-free cohort. A total of 89 patients were included for analysis; consisting of 47 (53%) pre-intervention and 42 (47%) post-intervention patients. Baseline characteristics were similar between groups. A significantly lower proportion of patients in the post-intervention group were administered opioids postoperatively (5% vs 53%, p

The current investigation represents the annual effective dose received due to ingestion and inhalation of radon present in drinking water. As radon itself contributes 3–14% towards the total proportion of lung cancer (WHO in Handbook on indoor radon. A public health perspective, World Health Organization, Geneva, 2009). The samples were taken from Sri Ganganagar region of Rajasthan province in India to calculate radon concentration and thereby to study the health risk. Total 100 water samples were taken from different sources of water which have been classified into two different categories as underground water and surface water sources. In-situ measurements of Rn-222 concentration was carried out using scintillation based radon monitor. The values of Rn-222 concentration were found to lie between 0.13 ± 0.04 and 3.74 ± 0.26 BqL−1 with mean value of 0.92 ± 0.12 BqL−1. These values are far below the maximum contamination level of 100 BqL−1, recommended by WHO, 2004 (Guidelines for drinking-water quality, WHO, Geneva, 2004). The ingestion and inhalation doses have been calculated for infants, children and adults from the derived radon concentration. The calculated doses are below the recommended level of 100 µSvy−1 (World Health Organisation in Guidelines for drinking water quality. Health criteria and other information, WHO Press, Geneva, 2003).

Introduction: Dipeptidyl peptidase-4 are a relatively new class of oral antihyperglycemic agent that enhance insulin secretion by reducing degradation of endogenous glucagon-like peptide 1. Currently, sitagliptin, vildagliptin, saxagliptin, linagliptin and alogliptin are approved in India, USA and Europe for the use in patients with type 2 diabetes. In this study we have tried to assess the safety of saxagliptin used in patients of type 2 DM who were previously on metformin monotherapy. Materials and Methods: A total of 35 patients who were previously on metformin montherapy with uncontrolled diabetes were enrolled. Patients were started with saxagliptin (2.5 mg OD) and were followed up at 1st, 3rd and 6th months for the estimation of Liver Function Test (SGOT, SGPT, Bilirubin direct & indirect), Renal Function Test (BUN and Sr. Creatinine). During the follow up period patients were also assessed for the adverse drug reactions. Results: Male and female patients mean age SD (61.42 yrs 6.99 and 55.93 yrs 5.74 respectively). The mean significant decrease in values from baseline at 24 weeks were seen for SGOT, SGPT, Blood urea nitrogen and serum creatinine. Conclusion: The combination of saxagliptin plus metformin for the treatment of type 2 diabetes offers an oral treatment regimen that is safe and well tolerated. Keywords: Saxagliptin, Uncontrolled type 2DM safety knee arthralgia.

Background Studies in the general population suggest that atrial fibrillation (AF) is an independent risk factor for decline in cognitive function, but this relationship has not been examined in adults with chronic kidney disease (CKD). We investigated the association between incident AF and changes in cognitive function over time in this population. Methods and Results We studied a subgroup of 3254 adults participating in the Chronic Renal Insufficiency Cohort Study. Incident AF was ascertained by 12-lead electrocardiogram (ECG) obtained at a study visit and/or identification of a hospitalization with AF during follow-up. Cognitive function was assessed biennially using the Modified Mini-Mental State Exam. Linear mixed effects regression was used to evaluate the association between incident AF and longitudinal change in cognitive function. Compared with individuals without incident AF (n = 3158), those with incident AF (n = 96) were older, had a higher prevalence of cardiovascular disease and hypertension, and lower estimated glomerular filtration rate. After median follow-up of 6.8 years, we observed no significant multivariable association between incident AF and change in cognitive function test score. Conclusion In this cohort of adults with CKD, incident AF was not associated with a decline in cognitive function.

Background The lack of a viable plantar flap in patients undergoing transmetatarsal amputation has been considered an indication for below-knee amputation (BKA). In an effort to reduce limb loss in this patient population, we sought to review our experience with transmetatarsal amputation salvage in patients with an open, guillotine transmetatarsal amputation. We hypothesized that performing a transmetatarsal amputation without a viable flap would extend time of independent ambulation and improve limb salvage. Methods This is a retrospective review of 27 consecutive patients who did not have a viable plantar flap and who underwent an open, guillotine transmetatarsal amputation. Patients presented with a nonviable plantar flap due to either extensive tissue loss on initial presentation, or secondary transmetatarsal amputation (TMA) flap necrosis. Patients initially underwent an open, guillotine TMA for control of infection and debridement of nonviable tissue. To achieve best results, during procedure, the metatarsals were resected to be as flush with soft tissue as possible. Once infection was resolved and all nonviable tissue debrided, negative pressure wound therapy (NPWT) was applied to the open wound. NPWT was continued until a base of granulation tissue covered the previously exposed bone. Wound closure was obtained by either the application of a split-thickness skin graft (STSG) or through continued NPWT allowing the wound to heal by secondary intention. Results Between January 2016 and December 2018, there were 27 open TMAs performed in 27 patients. Two patients did not granulate sufficiently and underwent BKA. Fourteen patients underwent STSG for closure, whereas 11 patients continued with NPWT. In the STSG group, 12 (86%) of the patients are healed, with a median time to complete healing of 75 days (range 28–330 days); the remaining 2 are ambulatory and undergoing continued wound care. In the 11 patients who did not receive STSG, 7 (64%) are healed with a median time to heal of 165 days. Of the remaining 4 patients in this group, 3 are ambulatory and still undergoing wound care, one was lost to follow-up. Overall, 19 patients (70%) have completely healed with a median time to heal of 82 days. Conclusions Limb salvage in patients with a nonviable plantar flap for TMA is possible and should be a considered procedure. This technique has the potential to improve functional outcomes and limb salvage in patients who might otherwise undergo BKA.

Background: Breast cancer is the most common cancer in urban and second common in rural Indian women. In India, in spite of the best treatment available being given to the patients they lose their lives because of paucity of diagnostic aids and lack of an organized breast cancer screening program. Early detection, accurate staging, and initiation of appropriate therapy are the key factors for improving the treatment outcome and prognosis of the disease for the patients. Traditional staging methods include clinical examination, blood tests, chest X-ray, ultrasound of the abdomen, and/or skeletal survey. As these tests lack sensitivity and specificity, these are being scaled down. The hybrid positron emission tomography-computerized tomography (PET-CT) is a unique tool in the field of imaging modalities that combines the effectiveness of PET and CT. This study was undertaken to assess the efficacy and accuracy of PET-CT as a single-session staging modality in the very initial stage itself and if it can replace the conventional means of staging. Methods: This was a cross-sectional study conducted in the Radiotherapy department at GGS Medical College and Hospital Faridkot from March 2014 to October 2015. 52 patients with newly diagnosed and histopathologically proven carcinoma breast were staged by conventional modalities (clinical examination, blood tests, X-ray chest, mammography, ultrasonography abdomen, skeletal survey) and by 18F-fluorodeoxyglucose (18F FDG) PET/CT. PET-CT images were used for the detection, localization, staging of tumors and detection, evaluation, and diagnosis of metastatic lesions, disease burden and organ function along with treatment planning and planning therapeutic procedures. Following the completion of initial study, the results of 18F FDG PET-CT staging in comparison with conventional staging method were assessed. Along with this, the accuracy, changes in staging of cases of carcinoma breast and cost-effectiveness of 18F-FDG PET-CT were also studied. Results: All the pathologic entities identified by conventional imaging were also perceived with 18F-FDG PET/CT. Therefore, we recommend the use of PET/CT as an important imaging modality for initial diagnosis of carcinoma breast.

Introduction Coronavirus disease-2019 (COVID-19) systemic illness caused by a novel coronavirus severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been spreading across the world. The objective of this study is to identify the clinical and laboratory variables as predictors of in-hospital death at the time of admission in a tertiary care hospital in India. Materials and methods Demographic profile, clinical, and laboratory variables of 425 patients admitted from April to June 2020 with symptoms and laboratory-confirmed diagnosis through real-time polymerase chain reaction (RT-PCR) were studied. Descriptive statistics, an association of these variables, logistic regression, and CART models were developed to identify early predictors of in-hospital death. Results Twenty-two patients (5.17%) had expired in course of their hospital stay. The median age [interquartile range (IQR)] of the patients admitted was 49 years (21–77 years). Gender distribution was male — 73.38% (mortality rate 5.83%) and female—26.62% (mortality rate 3.34%). The study shows higher association for age (>47 years) [odds ratio (OR) 4.52], male gender (OR 1.78), shortness of breath (OR 2.02), oxygen saturation 24 (OR 5.31), comorbidities like diabetes (OR 2.70), hypertension (OR 2.12), and coronary artery disease (OR 3.18) toward overall mortality. The significant associations in laboratory variables include lymphopenia (

Objectives: To know the Impact of Mass Media on Knowledge attitude and practices (KAP) amongst the ANC mothers attending the ICTC at DrRPG Medical College, Tanda. Materials and Methods:This was a Hospital based, cross sectional study. The data was collected from pregnant women attending outpatient antenatal care (ANC) with prior written informed consent, from August 2017 to September 2017. A semi structured survey questionnaire was prepared for the study containing 54 questions regarding demographic information, HIV/STD information sources, HIV transmission knowledge, Misconceptions and attitude towards PLHIV. The questionnaire was administered as a face-to-face personal interview, and participant answers were filled in by interviewers. Results:Mass media sources, such as TV programs, newspapers and magazines, were more frequently identified as the channels for HIV information than interpersonal sources, such as friends and service providers. Exposure to multiple sources of HIV information (where at least one source is mass media) was significantly related to HIV knowledge. Yet it is observed that the knowledge of transmission of HIV from mother to child is seen less than other mode of transmission amongst the ANC mothers. It is also seen that though the mothers know that the HIV testing is required but are not aware about the ICTC and its role. Even after so much of communication regarding the misconceptions, some misconceptions still exist among the ANC mothers. Conclusion: Even though mass media have played important role to increase knowledge about HIV, there is need to create a supportive health promotion education mechanism in the form of Health educators at grass root level, who can do intensified social behavioural communication campaigning to bring about the expected behaviour changes by providing correct knowledge about the mother to child transmission of HIV/AIDS, Use of Condom, and to remove the misconception regarding the mode of transmission o

Introduction: Diacerein and oxaceprol are frequently used for the treatment of Grade-I & II osteoarthritis of knees. Diacerein acts by blocking the action of interleukin-1 whereas oxaceprol prevents leukocyte infiltration in the synovial joints. Both the drugs are effective. But there are few comparative studies regarding safety and efficacy of these two drugs. Hence we planned this study. Materials and Methods: An open label randomized comparative study was conducted by the departments of Pharmacology and Orthopedics at Dr RPGMC, Tanda, H.P, after taking permission from the IEC. Patients were diagnosed clinically as per American College of Rheumatology (ACR) guidelines and graded radiologically as Grade I & II osteoarthritis of the knee joint based on Kellgren and Lawrence classification. Then considering exclusion criteria, patients were enrolled after taking written informed consent. 31 and 29 patients were enrolled in diacerein and oxaceprol groups respectively. Tab diacerein 50 mg and oxaceprol 200 mg were prescribed twice daily for three months in respective groups. One patient dropped out in each group, who opted for operative intervention after a few days of enrolment. Efficacy was assessed clinically by WOMAC scale during their follow up at three months. Safety was evaluated clinically considering adverse effects and by complete haemogram & blood biochemistry. Results: In diacerein-group, WOMAC score (mean ± S.D.) improved from 48.77± 18.17 to 29.40 ± 19.94 (p-value = 0.00001) and in oxaceprol group from 42.59 ± 19.49 to 26.58 ± 16.83 (p-value = 0.00001). No adverse effect was reported in any group. Conclusion: Both medicines are almost similar in safety and efficacy. Key words: Diacerein, Oxaceprol, Osteoarthritis of knee.

Aim To estimate the cost‐effectiveness of sequential addition of empagliflozin versus sitagliptin after metformin in patients with type 2 diabetes (T2D) with or without cardiovascular disease (CVD) from the perspective of the US healthcare payer. Methods An individual simulation model predicted lifetime diabetes‐related complications, using UKPDS‐OM2 equations in patients without CVD, and EMPA‐REG OUTCOME equations in patients with CVD. Additional US‐based sources informed inputs for population characteristics, adverse events, non‐CV death, treatment escalation, quality of life and costs. Costs and quality‐adjusted life‐years (QALYs) were discounted 3.0% annually. Results The incremental cost‐effectiveness ratio (ICER) for second‐line empagliflozin versus sitagliptin in the overall T2D population was $6967/QALY. Empagliflozin led to longer CVD‐free survival (0.07 years) and an 11% reduction in CV death in patients with CVD compared with sitagliptin. Empagliflozin resulted in greater benefits with greater costs in patients with versus without baseline CVD, yielding ICERs of $3589/QALY versus $12 577/QALY, respectively. Results were consistent across a range of deterministic and probabilistic sensitivity analyses and scenarios. Conclusion Compared with sitagliptin, empagliflozin was cost‐effective (at $50 000/QALY US threshold) as a second‐line treatment to metformin for T2D patients with or without CVD in the United States. Our findings lend additional support for more widespread adoption of guidelines by healthcare decision‐makers for T2D treatment.

Introduction: The cardio-vascular system being the basis of life along with the respiratory system has always been the centre of attention for researchers. Efforts have been made for ages to prop up the failing heart or to regulate its normal beat & rhythm so that life could be extended. A major source of drugs for the heart is the plant kingdom. With this in mind a saponin from a plant called Albizzia chinensis Merr. was taken up to profile its cardiovascular activities. Materials and Methods: Albichinoside (ALB), the test substance was evaluated for its cardio-vascular activities in dogs, rabbits, rats and frogs. The parameters were its effects on the rate, rhythm and tone of heart, blood pressure and studies on the blood vessels. Results: The test substance produced hypotension, increase in tone & force of contraction of the heart, and dilatation of the blood vessels, without any effect on the heart rate. Conclusions: The compound showed immediate and prolonged hypotension along with cardiotonic effect and vasodilatation. Keywords: Saponin, Cardiovascular system, Animals.

Objectives Spinal cord stimulation (SCS) is an established treatment of chronic neuropathic pain. Although a temporary SCS screening trial is widely used to determine suitability for a permanent implant, its evidence base is limited. The recent TRIAL‐STIM study (a randomized controlled trial at three centers in the United Kingdom) found no evidence that an SCS screening trial strategy provides superior patient outcomes as compared with a no trial approach. As part of the TRIAL‐STIM study, we undertook a nested qualitative study to ascertain patients' preferences in relation to undergoing a screening trial or not. Materials and Methods We interviewed 31 patients sampled from all three centers and both study arms (screening trial/no trial) prior to SCS implantation, and 23 of these patients again following implantation (eight patients were lost to follow‐up). Interviews were undertaken by telephone and audio‐recorded, then transcripts were subject to thematic analysis. In addition, participants were asked to state their overall preference for a one‐stage (no screening trial) versus two‐stage (screening trial) implant procedure on a five‐point Likert scale, before and after implantation. Results Emergent themes favoured the option for a one‐stage SCS procedure. Themes identified include: saving time (off work, in hospital, attending appointments), avoiding the worry about having “loose wires” in the two‐stage procedure, having only one period of recovery, and saving NHS resources. Participants' rated preferences show similar support for a one‐stage procedure without a screening trial. Conclusions Our findings indicate an overwhelming preference among participants for a one‐stage SCS procedure both before and after the implant, regardless of which procedure they had undergone. The qualitative study findings further support the TRIAL‐STIM RCT results.

Introduction Cardiovascular disease (CVD) is the leading cause of mortality among individuals with chronic kidney disease (CKD). Cardiac biomarkers of myocardial distention, injury, and inflammation may signal unique pathways underlying CVD in CKD. In this analysis, we studied the association of baseline levels and changes in 4 traditional and novel cardiac biomarkers with risk of all-cause, CV, and non-CV mortality in a large cohort of patients with CKD. Methods Among 3664 adults with CKD enrolled in the Chronic Renal Insufficiency Cohort Study, we conducted a cohort study to examine the associations of baseline levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), cardiac high-sensitivity troponin T (hsTnT), growth differentiation factor−15 (GDF-15), and soluble ST-2 (sST-2) with risks of all-cause and cardiovascular (CV) mortality. Among a subcohort of 842 participants, we further examined the associations between change in biomarker levels over 2 years with risk of all-cause mortality. We used Cox proportional hazards regression models and adjusted for demographics, kidney function measures, cardiovascular risk factors, and medication use. Results After adjustment, elevated baseline levels of each cardiac biomarker were associated with increased risk of all-cause mortality: NT-proBNP (hazard ratio [HR] = 1.92, 95% confidence interval [CI] = 1.73−2.12); hsTnT (HR = 1.62, 95% CI = 1.48, 1.78]); GDF-15 (HR = 1.61, 95% CI = 1.46−1.78]); and sST-2 (HR = 1.26, CI = 1.16−1.37). Higher baseline levels of all 4 cardiac biomarkers were also associated with increased risk of CV. Declines in NT-proBNP (adjusted HR = 0.55, 95% CI = 0.36−0.86) and sST2 (HR = 0.55, 95% CI = 0.36−0.86]) over 2 years were associated with lower risk of all-cause mortality. Conclusion In a large cohort of CKD participants, elevations of NT-proBNP, hsTnT, GDF-15, and sST-2 were independently associated with greater risks of all-cause and CV mortality., Graphical abstract

Background Chronic upper extremity pain (UEP) has complex etiologies and is often disabling. It has been shown that 10 kHz SCS can provide paresthesia-free and durable pain relief in multiple pain types and improve the quality of life of patients. Objective To gain additional evidence on the safety and effectiveness of 10 kHz SCS for the treatment of chronic UEP. Study design It was a prospective, multicenter, and observational study. The study was registered on ClinicalTrials.gov prospectively (clinical trial identifier: NCT02703818). Setting Multicenter. Patients intervention and main outcomes A total of 43 subjects with chronic UEP of ≥5 cm (on a 0-10 cm visual analog scale; VAS) underwent a trial of 10 kHz SCS, and subjects with ≥40% pain relief received a permanent implant. All subjects had upper limb pain at baseline, while some had concomitant shoulder or neck pain. Subject outcomes were assessed for 12 months, and the primary outcome was the responder rate (percentage of subjects experiencing ≥50% pain relief from baseline) at three months. Results Thirty-eight subjects successfully completed the trial (88.3% success rate), 33 received permanent implants (five withdrew consent), and 32 had device activation (per protocol population). There were no paresthesias or uncomfortable changes in stimulation related to changes in posture during the study and there were no neurological deficits. Responder rates at 12 months for upper limb, shoulder, and neck pain in per protocol population (N=32) were 78.1%, 85.2%, and 75.0%, respectively. At 12 months, 84.4% of subjects were satisfied or very satisfied with 10 kHz SCS, and 38.7% either reduced or eliminated opioid usage. Conclusion This study further supports the effectiveness of 10 kHz SCS for chronic UEP treatment and documents the safety profile of the therapy. Clinical trial identifier NCT02703818.

A case of central hypothyroidism, following controlled-release carbamazepine (CBZ-CR) monotherapy for focal seizure prophylaxis. A 19 years old woman, presented to the neurology department with history of three episodes of sudden onset, abnormal body movements during sleep. Patient was diagnosed as a case of focal seizures with secondary generalization and was prescribed tablet CBZ-CR 300 mg twice a day for seizure prophylaxis. 3 months later patient presented with complaints of facial hair growth and menstrual irregularities. The patient was seizure free and was continuing with the treatment. Blood biochemistry parameters indicated central hypothyroidism. According toWorld Health Organization Uppsala monitoring Centre (WHO-UMC) causality assessment, she was classified as ‘possible’ for carbamazepine-induced central hypothyroidism. Carbamazepine was discontinued. She was switched to tablet levetiracetam 500 mg twice daily, thyroxine 25 microgram once daily and clobazam 10 mg at bedtime. Conclusion: Thyroid function tests should be monitored in patients receiving carbamazepine therapy. Keywords: Carbamazepine, Drug induced hypothyroidism, Focal seizure, Thyroid function tests, Porencephaly.

Hand hygiene is a vital aspect of infection control and as such requires monitoring. The Association for Professionals in Infection Control and Epidemiology Guidelines on Hand Hygiene in Healthcare had been available since 2009 yet the average compliance of such practices among healthcare providers (HCPs) has remained unacceptably low.This study aimed to assess the compliance of hand hygiene practices and strategies for improvement in pediatric unit in a tertiary care hospital, Meerut, Uttar Pradesh.This prospective cross-sectional survey was conducted during November 2016 – Feb 2017. Data was collected during day as well as night duty hours in intensive care unit (ICU) and wards using a self-structured questionnaire. Data obtained was analyzed using descriptive statistics.A total of 114 HCPs participated in this survey of which seventy six percent had good knowledge regarding moments and steps of hand hygiene. Good compliance (> 80%) was seen among faculty and nursing staff during day in ICU and was poor (HCPs at Department of Pediatrics have good knowledge and average compliance to hand hygiene practices. However, there is wide scope for improvement. Infrastructural support can be provided along with clear guidelines and robust training to improve these practices.

Introduction: Type 2 diabetes affects millions of people worldwide and significantly contributes to morbidity and mortality of those affected by it. Current guidelines recommend individualized treatment regimens following first line metformin therapy. Saxagliptin, a dipeptidyl-peptidase 4 inhibitor, provides a secondary mechanism of action to decrease hyperglycemia when used in combination with metformin. In this study we have tried to assess the efficacy of saxagliptin in patients of type 2 DM. Materials and Methods: A total of 35 patients were enrolled who were on metformin monotherapy and with uncontrolled diabetes. Patients were given saxagliptin 2.5 mg once a day. Patients were followed up at 1st, 3rd and 6th month and HbA1c, FPG and 2h-PG estimation was done during the follow up period. Results: The mean age SD in male and female patients was 61.42 yrs 6.99 and 55.93 yrs 5.74 respectively. The mean change in value from baseline at 24 weeks was 10.7%, 16.48% and 21.63% for HbA1c, FPG and 2h-PG respectively and 20% of patient had achieved HbA1c Conclusion: Saxagliptin has shown an improvement in glycemic index (HbA1c, FPG, 2h-PG) during 6 months of treatment in patients of type 2 DM. Keywords: Saxagliptin, Uncontrolled type 2DM, Efficacy.

Background: Antibiotics are most commonly used prophylactically in a surgical set up. Avoidance of infection helps in early wound healing. Various guidelines are available for the use of antibiotics for surgical prophylaxis. Indiscriminate use of wide spectrum, newer antibiotics has lead to the problem of antibiotic resistance. Our aim was to evaluate the gap between the guidelines and the choice of antibiotics in a tertiary care hospital located in the sub Himalayan area. Materials and Methods: Data of all the patients who underwent surgery was analysed. Results: Record sheets of total 746 cases were included in the study. 376 (50.4%) patients were males and 370 (49.6%) were females. Maximum numbers of patients were from age group 36-45 years. Mean age SD of patients was 40.57 17.46. 572 (76.6%) patients stayed in hospital for 2 to 10 days, 138(18.5%) for 11 to 20 days, 24(3.3%) for 21 to 30 days, 6(.8%) for 31 to 40 days and 6 (.8%) for>40 days. 274 (36.6%) patients suffered from Hepatobiliary diseases, appendicitis was in 99 (13.3%), gastro-intestinal diseases in 98 (12.2%), hernias in 93 (12.47%), urinary system diseases in 30 (4.21%), male genital system diseases in 28 (3.75%), breast diseases 27 (3.62%), rectal and peri-anal diseases in 25 (3.35%), spinal diseases 16 (2.12%), brain diseases 14 (1.88%) other diseases in 43 (5.76%). Commonest antibiotic used was cefuroxime. Conclusions: The hepatobiliary disease was the commonest reason to undergo surgery. Keywords: Surgical prophylaxis, Rational use of antibiotics.

In an epidemiological study traumatic injury to the thoracolumbar area constitute of 75% of total back skeletal injuries. Most of these injuries comprises of thoracolumbar segment of the spine (t10 to l2), also high incidence of neurological deficits is associated with thoracolumbar fractures. Numerous classifications were proposed on an anatomical basis to guide the management of TL fractures and define the indications for surgery but none of these classification systems have taken into account the stabilizing effect of para- spinal muscles. The aim of this article is to review the present literature on evidence of management of TL fractures using operative versus conservative techniques. 40 patients with dorsolumbar spine injuries falling into inclusion criteria were managed with conservative and operative intervention between December 2008 to January 2010. 16 patients were treated with operative intervention with short or long segmented fixation & fusion with bone grafts.24 patients were treated non operatively with DLSO brace and kept immobilised for 4-6 weeks. The maximum period of follow up was 18 to 24 months with a minimum period of follow up of 9 to 12 months. At follow up on regular check of neurological status, 50% of operatively treated patients were showing improvement. Patients treated non operatively had no or occasional pain according to pain score. 10 patients had excellent score treated operatively while 12 patients had good score. 8 patients treated non operatively had good to fair score according to grading for neurological improvement by SRS (scoliosis research society). Surgical intervention should be advocated in cases of unstable burst fractures of the dorsolumbar region, irrespective of status of neurological damage, but might be restricted in the patients with incomplete spinal cord injuries.

Supplemental Digital Content is Available in the Text. The TRIAL-STIM randomised controlled trial found no evidence that a spinal cord stimulation screening trial strategy provides superior patient outcomes compared to a no trial screening approach., Spinal cord stimulation (SCS) is an established treatment of chronic neuropathic pain. Although a temporary SCS screening trial is widely used to determine whether a patient should receive permanent SCS implant, its evidence base is limited. We aimed to establish the clinical utility, diagnostic accuracy, and cost-effectiveness of an SCS screening trial. A multicentre single-blind, parallel two-group randomised controlled superiority trial was undertaken at 3 centres in the United Kingdom. Patients were randomised 1:1 to either SCS screening trial strategy (TG) or no trial screening strategy (NTG). Treatment was open label, but outcome assessors were masked. The primary outcome measure was numerical rating scale (NRS) pain at 6-month follow-up. Between June 2017 and September 2018, 105 participants were enrolled and randomised (TG = 54, NTG = 51). Mean numerical rating scale pain decreased from 7.47 at baseline (before SCS implantation) to 4.28 at 6 months in TG and from 7.54 to 4.49 in NTG (mean group difference: 0.2, 95% confidence interval [CI]: −1.2 to 0.9, P = 0.89). We found no difference between TG and NTG in the proportion of pain responders or other secondary outcomes. Spinal cord stimulation screening trial had a sensitivity of 100% (95% CI: 78-100) and specificity of 8% (95% CI: 1-25). The mean incremental cost-effectiveness ratio of TG vs NTG was £78,895 per additional quality-adjusted life-year gained. In conclusion, although the SCS screening trial may have some diagnostic utility, there was no evidence that an SCS screening TG provides superior patient outcomes or is cost-effective compared to a no trial screening approach.

Cardiac scintigraphy has emerged as a key diagnostic test for transthyretin cardiac amyloidosis (ATTR-CA). However, there are potential limitations and pitfalls in the interpretation of cardiac scintigraphy for ATTR-CA that are worth noting. We present here a series of three cases which illustrate some of these important principles.

Purpose: The impact of cardiology fellows (CFs) and interventional cardiology fellows (ICFs) on patient radiation and contrast exposure during diagnostic coronary angiography and percutaneous coronary intervention is unknown. Methods: Between 2011 and 2014, 16,175 cases were retrospectively assessed involving 27 CFs, 22 ICFs and 24 staff as primary operators. Results: During diagnostic coronary angiography, ICFs administered the lowest radiation dose (5,648±5,523 cGy*cm2; 1.30 ± 1.27 mSv)—achieving 22% less radiation than the staff (6,889±4,294 cGy*cm2; 1.58 ± 0.99 mSv) and 36% less than CFs (7,700±6,751 cGy*cm2; 1.77 ± 1.55 mSv) (p

Synovial sarcomas are highly aggressive soft tissue tumour with a poor and dismal prognosis. These tumours have a high propensity for distant metastasis and local recurrence. Although originally believed to arise from synovium, these tumours have been found to occur anywhere in body [1],[2]. We report here, a case of median nerve sarcoma in a 15-year female. This is a rare tumour, which is diagnosed only after histopathological examination with only a few cases reported in the literature (Table 1). Although preoperatively tumour was thought to be a nerve sheath tumour, on histopathology analysis was found to be synovial sarcoma. Despite aggressive behaviour, wide local excision is recommended even in smaller lesions. So, the diagnosis should always be kept in differentials of nerve sheath tumour, as what may be a synovial sarcoma.

Background Glaucoma surgical management has evolved significantly with the introduction of minimally invasive glaucoma surgery. Our aim was to evaluate trends in Canadian glaucoma surgery billing code usage as a surrogate index of the current impact of this new technology in Canada's publicly funded health-care system. Methods Retrospective administrative health records analysis of all patients who underwent a publicly funded glaucoma filtration procedure from January 2003 to December 2016 in the 6 largest Canadian provinces. The frequency of glaucoma-related procedures was adjusted against primary open-angle glaucoma prevalence data. Frequency of all glaucoma filtration procedures with and without implantation of a drainage device in each province per year is reported. Results Nationwide, glaucoma filtration procedures per 1000 primary open-angle glaucoma patients per year remained constant, with increased drainage device implantation over time (P

Introduction. Oncofertility is often omitted in pretreatment discussion and planning. This study seeks to evaluate the prevalence and influencing factors of cryopreservation discussions. Methods. A retrospective review was performed on 3,133 male patients aged 18–60 years with a cancer diagnosis at a single institution. Data was collected for cryopreservation discussion and if cryopreservation of sperm was performed. Age, race, cancer location, primary treatment, and chemotherapy status were also recorded. Results. A total of 2,504 patients were included for analysis. There was documentation of counseling in 14.1% and 5.0% underwent cryopreservation. Logistic regression indicated a significant effect of age, race, site of cancer, primary treatment, and chemotherapy treatment on whether cryopreservation was discussed (χ2 P Conclusion. Our study indicates that cryopreservation is vastly under-discussed, especially in older patients and those who do not receive chemotherapy. It is important to include preservation options and counseling for all patients.

Objectives: To study patients’ knowledge about their prescribed medication and factors affecting it. Patients and Methods: An observational, cross-sectional study was conducted in 500 outpatients in the Medicine department of a tertiary care teaching hospital. The patients were interviewed about prescribed medicines using a structured questionnaire. The average consultation time and average dispensing time was also recorded for 100 interactions each. Results: Among 500 patients interviewed, 55% were females. Hindi was the primary language in 99.6% of the patients and majority of the patients 75.2% could not read English. The mean total score for patients’ medication knowledge was 38.87 ± 10.42 (maximum 60). 95% of participants had ‘Adequate to Good Knowledge’, and 5% had ‘Poor Knowledge’. Only 1.8% of the patients surveyed had complete knowledge of their prescribed medications. Various factors like age > 60 years, female gender, illiteracy, inability to read English, the doctor informing the patient only in writing and the pharmacist not explaining the medication information were associated with lower scores. The average consultation time was 284.6 ± 172.87 seconds and the average dispensing time was 60.45 ± 22.3 seconds. Conclusion: Overall the patients appear to have an adequate basic knowledge of their prescribed medications despite inability to understand the language and less time given for doctor patient pharmacist interaction. Interventions are required to improve health care providers understanding of what is required to educate the patients about the same. This is especially so for patients with risk factors contributing to their low knowledge about prescribed treatment.

The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale. Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets. Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773–0.806, p

Introduction Previously, incisionless plication (IP) for correction of congenital penile curvature (CPC) has been performed after penile degloving via a circumscribing incision. Aim To describe our experience with non-degloving incisionless penile plication (NDIP) for correction of CPC and compare these outcomes with those of men who underwent degloving incisionless penile plication (DIP). Methods We conducted a retrospective review of men ≤ 45 years of age who underwent incisionless penile plication for correction of CPC between 2008 and 2020 at two adult tertiary hospitals. Patients underwent either NDIP, performed through a 2-3 cm longitudinal incision along the proximal-to-mid shaft opposite the point of maximum penile curvature, or DIP via a sub-coronal circumscribing incision. Main Outcome Measures Surgical and patient-reported outcomes were compared between the non-degloving and degloving groups. Results Among the 38 men (mean age, 26 years) who met the inclusion criteria, 25 underwent NDIP, including 6 patients with biplanar curvature (2 Ventral, 4 Dorsal, 6 Lateral). Thirteen patients underwent DIP, including 1 patient with biplanar curvature (1 ventral, 1 lateral). Curvature reduction was 50 ± 23 degrees for the NDIP group and 36 ± 10 degrees for the DIP group (P = .04). Five (20%) patients in the NDIP group and nine (69%) patients in the DIP group experienced a reduction in stretched penile length following plication (SPL) (P = .01). One patient in the NDIP group underwent an additional plication for recurrent curvature. Conclusion Both NDIP and DIP are safe and highly efficacious techniques for the correction of CPC.

Presacral dermoid cysts are rare, benign tumors of developmental origin that primarily affect women. Surgical resection is the mainstay of treatment for these cysts, even if asymptomatic, with the laparoscopic approach being safer and more efficient.

This is a case series of 4 patients who developed leukopenia on, controlled-release carbamazepine (CBZCR) monotherapy for focal seizure prophylaxis. All 4 cases (2 males and 2 females), presented to the neurology department with history of episodes of sudden onset, abnormal body movements. Patients were diagnosed as cases of focal seizures and were prescribed tablet CBZ-CR 300 mg twice a day for seizure prophylaxis. One month later patients presented for follow-up and were continuing with the treatment. Blood biochemistry parameters indicated leukopenia with total leukocyte count less than 4000 per mm3. According to World Health Organization Uppsala monitoring Centre (WHO-UMC) causality assessment, all 4 cases were classified as ‘probable/likely’ for carbamazepine-induced leukopenia. Carbamazepine was continued and total leukocyte count gradually recovered on 3-months follow-up. Conclusion: Total leukocyte count should be documented before initiating carbamazepine therapy. Patients with pre-existing leukopenia should not receive carbamazepine. All patients receiving carbamazepine should be monitored for leukocyte count in addition to other blood biochemistry parameters. Keywords: Carbamazepine,Drug induced leukopenia, Focal-seizure, Total leukocyte count.

Levetiracetam has been associated with aggressive behavior and mania.We are reporting a case of agitation and aggressive behavior following levetiracetam monotherapy for focal seizure prophylaxis. A 48 years old man, who presented to the neurology department with history of four episodes of sudden onset abnormal body movements. Patient was diagnosed with focal seizures with secondary generalization and was prescribed tablet levetiracetam 500 mg twice a day for seizure prophylaxis. Three weeks later patient presented with complaints of excessive sleepiness during daytime, agitation and aggressive behavior, though seizure free. According to World Health Organization Uppsala monitoring Centre (WHO-UMC) causality assessment system the case was classified as probable/likely for levetiracetam-induced altered behavior. Levetiracetam was discontinued, and tablet carbamazepine controlled-release 300 mg twice daily was substituted. Within 2 days of switching therapy the agitation and aggression reduced substantially. Although levetiracetam has fewer side effects than traditional antiepileptic medications, but it is imperative to continuously monitor the patient for infrequent adverse effects also, so that required modifications to drug label may be done. Keywords: Aggression, Agitation, Altered behavior, Levetiracetam.