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Background Multiple sclerosis (MS) is a chronic, demyelinating disease of the central nervous system that results in progressive and irreversible disability. Fatigue is one of the most common MS-related symptoms and is characterized by a persistent lack of energy that impairs daily functioning. The burden of MS-related fatigue is complex and multidimensional, and to our knowledge, no systematic literature review has been conducted on this subject. The purpose of this study was to conduct a systematic literature review on the epidemiology and burden of fatigue in people with multiple sclerosis (pwMS). Methods Systematic searches were conducted in MEDLINE, Embase, and Evidence-Based Medicine Reviews to identify relevant studies of fatigue in pwMS. English-language records published from 2010 to January 2020 that met predefined eligibility criteria were included. We initially selected studies that reported quality of life (QoL) and economic outcomes according to categories of fatigue (e.g., fatigued vs non-fatigued). Studies assessing associations between economic outcomes and fatigue as a continuous measure were later included to supplement the available data. Results The search identified 8147 unique records, 54 of which met the inclusion criteria. Of these, 39 reported epidemiological outcomes, 11 reported QoL, and 9 reported economic outcomes. The supplementary screen for economic studies with fatigue as a continuous measure included an additional 20 records. Fatigue prevalence in pwMS ranged from 36.5 to 78.0%. MS-related fatigue was consistently associated with significantly lower QoL. Results on the economic impact of fatigue were heterogeneous, but most studies reported a significant association between presence or severity of fatigue and employment status, capacity to work, and sick leave. There was a gap in evidence regarding the direct costs of MS-related fatigue and the burden experienced by caregivers of pwMS. Conclusion Fatigue is a prevalent symptom in pwMS and is associated with considerable QoL and economic burden. There are gaps in the evidence related to the direct costs of MS-related fatigue and the burden of fatigue on caregivers. Addressing fatigue over the clinical course of the disease may improve health and economic outcomes for patients with MS.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) claimed over 4 million lives by July 2021 and continues to pose a serious public health threat.ObjectivesOur retrospective study utilized respiratory pathogen panel (RPP) results in patients with SARS-CoV-2 to determine if coinfection (i.e. SARS-CoV-2 positivity with an additional respiratory virus) was associated with more severe presentation and outcomes.MethodsAll patients with negative influenza/respiratory syncytial virus testing who underwent RPP testing within 7 days of a positive SARS-CoV-2 test at a large, academic medical centre in New York were examined. Patients positive for SARS-CoV-2 with a negative RPP were compared with patients positive for SARS-CoV-2 and positive for a virus by RPP in terms of biomarkers, oxygen requirements and severe COVID-19 outcome, as defined by mechanical ventilation or death within 30 days.ResultsOf the 306 SARS-CoV-2-positive patients with RPP testing, 14 (4.6%) were positive for a non-influenza virus (coinfected). Compared with the coinfected group, patients positive for SARS-CoV-2 with a negative RPP had higher inflammatory markers and were significantly more likely to be admitted (P = 0.01). Severe COVID-19 outcome occurred in 111 (36.3%) patients in the SARS-CoV-2-only group and 3 (21.4%) patients in the coinfected group (P = 0.24).ConclusionsPatients infected with SARS-CoV-2 along with a non-influenza respiratory virus had less severe disease on presentation and were more likely to be admitted—but did not have more severe outcomes—than those infected with SARS-CoV-2 alone.

Background. Dry eye disease (DED) is a multifactorial and one of the most common problems treated in an ophthalmic outpatient clinic. Due to the variability in presentation, diagnosis of DED consists of a combination of subjective and objective clinical tests. The purpose of this study was to assess the effectiveness of a handheld smartphone-based infrared thermal (IRT) camera for screening symptomatic evaporative DED. Methods. This observational sex-matched control study assessed IRT images of 184 right eyes (46 normal and 138 DED) of 184 participants. Evaporative DED was assessed using noninvasive tear breakup time, fluorescein staining, and the Chinese version of the ocular surface disease index (C-OSDI) questionnaire and categorized into their respective dry eye symptomology group (none, mild, moderate, or severe). The ocular surface temperature (OST) at 8 anatomical regions of interest (ROI) (nasal conjunctiva, nasal limbus, nasal cornea, central cornea, inferior cornea, temporal limbus, temporal cornea, and temporal conjunctiva) were measured and compared using a handheld smartphone-based IRT camera. The effectiveness of these 8 ROIs OST in detecting varying severity of DED was evaluated in terms of correlations with severity of DED and their area under the curve (AUC). Results. OST at the 8 anatomical ROI was significantly higher in DED participants than in the non-DED group ( p < 0.05 ) except for inferior cornea, temporal limbus, and temporal conjunctival regions (>0.05). Analyzing 8 anatomical ROIs revealed that the nasal limbus had the highest Pearson correlation with the severity of DED (0.64, p < 0.001 ). Additionally, the nasal limbus ROI achieved the highest AUC of 0.79 (CI: 0.73–0.85; p < 0.05 ), sensitivity, and specificity (0.96 and 0.91) when comparing its ability to discriminated DED vs. non-DED eyes. Conclusions. Rather than a diagnostic tool, handheld smartphone-based IRT images can be considered as a rapid, noninvasive, and hygienic screening tool in discriminating DED and non-DED and potentially alleviating inconvenience experienced during conventional tests.

Background. Glenohumeral joint arthrodesis has become a rare entity due to the introduction of shoulder arthroplasty. It is an excellent salvage procedure for patients with severe shoulder dysfunction, with limited treatment options, indicated for brachial plexus injury, tumour resection, chronic infection, failed prosthetic arthroplasty, or pseudoparalysis of the shoulder due to combined rotator cuff and deltoid deficiency. Shoulder arthrodesis relieves the patient of pain and gives a decent amount of function. The aim of this study was to examine the mid-term outcomes of glenohumeral arthrodesis with 2 pelvic recon plates. Methods and methods. This study was done in a tertiary referral centre over a period of about 2 years. All the patients were operated on with 2AO 3.5mm recon plates and screws. Indications for surgery comprised unreconstructable rotator cuff tears, a neoplastic lesion, paralytic disorders, TB shoulder, arthritic disease unsuitable for arthroplasty, and sequelae of septic shoulder. Cancellous grafts were used in all operated patients, while a cortical graft was used in the tumour case to fill the bone defect after tumour excision. A minimum of 18 months was essential for inclusion into the study. Results. 15 patients were included in the study. All the patients had decreased postoperative pain, which further decreased to pain-free status at further follow-up visits. All the arthrodeses produced bony union with average time to union of 5.4 months. All patients could feed and dress themselves with the ipsilateral limb. The only complication noted in this series was a superficial infection in 3 patients only, which subsided after wound wash, debridement and antibiotics for 10 days. Conclusions. 1. With specific indications, shoulder arthrodesis results in a good painless postoperative shoulder function and thus presents an excellent operative option. 2. The position of arthrodesis chosen here ensures that the arm rests comfortably at the side. 3. The patients can move their hands to their mouth and facial regions. 4. Recon plates should be used for arthrodesis because they are easy to shape without compromising on strength. 5. Few complications of procedure are there but it is a great therapeutic measure in selected individuals.

To evaluate the effect of folic acid supplementation on seizure control in folate deficient children receiving long term antiepileptic therapy.In a prospective interventional study, 140 children between age group 6 mo to 180 mo fulfilling the inclusion criteria were enrolled in study group, from October 2015 through November 2016. On the basis of serum folate, study group was divided into two subgroups by non randomization: Group A (10 ng/ml) given folic acid supplementation for 3 mo and Group B (10 ng/ml) was not supplemented. Response to folic acid supplementation in group A was compared with group B in terms of change in blood folate levels, frequency and duration of seizures after three months.Mean age of study group was 73.58 ± 46.89 mo (72.14% boys and 27.85% girls). 67.85% children were in group A and 32.14% in group B. On 3 mo follow up, children supplemented with folic acid (Group A) had significant fall in mean seizure frequency while in non-supplemented children (Group B), no significant change was seen (p value0.05). Similar reduction in duration of seizure episode was seen in group A as compared to group B. Serum and RBC folate levels improved from baseline in group A, while in group B there was significant fall in folate levels.Folate deficiency is common in epileptic children on long term antiepileptic drugs (AEDs), contributes to poor seizure control and should be considered in the etiologic differentials of drug resistant epilepsy. Folate supplementation improves seizure control in these children.

BACKGROUND Before 2011, pegylated interferon plus ribavirin was the standard therapy for chronic hepatitis C. Interferon-free direct-acting antiviral agents were then approved. Although these treatments appear to be more effective, they are substantially more expensive. In anticipation of the need for information regarding the comparative cost-effectiveness of new regimens in a recent therapeutic review, we conducted the analysis to inform listing decision in Canada. METHODS A state-transition model was developed in the form of a cost-utility analysis. Regimens included in the analysis were comprehensive. The cohort under consideration had a mean age of 50 years. The cohort was defined by treatment status and cirrhosis status. Inputs for the model were derived from published sources and validated by clinical experts. RESULTS For each genotype 1 population, at least 1 of the interferon-free agents appeared to be economically attractive compared with pegylated interferon-ribavirin, at a willingness-to-pay of $50 000 per quality-adjusted life-year. The drug that was the most cost-effective varied by population. For genotype 2-4 population, the direct-acting antiviral therapies appeared not to be economically attractive compared with pegylated interferon-ribavirin for the treatment-naive; however, there were direct-acting antiviral therapies that appeared to be attractive when compared with no treatment for the treatment-experienced. INTERPRETATION Public health policy should be informed by consideration of health benefit, social and ethical values, feasibility and cost-effectiveness. Our analysis assists the development of reimbursements and policies for interferon-free direct-acting antiviral agent regimens for chronic hepatitis C infection by informing the last criterion. Considering the rapid development of treatments for chronic hepatitis C, further update and expanded reviews will be necessary.

Dissecting anterior inferior cerebellar artery (AICA) aneurysms are extremely rare, and only nine cases are reported till date. We are reporting a case of ruptured dissecting distal AICA aneurysm with spontaneous resolution; first of its kind in the indexed literature.

Aim: To assess the cost-effectiveness in Canada of atezolizumab compared with docetaxel or nivolumab for the treatment of advanced NSCLC after first-line platinum-doublet chemotherapy. Materials and methods: A three-state partitioned-survival model was developed. Clinical inputs were obtained from the phase III OAK trial comparing atezolizumab with docetaxel in patients with advanced NSCLC who progressed after first-line platinum-doublet chemotherapy. Overall survival (OS) and progression-free survival (PFS) were extrapolated beyond the trial period using parametric models. A cure model assuming a 1% cure fraction was fitted to the OS data for atezolizumab. Outcomes for nivolumab were informed by a network meta-analysis (NMA) versus atezolizumab. Resource use and costs were informed by clinical expert opinion and published Canadian sources. Utility values were obtained from the OAK trial. The perspective of the analysis was that of the Canadian publicly-funded health care system. The base case time horizon was 10 years, and the discount rate was 1.5% annually for both costs and effects. Scenario analyses were performed to test the robustness of the results and all analyses were performed probabilistically. Results: Atezolizumab demonstrated a quality-adjusted life-year (QALY) gain of 0.60 compared with docetaxel at an incremental cost of $85,073, resulting in an incremental cost-effectiveness ratio (ICER) of $142,074/QALY. Atezolizumab dominated nivolumab (regardless of dosing regimen), based on modest differences in both QALYs and costs. Docetaxel was most likely to be cost effective at willingness-to-pay (WTP) thresholds below $125,000/QALY gained, while atezolizumab was most likely to be cost effective beyond this WTP threshold. In most scenario analyses, the results remained robust to changes in parameters. A reduced time horizon and alternative approaches to the NMA had the greatest impact on cost-effectiveness results. Conclusion: Atezolizumab represents a cost-effective therapeutic option in Canada for the treatment of patients with advanced NSCLC who progress after first-line platinum doublet chemotherapy.

An emergency presentation of a paraoesophageal hernia with acute respiratory distress and an acute abdomen is a rare presentation. Hereby, we are presenting a 73year old female who presented with an acute dyspnoea and acute bowel obstruction, the imaging revealed large paraoesophageal hernia almost collapsing the right lung, she had an emergency surgery, an anterior gastropexy was performed since she was unstable. Despite subsequent surgeries e.g Collis gastroplasty and mesh cruroplasty, patient developed recurrent hiatal hernia. Unfortunately, the patient ultimately passed away from a vancomycin resistant enterococci (VRE) bacteraemia and due to overwhelming medical comorbidities. As presentation of paraoesophageal hernia with acute dyspnea and acute abdomen is a rare incidence, we discuss this and its management options through a case report.

Background: Trauma is emerging as an epidemic and a leading cause of morbidity and mortality in children. Children

Bilateral thalamic infarction is rarely seen in cases with artery of Percheron embolization. Artery of Percheron is a rare variant of arterial supply to both thalamus and midbrain. Occlusion of this artery following trauma and causing bilateral thalamic infarction is rare and very few cases are reported in world literature.

Introduction: Sexually Transmitted Infections (STIs) and Reproductive Tract Infections (RTIs) have been a major public health problem in all the developing countries. STDs and their complications are amongst the top five disease categories for which adults seek health care. The health-seeking behaviour among the general population in India shows that for STI/RTI treatment people prefer non-modern medicine private practitioners. Aims and objectives: 1) To determine awareness and opinion regarding syndromic approach towards STI / RTI case management among the practitioners in private sector. 2) To compare the results with the previous large scale studies and to provide suitable recommendations. Material and methods: This cross sectional study was carried out in urban Patiala in 2012-13 among 100 randomly selected private practioners by personal visiting and getting responses to a set questionnaire. Group A constitutes allopathic and group B constitutes non allopathic practioners. Results and observations: 60% in Group A and 38% in Group B admit to be aware of syndromic approach but only 16 in Group A and 4 in Group B had correctly replied about no. of kits available in syndromic approach. 70% in both the groups were of the opinion that it will generate better follow up while 35-40% believe there is a risk of over treatment with this approach. Discussion: Since, practice of syndromic case management of STIs is presumed to be dependent on the practioners individual opinion and attitude hence it is beneficial to know about their opinion. To raise the rates of treatment as per WHO advised strategy of Syndromic management, confidence building and appropriate knowledge to the health care providers is a must. Conclusion: Apparent need is there for regular educational activities for licensed private practioners as short trainings, CME, seminars on standard treatment protocols.

An increasing number of patients with previous minimally invasive thoracic procedures for anterior mediastinal tumors are now requiring cardiac surgery. This paper highlights the potential damage that can occur when standard sternal splitting techniques are used in these patients.

Background: Wrists injuries are one of the common presentations to emergency departments and orthopaedic clinics. The scaphoid bone is the most commonly injured of the carpal bones accounting for 50-80% of carpal injuries and predominantly occurs in young healthy individuals. Scaphoid fractures are the most problematic to diagnose in a clinical setting because it can take up to 6 weeks for scaphoid fractures to become conclusive on plain X-ray films. Aim of the study was to retrospective study was carried out to study the role of early CT scan in diagnosis of occult scaphoid fractures.Methods: A total of 123 patients presented with an acute wrist injury with subsequent signs of scaphoid injury in the absence of a diagnostic fracture on plain X-ray within the time period from June 2014 to May 2016 in a tertiary care centre.Results: This study shows that 31% of normal X-rays were pathological on CT scan and out of these; scaphoid fractures (74% of pathologies) represent a large number of patients with fractures that were missed by initial plain films.Conclusions: This study shows an extremely high false-negative rate for plain X-rays and advocate CT at the first attendance to fracture clinic if there is suspicion of scaphoid injury. An earlier diagnosis leads to appropriate management and reduces restrictions to the patient in terms of prolonged immobilization and repeated clinical reviews.

Background: Microalbuminuria is not only a predictor of subsequent kidney disease, but also an indicator of generalised endothelial injury and a manifestation of endothelial dysfunction. The present study is aimed to determine the prevalence of microalbuminuria among non–diabetic ischaemic stroke patients and find its correlation with ischaemic stroke which eventually will aid us in coming up with potent strategies to provide better prevention and cure.Methods: The present study was conducted in Department of Medicine in collaboration with Department of Biochemistry and Department of Radiology, Guru Nanak Dev Hospital, Amritsar, Punjab, India after taking approval from institutional thesis and ethical committee. The study included 60 patients (30 Cases + 30 Controls) in age group 20-80 years diagnosed as stroke and haemorrhage ruled out by NCCT Brain/MRI Brain at admission. Cases were patients with history of hypertension with acute ischaemic stroke. Controls were age and sex matched patients with no history of hypertension with acute ischaemic stroke. The microalbuminuria was assayed by immunoturbimetry. The stroke severity was assessed by NIH Stroke Severity scale. P value less than 0.05 was considered the level of significance.Results: The overall prevalence of microalbuminuria in acute ischaemic stroke patients was 41.67%. When comparing NIH SS (National Institutes of Health Stroke Scale) score with the levels of albumin in urine, there was a significant positive correlation with urinary albumin levels and stroke severity in the patients having urinary albumin levels in microalbuminuria range both in Case group and Control group with P value less than 0.05.Conclusions: Urine albumin excretion had a positive correlation with the NIH SS Score of the patient in acute ischemic stroke. Those with a higher NIH SS Score had a higher rate of urine albumin excretion and vice versa. Therefore, measurement of microalbuminuria may help to assess those who are at increased risk of severe stroke and may require a more aggressive management.

Low grade fibromyxoid sarcoma (LGFMS) is a rare soft tissue tumor, having metastatic potential and high local recurrence rate despite its low grade histologic findings. This tumor of deep and subcutaneous soft tissues occurs in 3rd and 5th decade of life. Diagnosis of LGFMS remains problematic because of its bland looking histologic features that can be potentially confused with other benign or low grade soft tissue tumors. We report here a rare case report of low grade fibromyxoid sarcoma of anterior abdominal wall.