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Background Coma is one of the frequently encountered clinical conditions in any intensive care unit (ICU), which is responsible for considerable morbidity and mortality. Therefore, this study was designed to look at the clinical and EEG profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG). Methods In all 102 patients of unresponsive coma (GCS ≤ 8), who remained in poor sensorium despite 48 h of optimum treatment in ICU, were included in the study. All patients underwent 1 h of electroencephalography (EEG) monitoring with a portable EEG machine. All EEGs were screened according to Salzburg Consensus Criteria (SCC) for Nonconvulsive Status Epilepticus (NCSE). Patients with evidence of NCSE were administered parenteral Antiepileptic Drugs (AED). A repeat EEG was done after 24 h of baseline to ascertain the effect of AED. The primary outcome was the recognition of patients with NCSE on the basis of established EEG criteria. The secondary outcome measure was the Glasgow outcome scale (GOS) at the time of discharge. Results Out of 102 cases enrolled, 12 (11.8%) cases were detected to have NCSE on portable EEG. The mean age of patients with NCSE was 52.2 years. In terms of gender distribution, 2/12 (17%) were female, and 10/12 (83%) were male (M: F = 5:1). Median GCS was 6 (range 3–8). Looking at CNS infections, 4/12 (33.3%) had evidence of some form of CNS infection in the NCSE group, compared to 16/90 (18%) in the group without NCSE. This difference was statistically significant (P-value 2 points) after administration of AED’ was noted with good clinical outcomes (GOS 5). In five of these 12 cases, death was the final outcome (GOS 1). Conclusions NSCE should be considered in the differential diagnosis of all unresponsive comatose ICU patients. In resource-limited settings, where continuous EEG monitoring may not be feasible, bedside portable EEG testing can be used to diagnose patients with NCSE. Treating NCSE reverses epileptiform EEG changes and improves clinical outcomes in a subset of comatose ICU patients.

World Health Organization (WHO) recommends the use of first-line anti-tuberculosis drugs, that is, rifampicin (RIF) and isoniazid (INH) fixed-dose combination (FDC) therapies in tuberculosis (TB) d...

We describe a case with complex Descemet membrane detachment (DMD) which persisted despite initial two failed surgical attempts to appose the ocular tissues. However, over time, tissue alignment was obtained spontaneously. A 60-year-old woman, operated trabeculectomy, had a total DMD intraoperatively during a complicated cataract surgery. Initial attempt to DM repositioning with intracameral air injection failed. Anterior Segment Optical Coherence Tomography (ASOCT) showed detachment of both DM and pre-Descemet’s layer (PDL). After consultation with a corneal surgeon, patient was again attempted for Intra-operative Optical Coherence Tomography (iOCT)-guided settlement of DMD with intracameral air which again failed. So, the patient was registered for lamellar corneal transplant, but at 3 months follow-up, DM had spontaneously attached, confirmed on ASOCT. This case shows for the first time that even complex DMDs involving PDL, can spontaneously appose despite failed surgical interventions.

Postoperative astigmatism is one of the common complications affecting visual outcomes after a penetrating keratoplasty. It can result from various factors related to host, donor and surgical technique, resulting in suboptimal visual outcome. While some of the measures taken during preoperative planning and during actual surgery can reduce the magnitude of postoperative astigmatism, postoperative correction of astigmatism is often required in cases with high degrees of astigmatism. When spectacles and contact lenses fail to provide optimal visual outcomes, various surgical techniques that include astigmatic keratotomy, compression sutures, toric intraocular lens placement, and laser refractive procedures can be considered. When none of these techniques are able to achieve a desired result with in the acceptable optical range, a repeat keratoplasty is considered a last option. We discuss the various causes and management of complication of postoperative astigmatism occurring after a full thickness corneal transplantation surgery.

Introduction Retrograde transvenous obliteration (RTO) with the assistance of a balloon (BRTO) or a vascular plug (PARTO) is an established method for treating gastric varices (GVs) secondary to portal hypertension. Most of the available studies on RTO have used lipiodol along with sclerosing agents like ethanolamine oleate or sodium tetradecyl sulfate (STS). We evaluated the safety and efficacy of RTO for treating GVs using STS as a sclerosant without lipiodol. Materials and Methods Sixteen patients (nine men, age range 16–74 years) were included in this retrospective study. Twelve patients presented with acute bleeding, two with chronic bleeding, one with large varices without bleeding, and one with refractory hepatic encephalopathy (HE). BRTO was attempted in 14 patients and PARTO in 2 patients. The technical and clinical success and complications of RTO were studied. Results The RTO procedure was technically successful in 14 (14/16, 87.5%) patients, with 13 (13/14, 93%) obtaining clinical success. One patient died due to the early recurrence of bleeding. Three patients had minor intraprocedural complications. Conclusion Retrograde gastric variceal obliteration using STS is safe and technically feasible with high technical and clinical success and low complication rate.

Endoscopic procedures are the front-runner of the management of bleeding duodenal ulcer. Rarely, surgical intervention is sought for acute bleeding, not amenable to endoscopic procedures. Oversewing of the gastroduodenal artery at ulcer crater by transduodenal approach is the most acceptable and recommended method of treatment. We describe a case of an intraoperative duodenal injury that occurred during an attempt to oversew the gastroduodenal artery after a duodenotomy, leading to an unsatisfactory and meagre duodenal stump. This case will highlight the intraoperative turmoil, postoperative complications and management of a series of anticipated but unfortunate events that have rendered us wiser in terms of surgical management of a bleeding duodenal ulcer.

The central nervous system (CNS) tumors constitute the most common type of solid tumors in the pediatric population. The cerebral and cerebellar parenchyma are the most common site of pediatric CNS neoplasms. Imaging plays an important role in detection, characterization, staging and prognostication of brain tumors. The focus of the current article is pediatric brain tumor imaging with emphasis on pearls and pitfalls of conventional and advanced imaging in various pediatric brain tumor subtypes. The article also elucidates changes in brain tumor terms and entities as applicable to pediatric patients, updated as per World Health Organization (WHO) 2016 classification of primary CNS tumors. This classification introduced the genetic and/or molecular information of primary CNS neoplasms as part of comprehensive tumor pathology report in the routine clinical workflow. The concepts from 2016 classification have been further refined based on current research, by the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy (cIMPACT-NOW) group and published in the form of updates. The updates serve as guidelines in the time interval between WHO updates and expect to be broadly adopted in the subsequent WHO classification. The current review covers most pediatric brain tumors except pituitary tumors, meningeal origin tumors, nerve sheath tumors and CNS lymphoma/leukemia.

In ophthalmology residency programs surgical training plays a vital role in creating confident and skillful surgeons. As almost all ophthalmic surgery needs microscope training, creating a well-taught environment for hand-eye coordination, ocular tissue handling, and anticipation of complications is essential. Wet lab training with animal or cadaver human eyes offers diverse possibilities. We conducted a thorough literature search on various databases to identify the existing literature on wet labs. The results revealed constructive efforts for training novice surgeons in all surgical ophthalmology subspecialties. Wet lab models were initially used only to practice cataract surgery; however, now various complex ocular procedures can be practiced. Ocular surface, corneal, iris, lenticular, scleral, vitreoretinal, extraocular, eyelid, and other adnexal surgeries were reproduced and mastered in many ways. Importantly, with repeated surgical practice, residents gained an increasing level of confidence with enhanced surgical accuracy. In addition, we propose a few novel techniques of various other procedures.

Background: Rickets is a disorder of defective mineralization due to deficiency of calcium and vitamin D and is more prevalent amongst the developing nations. Rickets has been ranked amongst the five most prevalent diseases in children of developing countries. The diagnosis of rickets is based on clinical features, biochemical studies and radiological signs and confirmed by response to treatment. Aims and Objectives: The purpose of this study is to evaluate the clinical, radiological and biochemical markers of the rickets by measuring the markers at the time of presentation, at 6 weekly intervals and after completion of treatment with standard regimen for rickets. Materials and Methods: 101 cases of nutritional rickets in age group 6 month to 18 years were allocated to receive combination therapy of calcium and vitamin-D according to their age and weight during a study period of 24 weeks. Radiographs (wrist and knee) and biochemical parameters (serum calcium, inorganic phosphate, alkaline phosphatase [ALP], and Vitamin-D), as well as clinical features, were evaluated at presentation, 6, 12, 18, and 24 weeks and response of treatment and markers were assessed at subsequent interval. clinical, radiological, biochemical parameters were evaluated statistically with Chi-square test for qualitative and 2 or more different variables by ANOVAs respectively. A P

Primary intracranial malignant peripheral nerve sheath tumors (MPNSTs) not associated with cranial nerves are rare and aggressive neoplasms. The rarity of presentation has precluded rigorous analysis of diagnosis, risk factors, treatment, and survival. We analyzed every reported case through exhaustive literature review. In addition, we present our own experience managed with resection, radiotherapy, and first use of targeted therapy in a tumor of this type for a BRAF mutation identified during next-generation sequencing.Two databases, PubMed and Embase, and crossed references were queried for intracranial MPNSTs not associated with a cranial nerve. Extracted variables included demographics, risk factors, tumor characteristics, interventions, and outcomes. Univariate and multivariate analysis was performed to identify factors with survival benefit.A total of 56 patients (including the present case) were included from 743 literature results. There was a male/female ratio of 1.5:1 and mean diagnosis age of 29.7 ± 21.8 years. Seventy-one percent of cases were sporadic and 23% neurofibromatosis type 1 related. Median survival was 29 ± 22.1 months with 1-year survival of 60%. Factors associated on univariate analysis with reduced survival were subtotal resection (P = 0.05), older age (P = 0.023), triton histology (P0.001), and early recurrence (≤6 months) (P = 0.018). On multivariate analysis, gross total resection reduced mortality risk (P = 0.011), whereas triton histology (P = 0.017) and infratentorial tumor location (P = 0.037) increased mortality.We present a systematic review of intracranial MPNSTs not associated with a cranial nerve. These tumors have poor prognosis and benefit from aggressive resection, multimodal treatment, and close follow-up. Next-generation sequencing can show molecular alterations for potential targeted therapy.

The obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) syndrome, a rare Mullerian duct anomaly, is a triad of uterine anomalies with ipsilateral renal agenesis and obstructed hemivagina. The aetiopathogenesis of this developmental anomaly is debatable, with several theories being postulated to explain its occurrence. We report two cases of this rare syndrome which were detected on imaging done for unrelated reasons. Case 1 is a 24-year-old woman who presented with primary infertility. After an incidental detection of the syndrome and ruling out a male factor, she has been planned for excision of the vaginal septum. Case 2 is a 47-year-old woman with OHVIRA detected during the evaluation of urolithiasis and is asymptomatic for the syndrome. The OHVIRA syndrome can be asymptomatic or may present as haematocolpos, pelvic pain and infertility which requires surgical intervention, after which successful pregnancies have been reported.

BACKGROUND: Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS: We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS: Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS: Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).

Improving investments in primary health care has become a mounting priority in the context of Universal Health Coverage and India’s National Health Policy 2017 goal to provide cost-effective care. The paper uses the India National Health Accounts, health care providers and health care functions classifications, to allocate current health expenditures (CHE) to primary, secondary and tertiary (PST) care and analyse the trends and composition of PST expenditures between 2013–2014 and 2016–2017. Findings reveal that 45.2% of CHE was spent on primary care in 2016–2017. The government spends 52% of its CHE for primary care. Private spending on primary care has declined from 44% to 41% during the study period. Disaggregate analysis shows that 41% of primary care expenditures were on medicines, 29% on curative care and 15% on preventive care services. About 32% of primary care expenditures were spent at government facilities/providers as compared to 10% at private facilities/doctors. Private sector share of secondary care (38%) and tertiary care (75%) reinforces the role of private sector in providing secondary and tertiary care services. In cognisance of national and international goals, an additional investment of 0.7% of gross domestic product or additional US$11 (₹754) per capita would be required in primary care.

Risk of metastatic disease in the cluster 2-related pheochromocytoma/paraganglioma (PPGL) is low. In MEN2 patients, identification of origin of metastases from pheochromocytoma (PCC) or medullary thyroid carcinoma (MTC) is challenging as both are of neuroendocrine origin. We aim to describe our experience and perform a systematic review to assess prevalence, demographics, biochemistry, diagnostic evaluation, management, and predictors of cluster 2-related metastatic PPGL. Retrospective analysis of 3 cases from our cohort and 43 cases from world literature was done. For calculation of prevalence, all reported patients (n = 3063) of cluster 2 were included. We found that the risk of metastasis in cluster 2-related PPGL was 2.6% (2% in RET, 5% in NF1, 4.8% in TMEM127 and 16.7% in MAX variation). In metastatic PCC in MEN2, median age was 39 years, bilateral tumors were present in 71% and median tumor size was 9.7 cm (range 4–19) with 43.5% mortality. All patients had a primary tumor size ≥4 cm. Origin of primary tumor was diagnosed by histopathology of metastatic lesion in 11 (57.9%), 131I-MIBG scan in 6 (31.6%), and selective venous sampling and CT in 1 (5.3%) patient each. In subgroup of neurofibromatosis 1 (NF1), median age was 46 years (range 14–59) with median tumor size 6 cm and 57% mortality. To conclude, the risk of metastatic disease in cluster 2-related PPGL is low, being especially high in tumors with size ≥4 cm and associated with high mortality. One-third patients of NF1 with metastatic PPGL had presented in second decade of life. Long-term studies are needed to formulate management recommendations.

Macromolecular therapeutics of biological origin, also known as biologics, have become one of the fastest-growing classes of drugs for management of a range of chronic and acute conditions. The majority of approved biologics are administered via the parenteral route and are thus expensive, have low patient compliance, and have high systemic toxicity. Therefore, tremendous efforts have been devoted to the development of carriers for oral delivery of biologics. This review evaluates key chemical (e.g. pH and enzymes) and physiological challenges to oral biologics delivery. We review the conventional formulation strategies and their limitations, followed by a detailed account of the progress on the use of nanocarriers used for oral biologics delivery, covering organic and inorganic nanocarriers. Lastly, we discuss limitations and opportunities presented by these emerging nanomaterials in oral biologics delivery.

The data on the congenital hyperinsulinism (CHI) in Asian Indian patients is limited. Diazoxide is often unavailable in India, which poses challenge in managing CHI. The study was aimed to present our experience with CHI with a special focus on the effectiveness and cost-effectiveness of octreotide long-acting release (OCT-LAR) among diazoxide-responsive CHI. The data of 14 index cases with CHI registered at our center were retrospectively analyzed. The diagnosis of CHI was based on elevated serum insulin (3.4–32.5 μIU/ml) and C-peptide (0.58–1.98 ng/ml) at the time of symptomatic hypoglycemia (BG≤41 mg/dl). Fourteen patients (13 males) presented at a median (range) age of 3 (1–270) days, seizures being the most common mode of presentation (78.6%). Ten patients were diazoxide-responsive, two were partially responsive, while two were unresponsive. Genetics was available for eight patients; ABCC8 (n=3, 1 novel) and HADH (n=2, both novel) were the most commonly mutated genes. OCT-LAR was offered to eight patients including four with diazoxide-responsive disease and was universally effective. We propose a cost-effective approach to use OCT-LAR in the management of CHI, which may also make it more cost-effective than diazoxide for diazoxide-responsive disease. Five of the 11 (45.5%) patients had evidence of neurological impairment; notably, two patients with HADH mutations had intellectual disability despite diazoxide-responsiveness. We report three novel mutations in CHI-associated genes. We demonstrate the effectiveness of and propose a cost-effective approach to use OCT-LAR in diazoxide-responsive CHI. Mutations in HADH may be associated with abnormal neurodevelopmental outcomes despite diazoxide-responsiveness.

Background The aim of this meta-analysis is to investigate the effectiveness of intravenous magnesium (IV Mg2+) in rate and rhythm control of rapid atrial fibrillation (AF) when administered in addition to standard-of-care for non-post-operative patients. Previous meta-analyses on this topic have demonstrated the efficacy of IV Mg2+ in achieving rate control, but not rhythm control. Methods Six randomized controlled trials comparing IV Mg2+ to placebo in the treatment of rapid AF were obtained from electronic databases totaling 745 patients. Outcomes were analyzed using a Mantel-Haenszel random-effects model and expressed as odds ratios (OR) for dichotomous outcomes with their 95% confidence intervals (CIs). Results Our pooled analysis showed that IV Mg2+ given in addition to standard-of-care was superior in achieving rate control (63% vs 40%; OR 2.49, 95% CI 1.80–3.45) and rhythm conversion to sinus (21% vs. 14%, OR 1.75, 95% CI 1.08–2.84) compared to standard-of-care alone. Flushing was more frequently observed in patients receiving IV Mg2+ compared to placebo (9% vs. 0.4%, OR 19.79, 95% CI 4.30–91.21). Subgroup analysis showed the superiority of a lower dose of IV Mg2+, which we designated as 5 g or lower (24% vs 13%, OR 2.10, 95% CI 1.22–3.61) compared to the higher dose (>5 g) (16% vs 13%, OR 1.23, 95% CI 0.65–2.32) in rhythm control when compared to placebo. Conclusions IV Mg2+ administered in conjunction with standard-of-care is effective for rate control and modestly effective for restoration of sinus rhythm in rapid AF without clinically significant adverse effects.

Background: Catheter ablation can be curative in patients with drug-refractory tachyarrhythmias. 3D electro anatomical mapping (EAM) is an established tool facilitating catheter ablation. This system is particularly valuable for mapping complex arrhythmias, which provide excellent assistance to catheter navigation, reduces fluoroscopy exposure, and also allow for the accurate placement of catheters. The Rhythmia Mapping System (RMS, Boston Scientific) is a novel system that allows for ultra-fast, high-density 3D mapping. Aim of this Study: The aim of this study was to find out the result of a high-density 3D mapping for the ablation of complex Cardiac Arrhythmias and to share our experiences. Methods: A total number of 44 patients of different tachyarrhythmias were scheduled for catheter ablation by Rhythmia Mapping System in National Institute of Cardiovascular Diseases, Bangladesh from 3rd February’2018 to 18th July’2019. During and after, the procedure all the cases were evaluated for different procedure parameters, acute success and in-hospital success. Results: Among the patients (28/44 male) 13 (25.55%) cases were atrial fibrillation, 6 (16.64%) cases were atrial flutter, 6 (16.64%) cases were atrial tachycardia, 2 (4.55%) cases were ventricular tachycardia, 11 (25%) cases were PVC and 6 (16.64%) cases were accessory pathway. The mean age was 38±4.5 years. In 25 (56.82%) of tachyarrhythmia patients, the mechanism was macro reentry/micro reentry, while in 19 (43.18%) cases the mechanism was increased automaticity. In all cases, the tachycardias were adequately mapped & proper identification of focus was done during the index procedure with the ultra-high density 3-D Rhythmia Mapping System (RMS). These all were successfully terminated by radiofrequency ablation, except one, which was one of the two cases of Ventricular tachycardia. With this system our study samples had a success rate of 98% with arrhythmia elimination. In patients of atrial fibrillation, all 4 pulmonary veins isolation were done. The mean mapping time was 28.6 ± 17 minutes, and the mean radiofrequency ablation time to arrhythmia termination was 3.2± 2.6 minutes. During our study only two out of 44 patients developed complications. One of the patients with atrial fibrillation developed cardiac tamponade and the other patient with PVC originating from Aortic cusp developed ischemic stroke. Fortunately, they were both managed accordingly. During hospital discharge, all the patients were free of tachyarrhythmia and were in sinus rhythm. Conclusions: This new automated ultrahigh-resolution mapping system allows accurate diagnosis of tachyarrhythmia circuits. Ablation of the focus resulted in high acute success. Bangladesh Heart Journal 2021; 36(2): 98-104

Pharmacological therapy is mostly employed in the management of supraventricular tachyarrhythmias in different part of the world including Bangladesh. However, Radiofrequency catheter ablation has been found to be highly effective and safe in the treatment of such tachyarrhythmias. Objective: The current study is aimed at sharing our experiences of 842 patients who presented with Supraventricular tachycardias and were diagnosed by EPS and treated with Radiofrequency catheter ablation. Methods: This descriptive study has been carried out in the cardiac electro physiology Department of NICVD, Dhaka, Bangladesh from 2nd January 2015 to 31st December, 2020. Electrophysiology study(EPS) was carried out to identity and diagnose the mechanism of different SVTs in 842 consecutive patients. RF catheter ablation was used to interrupt the tachycardia circuit. Results: Out of a total 842 patients who underwent Electrophysiology study, 435 were found to have atrioventricular nodal re-entry tachycardia (AVNRT) as underlying mechanism and 391 were having accessory pathway responsible for the reentry mechanism; of these accessory mediated tachycardia, 250 patients were manifested accessory pathway (WPWS); 141 were concealed accessory pathway (out of them 365 were presented with orthodromic and 26 as antidromic reciprocating tachycardia); moreover among the accessory pathway 231 patients were found having left sided accessory pathway whereas 155 having right sided pathway; 12 patients were having focal atrial tachycardia and 4 were found atrial flutter as the underlying cause for SVT. Radiofrequency catheter ablation was used with an overall success rate of 95%, recurrence rate of 2% without any significant complication. Complication: One patient developed pulmonary thrombo-embolism, 6 patients developed DVT of right lower limb, 4 patients developed complete heart block. Conclusion: RF catheter ablation is safe and highly effective mode of treatment of different types of supraventricular tachyarrhythmias which is emerging and becoming popular in our country. Bangladesh Heart Journal 2021; 36(2): 68-73

Background: The risk of coronary artery disease in women after menopause sharply rises in contrast to that of women before menopause because of hormonal protection against atherosclerosis. No research work has been done so far to see the angiographic pattern and severity of coronary artery disease in premenopausal women and their comparison with those of postmenopausal women. This study will help understand the pattern and severity of CAD both in premenopausal and postmenopausal women. Methods: This cross sectional analytical study was conducted over 100 ACS female patients who were purposively selected and agreed to do coronary angiogram during index hospital admission. Among them 50 patients were premenopausal status with CAD constituted study group I and another 50 postmenopausal women with CAD constituted study group II. The main objective of the study was to compare the angiographic severity of coronary artery disease between premenopausal and postmenopausal women with acute coronary syndrome. Angiographic severity of CAD was assessed by vessel score, Gensini score and Friesinger score. Results: LAD was the common artery involved (76% vs. 56%) followed by RCA (72% vs. 36%) and LCX (62% vs. 30%) in group-II compared to group-I and involvement of individual coronary artery was statistically significant (P values were 0.03, 0.003 and 0.001 respectively). Critical stenosis (70-99%) involving the all three major epicardial vessels (LAD, LCX and RCA) were found most frequently in group-II and the percentage of lesions were 56% vs. 30%; 56% vs. 22% and 54% vs. 22% respectively (p< 0.05). The vessel score of the study patients revealed that singe vessel involvement was significantly higher in group-I (52% vs. 24%) (p=0.003) and triple vessel involvement was found significantly higher in group-II (40% vs. 12%) (p=0.001). Severity assessment by Friesinger score showed normal (0) and low (1-4) Friesinger score significantly higher in group-I patients (P=0.04 and P=0.007 respectively) and high Friesinger score (11-15) was found significantly higher in patients in group II (p=0.001). Severity assessment by Gensini score of the study patients revealed significantly higher mild Gensini score in group-I patients (P=0.002) and severe Gensini score in group II patients (p=0.002). Conclusion: Coronary artery disease is one of the major important problems not only in postmenopausal women but in premenopausal women also. Postmenopausal women suffer from more triple vessels involvement, more diffuse and severe disease. This study results point out that premenopausal women suffer from less severe coronary artery disease and there is a trend to involve mid LAD more frequently in comparison to other two major coronary arteries and LM coronary artery in comparison to postmenopausal women. Bangladesh Heart Journal 2021; 36(2): 113-123

The incidence of bariatric surgery is increasing due to obesity being one of our top public health challenges. As such, bariatric-related ophthalmic changes are a potentially new clinical area of knowledge, with increasing published evidence on post-bariatric complications experienced by patients and identified by clinicians. We reviewed the available literature and summarised the different complications and potential recommendations. A search strategy was conducted with PubMed, Cochrane, Medline, Embase, Allied and Complementary Medicine and DH-DATA databases to look for papers answering our research question: "What are the ophthalmological complications for patients after bariatric surgery?". Our search gave a total of 59 relevant papers. Bariatric surgery, particularly subtypes that cause direct bypass of nutrients from the stomach, lead to nutritional deficiencies. Vitamin A, crucial for proper functioning of body systems and specialised cells, manifests ophthalmologically as corneal ulceration, nyctalopia, conjunctival xerosis and more. Thiamine levels are also depleted, leading to Wernicke's Encephalopathy. Pre-existing diabetic retinopathy is also noted to worsen sub acutely, although evidence is conflicting. Patients undergoing surgery to treat idiopathic intracranial hypertension would have reduced IOP and resolving papilloedema. Other comorbidities of obesity like HB摘要: 肥胖是我们最大的公共卫生挑战之一, 减肥手术的实施率正在增加。随着关于减肥后并发症报道越来越多, 且这些都是由患者亲身经历或者经临床医生确认的, 因此与肥胖相关的眼部变化是一个潜在的新的临床知识领域。我们回顾了现有的文献, 总结了不同的并发症和潜在的建议。我们通过PubMed、Cochrane、Medline、Embase、联合和补充医学以及DH-DATA数据库进行了搜索, 以寻找能够回答我们关于““减肥手术后患者的眼科并发症是什么? ”问题的论文。我们共搜索到59篇相关论文。减肥手术, 特别是导致直接从胃中摄取营养的亚型手术, 会导致营养不足。维生素A对维持身体系统和特殊细胞的正常功能至关重要, 当维生素A缺乏时在眼部的表现为角膜溃疡、夜视、结膜干燥等。硫胺素水平也会下降, 并导致韦尼克脑病。术前存在的糖尿病视网膜病变也会亚急性恶化, 尽管目前的论文证据还存在相互矛盾。特发性颅内高压的患者在接受手术治疗后眼压会降低并缓解视乳头水肿。其它与肥胖的共患疾病如高糖化血红蛋白水平、阻塞性睡眠呼吸暂停综合症和代谢综合征也会在术后得到解决。病史记录仍然是医学实践的基石。根据证据, 我们建议考虑术前进行眼科病理筛查和术后的疾病进展监测。我们需要不断分析真实世界数据, 创建明确的管理途径, 帮助临床医生尽早识别眼部并发症, 改善患者预后。.

Hemodialysis-central venous catheter (HD-CVC) insertion is a most often performed procedure, with approximately 80% of patients with end-stage kidney disease in the United States initiating kidney replacement therapy through a HD-CVC. Certain adverse events arising from HD-CVC placement, including catheter-related bloodstream infections (CR-BSIs), thrombosis, and central vein stenosis, can complicate the clinical course of patients and lead to considerable financial impact on the health care system. Medical professionals with different training backgrounds are responsible for performing this procedure, and therefore, comprehensive operator guidelines are crucial to improve the success rate of HD-CVC insertion and prevent complications. In this review article, we not only discuss the basic principles behind the use of HD-CVCs but also address frequently asked questions and myths regarding catheter asepsis, length selection, tip positioning, and flow rate assessment.

Background Erdheim–Chester disease (ECD) is a rarely encountered idiopathic systemic form of non-Langerhans cell histiocytosis. The clinical manifestations of ECD are highly heterogeneous, ranging from unifocal forms to life-threatening multisystem involvement. Patients with CNS involvement often do not show clinical remission. Case presentation We present a case of a 60-year-old male patient with worsening complaints of loss of balance, involuntary jerky movements, emotional lability and scanning speech developing over a period of 5 years. Magnetic resonance imaging of the brain at present institute revealed signal abnormalities in the midbrain, pons, cerebellar peduncles and cerebellar white matter with mineral deposition and volume loss in the bilateral basal ganglia and midbrain. Positron emission tomography–computed tomography of chest and abdomen revealed 18-fluorodeoxyglucose avid soft tissues lesion in the retroperitoneum involving bilateral perinephric spaces with intra-renal sinus extension, in pre- and paraaortic regions with enlargement of both adrenal glands. The radiographs of the long bones revealed multiple areas of sclerosis. The suspected diagnosis of ECD was confirmed on histopathology. ECD is a rare disease and has a predilection towards middle-aged males and is usually diagnosed late after the onset of initial symptoms. Conclusions Our case was an atypical presentation of an extremely rare disease, presenting with ataxia and choreoathetoid movements linked to ferromagnetic deposition on brain scans. Multiple other imaging feature characteristics of the disease like the hairy kidney sign, coated aorta sign, skeletal, extra-skeletal and central nervous system manifestations were noted in this single patient.

Food handlers and workers are exposed to several occupational hazards not frequented by the general population. Grinder injuries of the hand present a devastating consequence of industrial food processing that is infrequently described. Herein, we describe two cases that presented to our department with meat grinder injuries of the hand.

Introduction Coronavirus disease 2019 (COVID‐19) caused by SARS‐CoV2 can present from mild flu‐like symptoms to acute respiratory distress syndrome. There is multi‐organ involvement; particularly, hematopoietic system can be associated with morphological changes in blood cells of COVID‐19 patients. Method We conducted a cross‐sectional study on a cohort of 50 COVID‐19 patients, confirmed on RT‐PCR with documented cycle threshold (Ct) value. Peripheral blood sample of these patients was collected and examined for complete blood counts (CBC) on automated haematological analyser as well as Leishman‐stained blood smears to look for morphological changes in blood cells. Morphological changes were evaluated with reference to clinical severity and Ct value. Additionally, association between Ct value and clinical severity was also performed. Statistical tests were performed, and P value

Introduction:The most challenging hurdle faced by national health systems worldwide in the last century is the ongoing COVID 19 pandemic. Initial cases of atypical pneumonia of unknown origin started in Wuhan, Hubei province, China which started the outbreak of COVID 19 in December 2019. This infection later on spread to rest of the world. Case series:Here we present a series of 3 patients who came to our casualty with polytrauma after a suspected suicidal fall from height. The patients were managed by adequate surgical interventions. Postoperative physiotherapy started with gradual mobilization. We did a psychiatric reference and proper counseling of all 3 patients patients both pre and postoperatively. Conclusion:We conclude that this COVID-19 pandemic has taken a great toll both physically and mentally on people in the form of increased mortality and morbidity as shown daily in media, increased unemployment and strict self isolation has further put a strain on peoples mind leading to psychiatric disorders and suicidal behaviour. This has increased cases of polytrauma due to suspected suicidal falls. We have adequately treated such patients who came to our institute operatively and with psychiatric support.

BACKGROUND AND AIMS Intrahepatic cholangiocarcinoma (iCCA) and hepatocellular carcinoma (HCC) are the most common primary liver cancers (PLCs). Differences in their clinical features and outcomes are open for investigation in a large-scale study. We aim to investigate the differences in clinical features and outcomes between iCCA and HCC. APPROACH AND RESULTS The Surveillance, Epidemiology, and End Results Program 18 Database (2000-2017) was used to extract demographic and clinical features of HCC and iCCA patients. Logistic regression analysis was performed to identify factors associated with iCCA diagnosis versus HCC. Cox regression analysis was used to assess factors affecting overall survival (OS). There were 13,611 iCCA and 96,151 HCC patients. Half of iCCA (50.7%) and three quarters of HCC (76.3%) patients were male. Diagnosis in recent year, age (

Objective Literature regarding utility of 68 Ga-DOTATATE PET/CT in insulinoma localization across various subgroups [benign/malignant/multiple endocrine neoplasia-1 (MEN-1) syndrome associated] remains scarce. In this study, the performance of 68 Ga-DOTATATE PET/CT was compared with contrast-enhanced computed tomography (CECT) and 68 Ga-NODAGA-Exendin-4 PET/CT (whenever available) in an endogenous hyperinsulinemic hypoglycemia (EHH) cohort. Design Retrospective audit. Patients EHH patients [N = 36, lesions (n) = 49, final diagnosis: benign sporadic insulinoma (BSI) (N = 20), malignant insulinoma (N = 4, n = 14), MEN-1 syndrome associated insulinoma (N = 9, n = 15), Munchausen syndrome (N = 2) and drug-induced hypoglycemia (N = 1)] having both preoperative imaging modalities (CECT and 68 Ga-DOTATATE PET/CT). Measurements Per-lesion sensitivity (Sn) and positive predictive value (PPV) for histopathological diagnosis of insulinoma. Results Sn and PPV of 68 Ga-DOTATATE PET/CT were 67.3% and 89.2%; 55% and 100%; 85.7% and 100%; and 66.7% and 77% for overall EHH, BSI, malignant, and MEN-1 syndrome associated insulinoma cohorts respectively. Despite having comparatively lower sensitivity in BSI cohort, 68 Ga-DOTATATE PET/CT localized a pancreatic tail lesion missed by other modalities. 68 Ga-DOTATATE PET/CT had comparatively higher sensitivity in malignant insulinoma than BSI cohort. 68 Ga-DOTATATE PET/CT also paved the way for successful response to 177 Lu-based peptide receptor radionuclide therapy (PRRT). In MEN-1 cases, lower PPV as compared with BSI was due to uptake in non-insulinoma pancreatic neuroendocrine tumours (Pan-NET). Conclusions 68 Ga-DOTATATE PET/CT has supplemental role in selected cases of BSI with negative and/or discordant results with CECT and 68 Ga-NODAGA-Exendin-4 PET/CT. In malignant insulinoma, 68 Ga-DOTATATE-PET/CT has an additional theranostic potential. Interference due to uptake in non-insulinoma Pan-NET in MEN-1 syndrome may hinder insulinoma localization with 68 Ga-DOTATATE-PET/CT.

Lithium is one of the first-line agents for treating bipolar disorder. Although this agent is highly effective in treating mood disorders, renal toxicity is a frequent side effect. Lithium metabolism is affected by sodium-lithium counter-transporter (SLC-T) in erythrocytes. The high activity of SLC-T can result in decreased urinary lithium clearance and may lead to accumulation of lithium in the distal renal tubular cells, causing lithium toxicity. SLC-T is a genetic marker in primary hypertension (HTN), HTN in pregnancy, diabetic nephropathy, and IgA nephropathy (IgA-N) with HTN. Patients with IgA-N have been reported to have enhanced SLC-T activity and are likely to have considerably lower renal fractional clearance of lithium. Therefore, patients taking lithium for bipolar disorder with coexisting IgA-N can have severe lithium-induced nephropathy and nephrotoxicity even at therapeutic serum levels. Serum lithium levels reflect only extracellular lithium concentration. However, lithium exerts its effects once it has moved to the intracellular compartment. This phenomenon illustrates the reason why patients with significantly elevated serum levels might be asymptomatic. Creatinine clearance is inversely related to the duration of lithium therapy. The degree of interstitial fibrosis on renal biopsy has been known to be associated with the duration of lithium therapy and cumulative dose. We present a case with a past medical history of bipolar disorder treated with lithium for almost 20 years. His family history was significant for HTN. The patient was diagnosed with renal insufficiency of unknown causes, for which he underwent renal biopsy. The renal biopsy showed a typical lithium-induced tubulointerstitial nephritis and a coincidental finding of IgA-N. We suspect a high activity of SLC-T seen in IgA-N, and the adverse effects of lithium on SLC-T activity might cause reduction of urinary lithium clearance and accumulation of lithium in distal renal tubular cells, contributing to nephrotoxicity. There is a lack of the literature on the coexistence of IgA-N and lithium nephrotoxicity. We recommend in patients with concomitant IgA-N, taking lithium, more frequent monitoring of renal functions, and dose adjustments may reduce the risk of lithium-induced nephrotoxicity.

Carotid body tumor excision can lead to various complications including vascular injury and pseudoaneurysm formation. Here we describe a case of carotid body tumor excision followed by series of complications including pseudoaneurysm formation, failure of primary surgical repair, carotid stump syndrome following parent artery occlusion, and persistent hypotension.

Summary Introduction The anterolateral thigh (ALT) flap has become the universal workhorse for Head and Neck reconstruction. Being a perforator-based flap, accurate planning by preoperative perforator localisation is clearly beneficial. Acoustic Doppler (AD) and Colour Duplex Ultrasound (CDU) are the most practicable methods of localisation available. We designed a prospective study to analyse the correlation between preoperative localisation (by AD and CDU) and intraoperative findings, factoring in the advantages of using a high frequency probe for CDU. Methods Thirty-three consecutive patients were analysed in a prospective, observational study. AD was first used to mark the perforator point and its distance measured from two anatomical landmarks, the Anterior Superior Iliac Spine (ASIS) and the ‘Reference line’ (a line joining ASIS with the superior patellar border). CDU was then carried out to mark the perforator position with two probes (9 and 14 MHz), and the above distances measured for both points. At surgery, the actual point of perforator entry was separately marked and the same two distances were measured. A note was also made of perforator characteristics such as size and flow rate. Results In 21/33 cases, there was a close concordance between pre- and intraoperative localisation (complete success). From the remaining 12 cases, the complete absence of perforator was found in one case, a small, unreliable perforator in 2 cases and a site disparity of > 2 cm between true and preop points in 9 cases. Conclusion No significant advantages were found with either a high frequency probe or indeed for CDU over AD. AD is sufficient for effective perforator localisation and should be routinely employed to accurately plan the anterior incision. CDU can be employed in cases where AD is unconvincing.

Electrical burns account for a small percentage of all burn injuries. However, in burn patients, they are a major source of disability. They put socioeconomic burden on the society. This is a retrospective epidemiological study of 282 electrical burn patients admitted in burn unit of a tertiary care hospital of North India. Majority of the electrical burn was due to accidental touching of uncovered wires and occupation-related burns in laborers and industrial workers who were mainly young males in the age group 20 to 40 years. Most of the cases were of high-voltage (≥1000 V) electrical burns. More severe burns, longer hospital stays, and more problems and operations were all linked to high-voltage burns. Amputation rates for high-voltage burns were significantly higher (37.3%) as compared to low-voltage burns (13.6%). Electrical burn injuries can be prevented by awareness programs, proper training, and safety measures both by public and government.

Objective Families of children with cancer undergoing treatment during COVID‐19 pandemic represent a vulnerable population for psychological distress and early identification and remedial measures are imperative for wellbeing of both the children and the caregivers. This article reports the results of assessment of psychological distress in primary caregivers of children with cancer undergoing treatment at a tertiary care center. Methods Primary caregivers of children with cancer (≤15 years) taking treatment at our institute during the period of July 2020 to August 2020 were prospectively evaluated for psychological distress using Patient Health Questionnaire‐9 (PHQ‐9) and Generalized Anxiety Disorder‐7 (GAD‐7) tools over a telephonic call. There were 2 cohorts, A and B (50 participants each) depending on whether child was diagnosed with COVID‐19 or not respectively during the study period. Results The assessment tool, PHQ‐9 showed a score of ≥10 in 13% (n = 13) participants (95%CI:7.1%–21.2%) in the entire cohort and in 16% (n = 8, 95%CI:5.8%–26.2%) and 10% (n = 5, 95%CI:1.7%–18.3%) participants in cohort A and cohort B respectively. GAD‐7 showed a score of ≥8 in 18% (n = 18) participants (95%CI:11.0%–27.0%) in the entire cohort and in 20% (n = 10, 95%CI:8.9%–31.1%) and 16% (n = 8, 95%CI:5.8%–26.2%) participants in cohort A and cohort B respectively. All participants were assessed, and supportive psychotherapeutic interventions administered over telephonic call. Conclusions Primary caregivers should be assessed and followed up for psychological distress irrespective of other co‐existing factors. Robust support systems built over time could help withstand the exceptional strain of a major surge during a pandemic.

In developing part of the world, it is common to see complete destruction of vertebral bodies in tuberculosis. Our study aims to assess the effect of spinal tuberculosis with vertebral shortening on pulmonary function. Fifty cases of spinal TB (14 males, 36 females) managed both operatively and non-operatively, who presented to tertiary care institute between years 2011 and 2016 were assessed. Vertebral height loss was assessed by spinal deformity index (SDI). All patients underwent pulmonary function testing using same equipment sitting in upright position. Mean age was 27.9 years (27.9 ± 11.9). 11 patients with mean SDI of 2.7 ± 1.1 showed normal lung function. 36 patients showed restrictive pattern of which 12 were mild, 14 were moderate and 10 showed severe pattern with a mean SDI of 3.8 ± 1.2, 5.6 ± 1.3 and 6.1 ± 1.4, respectively. 3 cases showed obstructive pattern. As the apex of curve shifted proximally, FVC% reduced. Increase in SDI value was associated with a fall in the vital capacity and FEV1. Increase in the kyphotic angle was associated with a deleterious effect on PFT results. Risk stratification of pulmonary dysfunction resulting from vertebral body height loss due to kyphosis will emphasize the need for early detection of spinal tuberculosis before deformity occurs.

Angiofibroma of the soft tissue is a recently described benign fibroblastic/ myofibroblastic tumor. Histologically, it is diagnosed by bland spindle cells dispersed in a myxocollagenous stroma with interspersed angulated and slit-shaped, small vessels. Scattered inflammatory cells are also common in the stroma. The cytology of this tumor has not been reported in the literature, to the best of our knowledge. We report the cytology of an angiofibroma of soft tissue occurring in a 30-year-old lady which showed bland spindle cells, occasional polygonal cells with nuclear grooving, prominent vessels, frayed stroma around the blood vessels, and scattered lymphocyte-rich inflammatory cells in the background.

BACKGROUND Diabetic retinopathy (DR) is a major microvascular complication of diabetes. It has a significant impact on the world’s health systems. Due to a rapid increase in disease burden globally, there arises the need for newer methods of early detection of DR to prevent various complications including total blindness. The association between periodontal problems and diabetes has been studied widely and a positive correlation has been found. Literature search revealed that no studies have been done so far comparing the oral hygiene status among type 2 diabetics with and without retinopathy, thus the purpose of the study was to compare oral hygiene status among type 2 diabetics with and without progressing diabetic retinopathy and thus look for any association between existing oral hygiene status and severity of diabetic retinopathy. METHODS Study was conducted on type 2 diabetic patients with and without progressing diabetic retinopathy visiting the Department of Opthalmology at the University Medical College. A thorough evaluation of oral hygiene status of patients participating in the study was done using OHI - S and Gingival Index. RESULTS There was no statistically significant difference between the OHI - S and diabetic retinopathy, P value (0.522). The gingival index showed statistically significant relation with severity of diabetic retinopathy with P - value of 0.027. The intergroup comparison of the association between the mean OHI - S and GI scores and severity of diabetic retinopathy was found to be statistically insignificant P < 0.269 and P < 0.125. CONCLUSIONS There could be a plausible relationship between diabetic retinopathy and oral hygiene condition. Because of the regional variation in the oral hygiene condition further prospective studies on a large population are required to ascertain whether the existing oral hygiene status has a direct impact on the progression and severity of diabetic retinopathy. KEY WORDS Diabetic Retinopathy, Oral Hygiene, Periodontitis, Type 2 Diabetes Mellitus, Oral Hygiene Index Simplified, Gingival Index

Neoadjuvant chemotherapy followed by radical cystectomy is the standard of care for muscle invasive non-metastatic bladder cancer patients. While cisplatin based neoadjuvant chemotherapy has been recommended, systemic therapy in a neoadjuvant setting for cisplatin ineligible patients still needs to be addressed. Various strategies like split dosing cisplatin chemotherapy, carboplatin based chemotherapy and taxanes based chemotherapy have been tried as neoadjuvant therapy for cisplatin ineligible patients. Immunotherapy is a promising tool in this regard with a need for the development of predictive and prognostic biomarkers which can bring out the true potential of these immunotherapeutic agents.

Background: Emergence of new diabetes mellitus cases, after infection with SARS Co-V2 is a serious concern. Understanding them and then following up these cases can enrich our knowledge about the etiopathogenesis of diabetes mellitus, and the diabetogenicity of these viral infections. Observation: We had a series of adult Covid 19 cases in our hospitals in north India, during the early summer 2021. They did not have prediabetes or any predilection to develop diabetes. On admission, they had high blood sugar and needed insulin. After discharge from hospital, they needed insulin or oral antidiabetic drugs. Eight weeks into follow up, these cases still needed antidiabetic medicines. Methods: Observational prospective study. Analysis of the past medical history, and comparison with the acute covid and post covid illness. Results:The analysis of these cases shows that the SARS CoV2 infection results in diabetogenic changes leading to new onset diabetes. Conclusion: Diagnosis of new onset diabetes must be kept in mind with every case of SARS CoV-2 infection, even after full recovery from acute covid -19.

Objective To report the experience with COVID-19 in children with cancer at the largest tertiary-cancer care and referral center in India. Methods This study is a single tertiary center experience on COVID-19 in children with cancer and continuation of cancer-directed therapy in them. Children ≤ 15 y on active cancer treatment detected with COVID-19 until September 15th, 2020 were prospectively followed up in the study. Patients were managed in accordance with well-laid guidelines. Treatment was continued for children with COVID-19 who were clinically stable and on intensive treatment for various childhood cancers. Results One hundred twenty-two children (median age 8 y; range 1–15 y, male:female 1.7:1) with cancer were diagnosed with COVID-19. Of 118 children, 99 (83.9%), 60 (50.8%), 43 (36.4%), 26 (22.0%), and 6 (5.1%) had RT-PCR positivity at 14, 21, 28, 35, and 60 d from diagnosis of COVID-19, respectively. Scheduled risk-directed intravenous chemotherapy was delivered in 70 (90.9%) of 77 children on active systemic treatment with a median delay of 14 d (range 0–48 d) and no increased toxicities. All-cause mortality rate was 7.4% (n = 9) and COVID-19 related mortality rate was 4.9% (n = 6). One hundred-fifteen (94.2%) children with COVID-19 did not require any form of respiratory support during the course of infection. Conclusions COVID-19 was not a major deterrent for the continuation of active cancer treatment despite persistent RT-PCR positivity. The long-term assessment of treatment adaptations requires further prospective follow-up and real-time addressal.

The hand is one of the top 3 locations for burn scar contracture deformity. The functionality of the hands is one of the primary determinants of burns survivors’ quality of life. Although most burn abnormalities are preventable, they do arise when adequate treatment is not delivered in an emergency or when they are part of a major burn. Reconstructive surgeries can significantly improve hand function. For a burn’s survivor, the right methods and timing of surgery, followed by supervised physiotherapy, can be a game changer.

Beta thalassemia major is associated with a subclinical hypercoagulable state. Endothelial activation markers like soluble Intercellular adhesion molecule (sICAM-1) and E-selectin have been implicated in the pathogenesis of endothelial dysfunction and hemostatic alterations. In this study we aimed to study serum levels of sICAM-1 and E-selectin in polytransfused children with β thalassemia major and their association with serum ferritin and D-dimer levels. Sixty-two polytransfused β-thalassemia major children aged between 5 and 17 years and 26 age and gender matched healthy controls were enrolled in the study. Complete blood count with peripheral smear, liver function tests, serum ferritin, coagulation tests [PT, APTT, D-dimer] and endothelial activation marker tests [ICAM-1 and E-selectin] were performed. PT, APTT and D-dimer levels were significantly higher in beta-thalassemia major patients than in control group (p = 0.003, p

Comminuted fractures of the posterior acetabular wall, pose a significant challenge in the reduction and fixation of the fracture fragments and usually result in dubious functional outcomes. Primary reconstruction of the severely comminuted posterior wall using the autologous tricortical iliac crest graft has shown promising results, especially in fractures not amenable for anatomical reduction and fixation. Thus, the present study analyses the functional and radiological outcomes of severely comminuted posterior wall acetabular fractures, primarily reconstructed with an autologous tricortical iliac crest graft. This is a retrospective study, where all cases of comminuted posterior wall acetabulum fractures treated primarily with reconstruction using ipsilateral autologous tricortical iliac crest graft between January 2011 and November 2018 were included. The data of patients were retrieved from the hospital records and all the patients were assessed clinically and radiologically at the final follow-up. Fourteen patients (ten males and four females) were operated on with a mean operative time of 160 min (range 125 to 190 min) and a mean blood loss of 410 ml (range 320 ml to 830 ml). At 2 years of follow-up, 11 patients (78.57%) had good to excellent functional outcomes based on the modified Merle d’Aubigne and Postel scoring system. The radiological assessment using Matta’s criteria indicated excellent outcomes in two patients (14.48%), good in six patients (42.85%), fair in six patients (42.85%). Primary reconstruction of the comminuted posterior wall acetabulum fractures is a potential alternative and salvageable option with favourable outcomes. However, it ought to be considered in severely comminuted fractures where anatomical reduction and internal fixation is not feasible.

A cochlear implant is an electronic sensory system that converts mechanical energy into coded electrical signals that directly activate the auditory nerve fibers. Present review article investigates the findings of previous research papers which have assessed speech and language outcome in children who underwent early cochlear implantation. Several databases, including PubMed, Google, Google Scholar, and Medline, were investigated for research papers on the speech and language outcomes of children who had early-life implants. According to previous research, early detection and intervention of hearing loss are critical for the growth of speech and language skills. The effect of early detection of hearing loss and early cochlear implantation on a child's overall speech-language and auditory growth is highlighted in this article.

Background and Aim: The attitude of Non Psychiatry Post Graduate Residents towards Psychiatry is crucially important because of its influence on impressionable medical students and the large number of psychiatric patients who present to Non Psychiatry Doctors like General Practitioners. Present study was done with an aim to study the Non-Psychiatric Doctor Attitude towards Psychiatry. Material and Methods: Present study was Conducted at two Major Institute: K. M School Post-Graduate medicine and Research and B.J. Medical College at Ahmedabad, Gujarat. At Both Institute Psychiatric lectures during 1st MBBS, lectures on Psychiatry during final MBBS and 2 week clinical rotation during final MBBS. Modified version of attitude towards Psychiatry questionnaire (Nielsen and Eaton, 1981) was the study instrument. The non- Psychiatry post-graduate students were asked to fill the Questionnaire. Questionnaire consists of 21 statements to be responded with one of the three alternate responses- Agree, neutral and disagree. Results: Most P.G. thought that Psychiatry is making advancement and most was positive about psychoanalysis. Only 6.6% of P.G.s thought that Psychiatry is unscientific and inexact. With respect of therapeutic efficacy 83.8% would refer emotionally upset family members for Psychiatry consultation. Psychiatrist were considered as unclear thinker by 8% and overly apologetic in teaching. 40% agreed that psychiatrist tended to over analyze human behaviour.27% of P.G.s thought that on an average psychiatrist make less money than other physician.31% of P.G.s viewed that Psychiatry status as low compared to other specialties. 47% agreed that Psychiatry are often rightly seen by others as odd, peculiar and emotionally disturb them. Conclusion: Non Psychiatry Post-Graduates at a tertiary hospital in Gujarat have a moderately positive attitude to Psychiatry. However some erroneous beliefs are still prevalent among the consultants. The attitude of Non-Psychiatry consultants directly/indirectly affects the development of Psychiatry as a discipline.

Mohamed Ibrahime Asif,1 Rahul Kumar Bafna,1 Namrata Sharma,1 Ananya Kaginalkar,1 Rajesh Sinha,1 Tushar Agarwal,1 Prafulla Kumar Maharana,1 Manpreet Kaur,1 Priya Taank,2 Jeewan S Titiyal1 1Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; 2Department of Ophthalmology, Command Hospital, Pune, 411040, IndiaCorrespondence: Namrata SharmaDepartment of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, IndiaTel +91 9810856988Fax +91 11-26588919Email namrata.sharma@gmail.comPurpose: To describe the outcomes of descemet stripping automated endothelial keratoplasty (DSAEK) in congenital hereditary endothelial dystrophy (CHED) and to evaluate the role of microscope integrated optical coherence tomography (Mi-OCT) during the surgery.Design: Retrospective data analysis.Methods: A retrospective study from the medical records of all those patients who were diagnosed with CHED and underwent DSAEK at our centre from 2015 were evaluated. All patients underwent Mi-OCT-guided standard DSAEK procedure. Intra-operative difficulties, visual outcomes and graft survival were recorded.Results: A total of 48 eyes of 29 patients with a mean age of 9.87 ± 8.2 years and mean follow-up of 17.3 months were evaluated. Thirty-nine eyes underwent primary DSAEK and 9 eyes underwent PKP. Three eyes who underwent PKP had failed graft for which they underwent DSAEK. The mean preoperative Snellen’s visual acuity was 1.71 ± 0.66 and the mean preoperative central corneal thickness was 1.10 ± 0.174 mm. Intraoperatively, all the grafts were attached which was confirmed using Mi-OCT. Graft detachment was seen in the immediate postoperative period in 10.4% (4 eyes) of primary DSAEK, out of which DM scoring was not performed in 2 eyes. Following DSAEK, cornea cleared at four-week follow-up in 89.7% eyes and in all the eyes the cornea cleared at six-week follow-up.Conclusion: Primary DSAEK could be a preferred option over PKP for CHED with early presentation and in those eyes with failed primary PKP. Mi-OCT is a very useful tool in these eyes for various intraoperative procedures, thereby improving the outcomes of the procedure.Keywords: DSAEK, CHED, Mi-OCT

In the United States, hemodialysis remains the most common treatment modality for kidney failure, chosen by almost 90% of incident patients. A functioning vascular access is key to providing adequate hemodialysis therapy. Recently, major innovations in devices and technology for hemodialysis vascular access care have rapidly changed the landscape. Novel endovascular devices for creation of arteriovenous fistulas may offer a solution to the barriers encountered in initiating maintenance hemodialysis with a permanent vascular access rather than a central venous catheter (CVC). Furthermore, in the prevalent hemodialysis population, the minimally invasive endovascular arteriovenous fistula procedure should help improve long wait times for vascular access creation, which remains a major barrier to reducing CVC dependence. Bioengineered grafts are being developed and may offer another option to polytetrafluoroethylene grafts. Early studies with these biocompatible grafts are promising, as additional studies continue to evaluate their clinical outcomes in comparison to cryopreserved or synthetic options. Prolonging the vascular access patency with appropriate use of devices such as drug-coated balloons and stent grafts may complement the novel techniques of creating arteriovenous access. Finally, innovative solutions to treat stenosed and occluded thoracic central veins can provide an approach to creating a vascular access and allow patients with exhausted vasculature to remain on hemodialysis. The robust developments in hemodialysis vascular access are likely to change practice patterns in the near future.

Introduction: Bovine-derived collagen membrane is usually and regularly used as a temporary cover or dressing for extraoral wounds and burns. It has wide applications because of its usefulness and biocompatibility. This has provoked us to do a study with the use of collagen membrane even for minor intraoral surgical defects. The aim of this evaluative study was to evaluate the clinical efficacy of collagen membrane in intraoral wounds created by removal of various soft tissue lesions. Materials and Methods: A total of 25 healthy patients (16 males and 9 females) were taken for this study. This study was confined to secondary defects of the oral mucosa, which occur after excision of premalignant lesions and other conditions, such as benign lesions, reactive proliferations, and incisional biopsy wounds. Only those lesions that were sufficiently large and could not be closed primarily were included in the study. Results: The results were evaluated on the day of surgery and in the postoperative period. The usefulness of collagen membrane as an intraoral temporary wound dressing material to promote haemostasis, relieve pain, induce granulation, and assist in rapid epithelialization at the wound site and prevent infection, contracture, scarring, and donor-site morbidity was evaluated, and finally, the efficacy of collagen membrane was tested by the use of Chi-square test and P < 0.001, which is a statistically and clinically significant value. Discussion: Collagen membrane was observed as both biological dressing material and drug carrier. It was found to be a suitable alternative to other graft materials mentioned for the repair of defects in the mucous membrane created by surgical excision of lesions. Therefore, when used judiciously in a controlled clinical situation, collagen membrane is biologically acceptable in nature. It is an alternative to autologous grafts rather than a replacement of other grafts used in the oral cavity.

Suicide can be defined as intentional self-inflicted death. It is a serious cause of mortality worldwide. Suicide is considered as a psychiatric emergency and the awareness of the seriousness of suicide in our society should not be overlooked. It is estimated that approximately 1.5% of all deaths worldwide are by suicide in the year 2020. The suicide mortality rate in 2015 was 12% in 100,000, which means about one death every 20 s. Rates of completed suicides are generally higher among men than among women, ranging from 1.5 times as much in the developing world to 3.5 times in the developed world. Suicide is generally most common among those over the age of 70; however, in certain countries, those aged between 15 and 30 are at the highest risk. Suicidal behavior is the second leading cause of death in adolescents in the world. Suicide behavior in adolescents can be prevented by recognizing risk factors and protective factors originating from themselves and the surrounding environment. This study aimed to identify risk factors and protective factors for adolescents who demonstrate suicidal behavior. Prevention programs that target young people, females, and low socioeconomic groups, and aimed to reduce harmful alcohol use can help prevent suicidal behaviours.

Postural and physiological changes are the distinct changes occurring in the adolescence which contributes fitness level of a child. The biomechanics of these children are highly affected by load carriage while climbing stairs which results in increase in cardio respiratory responses. Evaluation of the cardio respiratory changes is necessary in curbing further damage. In the study we evaluated the effect of backpack load influencing the cardio respiratory measures in stair climbing adolescents. 100 adolescents subjects aged 13-16 yrs were selected for the study, with graded loading for three consecutive days. Heart rate, rate of perceived exertion and respiratory rate were measured pre and post loading. Values of all the parameters on each day were compared. With increase in load, increase in heart rate, rate of perceived exertion and respiratory rate were significant when compared with progression in load. Although the measure which is highly affected amongst these was heart rate. The backpack with 30% load produces the elevation of variables at a greater extent hence there should be curbing of weight of 30% of adolescent’s body weight. Key words: Adolescence, Backpack load, Rate of Perceived Exertion.

BACKGROUND Mediastinal masses, an enigma to surgical pathologist are among the most complicated lesions explored and relatively inaccessible. They often connote a process with mass effect presenting with superior mediastinal syndrome. This is a challenging area faced by surgical pathologist as varied lesions are found here and often biopsies obtained are tiny and crushed. Appropriate therapy of various mediastinal tumours differs considerably and may significantly impact survival. We wanted to evaluate the various lesions in different compartments of mediastinum and categorise them according to anatomical location, and histopathology. METHODS Patients with mediastinal masses attending outpatient department were selected, history taken and relevant investigations done with radiological evaluation for proper anatomical location of lesion. Histopathological study done on tissues obtained by ultrasound / CT guided biopsy, open surgical biopsy were categorized according to histologic types. Immunohistochemistry was done wherever applicable. RESULTS A total of 58 cases of mediastinal lesions were studied where males predominated and age of patients ranged from 11 months to 68 yrs. All patients were symptomatic. Shortness of breath, superior vena cava syndrome was dominant in anterior and superior mediastinal lesions, middle and posterior mediastinal masses presented with chest pain. Most lesions were neoplastic. Germ cell tumours were found in (24.14 %) followed by lymphoma in (20.69 %) and thymic lesions in (18.97 %) of patients. Neurogenic tumours found in (13.79 %) were located in posterior mediastinum whereas, germ cell tumours and lymphomas were located in anterior mediastinum. Non neoplastic lesions included tuberculosis, sarcoidosis. Unsuspected lesion was metastatic deposit of adenoid cystic carcinoma. CONCLUSIONS A wide variety of non-neoplastic and neoplastic lesions can be found in different compartments of mediastinum and accurate diagnosis is considered necessary to formulate management strategies. KEYWORDS Mediastinum, Biopsy, Radiology, Histopathology